Sphenoid sinus mucocele causing third nerve paralysis: CT and MR findings

A 64-year-old woman presented with a 2 week history of ptosis and medial-gaze paralysis of her left eye. Computed tomography scanning of the paranasal sinuses revealed an expansile, homogeneous lesion with no contrast enhancement in the sphenoid sinus. The mass was hyperintense on all MR sequences and there was extension of the mass to the left cavernous sinus and optic canal. Operation revealed a large mucocele. Third nerve palsy disappeared 4 weeks after operation. Because the spread of mucoceles is variable, they may cause different symptoms. Radiological evaluation, especially computed tomography and magnetic resonance imaging, are useful in diagnosis of mucoceles and help to explain the clinical symptoms by showing the spread of the lesion.

[Course and therapy of an invasive aspergilloma of the skull base in a non-immunocompromised patient]

Fulminant-invasive sinus aspergillosis affects immunocompromised patients and is usually lethal because of intracranial complications. Chronic-invasive and non-invasive types occur in non-immunocompromised patients. In these cases, intracranial extension is possible and life-threatening. The effective management of sinus aspergillosis requires early diagnosis by CT and histological classification, surgery, and if necessary, chemotherapy or steroids in case of allergy. Here we report a successfully treated case in a 29-year-old non-immunocompromised patient with chronic-invasive sinus aspergillosis. He presented a recurrent sphenoid sinus aspergillosis with destruction of the clivus and ophthalmoplegia. Diagnostic and therapeutic procedures are described.

[Sphenoid sinus surgery]

Sphenoid sinus surgery due to specific localization is placed in otolaryngologists and neurosurgeons field of interest. Surgery of this area, from one side, causes number of problems, which usually arise due to close neighbourhood of important structures, but on the other, serves as alternative approach, eliminating necessity of extended operations with craniotomies. The article summarizes results of sphenoid sinus surgery at ENT Department, University of Medical Sciences in Poznan between 1990 and 2003, as well as points out characteristic features of the surgery in this specific localization.

[Metastasis from a colonic adenocarcinoma to the sphenoid sinus]

The authors present a very rare disease--metastasis of colon adenocarcinoma to the sphenoid sinus based on their own case. The sphenoid sinus was the first place of metastasis. Symptoms were characteristic of sphenoid sinus lesions. Histological examination of sphenoid sinus tissues revealed primary site of the tumour.

Fungus-like sinusitis

Fungus-like sinusitis is also called eosinophilic mucin rhinosinusitis (EMRS). This terminology is purely descriptive and refers to a rhinosinusitis, whose clinical presentation and imaging are similar to those of a noninvasive fungal sinusitis but in which fungus could not be demonstrated pathologically using the conventional silver staining technique or on culture. The authors report 2 clinical cases and recall the diagnostic criteria for the different forms of fungal sinusitis in immunocompetent patients.

Ocular presentation of sphenoid mucocele

A sphenoid mucocele often presents late due to its deep-seated anatomical site. It has a varied presentation, due to its close relationship to the cavernous sinus and the base of the skull. It can present initially to the ophthalmologist with ocular complaints. In the present paper, the authors present two cases of sphenoid mucocele, one with an isolated third and one with an isolated sixth cranial nerve palsy.

Solitary Langerhans-cell histiocytosis of the clivus and sphenoid sinus with parasellar and petrous extensions: case report and a review of literature

BACKGROUND

In Langerhans-cell histiocytosis, there occurs an uncontrolled clonal proliferation of dendritic cells that have Langerhans cell like characteristics. In this report, a unique case of a solitary, skull base Langerhans-cell histiocytosis (LCH) is described.

CASE DESCRIPTION

A 15-year-old boy presented with raised intracranial pressure, decreased visual acuity, bilateral abducent nerve palsy, and 25% hypoesthesia in all three divisions of the right trigeminal nerve. He had normal strength but with a left-sided upper and lower limb hypertonia and hyper-reflexia and an upgoing plantar reflex. The magnetic resonance (MR) imaging revealed a heterogeneously iso-to hyperintense lesion of the clivus and the sphenoid sinus, extending to the right cavernous sinus to encase the right cavernous internal carotid artery segment, and also involving the right petrous apex and the extradural space in the prepontine region. The lesion was brilliantly enhancing on contrast. An extended frontobasal approach was used to excise the lesion. Following surgery, the residual parasellar and the right petrous apex tumor was treated with a low dose radiation therapy. At follow-up after 1.5 years, there was significant clinical improvement and the computed tomographic scan showed no residual lesion.

CONCLUSION

A review of the literature reveals that this is only the second reported case of a spheno-clival LCH. An additional feature includes extensions into the parasellar as well as the petrous apex regions. Despite the extensive spread, the surgical excision with low dose radiation therapy was successful in providing complete resolution of the tumor.

Primary sphenoid sinus esthesioneuroblastoma

Esthesioneuroblastoma is a rare malignant tumor of undifferentiated neuroectodermal origin. Because these tumors are derived from olfactory epithelium, most cases arise in the superior nasal cavity at the level of the cribriform niche. The development of an esthesioneuroblastoma outside of the region in which olfactory epithelium exists is exceedingly rare. We report a rare case of a primary sphenoid sinus esthesioneuroblastoma and discuss the pathogenesis, clinical presentation, and treatment of this rare entity.

Basilar artery herniation into the sphenoid sinus resulting in pontine and cerebellar infarction: demonstration by three-dimensional time-of-flight MR angiography

We report a unique case of basilar artery herniation into the sphenoid sinus caused by a traumatic skull base fracture, with persistent patency of the basilar artery. Clinical and imaging features, as well as the relevant literature, are described.

[Prolactinoma of the sphenoid sinus. Case report and literature review]

In this case study, we report on a patient complaining of headache who, after CT and MRI, was found to have a neoplasia of the left sphenoid sinus. After a transnasal biopsy and histological examination, a prolactinoma was diagnosed. Based on this case, we discuss important aspects of tumor biology, diagnostic procedures, histology as well as differential diagnosis. Prolactinoma has to be considered as a differential diagnose in all sphenoid sinus neoplasias with close contact to the pituitary gland.

Hypophosphaturic mesenchymal tumor of the ethmoid associated with oncogenic osteomalacia

Oncogenic osteomalacia is an uncommon syndrome characterized by bone pain, proximal muscle weakness, hypophosphatemia, hyperphosphaturia, and a low plasma concentration of 1,25-dihydroxy-vitamin D. The disease affects both sexes at around 40 years of age, although it can sometimes affect children and adolescents. Generally, the syndrome is associated with a tumor, usually benign, of mesenchymal origin and is resolved after removal of the tumor; this syndrome can sometimes be associated with malignant tumors. These tumors seem to be histologically heterogeneous and are generally localized in soft tissues and bone. In this article, a case of oncogenic osteomalacia associated with a hypophosphaturic mesenchymal tumor of the ethmoid is reported in a 24-year-old man. After surgical and radical removal of the tumor, the patient noted a decrease in the clinical symptoms and signs.

Brown tumor of the sphenoid sinus in a patient with secondary hyperparathyroidism: CT and MR imaging findings

We present a case of brown tumor of the sphenoid sinus in a patient with secondary hyperparathyroidism. CT showed an expansile soft-tissue attenuation mass centered in the sphenoid sinus. CT at bone window setting demonstrated expansile, lytic change and remodeling of the surrounding bone. On MR imaging, the lesion showed iso-intensity to gray matter on T1-weighted images and heterogeneous hyperintensity on T2-weighted images, and showed intense enhancement. The extent of the lesion and its relationship to the surrounding structures were best evaluated by CT and MR imaging.

Regression of a sphenochoanal polyp in a child

OBJECTIVES

To present an unusual case of a sphenochoanal polyp that regressed and review the etiology of such polyps in comparison to the commoner antrochoanal polyp.

STUDY DESIGN

Case study.

METHODS

One was incidentally discovered in a girl aged 3 years, 8 months at postnasal mirror examination after adenotonsillectomy.

RESULTS

Computed tomography scans 1 month later confirmed the polyp, but three months later, MRI scans only revealed sphenoid sinus opacification. Sphenoidotomy revealed normal sinuses implying inflammation had resolved.

CONCLUSION

This patient is believed to be the youngest reported to have sphenochoanal polyp, and the only one where the polyp had completely regressed. This regression suggests that sphenochoanal polyps may be more common than is thought but are mostly asymptomatic.

Recurrence rates after endoscopic sinus surgery for massive sinus polyposis

BACKGROUND AND OBJECTIVES

Most studies on outcome after endoscopic sinus surgery (ESS) include patients with varying degrees of disease severity. Recurrence rates cited by those studies may not apply to the subset of patients with severe polyposis. Our aim is to provide reference information for recurrence rates and need for revision surgery in patients with severe disease.

STUDY DESIGN, PATIENTS, AND METHODS

Review of patients with severe polyposis with a minimum Lund-McKay score of 16 and with a Kennedy computed tomography stage 3 or 4. Data collection included demographics, presence of asthma or documented allergy, history of previous surgery, extent of surgery, preoperative and postoperative management, recurrence rates, revision surgery rates, and follow-up.

RESULTS

One hundred and eighteen records were reviewed. Fifty-nine (50%) patients had asthma, and 93 (79%) had documented allergy. All patients required extensive bilateral nasal polypectomy, complete anterior and posterior ethmoidectomy, and maxillary sinusotomy. One hundred (85%) also had frontal or sphenoid sinusotomy. Follow-up ranged from 12 to 168 (median 40) months. Seventy-one (60%) developed recurrent polyposis. Fifty-five (47%) were advised to undergo revision surgery, and 32 (27%) underwent surgery. History of previous sinus surgery or asthma predicted higher recurrence (P <.005, P <.001) and revision surgery rates (P =.02, P <.001). History of allergy also predicted recurrence and need for revision (P <.001, P <.001).

CONCLUSIONS

Recurrence rates after ESS for severe polyposis are significant. In our study, patients with asthma are at higher risk of recurrence.

Fibrous dysplasia of the sphenoid sinus and skull base presents in an adult with localized temporal headache

Fibrous dysplasia (FD) of the sphenoidal sinus is a rare disease, especially during adulthood. We report a case of FD of the right sphenoidal sinus in an adult male patient who presented with nonspecific symptoms limited to headache localized to the right temporal area and to the inferior orbital rim of both sides. Magnetic resonance imaging revealed a dense mass that occupied the entire right sphenoidal sinus and skull base with typical ground-glass opacification and bony sclerosis of the whole sphenoidal wall. The diagnosis of FD was confirmed on pathological examination of a biopsy taken through sphenotomy. The patient underwent a subcranial craniotomy for tumor resection. After more than 4 years of follow-up, the patient was disease-free. On the basis of these clinical features, it is important to consider sphenoidal FD in both young and adult patients complaining of an unexplained headache, because it may present unusually with headache localized to the temporal region or the inferior orbital rim.

[Melanoma of sphenoid sinus. Case presentation and review of literature]

The primary malignant melanomas of sphenoidal sinus are very uncommon tumours. We are reporting a clinical case of a 56 years-old male who was sent from the Neurology Department with ocular pain and headache of several months evolution and without personal history. Exploration revealed a VIth palsy, diplopia and ptosis. The complementary imaging tests (CT and MR) showed and expansive tumour of the sphenoidal sinus involving the right cavenous sinus. A F.E.S.S. with biopsy was performed to confirm the diagnosis. Our patient was treated by Radiotherapy and after a 4 year follow-up period he is still alive. We have carried to a bibliographic review of this pathology whose differential diagnosis must be done with epidermoid carcinomas, adenocarcinomas and lymphomas on that location.

Sphenoid sinus brown tumor, a mass lesion of occipital bone and hypercalcemia: an unusual presentation of primary hyperparathyroidism

Brown tumor is a focal lesion of the bone caused by primary or, less commonly, secondary or tertiary hyperparathyroidism (HPT). While the mandible is the most frequently involved bone in the head and neck region, atypical involvement of the cranium in the area of the sphenoid sinus is exceedingly rare. In the literature, a unique case of brown tumor of the sphenoid sinus was reported in a patient with primary HPT. We present a case of sphenoid sinus and occipital bone brown tumor associated with primary HPT. A 47-yr-old woman presented a 2-yr history of headaches, dizziness, diffuse body and articular pain, fatigue, and a 6-month history of intermittent nausea and vomiting, polydipsia, and polyuria. Magnetic resonance imaging (MRI) demonstrated an expansive mass lesion in the sphenoid sinus with erosion of the sellar floor and medial wall of the right orbit, and expansion in the medulla of bone. Examination of biopsy specimens obtained from sphenoid sinus mass confirmed the diagnosis of brown tumor. The biochemical laboratory studies showed elevation of parathyroid hormone and confirmed the diagnosis of primary HPT. Excision of a parathyroid adenoma affected the metabolic status into normalizing. At the follow-up of 12 months postoperatively, the size of sphenoid sinus brown tumor decreased and the mass of occipital bone disappeared. In conclusion, this is a first report of primary HPT masquerading as a destructive fibrous sphenoid sinus brown tumor associated with a mass lesion of occipital bone and hypercalcemia in the literature.

Cerebral infarct and meningitis secondary to Lemierre's syndrome

The case is reported of a young man with Fusobacterium necrophorum septicemia who developed cavernous sinus thrombosis, meningitis, carotid artery stenosis and stroke. This article presents the only reported case of arterial stroke in Lemierre's syndrome. Clinical presentation, diagnostic difficulty and treatment are discussed.

[Ptosis and ophthalmoplegia as predominant signs of multiple myeloma]

HISTORY AND ADMISSION FINDINGS

A 59-year-old woman was diagnosed as having solitary bone plasmacytoma of the sternum which was resected. Five month later she presented with a pathological fracture of the clavicle. On examination she had a ptosis and an ophthalmoplegia.

INVESTIGATIONS

A mass in the clivus extending into the left sphenoid sinus as well as multiple osteolytic lesions in the skull were shown by cranial MRI. Skeletal survey showed multiple osteolytic lesions. Laboratory test did not show any specific abnormalities.

DIAGNOSIS, TREATMENT AND COURSE

The biopsy taken from the mass at the sphenoid sinus demonstrated plasmacytoma. The diagnosis of multiple myeloma was based on the histological evidence of plasmacytoma and the occurrence of multiple lytic bone lesions although no infiltration of bone marrow and none of the specific laboratory findings were present. The patient underwent local radiotherapy with 30 Gy followed by systemic chemotherapy. The symptoms regressed completely under this therapy.

CONCLUSION

Various cranial nerve syndromes such as the superior orbital fissure syndrome are most often caused by tumors at the skull base. Knowledge of the histological entity is essential for the correct diagnosis and the appropriate therapy because rare tumors like multiple myeloma may also cause such syndromes.

Incidental magnetic resonance image sinus abnormalities in asymptomatic Australian children

Plain X-rays, computed tomography (CT) and magnetic resonance imaging (MRI) scans performed for non-ENT reasons often reveal incidental sinus mucosal changes. These changes need to be correlated clinically before diagnosing rhinosinusitis. This study examined the prevalence of such changes in MRI scans in children up to age 16. Scans were scored using an adapted Lund-Mackay classification and were positive when one or more sinuses showed abnormalities. Randomly selected scans in the retrospective arm revealed a prevalence of 20 of 62 (32.3 per cent). In the prospective arm 45 of 60 children were defined as truly asymptomatic, of which 14 scans (31 per cent) were positive. Other studies in adults and children using CT and MRI report a prevalence range of roughly 30 to 45 per cent. This variability may be attributed to differences of study design, definitions of population age, definitions of asymptomatic and definition of abnormal sinus. Other plausible factors to explain regional differences are climate and frequency of upper respiratory tract infections.

[Rare case of congenital transsphenoidal meningoencephalocele causing respiratory problems]

INTRODUCTION

Congenital meningoencephalocele is a rare and severe malformation.

AIMS

The authors describe the case of congenital, basal transsphenoidal meningoencephalocele associated with other neurological malformations, which projected between the margins of palatoschisis producing respiratory problems at neonatal age.

METHOD

Presented with detailed photo-documentation.

RESULTS

Cranial meningoencephalocele reconstruction with an approach of bifrontal craniotomy was performed. The base of skull was closed multilaminarly with auto-graft gained from parietal bone and Lyodura. The closure of nasopharyngeal sac was performed in second sitting. Postoperatively the progression of hydrocephalus was so extensive, that implantation of ventriculo-peritoneal shunt was unavoidable. Later on closure of tracheotomy performed for continued air passage support was done. The authors report the course of disease and the surgeries performed.

CONCLUSIONS

Auto-graft from skull bone for closure of large basal-cranial defect proved to be ideal. Prognosis depends on other malformations. Successful treatment needs co-operation of different specialties.

An aberrant ACTH-producing ectopic pituitary adenoma in the sphenoid sinus

A 32-year-old woman with an ectopic adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma (EAPA) is presented. She had rapidly gained weight and suffered recurrent facial acne for a few years but lacked the typical Cushingoid features. Endocrine examinations revealed that her plasma ACTH was markedly high (196 to 280 pg/ml) without showing normal circadian rhythm and failed to respond to corticotropin-releasing hormone stimulation. Her cortisol levels ranged from 22 to 30 microg/dl throughout observation but low doses (1 and 2 mg) of dexamethasone failed to suppress either ACTH or cortisol level. Magnetic resonance imaging study revealed a 3-cm mass occupying the sphenoidal sinus with partial enhancement by gadolinium, which was separated from the normal pituitary in the sella region. The tumor resected by transsphenoidal surgery was histologically diagnosed as an ACTH-producing pituitary adenoma. After surgery her weight gain and acne remitted in accordance with decreases in plasma ACTH. Analysis of patient plasma by gel filtration method revealed the existence of big ACTH molecules eluted with a peak of authentic 1-39 ACTH, suggesting that this biologically less-active ACTH might be the reason why overt features of Cushing's syndrome failed to develop in this case. Although EAPA is clinically rare in parasellar disorders, the presence of ectopic pituitary adenoma should be considered in such cases showing ACTH hypersecretion without typical Cushingoid features.

A rare expression of neural crest disorders: an intrasphenoidal development of the anterior pituitary gland

Congenital abnormalities of the pituitary gland are rare and may be associated with midline cranial, orbital, and facial anomalies and with hormonal insufficiency. Here we report a case of asymptomatic, abnormal migration of the adenohypophysis. The normally developed adenohypophysis was located in the sphenoid bone and developed on the intersphenoidal septum, extending from the superior pharyngeal wall to the floor of the sella turcica (craniopharyngeal canal). The abnormal migration of the pituitary gland was isolated without hormonal deficit, brain, or facial developmental anomalies.

Chordomas of the skull base: manifestations and management

PURPOSE OF REVIEW

Chordomas are rare congenital tumors of the midline skull base. They are slow-growing and usually cause symptoms only when they compress a cranial nerve.

RECENT FINDINGS

The MRI will show the lesion with irregular uptake of gadolinium. The only way to define the diagnosis is with tissue, and there are two primary pathologic forms of the disease. Resection approaches vary with extent of disease, surgeon preference, and critical structures involved.

SUMMARY

There is building evidence that proton beam therapy improves survival and duration of a disease-free state.

[Sphenochoanal polyp: report of two cases]

OBJECTIVE

Report of 2 cases of sphenochoanal polyp.

MATERIAL AND METHOD

We present two cases of sphenochoanal polyp aged of 22 and 53. They were operated by endonasal endoscopic approach. They are still free of symptoms and no recurrence are observed after 13 and 56 months of follow-up.

CONCLUSION

The clinical, radiological and pathological features of the sphenochoanal polyp are reviewed. Different etiopathogenic hypothesis are discussed and particular the gastroesophageal reflux. The treatment is surgical.

[The giant osteoma of the ethmoid labyrinth in the patient cured in 1991 year]

A 52-year-old female patient is described who was aperated upon for a giant osteoma involving the right side ethmoid labyrinth bulging into the orbit shifting the eyeball, passing into right of the frontal and sphenoidal sinuses. We obtained complete cure and good cosmetic result.

Psammomatoid ossifying fibroma

Psammomatoid ossifying fibroma (POF) represents a unique subtype of fibro-osseous lesions. We describe a case of POF involving the orbit and the sinonasal tract, in a 13-year-old white female. Diagnosis depends on the histological, radiological and clinical features. Complete excision by endoscopic nasal surgery was the treatment of choice. Five years later the patient was free from symptoms and tumour recurrence. Differential diagnoses are discussed.

Intrasphenoidal transsellar encephalocele repaired by endoscopic approach

Spontaneous sphenoidal encephaloceles are rare entities. In the case of intrasphenoidal encephaloceles, most defects are temporosphenoidal and occur in the lateral wall of the sphenoidal sinus. There have been to our knowledge only 7 reports of medial, transsellar encephaloceles in the literature. We report a case of intrasphenoidal transsellar encephalocele that was successfully managed through an endoscopic approach with complementary lumboperitoneal shunting. This disorder presents a challenge in surgical management because of the involvement of opticochiasmatic structures, the hypothalamopituitary axis, and the delicate vasculature of the circle of Willis in and around the encephalocele, besides proximity to the cavernous sinus. Rhinologists should be aware of these malformations, since the optic nerve or chiasma may be totally exposed in the sphenoidal sinus in the course of this disease. This case illustrates the need for magnetic resonance imaging in case of sphenoidal abnormalities, as well as the possibility of endonasal repair without a transcranial approach for large intrasphenoidal encephaloceles.

MRI cisternography with gadolinium-containing contrast medium: its role, advantages and limitations in the investigation of rhinorrhoea

Our purpose was to evaluate the utility of intrathecal gadopentetate dimeglumine -enhanced magnetic resonance cisternography (GdMRC). We injected 0.5 ml contrast medium into the subarachnoid space via lumbar puncture in 20 patients with suspected cerebrospinal fluid (CSF) rhinorrhoea. MRC showed CSF leakage in 14 patients with rhinorrhoea at the time of the examination, into the ethmoid air cells in nine, the sphenoid sinus in three and the frontal sinus in two cases. In 12 of these the site leakage was confirmed during surgical repair of the fistula. No leakage was observed in four patients with intermittent rhinorrhoea, not present at the time of the examination. GdMRC showed leakage in two patients with negative CT cisternography. GdMRC may prove better than CT cisternography, especially with slow CSF flow. We also showed low-dose GdMRC to be a feasible and relative safe way of confirming the presence of and localising active CSF leaks prior to surgical repair.

[Malignant transformation of a tubular adenoma in the paranasal sinuses?]

BACKGROUND

Whereas a tubular adenoma is a unique finding within the paranasal sinuses, intestinal adenocarcinomas are especially in patients with long-term exposure to wood dust, common tumours in this location.

CASE

In a 65 year old joiner endonasal sinus surgery performed to treat suspected chronic pansinusitis brought up by chance the histological finding of a tubular adenoma. As the patient at first refused surgical revision, but magnetic resonance imaging during follow-up revealed evidence for a space occupying lesion affecting the ethmoid and sphenoid sinuses revision surgery took place one year later. Histopathological evaluation now found a papillary adenocarcinoma. Clinical follow-up and magnetic resonance imaging one year after second surgery found no evidence for tumour recurrence.

CONCLUSIONS

Progression of a tubular adenoma to an adenocarcinoma like in the adenoma-carcinoma model well known for colorectal carcinomas has so far not been observed within the paranasal sinuses. But, an adenocarcinoma already present at the time of first surgery can not be ruled out completely in the presented case as histopathological evaluation may have failed to detect an adenocarcinoma in the available specimens after first surgery. Either malignant transformation of a tubular adenoma had occurred or proof of an adenocarcinoma has failed with misdiagnosis of a tubular adenoma. A tubular adenoma as well as an adenocarcinoma require complete resection and careful clinical and radiological follow-up to avoid adenocarcinoma development from a tubular adenoma or to detect an adenocarcinoma by histological evaluation of the whole specimen.

Imaging features of sellar cysticercosis

Cases of sellar involvement of neurocysticercosis (NCC) are rare. Little is known about the mechanisms by which the parasite can compromise the pituitary gland. Although NCC damages sellar structures with direct compression by large cysts, extension through the basal cisterns and third ventricle with focal arachnoiditis can result as an inflammatory response. Evaluation for hypophyseal lesions in patients with NCC may allow for the diagnosis of unexplained loss of visual acuity and hormonal disturbances.

Shunt migration into the sphenoid sinus: case report

OBJECTIVE AND IMPORTANCE

Shunt catheter migration is a potential complication of cerebrospinal fluid shunting procedures. We report an unusual case of proximal shunt migration into the sphenoid sinus. To our knowledge, there have been no previous reports of shunt migration through the bony structures of the cranial base.

CLINICAL PRESENTATION

A 41-year-old man who had had a cyst-to-peritoneum shunt placed 21 years earlier for a temporal lobe arachnoid cyst presented with cerebrospinal fluid rhinorrhea. Neuroradiological imaging revealed migration of the shunt catheter through the medial wall of the middle temporal fossa into the sphenoid sinus.

INTERVENTION

The patient underwent shunt removal and repair of the dural defect. Intraoperatively, the proximal catheter tip was found in the sphenoid sinus with dural and bony erosion. The patient made an uneventful recovery.

CONCLUSION

We present a unique long-term complication associated with intracranial shunt catheters. We hypothesize that excessive proximal catheter length and chronic cerebrospinal fluid pulsations contributed to migration of the catheter into the sphenoid sinus.

Lymphangioma of the sphenoid sinus

Lymphangiomas are rare benign lymphatic tumours found predominantly in the head and neck region. A case of a cavernous lymphangioma isolated to the sphenoid sinus is described. The authors emphasize the extreme rarity of the isolated sphenoid lymphangioma, as to their knowledge this is the first report in the English literature.

Intrasphenoidal encephalocele associated with cerebrospinal fluid fistula and subdural hematomas: technical case report

OBJECTIVE AND IMPORTANCE

Intrasphenoidal encephalocele is a rare clinical entity that is often complicated by rhinorrhea, recurrent meningitis, and headache, but in no case has the association of rhinorrhea with subdural hematomas been described. A surgical procedure to stop persistent cerebrospinal fluid leakage is reported.

CLINICAL PRESENTATION

A 59-year-old man sought care for intractable rhinoliquorrhea of 6 months' duration. Cranial computed tomographic and magnetic resonance imaging scans revealed a basal posterior frontal bony defect and an evocative image suggesting intrasphenoidal encephalocele.

INTERVENTION

A transnasal transsphenoidal surgical procedure was performed; the encephalocele was removed, and the sphenoid sinus was filled with an inflatable pouch made of synthetic dura mater containing abdominal fat. Postoperative reduction of the rhinoliquorrhea, but not its total disappearance, was observed. Total disappearance was achieved only after endonasal, transmucosal inflation of the pouch with human fibrin glue. One of the subdural hematomas disappeared spontaneously, and the other was treated by a surgical procedure.

CONCLUSION

The possible role of the presented technique in the treatment of cerebrospinal fluid leakage is discussed.

[Expression of members of the cadherin-/catenin-protein family in juvenile angiofibromas]

BACKGROUND

Angiofibromas are benign, but locally aggressive tumors occurring nearly exclusively in adolescent males. Pathogenesis of this fibrovascular neoplasm is still unknown. Detection of beta-catenin gene mutations and immunohistochemical localization of beta-catenin only in the nuclei of stromal cells has been proposed as evidence for the stromal cells to be the neoplastic cells in angiofibromas (Abraham et al., 2001).

METHODS

Paraffin embedded tissue of 13 angiofibromas was analysed immunohistochemically for expression of E-cadherin, N-cadherin, alpha-catenin, beta-catenin and gamma-catenin.

RESULTS

In all angiofibromas stromal cells showed in their cytoplasm and their nuclei strong immunoreaction for beta-catenin. In 10 out of 13 angiofibromas strong immunoreaction was also observed in endothelial cells covering the irregular lined vascular spaces. While gamma-catenin was detected in 7 out of 13 angiofibromas in the stromal cells and endothelial cells, N-cadherin was found only in the stromal cells in 8 out of 13 angiofibromas. No significant immunoreaction in angiofibromas was seen for E-cadherin and alpha-catenin.

CONCLUSIONS

Proof of strong beta-catenin-expression in stromal cells and endothelial cells stress possible importance of the APC/beta-catenin-pathway in angiofibromas, but gives no certain evidence for the assumption that stromal cells may be the neoplastic cells. As beta-catenin can increase sensitivity of the androgen receptor, it may be assumed that the increased beta-catenin-expression in angiofibromas is involved in the typical growth stimulus of this tumor in adolescent males.

Inverted papilloma of the sphenoid sinus

Inverted nasosinusal papilloma is a benign tumor accounting for less than 4% of all nasal masses. The lesion originates in the mucosa lining the nasal cavities, the locations in decreasing order of frequency being the lateral wall of the nasal fossa, ethmoid sinus, and maxillary sinus; the sphenoid sinus is only rarely affected. Despite its benign histology, the tumor shows aggressive behavior and can be associated to carcinomas. Surgery is therefore indicated in such cases.

Juxtaposition of an ectopic corticotroph adenoma of the sphenoid sinus with orthotopic intrasellar corticotroph hyperplasia in a patient with Cushing disease. Case report

Ectopic pituitary adenomas (EPAs) are rare and their association with orthotopic corticotroph hyperplasia has not been published. The case of a 30-year-old woman with clinical and biochemical evidence of Cushing disease (CD) is reported. A magnetic resonance image obtained preoperatively revealed asymmetrical inhomogeneity of the pituitary gland, which was suggestive of localized adenoma. It also showed what was thought to be a small sphenoid polyp. Postoperatively the latter lesion was found to be an ectopic corticotroph adenoma. The pituitary gland, which was free from any tumor, exhibited diffuse unilateral corticotroph hyperplasia. Clinical, radiological, laboratory, and histopathological findings are presented. A review of the literature and a discussion of possible causes of this unique association between the ectopic corticotroph adenoma and the pituitary hyperplasia are provided.

Malignant giant cell tumor of the sphenoid

Malignant giant cell tumors (MGCTs) of the sphenoid sinus are extremely rare neoplasms. They are challenging to diagnose and difficult to treat because of their skull base location. To the best of our knowledge, we report the first case of a primary MGCT of the sphenoid arising in a patient with Paget's disease. A 77-year-old man presented with epistaxis and a history of Paget's disease. There was normal cranial nerve function although radiographic images disclosed a large mass centered in the sphenoid sinus and extending into the ethmoid and maxillary sinuses. Excisional biopsy revealed a MGCT composed of a cellular stroma with increased mitotic activity and necrosis with giant cells present throughout. Additional therapy was declined and the patient died with disease 7 months later. Because of their rarity, no treatment guidelines exist for the management of MGCTs of the sphenoid. We discuss both the diagnostic and therapeutic considerations based on a review of the pertinent literature.

Tension pneumocyst after transsphenoidal surgery for Rathke's cleft cyst: case report

OBJECTIVE AND IMPORTANCE

Tension pneumocephalus is a rare but well-described complication of transsphenoidal surgery. It is usually associated with postoperative cerebrospinal fluid fistulae causing lower intracranial pressure, with air located in the subdural, subarachnoid, or intraventricular space. We report a case of suprasellar tension pneumocyst that caused visual deterioration to develop after an operation for a Rathke's cleft cyst. Only one similar case has been reported previously.

CLINICAL PRESENTATION

A 54-year-old woman with a cystic sellar-suprasellar mass compressing the chiasm was operated on via a standard transsphenoidal approach. The intraoperative diagnosis was Rathke's cleft cyst, and the floor of sella was left open to avoid recurrence. The sphenoid sinus was filled with a fat graft, and the rostrum of the sphenoid was reconstructed with a bone fragment. The patient's postoperative course was uneventful, and her vision improved. Ten days after discharge, the patient was readmitted to the emergency service with headache and visual impairment. Emergent computed tomography confirmed a suprasellar tension pneumocyst.

INTERVENTION

The patient underwent immediate reoperation via an endonasal endoscopic approach. After the trapped air was evacuated, the sella was closed with fascia lata and muscle using fibrin glue. The patient's vision improved postoperatively.

CONCLUSION

Suprasellar tension pneumocyst is an extremely rare complication of transsphenoidal surgery. To avoid this complication, the sellar floor should be repaired in a watertight fashion, and patients should be instructed to avoid blowing the nose, sneezing, straining, and coughing postoperatively.

The extradural subtemporal keyhole approach to the sphenocavernous region: anatomic considerations

Fourteen cadaver specimens (28 sides) and twelve dry human skulls (24 sides) were used to study the anatomic relationships between bony, neurovascular and foraminal landmarks in the floor of the middle fossa in preparation for performing the extradural subtemporal keyhole approach to the sphenocavernous region. The interforaminal distance was largest between the foramina rotundum (FR) and ovale (FO) and was smallest between the FO and foramen spinosum (FS). The largest angle between exit foramen was the FR to FO. The greater superficial petrosal nerve (GSPN) was always found to overlie and run parallel to the petrous internal carotid artery, however, its location over the artery and its separation from it by bone was variable. With a subtemporal "keyhole" placed above the posterior zygomatic root (PZR), a 0 degrees endoscope allowed easy visualization of the middle meningeal artery (MMA) and the mandibular nerve (V 3 ) however, a 30 degrees endoscope was more useful for visualizing the maxillary nerve (V 2 ) and the ophthalmic nerve (V 2 ). With a sphenoidotomy performed between V 1 and V 2, the 30 degrees endoscope was found to be the most useful for visualizing the carotid siphon and the contralateral wall of the sphenoid sinus, while the 70 degrees endoscope was the most useful for visualizing of the floor of the sella and the walls of the sphenoid sinus. Two venous concerns with respect to performing endoscopic approaches to the region were identified: a fibrous layer overlies a heavy venous plexus that encircles the petrous carotid artery, and the foramen Vesalius, which transmits a large emissary vein draining the cavernous sinus, was identified medial to the FO in 30 % of our dissected sides.

Image-guided transsphenoidal surgery for pituitary lesions using Mehrkoordinaten Manipulator (MKM) navigation system

Twenty-five patients with pituitary lesions were operated on by image-guided transsphenoidal surgery (TSS) using the Mehrkoordinaten Manipulator (MKM) navigation system. The cases included 21 cases of pituitary adenomas, 2 cases of craniopharyngioma and 2 cases of Rathke's cleft cyst. All operations were performed through the sublabial approach under an operative microscope. In some cases, an endoscope was used for the observation of the residual tumor and surrounding structures. The tumors and surrounding important structures such as the internal carotid arteries, the basilar artery, and the optic nerves were precisely localized, and mechanical error was less than 2 mm in almost all cases. In 3 early cases of pituitary adenoma, the patient's head was moved slightly during the insertion of the nasal speculum; in these cases, the resulting error was more than 2 mm. In evaluating the procedures, we determined that the most useful benefit of the MKM system compared with other systems is that the navigation information is not only displayed on the monitor, but also presented in the operative field under the microscope. Therefore, the surgeon can obtain the navigation information without removing his eyes from the operative field under the microscope. The most important drawback to the system is its bulky size.

Fungal granuloma of the sphenoid sinus and clivus in a patient presenting with cranial nerve III paresis: case report rand review of the literature

OBJECTIVE AND IMPORTANCE

Isolated fungal granulomas originating within the sphenoid sinus are extremely rare in immunocompetent patients. In their symptoms and morphological appearance, these lesions may be mistaken for pituitary tumors. We report such a case and review the literature.

CLINICAL PRESENTATION

A 74-year-old man presented with a 3-week history of Cranial Nerve III paresis. The patient had a long-term history of snuff abuse. Computed tomography demonstrated a space-occupying lesion of the sellar and sphenoid sinus region with displacement of the cavernous sinus.

INTERVENTION

The lesion was operated on via a transnasal-transsphenoidal approach. After the sphenoid sinus was opened, mucus extruded spontaneously, and a brownish, crumbly mass was found and removed. The lesion had completely eroded the sella and clivus. Histological analysis revealed numerous Aspergillus hyphae. Postoperatively, the IIIrd cranial nerve paresis resolved completely within a few days. No systemic fungal infection was found in extensive serological studies. There was no evidence of immunosuppression.

CONCLUSION

Fungal granuloma must be included in the differential diagnosis of lesions in the sellar region, even in nonimmunosuppressed patients. Early diagnosis and transsphenoidal extirpation is crucial with this potentially life-threatening disease.

Cementifying fibroma in the ethmoidal sinus extending to the anterior cranial base in an 11-year-old girl: a case report

A case of an 11-year-old female with cementifying fibroma in the ethmoidal sinus extending to the anterior cranial base was presented. She complained of slowly progressive nasal obstruction and anosmia. Magnetic resonance imaging (MRI) revealed a tumor in both ethmoidal and sphenoidal sinuses and nasal cavity. Although a tumor reduction surgery was attempted through a transnasal approach, tumor size increased gradually and right exophthalmos subsequently appeared. The pathological diagnosis was cementifying fibroma of the nose. Total tumor removal was consequently accomplished through the intracranial anterior transbasal approach. The surgical approach should be selected according to the site and expansion of the lesion in individual patients.

[Sinus cavernous syndrome caused by isolated aspergillosis of the sphenoid sinus]

Isolated aspergillosis of the sphenoid sinus is a rare condition that is frequently diagnosed at a late stage because of its nonspecific and varying symptomatology. We report the case of a 75-year-old diabetic woman with a long history of retroorbital pain before she developed a subacute cavernous sinus syndrome. Neuroimaging including CT scan and MRI suggested a malignant tumor involving the sphenoid sinus but the diagnosis of aspergillosis was made intraoperatively and by histopathological examination. Soon after surgical drainage of the sphenoid sinus and systemic anti-fungal drug therapy, both retroorbital pain and cavernous sinus syndrome had completely resolved. This case emphasizes the fact that invasive isolated sphenoid sinus aspergillosis must be considered in the list of lesions causing sinus cavernous syndrome.