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Sinusitis, Sphenoid, Acute, Surgical Treatment: Treatment
Updated: Jan 2, 2009
Treatment
Medical Therapy
Initial treatment of a patient with uncomplicated sphenoiditis begins with medical therapy. Once the diagnosis is made, begin administration of broad-spectrum antibiotics. Also add topical and systemic decongestants to the regimen. Try medical treatment for 24 hours. If the patient does not improve over this time course, schedule surgical therapy; if the patient has evidence of complications, undertake urgent surgical decompression.
Sethi described an interesting modification of this algorithm.5 Daily endoscopic decongestion and assessment of the sphenoethmoidal recess was performed, allowing direct evaluation of the anatomy. Three of the 8 patients in this study did well with this regimen, while 5 patients did not improve and required surgery.
Surgical Therapy
The goals of surgery are to identify the sphenoid ostium, enlarge it, and establish drainage. Diseased mucosa should be removed and cultures should be obtained. Many surgical approaches have been described. The classic approaches include transseptal, transantral, intranasal, and external, but endoscopic surgery is now commonly used.
Preoperative Details
Preoperatively, review the imaging studies to determine bony anatomy and areas of disease. Decide the approach to the sphenoid sinus based on associated disease as well as surgeon preference.
Intraoperative Details
When operating on the sphenoid sinus, be aware of the relationship of the sphenoid to the surrounding structures. The anterior wall of the sphenoid is approximately 7 cm from the anterior nasal spine and 30° off the nasal floor. The distance to the posterior sphenoid wall is approximated by measuring the distance to the posterior nasopharynx, which is about 9 cm. The carotid artery and optic nerve may be observed indenting the lateral walls of the sphenoid sinus. The carotid artery is dehiscent in 4% of patients and covered with only a thin bony covering in 71% of patients. The optic nerve is found in the superolateral aspect of the sinus, also dehiscent in 4% of patients. A margin of safety can be obtained by staying medial and inferior when opening and exploring the sphenoid.
Transseptal transsphenoidal approach
Many approaches to the sphenoid have been described. Among the earliest was the transseptal transsphenoidal approach, described by Cushing and Hirsh in 1910 in the context of pituitary tumor resection.6 This approach was repopularized by Hardy in the 1950s and is still in use today. The transseptal approaches can be via sublabial incision, external rhinoplasty incision, or alar incision. The sublabial incision is most common because of the relative ease of the procedure, midline exposure, and lack of external scar. However, oral contamination is a disadvantage.
For the sublabial approach, inject lidocaine with epinephrine into the upper buccal sulcus, septum, and floor of nose. Make an incision in the upper sulcus and carry the incision down to bone. Elevate the periosteum to the piriform aperture laterally and elevate the anterior nasal spine medially. Elevate a mucoperichondrial flap on one side of the septum and the nasal floor bilaterally, leaving the contralateral septal mucosa intact. Disarticulate the septum at the bony-cartilaginous junction, and remove the perpendicular plate to expose the sphenoid rostrum. Following placement of a pituitary speculum, fluoroscopy can be used if needed to confirm placement. Enter the sphenoid sinus in the midline with an operating microscope.
Transantral approach
The transantral approach has also been used for sphenoid disease. For this approach, make a sublabial canine fossa incision. Open the anterior maxillary sinus wall and address any antral disease. Remove the nasoantral wall, exposing the middle turbinate. Use the middle turbinate as a guide to the sphenoid ostium, which is found superior and medial to the posterior aspect of the middle turbinate. Then, open the anterior sphenoid wall.
Intranasal approach
Another classic approach is the intranasal approach. Perform typical nasal decongestion; then, fracture the middle turbinate medially. Perform an ethmoidectomy followed by lateralization of the posterior attachment of the middle turbinate. Identify the sphenoid ostium medially to the middle turbinate, enter it, and enlarge it toward the midline. Remove the posterior ethmoid cells to create a common cavity between the sphenoid sinus and the posterior ethmoid. External sphenoethmoidectomy is used infrequently because an external incision is needed.
Endoscopic approach
The advent of endoscopic sinus surgery has dramatically changed the approach to sphenoid disease. Endoscopic approaches provide excellent visualization of the anatomy and disease process. Advantages include reduced operating time, minimal blood loss, and decreased morbidity compared with classic techniques. In a 1996 article, Metson commented on the widespread popularity of endoscopy and went on to evaluate the efficacy of the endoscopic approach.7 Metson deemed it effective and safe in the treatment of sphenoid sinusitis.
Transethmoidal approach
If sinus disease involves both the sphenoid and the ethmoid sinuses, a transethmoidal approach is taken. Medialize the middle turbinate to visualize the uncinate process. Remove the uncinate, and identify and open the ethmoid bulla. Then, perform an anterior and posterior ethmoidectomy. The sphenoid sinus is located medial and inferior to the posterior ethmoid air cells. Use a probe to approximate the anterior wall of the sphenoid at 7 cm from the nasal spine and 30° off the nasal floor. Enlarge the opening while taking care to stay medial and inferior in order to avoid the vital structures. The distance to the posterior nasopharyngeal wall approximates the posterior wall of the sinus and usually measures 9 cm.
Transnasal approach
If isolated sphenoid disease is present, a transnasal approach can be used. Displace the middle turbinate laterally and pass the endoscope along the septum until the superior turbinate is identified. Transect and remove the superior aspect of the superior turbinate. Identify the sphenoid ostium in the area between the remnant and the septum. Inferiorly enlarge the ostium. An endoscope can then be passed directly into the sphenoid sinus to evaluate the location of the carotid artery and optic nerve. With these structures identified, the ostium can be enlarged further. A diameter of 5-10 mm is advocated to reduce the likelihood of recurrent obstruction.
Alternate approach to isolated sphenoid disease
Stankiewicz describes an alternate approach to isolated sphenoid disease.8 He advocates fracturing the middle turbinate toward the septum. Make incisions in the anterior superior and posterior inferior portion of the middle turbinate and remove this tissue. The basal lamella remains intact as a landmark. With a probe, measure the distance to the sphenoid ostium; then, enter the sphenoid.
Postoperative Details
Postoperatively, continue administration of broad-spectrum antibiotics. Adjust antibiotic choices when culture results are available. Closely monitor the patient for complications of the sinus disease as well as the procedure.
Follow-up
Acute sphenoid sinusitis should respond to medical and surgical management as described above. Monitor patients who develop complications of sphenoid sinusitis for progression or resolution of their symptoms. Patients who develop repeated episodes of sphenoid sinusitis may have an anatomic predisposition, such as a narrowed ostium, and may require surgery. Chronic sphenoid sinusitis is a different entity and may respond to medical or surgical treatment. In contrast to acute sphenoiditis, chronic disease is not considered a medical emergency.
Complications
Complications of acute sphenoid sinusitis relate to the vital structures that surround the sinus. Expansion into surrounding structures, local osteitis, or thrombophlebitis in draining vessels may cause complications. Orbital cellulitis, orbital abscess, and orbital fissure syndrome occur from extension towards the orbit; cavernous sinus thrombosis and blindness may occur. Meningitis, epidural, and subdural abscess result from intracranial extension. Carotid artery thrombosis may also occur, although very infrequently. The close proximity of the sphenoid to the pituitary can lead, in some cases, to hypopituitarism.
The sinus surgery itself has potential complications, again based on the vital structures that surround the sphenoid sinus. Intraoperative complications are predominantly vascular in nature and include persistent hemorrhage from the carotid artery or, infrequently, the cavernous sinus. Retrobulbar hemorrhage with proptosis and visual compromise requires urgent ophthalmological consultation and lateral canthotomy. Persistent hemorrhage from the sphenoid or cavernous sinus may require angiography to localize and control bleeding.
Postoperative complications may be nasal, neurologic, or vascular in nature. Long-term complications include cosmetic deformities; septal perforations may occur and are predominantly related to approach. In the perioperative state, epistaxis is also a risk. Neural structures, including the optic nerve or any structures running through the cavernous sinus, may be damaged during surgery. Cranial nerves that control extraocular movements (ie, CN III, IV, VI) are at risk, as are the ophthalmic (ie, V1) and maxillary (ie, V2) branches of CN V. Cerebrospinal fluid leak is possible if the roof of the sphenoid is violated. Hemorrhage from the internal carotid artery or cavernous sinus is a devastating complication that may occur intraoperatively or postoperatively. Immediately evaluate any unexplained mental status changes or excessive bleeding.
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References
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Further Reading
Keywords
sphenoid, sinusitis, acute sphenoiditis, sphenoid sinusitis, acute sinusitis, acute sphenoid sinusitis, sinus infection sphenoid
