eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Nasal & Sinus Diseases

Sinusitis, Sphenoid, Acute, Surgical Treatment

Author: Rami K Batniji, MD, Private Practice, Batniji Facial Plastic Surgery
Coauthor(s): Michelle S Marrinan, MD, Staff Physician, Department of Otolaryngology, Montefiore Medical Center, Albert Einstein College of Medicine
Contributor Information and Disclosures

Updated: Jan 2, 2009

Introduction

Acute sphenoid sinusitis is relatively uncommon; comparatively, chronic sphenoid sinusitis is more common. Signs and symptoms are often subtle, making the diagnosis difficult. However, early diagnosis and treatment are essential because the disease can be rapidly progressive and complications can be devastating. Complications arise from the relationship of the sphenoid sinus to vital vascular, neurologic, and optic structures.

Treatment is initially medical; surgery is reserved for unresponsive disease and impending complications. Surgical treatment involves opening the sphenoid sinus, establishing drainage, and obtaining material for culture. Endoscopic methods of sphenoidotomy are now accepted, and several approaches have been described. Open approaches, including an external ethmoidectomy or transseptal approach, can also be used. The outcome of sphenoid sinusitis is highly dependent on the speed of diagnosis.

History of the Procedure

The sphenoid sinus has been described as the forgotten sinus or neglected sinus because of its anatomical location and the difficulty in diagnosing disease there. Diseases of the sphenoid were often determined only when complications arose. With the advent of modern imaging techniques and a higher index of suspicion, diseases of the sphenoid are much more easily found and treated. Modern imaging, antibiotic, and surgical options have changed the presentation and, often, the treatment of acute sphenoid sinusitis.

Problem

According to the American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) task force on rhinosinusitis, sinusitis is defined as an inflammatory response involving mucous membranes of the nasal cavity and paranasal sinuses, fluids within these cavities, and/or bone. The condition is classified as acute if it persists for 4 weeks or fewer. In contrast, a subacute infection is defined as lasting 4-12 weeks, and a chronic infection persists for more than 12 weeks.

When this inflammatory response occurs in the sphenoid sinus, the result is sphenoid sinusitis or sphenoiditis. The disease may be limited to the sphenoid sinus or, more commonly, may involve multiple sinuses or pansinusitis.

Frequency

Sphenoid sinusitis often occurs in the context of pansinusitis. In the preantibiotic era, Teed reported an incidence of sphenoid involvement of 33% in patients with pansinusitis. A 1977 study by Weisberger and Dedo suggested that in the antibiotic era, incidence decreased to 8%.¹ Isolated sphenoid sinusitis is much less common. Lew reported a 2.7% incidence in patients hospitalized for sinusitis in a 12-year period.² Of these incidences, only one half had acute disease. Hnatuk et al suggest that the incidence is actually much lower, and that sphenoid sinusitis represents fewer than 1% of all cases of sinusitis.³

Etiology

The microbiology of acute sphenoid sinusitis differs from that of uncomplicated maxillary sinusitis. Whereas maxillary sinusitis is caused predominantly by Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, sphenoid sinusitis has a different profile. Gram-positive organisms predominate, with Staphylococcus aureus most common, followed by S pneumoniae. Chronic sphenoid sinusitis can be caused by both gram-negative and gram-positive organisms, anaerobes, and mixed flora, which are more common. Fungal disease must also be considered, especially in the context of a patient who is immunocompromised.

Pathophysiology

The pathophysiology of sphenoid sinusitis involves blockage of sinus ostia and impaired mucociliary clearance leading to stasis and secondary bacterial infection. Several predisposing factors have been implicated. Anatomic differences include variations in the position of the intersinus septum and small or abnormally placed ostia. Blunt, penetrating, or surgical trauma can alter drainage patterns as well as allow entry of pathogenic organisms. Swimming or diving with forceful water entry through the nose also has been implicated in causing disease. Immunosuppression due to long-term steroids, diabetes, or radiotherapy can predispose patients to this disease, as can obstruction of sinus ostia by polyps or tumor.

Presentation

Patients with acute sphenoid sinusitis often present with vague nonlocalizing symptoms. Headache is the most common symptom; almost all patients in various studies complain of headache. Although the vertex headache is classic, the pain also can be retroorbital, parietooccipital, or frontal. In general, the headache is described as severe, interfering with sleep, and not relieved by narcotics. Fever and purulent rhinorrhea often are noted, and hypoesthesia of the trigeminal nerve may be present in select cases. Neurologic and ophthalmologic findings suggest impending complications. Decreased mental status, lethargy, and seizures point to intracranial extension or meningitis. Ophthalmologic findings may include abducens nerve palsy or hypoesthesia of V1 and/or V2. Chemosis, proptosis, ptosis, diplopia, or decreased visual acuity and ophthalmoplegia may be noted.

Maintain a high index of suspicion for sphenoid sinusitis. A review by Hnatuk et al reported that 78% of cases of sphenoid sinusitis were initially misdiagnosed.³ Evaluate patients with severe progressive headache, with or without fever, for sphenoid sinusitis. Thoroughly investigate signs of orbital or neurologic complications.

Disease in the sphenoid sinus is not always inflammatory in nature. Consider a broad differential diagnosis in a patient with clinical suggestion of sphenoid disease and imaging studies consistent with sphenoid opacification. Isolated sphenoid lesions, for example, merit special consideration. In his review of 132 cases of isolated sphenoid disease, Lawson found that, while inflammatory disease predominates, neoplasms, fibroosseous disease, and other entities were significant.⁴

In addition to acute and chronic sinusitis, inflammatory diseases included mucoceles, polyps, retention cysts, and fungal disease. Neoplasms included benign tumors, such as inverting papilloma, myxofibroma, plasmocytoma, and schwannoma. Salivary gland malignancies, such as adenoid cystic carcinoma and epidermoid carcinoma, were present, as well as malignancies including squamous cell, melanoma, and hemangiopericytoma.

Extension from adjacent sites, such as the nasopharynx and pituitary, was noted, as was metastatic disease from the prostate, kidney, and tonsil. Several cases of fibrous dysplasia and ossifying fibroma were observed.

Miscellaneous entities including foreign bodies, encephaloceles, and even an internal carotid aneurysm were also included. In general, although many clinical cases of sphenoid disease may be inflammatory in nature, consider other entities.

Indications

In general, start medical treatment of acute sphenoid sinusitis once the diagnosis is made. Institute antibiotics and decongestants for 24 hours, and, if the patient does not improve over this time course, schedule surgical therapy. If the patient has evidence of complications, undertake urgent surgical decompression.

Some individuals advocate early and aggressive surgical and medical treatment for acute sphenoid sinusitis. Hnatuk comments on the aggressive nature of the disease and concludes that nonoperative medical management is not indicated.³ These conclusions are based on a small number of patients, all in their teenage years.

Relevant Anatomy

The sphenoid sinus is the most posterior of the paranasal sinuses. It is a paired structure, divided asymmetrically by an intersinus septum. Pneumatization begins at age 3 years and progresses rapidly between ages 5-7 years. Various degrees of pneumatization exist. Although the sphenoid most commonly is fully pneumatized, the structure can be only partially aerated or can be filled completely with bone. Pneumatization may also occur in the bones adjacent to the sinus, such as the greater wing of the sphenoid bone or the vomer or palatine bones.

The anterior wall of the sphenoid is adjacent to the sphenoethmoidal recess. The floor of the sinus contributes to the roof of the nasopharynx. Posterior to the sphenoid is the clivus. The inferior aspect where it articulates with the vomer is known as the sphenoid rostrum. The pituitary gland sits superior to the sinus. The sphenoid ostium is membranous but surrounded by bone. It lies approximately 30° from the nasal floor and 7 cm from the nasal vestibule.

Lateral to the sphenoid sinus lies the cavernous sinus. The close proximity of the sphenoid to the structures within the cavernous sinus accounts for much of the danger of acute sphenoiditis. Within the cavernous sinus lies the internal carotid artery as well as cranial nerves (CN) II, III, IV, and VI and V3. These structures may lie adjacent to the sphenoid and cause indentations within the wall. The internal carotid artery can be observed indenting the posteroinferior surface of the lateral wall. Cadaver studies have shown that the bony covering is thin in 71% of patients and absent in 4% of patients.

The optic nerve also has a significant relationship to the sphenoid sinus. As the optic nerve travels within the optic canal, it passes over the anterolateral region of the sphenoid roof. The bony covering over the nerve has been noted to be absent in 4% of individuals.

Contraindications

Very few contraindications to urgent surgical decompression of the sphenoid sinus exist if a patient is having complications or is unresponsive to medical management. Unstable vital signs or excessive bleeding might require waiting until these problems can be temporized. Chronic medical conditions might preclude general anesthesia. If the sphenoid sinus is the underlying problem, however, decompression is beneficial.

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