Schwannomas of the paranasal sinuses. Case report and clinicopathologic analysis

Schwann's cell tumors are common neoplasms arising from the neural sheath of autonomic, cranial, or peripheral nerves. We describe a case of destructive malignant schwannoma of the right ethmoid and sphenoid sinuses. The tumor was successfully treated by surgical excision, external radiotherapy, and radon seed implants. The patient remains symptom free 3 years after therapy ended, emphasizing the previously unrecognized benefits of radiotherapy for these types of tumors. The value of endoscopy in diagnosing and following schwannomas of the nasal and paranasal sinuses is highlighted in our review of the clinicopathologic features and radiologic findings of this tumor.

Isolated sphenoid sinus disease

Isolated sphenoid sinus disease is an unusual entity that is encountered infrequently. With advances in antibiotic therapy and imaging techniques, the nature of isolated sphenoid sinus disease has significantly changed. More tumors and less inflammatory disorders are being encountered. We have retrospectively reviewed the medical records of patients who had undergone sublabial transseptal sphenoidotomy for isolated sphenoid sinus disease at Allegheny General Hospital for Pittsburgh between January 1985 and July 1989. Thirteen patients were identified with isolated sphenoid sinus disease who were successfully managed with sublabial transseptal sphenoidotomy. This approach allows maximal visualization and safety with minimal morbidity.

Studying whole-mounted sections of the paranasal sinuses to understand the complications of endoscopic sinus surgery

Endoscopic techniques for paranasal sinus surgery have allowed detailed and complete removal of sinus disease while promising minimum distress to the patient. The telescopic view of the operative field shows detail of the sinus anatomy and its disease, not possible in earlier transnasal techniques. Several articles document the serious complications seen with the endoscopic surgery. To understand the paranasal sinuses and their relationships to the orbit and cribriform plate, blocks of cadaver heads that included the orbit and paranasal sinuses were whole sectioned. It has been possible to see areas of the cribriform and orbital wall that are at risk to produce cerebrospinal fluid rhinorrhea and orbital complications. At the same time, landmarks for avoiding these complications can be defined to guide the surgeon during this dissection as seen through the endoscope.

Midfacial split for access to the central base

The technique of the midfacial split for access to the central cranial base is described. It provides--using bilateral facial osteotomies and soft tissue mobilization--a unified surgical field extending in the sagittal plane from the anterior cranial fossa floor and sphenoid sinus to the level of the fourth cervical vertebral body. In the axial plane, the periphery of the surgical access may extend to the jugular fossae and the hypoglossal canals. Experiences and results in eight patients are presented.

"Unusual" MRI appearance of sphenoid sinus mucocele

The authors report a case of sphenoid sinus mucocele which exhibited unusual MRI features. However a review of the literature shows that these lesions may present with different MRI appearances probably related to the variability of the cyst content. Further series are needed for a better definition of the MRI behaviour of the lesions.

Facial translocation approach to the cranial base

Facial translocation is a new approach which has been developed for surgical management of extensive lesions of the anterolateral cranial base, including the nasopharynx, sphenoid sinus, clivus, infratemporal fossa, superior orbital fissure, and cavernous sinus. Temporary displacement of the craniofacial skeleton allows direct, wide access to this complex anatomic area, while giving the surgeon a high degree of control over critical neural and vascular structures.

Chondrosarcoma of the sphenoethmoid complex

Chondrosarcoma of the nose and paranasal sinuses is extremely rare. We report a case of a child with a massive chondrosarcoma of the sphenoethmoid complex who presented with a change of visual acuity. Clinical and histologic characteristics of this lesion are discussed, along with treatment options and factors affecting prognosis.

Sphenoid sinusitis, a cause of debilitating headache

We present a case of sphenoid sinusitis resulting in a debilitating headache refractory to both oral and intramuscular analgesics. Despite an aggressive evaluation in the emergency department, the correct diagnosis and appropriate treatment were delayed. Recognition of sphenoid sinusitis, the complications associated with it, and the need for aggressive management are addressed.

Visual dysfunction: abnormal sign of benign sphenoethmoidal lesions

Isolated visual dysfunction with or without proptosis is rarely described as a sign of benign sphenoethmoidal lesions. Five patients with benign swelling of the sino-orbital region and related visual defects are reported. Cases include one patient with fibrous dysplasia, two patients with mucocoeles and two patients suffering from aspergillosis of the sinuses. A review of the literature and discussion of the cases is presented.

Rhinocerebral mucormycosis: a case report with magnetic resonance imaging findings

Mucormycosis is a rare fungal disease most often encountered in patients who are diabetic, immunocompromised, severely burned, or who have a history of intravenous drug abuse. Intracranial presentation includes the isolated cerebral and the more common rhinocerebral forms. The computed tomography picture in mucormycosis is well documented. The magnetic resonance (MR) findings associated with mucormycosis have not been previously described. We report a case of rhinocerebral mucormycosis in a poorly controlled diabetic man where the MR findings of cavernous sinus thrombosis and thrombosis of the cavernous portion of the internal carotid artery demonstrated progression of the patient's disease in spite of his stable clinica course. The results of the MR findings directly altered the patient's therapy, thus leading to a favorable outcome.

Langerhan's cell histiocytosis in the sphenoid sinus: a case of diabetes insipidus

We present a case of diabetes insipidus in a young man caused by Langerhan's cell histiocytosis of the sphenoid sinus with involvement of the pituitary gland. Diagnosis and management of this rare condition is discussed, along with a brief view of the literature.

Adenocarcinoma of the sphenoid sinus. Case report

We report a rare case of adenocarcinoma of the sphenoid sinus in which the very rarity of the site made for considerable uncertainty in the early diagnosis despite major neurological deficits at onset. Only the subsequent course of the tumor enabled us to identify the site in the sphenoid sinus, an atypical area surrounded by numerous neurovascular structures which, if involved, may give rise to a protean and nonspecific symptom-complex.

Sphenoid sinus mucocele

Sphenoid sinus mucocele is a rare entity that can occur alone or as a result of ethmoid sinusitis and polyposis. A myriad of presentations is possible due to the presence of important contiguous neurologic and vascular structures. Past surgical approaches to the sphenoid sinus have problems associated with them. The endoscopic sinus technique offers outstanding visualization and a safe, straight-forward approach to the sphenoid sinus. Four patients with documented mucocele of the sphenoid sinus were treated successfully with endoscopic sinus surgery. The technique involves partial removal of the inferior middle turbinate and direct entrance into the sphenoid sinus through the anterior sinus wall. Other sinus abnormalities can be treated simultaneously as required. Sphenoid sinus mucocele is discussed from the standpoint of cause, clinical presentation, and treatment options.

Significance of CT and MR findings in sphenoid sinus disease

Disorders of the paranasal sinuses, particularly the sphenoid sinus, can be associated with significant disorders of the optic and other cranial nerves. We examined 100 consecutive routine CT scans, 100 posterior fossa CT scans, and 100 MR scans to look for evidence of sinus disease, especially of the sphenoid sinus. The sphenoid sinus was abnormal in 7% of scans by all methods. Other sinuses were more frequently abnormal, including maxillary (23%), ethmoid (34%), and frontal (16%). Although MR was more sensitive in detecting sinus inflammation in the ethmoid and maxillary sinuses, the frequency of visible sphenoid sinus abnormalities detected by MR was not significantly greater when compared with CT. Of those patients with abnormal sphenoid sinuses, 24% had visual problems associated with the abnormality.

Adult T-cell leukemia/lymphoma originating in the paranasal sinus

A case of adult T-cell leukemia/lymphoma (ATLL) occurred in a 60-year-old woman who had a disturbance of right eye movement and visual acuity. She was born and lived in southwest Japan, an endemic area of ATLL. Rhinoscopic and roentgenologic examinations revealed a mass in the ethmoidal and sphenoidal sinuses. Histologic examination showed a diffuse lymphoma (a medium cell type with T-cell properties). The ATL (adult T-cell leukemia) cells (abnormal multi-lobed lymphocytes) were found in the peripheral blood. Human T-cell leukemia virus type I antibody was found to be 320 times positive. Based on the above findings, the patient's condition was diagnosed as ATLL, and she was treated by chemotherapy. However, the patient died due to general prostration seven months after the onset of the disease. The literature on this disease is summarized.

Rhinocerebral mucormycosis: MR manifestations

Magnetic resonance (MR) examinations of three patients with rhinocerebral mucormycosis are reviewed. The clinical course is outlined and the MR characteristics are analyzed in light of the known pathology. The major MR findings include sinus and orbital disease followed by deep facial extension. Involvement of basal portions of the hemispheres, brain stem, and hypothalamus occurred rapidly following ipsilateral facial or orbital invasion in all three cases. Regions of intracerebral inflammation were hyperintense compared with normal parenchyma on T2-weighted and proton density-weighted images. Septic cavernous sinus and internal carotid artery thrombosis was diagnosed by MR in one case. Magnetic resonance demonstrated partial resolution of intracerebral abnormalities that accompanied clinical improvement in the one surviving patient.

Embryonal rhabdomyosarcoma of the sphenoid sinus

Rhabdomyosarcoma is a diagnostic and therapeutic problem in the management of childhood tumours. A case of embryonal rhabdomyosarcoma affecting the sphenoid sinus and involving the cavernous sinus is presented. It has become evident that modern combined modality therapy, including surgery when required, radiation and adjuvant multi-drug chemotherapy offers the best chance of survival.

Intracranial granulocytic sarcoma (chloroma): MR findings

Complications of the central nervous system are not uncommon in patients with a diagnosis of leukemia including infections and hemorrhage. We present the magnetic resonance (MR) findings of granulocytic sarcoma (chloroma) in two leukemic patients who presented with masses in the cerebellopontine angle and in the cavernous and the sphenoid sinuses. The MR signal displayed by these two lesions was isointense to the brain on both T1- and T2-weighted images. This signal intensity differs from that observed in cases of hemorrhage or infection.

Diffuse meningeal melanosis (an unusual presentation)

An unusual presentation of diffuse meningeal melanosis with involvement of the temporal bones, the spheno-ethmoidal complex, the pharynx and the viscera is reported.

Chondroma of the nasal cavity and nasopharynx--a case of chondroma arising from the nasal septum

Chondromas of the nasal septum are rare. A case of chondroma originating in the left side of the nasal septum is reported. The patient, a 61-year-old female, presented bilateral nasal obstruction, headache, and nasal bleeding. The tumor was removed surgically through the transpalatal approach under general anesthesia. No recurrence was noticed after 6 months follow-up.

A case of cebocephaly-holoprosencephaly with an aberrant adenohypophysis

An autopsy case of cebocephaly-holoprosencephaly at 27 weeks' gestation is reported. Chromosome analysis revealed a 46, XX,-7, +der(7), t(7;13) (q32;q34) pat karyotype. Pathological examination disclosed a hypoplastic aberrant adenohypophysis, in which immunohistochemical localization of four anterior pituitary hormones (ACTH, GH, PRL, TSH-beta) was demonstrated. Malformation of the pituitary gland in holoprosencephaly can include ectopic adenohypophysis as well as pituitary dysgenesis, so a careful search for adenohypophysis should be made in future cases for a better understanding of endocrine dysgenesis associated with holoprosencephaly.

Prostatic cancer presenting as metastatic adenocarcinoma of sphenoid sinus

Prostatic cancer is commonly manifested by obstructive uropathy, regional lymphatic metastases, and hematogenous metastases to the axial skeleton. It is relatively rare that initial signs begin with the involvement of other sites. Intracranial metastases especially are seldom found and may be unfamiliar to not only pathologists but also to physicians. In this article, we present a case where the metastasis was first manifest as a sphenoid sinus tumor prior to the demonstration of the primary site and the prostate was confirmed to be primary by biopsy specimen with immunoperoxidase method. In addition to discussing the route of the tumor spread, we deal with a prostatic specific antigen efficient for identifying the primary site.

Sphenoid sinus brown tumor, hypercalcemia, and blindness: an unusual presentation of primary hyperparathyroidism

This is a first report of primary hyperparathyroidism (HPT) masquerading as a destructive fibrous sphenoid sinus "Brown tumor" associated with progressive blindness and hypercalcemia. Diagnosis of a Brown tumor was delayed despite serial computerized tomography of the head and repeated transnasal and transethmoid sphenoid biopsies demonstrating diffuse fibrosis. Only detection and medical evaluation of hypercalcemia, demonstrating elevation of both serum calcium and C-terminal parathyroid hormone with an elevated chloride/phosphate ratio, prompted neck exploration, thus confirming a solitary left superior parathyroid adenoma. Postoperative normocalcemia occurred synchronously with the return of light perception and the arrest of sphenoid sinus and parasellar erosion. Although maxillary Brown tumors of secondary HPT have been reported, this is the first report of osteitis fibrosa of the sphenoid sinus. Differential diagnosis of an erosive sphenoid lesion with cranial nerve dysfunction, exclusive of inflammatory or vascular disease, should include sarcoidosis, primary and metastatic sphenoid carcinoma, fibrous dysplasia, giant cell reparative granuloma, midline lethal granuloma, chordoma, and chondrosarcoma. Furthermore, the bony destructive lesions with concomitant hypercalcemia of sarcoidosis and HPT are distinguishable by radiographic and laboratory analyses and by the Dent corticosteroid suppression test. Hypercalcemia of primary HPT is associated with elevated serum C-terminal parathormone, osteitis fibrosa, a negative Dent test, and a chloride/phosphate ratio greater than 33 in 94% of primary HPT patients. Hypercalcemia of sarcoidosis is associated with a normal or decreased C-terminal parathormone assay and a positive Dent test, as well as elevated serum immunoglobulins and erythrocyte sedimentation rate, and a positive angiotensin-converting enzyme assay.(ABSTRACT TRUNCATED AT 250 WORDS)

Intracranial extension and bone destruction in orbital pseudotumor

Three cases of surgically proved pseudotumor of the orbital apex with intracranial extension occurred. All demonstrated bony destruction. Varying degrees of ophthalmoplegia and visual loss were present in all three. Previous computed tomographic descriptions of the patterns of orbital pseudotumor have not included bone destruction. Further, intracranial extension has been reported in only one patient. These three cases are reported to emphasize the fact that while these manifestations may be rare, it is appropriate to include orbital pseudotumor in the differential diagnosis of orbital apex lesions that are associated with both bone destruction and/or intracranial extension.

Cancer of the paranasal sinuses

Cancers of the paranasal sinuses, although rare, continue to cause the death of more than half of patients afflicted with them. The use of combined therapy (surgery and irradiation) has effected some improvement in control, particularly with better surgical and radiation techniques. Unfortunately, better results will not be obtained until earlier diagnoses can be achieved.

Abducens nerve paralysis: a potential presentation of sphenoid sinus cancer

The sphenoid sinus is the paranasal sinus most commonly implicated when cranial neuropathies are present. Two patients presenting with sixth nerve paralysis secondary to sphenoid sinus involvement are presented. One patient had a primary sphenoid sinus tumor, and the other a metastasis from a bronchogenic carcinoma. Of the two patients, one carried the diagnosis of idiopathic sixth nerve paresis and had had a normal sinus x-ray film and CAT scan done previously. Even in the absence of positive radiographic findings, the high clinical suspicion of sinus malignancy must be maintained in patients manifesting abducens nerve paralysis. In these patients, the petrous apex and cavernous sinus "silent area" must be diligently evaluated. For the patient to have any chance for palliation or potential cure, the tumor must be diagnosed as soon as possible.

Pneumosinus dilatans of the sphenoid sinus

Four cases of pneumosinus dilatans of the sphenoid sinus are reported, supplementing the eight cases previously reported in the literature. This rare entity is characterized by expansion of a paranasal sinus that contains only air. In one patient, severe visual loss due to compression of the optic canal by the adjacent enlarged sinus was seen. Galactorrhea occurred in one patient, and three of the four patients reported headaches. There was dehiscence of the sinus roof in two cases, which apparently resulted in a cerebrospinal fluid fistula in one. Previous reports of this entity are reviewed, and the radiographic findings and clinical presentations are discussed. It is proposed that the term "pneumosinus dilatans" be used to describe all dilated, air-filled sinuses with outwardly bulging walls when the primary cause is uncertain.

Chondrosarcoma of the ethmoidal and sphenoidal sinuses. A case of chondrosarcoma arising from postparanasal sinuses

A case of chondrosarcoma originating within the postethmoidal and sphenoidal sinuses with intracranial invasion will be reported. The patient, a 54-year-old female, presented severe headaches and diminished visual acuity of the right eye. Angiographic findings showed both the left carotid artery to be completely occluded and the right inner carotid artery to be narrowed at the site of the carotid bifurcation. Computerized tomography scan findings showed a tumor, located mainly in the frontal base and temporal fossa, that had invaded the cranium through the skull base. Several tumor excisions were performed using a combined extranasal and transmaxillary approach. The diagnosis 'chondroma' was changed to 'chondrosarcoma' during autopsy.

[Invasive aspergillosis of the head and neck]

Aspergillosis of the paranasal sinuses after invasion of the neighbouring orbit and/or the sella turcica may simulate a malignant tumour. Exploratory excisions usually lead to the diagnosis of a chronic sinusitis. With the aid of special staining methods as well as cultural and serological tests the diagnosis of an aspergilloma can be established.

Cholesterol granuloma of the petrous apex and sphenoidal sinus: a case report

A case of a cholesterol granuloma located in the petrous apex and eroding into the sphenoidal sinus is reported. Cholesterol granuloma is thought to occur when pneumatized cells in the temporal bone become obstructed. Although usually occurring in the middle ear, it can occur in the petrous apex. The diagnosis and surgical management are discussed.

Neuro-ophthalmology of sphenoid sinus carcinoma

Three cases of sphenoid sinus carcinoma observed personally and 39 identified in the English language publications are reviewed. Sphenoid carcinoma constitutes only 0.3 per cent of sinus cancer. Its symptoms and signs are nonspecific until the sinus wall is penetrated. Once breached, specific neuro-ophthalmological symptoms and signs ensue, resulting from involvement of anatomically contiguous structures. These are characterized most commonly by the sphenocavernous syndrome and less frequently by isolated sixth nerve palsies and visual loss. Identified best by plain radiography, polytomography and computerized tomography, diagnosis of sphenoid carcinoma requires direct biopsy. Treatment, principally with radiotherapy supplemented by chemotherapy, has been disappointing with most patients dead by three years. The authors believe that in rapidly evolving neuro-ophthalmological syndromes of basal origin, accompanied by intractable headache, sphenoid sinus cancer must be considered.

A prolactin producing tumor originated in the sphenoid sinus

The case presented is a prolactin producing tumor originated in the sphenoid sinus of a 40-year-old woman. Histologically this tumor is a typical chromophobe adenoma of the pituitary gland. Human prolactin was immunohistochemically detected in the cytoplasm of most tumor cells. The tumor invaded around the pituitary gland and in the nasal cavity without distant metastasis. Clinically the patient showed hyperprolactinemia and amenorrhea.

Patterns of pneumatization and septation of the sphenoidal sinus

The sphenoidal bones of 70 adults were removed at post-mortem and were examined for the degree of pneumatization, number of intersphenoidal septa and the relationship of the septa to the lowest portion of the sellar floor. In 85.7%, pneumatization was of the sellar type, in 11.4% of the pre-sellar type and in 2.8% of the conchal type, as defined here. A single septum was present in 61%, two septa in 14%, more than two septa in 12.8% and no septum was present in 11.4%. The insertion of the septum represented the lowest point in the sellar floor in 50% of the bones. In these the septum was located in the center of the sellar floor. Attachment to one or the other side did not correspond to the lowest point of the sellar floor.

Excessive pneumatization of the sphenoid sinus: a case report

A rare case, where excessive pneumatization of the sphenoid sinus resulted in a clinically obvious swelling of the temporal region and proptosis of the globe on the affected side, is reported. The relevant literature is discussed.

Diagnosis and management of the opacified sphenoid sinus

The growing number of surgical procedures at the base of the skull makes a clear understanding of sphenoid disease and its anatomic relationships important for the modern otolaryngologist. We present five cases demonstrating the spectrum of sphenoid sinus disease, its systemic as well as local complications, and its surgical management. Pertinent anatomic and embryologic relations are reviewed and their diagnostic evaluation is discussed. Pitfalls in the diagnosis and management of these diseases are reviewed noting possible complications and significant danger points. The necessity for cooperation among the otolaryngologist, neurosurgeon, and ophthalmologist in the management of these entities is also demonstrated.