Isolated Sphenoiditis

Rhinosinusitis is an inflammation of the nose and paranasal sinuses marked by nasal blockage or nasal discharge, sometimes associated with facial pain or a loss of smell. Nasal polyps, mucopurulent secretions, or mucosal blockage of the meatus are all possible endoscopic findings. A computed tomography scan can also reveal mucosal abnormalities within the sinuses. Clinical signs of chronic rhinosinusitis remain for at least 12 weeks without disappearing completely. Because there is no precise definition for chronic sphenoid rhinosinusitis, we describe it as a spectral range of infective or inflammatory disorders that occur only in the sphenoid sinus, on one or both sides, and last for more than 12 weeks. Bacterial rhinosinusitis, fungal rhinosinusitis, and mucocele are all possibilities. The isolated sphenoid lesion is a rare disorder that is becoming more common.

Vague and general symptoms such as headaches, face pain, and heaviness may be experienced by patients. Symptoms of the nose are sometimes nonexistent. Inflammatory diseases are the most prevalent of solitary sphenoid disorders, with a prevalence of over 50 percent. They are now more commonly detected as a result of greater detection of the disease by primary care physicians and improved access to diagnostic techniques including endoscopy and imaging techniques such as computed tomography (CT) and magnetic resonance (MRI) imaging. The probability of persistent neuro-ophthalmological consequences is reduced by earlier detection, proper radiological examination, and timely therapy. 

What is an Isolated Sphenoiditis?

Sphenoid sinusitis is characterized by an acute inflammatory process of the sphenoid sinuses, either one or both (the two large holes present directly behind the nose and located between the eyes).

Isolated sphenoid sinusitis is a term used to describe a disease that affects only the sphenoid sinuses. In many situations, however, the inflammatory process can spread across the sinuses, affecting several structures such as the ethmoid air pockets or the maxillary sinuses.

Isolated sphenoid sinusitis is a rare ailment that affects only around 3 percent of all sinus problems.

Sphenoid sinusitis, if goes untreated, can lead to serious problems such as neurologic signs, brain abscess, and meningitis.

When the inflammation of the affected region lasts more than 12 weeks, it is diagnosed as chronic sphenoid sinusitis.

Sphenoid Sinus Anatomy

After birth, the sphenoid sinus forms. Pneumatization begins at the age of five and is finished between the ages of eight and eleven. Sphenoiditis was diagnosed and reported in the youngest known patient at the age of ten. In the top of the nasal cavity, the sphenoid sinus is located. The optic tract, dura mater, pituitary gland, and cavernous venous sinus, which contain the external carotid arteries and the third, fourth, fifth, and sixth cranial nerves, attach to the walls of this sinus. Due to their near closeness to the sinus cavity, infection of the cavity can easily migrate to these structures, causing significant consequences.

Isolated Sphenoiditis Causes

Bacterial Infection

In isolated inflammatory sphenoid lesions, the bacterial infection is the most frequent pathogenesis. The majority of existing studies don't specify whether their patients have an acute or chronic infection. Because the most frequent sphenoiditis presenting symptom of headache is vague and may not be easily recognized, determining the exact length of the presenting symptom might be challenging. Children with bacterial infection, on the other hand, may appear to be in less serious condition than those with acute infection. The symptoms, as well as the clinical and endoscopic evidence, can be difficult to identify from fungal infection or mucocele. Computed tomography could be the key to a definitive diagnosis. Mucosal thickness, variations in the air-fluid level, and partial or total opacification may be seen on computed tomography in bacterial sphenoiditis. Antibiotics for cultured organisms are advised once a diagnosis has been made. The most often cultured organism has been identified as Staphylococci. Streptococcus pneumonia, aerobic bacilli (Pseudomonas aeruginosa, Klebsiella pneumonia, Hemophilus influenza, Escherichia coli), and anaerobes have also been identified.

Surgery is required when the medical failure occurs after 5-8 weeks of complete pharmacological therapy with culture-based antibacterial, intranasal steroids, and spray decongestants. However, in cases presenting with cranial nerve consequences, surgical intervention may be required sooner since timely drainage of the sphenoid sinus can prevent long-term consequences. Pus discharge packed in the sinus canal, mucosal thickness, and polyps are all possible intraoperative indications of chronic bacterial sphenoiditis.

Fungal Infection

Invasive and noninvasive fungal sinus infections are two types of fungal sphenoid sinusitis. The detection of fungal invasion in sinus tissue from a histological examination distinguishes invasive fungal infection from noninvasive infection. There are at least five subgroups of fungal infections, but only three of them can be identified as a cause of isolated sphenoiditis: invasive fungal infection, allergic fungal sinus infection, and aspergilloma (fungal ball). Each subgroup has a different therapeutic strategy and outcome.

Sphenoid Sinus Aspergilloma

Aspergilloma, also known as fungal ball, is a form of fungal rhinosinusitis that is not invasive. It's diagnosed when the sinus cavity is filled with a thick aggregation of hyphae and gritty or clay-like debris, and histology demonstrates a chronic inflammatory mucosal reaction without eosinophils dominance, granulomatous reaction, and indications of tissue or vascular invasion. Although the fungal ball of the sphenoid sinus has been described in the literature as an uncommon occurrence, it is now more routinely detected, with an incidence of 11–21 percent in more recent case studies. The second-most-commonly-affected sinus by a fungus ball is the sphenoid sinus.  Children usually have a healthy immune system status. Girls are more affected than boys.

Endoscopic tests of the nose should be undertaken; however, the evaluations may not provide any clues to the diagnosis, as Lee et al. observed negative findings in all patients in their studies. A computed tomography (CT) is a helpful technique for sphenoid sinus fungal ball diagnosis. Due to densely interwoven hyphae, a fungal ball looks hyperattenuating in non-contrast computed tomography. The sinus irritated mucosal membrane, on the other hand, is hypoattenuating. Metallic calcifications in the intra-sinus have been documented in 50 percent of cases. The sinus bony wall may be sclerotic and thicker, or it may be enlarged and weakened with pressure necrosis-induced erosion. In 63 percent of fungal ball episodes, bone erosion has been recorded, however, it is not an indication of invasive fungal infections. On magnetic resonance scans, the fungal ball appears hypointense. On T2-weighted MRI, calcifications also cause signal holes. Aspergilloma does not respond to medical therapy.

Surgical intervention is almost always necessary. Fungal concernment with purulent secretions may be discovered intraoperatively. The sphenoid sinus mucosa should be of a healthy hue. The histopathological examination should be performed on the sinus mucosa. Invasive fungal infection is indicated by tissue or vascular invasion.

Sphenoid Sinus Mucocele

Mucoceles are mucus-filled enclosed lesions that are bordered by epithelium. They are expanding and locally damaging, capable of resorbing bone and causing erosion of the sinus bony sidewalls. Mucocele of the sphenoid sinus is extremely prevalent. It accounts for up to 20 percent of all paranasal sinus mucoceles. The pathogenesis of this lesion is uncertain; however, it is thought to be produced by sinus ostial obstruction, cystic enlargement of glandular tissues, or cystic formation from embryonic epithelial remnants. There has also been speculation about radioactive contamination in the head and neck area. Asymptomatic sphenoid sinus mucocele is possible. It is frequently identified by chance during a head and neck CT or MRI.   When the mucocele around the sphenoid sinus pushes or displaces surrounding tissues, patients with sphenoid sinus mucocele may have symptoms. Clinical signs may resemble those of a tumor. As a result, vision loss in sphenoid sinus mucocele is more frequent than in other inflammatory sphenoid conditions. To detect and characterize the exact borders of the mucocele, CT imaging is essential.

Isolated Sphenoiditis Symptoms

Patients with isolated sphenoiditis can have a variety of symptoms and findings. The most prevalent symptom is headache, which occurs in more than 80 percent of patients. Patients may experience headaches on and off for years. The ache is described as mild or sharp. It can disrupt sleep and is not always alleviated by medications. The retro-orbital or forehead is the most common location for a headache. There have also been reports of frontotemporal, and hemi-cranial headaches. The excitation of the first and second divisions of the trigeminal nerve through the nasociliary and sphenopalatine nerves, which supply the sphenoid sinus, is thought to be the cause of the headache. Although cranial nerve disease is more frequent in sphenoid malignant tumors, isolated sphenoiditis can also present with these symptoms. Isolated sphenoiditis presenting features were shown to have a 12 percent frequency of vision impairment and other cranial nerve dysfunction. Dysfunction of the optic nerve in the presence of bacterial sphenoiditis, or mass impact in the event of the fungal ball or allergic fungal sphenoiditis, can cause vision loss. Diplopia (double vision) is caused by paralysis of the third, fourth, or sixth nerves as a consequence of the sphenoid and cavernous sinuses' proximity. In isolated sphenoiditis, the abducens nerve (6th cranial nerve) is the most usually damaged cranial nerve, and this impact can occur alone or in combination with other cranial nerve palsies.

Isolated Sphenoiditis Diagnosis

Physical Examination

Every patient with isolated sphenoiditis should have a rigid nasal endoscopy done. The endoscopic evaluation showed numerous characteristics of inflammatory sphenoid pathology, such as suppurative discharge, swelling, or polyps in the sphenoethmoidal recess, even if some individuals do not experience nasal symptoms. Nasal endoscopy, on the other hand, does not eliminate the need for imaging. On nasal endoscopy, a normal-appearing sphenoethmoidal recess does not rule out sphenoid sinus disease.

The appearance of suppurative discharge leaking from the sphenoethmoidal recess, on the other side, should not be mistaken for bacterial infection. To identify possible surgical patients, advanced imaging studies are still required.

Imaging Studies

The paranasal sinus must be scanned with a computed tomography scan. It should always be done to diagnose the problem and create a plan for sinus surgery. With the diverse characteristics of mucosal and bony looks of each disease, a computed tomography (CT scan) can identify the inflammatory process from malignancy and bacterial from fungal infections. Magnetic Resonance (MRI) is only needed when the cerebral or orbital spread is expected, in order to characterize the interface with surrounding structures and exclude any related intracranial pathology. It could help distinguish between mucoceles, benign growths, encephaloceles, and congenital aneurysms of the internal carotid artery.

Isolated Sphenoiditis Medical Treatment

Sphenoiditis is usually treated with a broad-spectrum antibiotic to address the bacterial infection at the base of the problem (Streptococcus pneumonia infection). Many people with sphenoiditis utilize over-the-counter medications, nasal sprays, and decongestants to ease symptoms like headache, upper respiratory cough syndrome (known as a post-nasal drip), and sinus congestion.

A nasal nebulizer can help with many sphenoiditis symptoms such as post-nasal drip and sinus discomfort. Nasal nebulizers assist cure and healing the underlying reasons by delivering prescription and over-the-counter remedies directly within the sinuses. They also provide pain and discomfort alleviation when combined with nasal sterile saline treatments and moisturizers.

Because sphenoiditis can lead to serious neurological symptoms and physical consequences, it's critical to get a diagnosis and start treatment as soon as possible.

The majority of patients with isolated sphenoiditis react well to therapy when diagnosed early. However, if an infection is not treated promptly or becomes too serious, surgical treatment may be required to avoid additional health problems.

Isolated Sphenoiditis Surgical Treatment

When working on the sphenoid sinus, keep in mind the sphenoid relations to the nearby structures. The sphenoid anterior border is around 4 cm from the anterior nasal spine and 30 degrees off the nasal surface. The length between the posterior sphenoid border and the posterior nasal passages, which is roughly 7 cm, is used to estimate the distance to the posterior sphenoid border.

The carotid artery and optic nerve can be seen indenting the sphenoid sinus lateral borders. In 5% of patients, the carotid artery is dehiscent, and in 70% of patients, the carotid artery is only coated by a thin bony coating. In 5% of cases, the optic nerve is discovered in the superolateral portion of the sinus, which is also dehiscent. Staying medial and inferior when opening and investigating the sphenoid can provide a degree of safety.

Transseptal Transsphenoidal Approach

Sublabial incisions, external rhinoplasty incisions, and alar incisions are all options for transseptal techniques. Because of its considerable convenience, midline access, and lack of external scarring, the sublabial incision is the most popular. Oral infection, on the other hand, is a risk.

Inject lidocaine with epinephrine into the upper buccal sulcus, septum, and nasal floor for the sublabial route. Make a cut in the upper sulcus and follow it all the way to the bone. Lift the anterior nasal spine medially and the periosteum to the piriform orifice laterally. Lift a mucoperichondrial membrane and the nasal floor bilaterally on one side of the septum, keeping the contralateral septal mucosa untouched.

Remove the perpendicular plate from the sphenoid rostrum and disarticulate the septum at the bone-cartilage junction. Fluoroscopy can be used to assess the location of a pituitary speculum after it has been implanted.

Transantral Approach

The sphenoid disease has also been treated with the transantral method. Make a sublabial canine fossa cut for this method. Remove any antral pathology by opening the front maxillary sinus border. The nasoantral membrane is removed, revealing the middle concha (turbinate). The sphenoid ostium, which is superior and medial to the posterior portion of the middle concha, can be discovered using the middle turbinate as a guide. The anterior sphenoid border should then be opened.

Intranasal Approach

The intranasal technique is another well-known method. Relieve congestion of the nose, as usual, then break the middle turbinate medially. Conduct an ethmoidectomy and lateralization of the middle turbinates' posterior connection. Locate the sphenoid ostium, penetrate it, and widen it toward the centerline, which is medial to the middle turbinate. To make a shared cavity between the sphenoid sinus and the posterior ethmoid, excise the posterior ethmoid cells. Because an external cut is required, external sphenoid-ethmoidectomy is rarely done.

Endoscopic Approach

The introduction of endoscopic surgical treatment has revolutionized the treatment of sphenoid pathology. Endoscopic techniques allow us a clear view of the anatomy and disease process. When compared to traditional procedures, advantages include shorter operating times, less blood loss, and lower morbidity. Metson (ENT specialist in Boston, Massachusetts) discussed the popularity of endoscopy and analyzed its performance in the treatment of sphenoid sinusitis, considering it effective and safe.

Transethmoidal Approach

A transethmoidal method is used when sinus infection affects both the sphenoid and ethmoid sinuses. Observe the uncinate process by medializing the central turbinate. Locate and release the ethmoid bulla after removing the uncinate. Then, do an ethmoidectomy on both the anterior and posterior sides. The sphenoid sinus is placed between the posterior ethmoid air pockets and the sphenoid sinus. Use a probe to approximate the anterior border of the sphenoid. To prevent damaging the vital structures, widen the hole while staying medial and inferior. The gap between the posterior nasopharyngeal border and the posterior border of the sinus is typically 10 centimeters.

Transnasal Approach

A transnasal technique can be performed if isolated sphenoiditis is observed. Move the endoscope along the septum till the superior turbinate is found, displacing the middle turbinate laterally. Traverse the superior turbinate and eliminate the superior portion. In the space between the remnant and the septum, locate the sphenoid ostium. Expand the ostium from below. The carotid artery and optic nerve can then be evaluated using an endoscope delivered straight into the sphenoid sinus. The ostium can be expanded even further now that these structures have been recognized. To lessen the chances of repeated obstruction, a diameter of 6-10 mm is recommended.

How to Prevent Isolated Sphenoiditis?

Reduce the exposure to hazardous bacteria, viruses, pollutants, and other factors that might aggravate and inflame the sinus passages to help prevent isolated sphenoiditis. Here are a few things you can do to keep the nose in good health:

• Smoke, odors, and other airborne allergens should be avoided.
• Maintain nasal cleansing on a daily basis.
• Maintain child’s allergy-prevention habits.
• When required, the child should wear a mask.
• If the sinus problems don't improve after 3 to 5 days, see a physician.

In addition to these methods, using a nasal spray to rinse the sinuses on a regular basis can help limit the exposure to potentially hazardous viruses, bacteria, and allergens that induce sphenoiditis. You can wash and eliminate entrapped dust and pollutants inside the child’s sinuses by using a nasal sterile saline solution. A moisturizing remedy, on the other hand, can aid to revive the sinuses and provide extra comfort.

Conclusion

Although sinus inflammatory disorder is a prevalent condition in all people, isolated acute sphenoiditis is a rare ailment with a non-specific clinical presentation that makes diagnosis difficult. Because the sphenoid sinus contains anatomical access to various essential tissues, any latency in obtaining a definitive diagnosis, and hence timely and appropriate management, can lead to serious and life-threatening problems. Sphenoiditis is normally treated with broad-spectrum antibiotics, but if symptoms continue or complications arise, surgical sinus drainage is required. To date, there are various surgical options for draining the sphenoid sinus. Many patients with sphenoiditis with unilateral vision loss were treated with transnasal endoscopic surgery, which resulted in total symptomatic relief. The importance of accurate identification and treatment of this rare disease is likewise a top priority.