Coronal CT of the paranasal sinuses before and after functional endoscopic sinus surgery

Coronal CT of the paranasal sinuses and the ostiomeatal complex (OMC) was performed before and 12 months after bilateral functional endoscopic sinus surgery (FESS) in 30 patients with sinusitis and 12 patients with nasal polyposis. The extent of sinus mucosal thickening was graded, and the patency of the OMC was evaluated. After FESS, the percentage of open OMCs had increased from 42% to 83% in the sinusitis group, and from 8% to 45% in the polyposis group. There was only a small improvement in mucosal score in sinuses with opened OMC, so that the overall extent of sinus opacification before and after FESS was almost the same. Despite this, 91% of the patients reported clinical relief of symptoms. Preoperative coronal CT of the paranasal sinuses serves as an anatomical map for the surgeon, but there is no benefit of routine postoperative CT.     

Venous angiography is needed to interpret inferior petrosal sinus and cavernous sinus sampling data for lateralizing adrenocorticotropin-secreting adenomas

Bilateral simultaneous venous sampling of ACTH from the inferior petrosal sinus is a reliable test for diagnosing Cushing's disease, but is not reliable for lateralizing ACTH-secreting pituitary adenomas. We reviewed 23 consecutive patients with Cushing's disease who underwent venous angiography of the cavernous and inferior petrosal sinuses followed by bilateral simultaneous venous sampling of ACTH in the inferior petrosal and cavernous sinuses. Venous drainage was bilaterally symmetric in 14 patients (61%) and asymmetric in 9 (39%). The most common asymmetric pattern (6 patients) was for blood from both cavernous sinuses to drain into the right inferior petrosal sinus, with no significant drainage into the left. Cavernous sinus sampling in 21 patients correctly lateralized the tumor in 12 cases of symmetric venous drainage, but in only 3 cases of asymmetric drainage. Inferior petrosal sinus sampling in all 23 patients correctly lateralized the tumor in 12 cases of symmetric drainage, but in only four cases of asymmetric drainage. Overall, venous sampling correctly lateralized 70% of the tumors. Incorrect lateralization in cases of asymmetric venous drainage is probably attributable to shunting of blood toward the side of dominant venous drainage. Our findings illustrate the need for venography in all patients undergoing venous sampling of ACTH because an understanding of the venous drainage patterns is essential to correctly interpret venous sampling data and warn physicians that the lateralization data may be incorrect or unreliable.     

Fatal subarachnoid hemorrhage from an inflammatory cavernous carotid artery aneurysm: failure of conservative treatment after early diagnosis--case report

Inflammatory carotid artery aneurysm is a rare complication of acute paranasal sinusitis. A 50-year-old female presented with a ruptured giant carotid artery aneurysm secondary to infection of the sphenoid sinus and cavernous sinus. She had been healthy until 5 days before admission, when she developed orbital phlegmon and meningitis. She received antibiotic therapy for 10 days. Computed tomography (CT) of the brain 2 days after admission showed no abnormality. However, repeat CT on day 6 showed a round isodense mass in the suprasellar cistern suggesting a cerebral aneurysm. Twelve days after admission, she suffered a fatal subarachnoid hemorrhage. Cerebral angiography revealed a giant left cavernous carotid artery aneurysm with a very irregular shape. Autopsy found sphenoid sinusitis and osteomyelitis extending into the cavernous sinuses. Diagnosis of bacterial inflammatory aneurysms before rupture is very important. Appropriate surgical intervention should be considered if there is enlargement of the original aneurysm or appearance of a new aneurysm indicating a potentially dangerous situation.     

Atypical localization of a small cell carcinoma in the paranasal sinus area--case report

BACKGROUND: Malignant neoplasms of the paranasal sinuses are estimated at 3 to 5% of all head and neck malignant neoplasms. More than 50% of the cases are classified as squamous cell or anaplastic undifferentiated carcinomas. Extremely rare are small cell carcinomas localized in the paranasal sinuses. METHOD AND PATIENT: A 60-year-old male patient was seen in February 1996 in our ENT Department with unspecific pain on the left maxillary sinus and alveolar ridge. Anterior rhinoscopy revealed an extended tumor on the left nasal fossa; histopathological examination showed a small cell carcinoma. No other primary tumors or metastases were detected in extended staging. Due to the extended paranasal tumor as well as the histopathological findings, the patient was given induction chemotherapy followed by radiation therapy. RESULTS: To date (4/97), we achieved partial remission without any clinical complaints. CONCLUSIONS: The therapeutical result is comparable to other therapeutical regimens.     

Overattendance at primary care: a study of psychosocial factors]

We compared MRI studies of the sellar area and embryological and adult histological studies of the cavernous sinuses and pituitary fossa. MRI studies were performed in 50 normal subjects with coronal sections using a fast inversion-recovery sequence to demonstrate the dural walls of the cavernous sinus and pituitary fossa. With this sequence, dura mater appears as a high-signal linear structure. The lateral and superior walls of the cavernous sinus was easily identified on all studies, but demonstration of a dural wall separating the cavernous sinus from the pituitary fossa was not possible. These results correlated well with embryological and adult histological studies obtained from 14 specimens. The absence of a strong separation between the pituitary fossa and the cavernous sinus explains the high incidence of extension of pituitary tumours to the cavernous sinuses and vice versa.     

Fenestrated oculomotor nerve caused by meningioma around the cavernous sinus: a surgical pitfall in tumor removal: case report

OBJECTIVE AND IMPORTANCE: The preservation of oculomotor nerves is one of the most significant issues regarding the resection of meningiomas around the cavernous sinus. CLINICAL PRESENTATION: We report the case of a patient whose oculomotor nerve was fenestrated, caused by a large meningioma around the cavernous sinus. The nerve function remained intact until surgery. INTERVENTION: During surgery, one trunk of the fenestrated nerve behind the tumor was sacrificed. The fenestrated shape of the nerve led us to the misjudgment that the preserved other trunk located along the upper margin of the tumor was the whole nerve. CONCLUSION: Although fenestrated oculomotor nerves may be rare, their possibility should be kept in mind during surgery around the cavernous sinus.     

Prevalence, follow-up and clinical significance of the anticardiolipin antibodies in normal subjects

We evaluated the occurrence of abnormalities in paranasal sinus radiographs in acute asthma by taking a radiograph of the sinuses of 110 consecutive patients admitted to a medical ward a total of 149 times for asthma. Maxillary sinus infection was assessed by taking aspirate from radiologically abnormal maxillary sinuses. An abnormal finding in any paranasal sinus was detected on 87% (130 of 149) of admissions and the yield of maxillary aspirate was macroscopically mucous, purulent or mucopurulent in 60% (42 of 70) of aspirates. A positive bacteriological culture was obtained from 23 aspirates and a virus was detected in 15, there being 7 aspirates in which both a bacterium and a virus could be detected. Although the correlation between radiographic findings and the aspirates was not very close we conclude that radiographic abnormalities of the paranasal sinuses are common in acute asthma as are infections of maxillary sinuses with an abnormal radiographic finding. There is an obvious need to look for sinusitis when a patient with an exacerbation of asthma is being evaluated.     

Ocular presentation and successful outcome of invasive sphenoid sinus aspergillosis in acute myelogenous leukemia

We report the case of a 73-year-old male with acute myelogenous leukemia, who progressively developed a cavernous sinus syndrome during the aplastic phase after induction chemotherapy. Although the clinical, serological and radiological findings suggested an invasive sphenoid sinus aspergillosis, endoscopic ethmoido-sphenoidectomy allowed definitive diagnosis of the infection. After surgery, fungal eradication and reversal of the neurophtalmological damage paralleled complete hematologic remission. The differential diagnoses of the patient ocular symptoms are discussed. Early recognition, prompt intervention and immunologic reconstitution are essential for successful outcome of paranasal mycoses in immunosuppressed patients.     

Follicular adenocarcinoma of the thyroid in the maxillary sinus

No reports of metastatic thyroid carcinoma in the maxillary, ethmoid, or sphenoid sinuses can be found in the literature. A woman with severe posterior epistaxis was examined recently. She had undergone a partial lobectomy for a thyroid tumor 16 years previously. Hemorrhagic thyroid tissue was in the maxillary sinus. The results of subsequent examinations indicated thyroid deposits in the lung and spine. The patient received radioactive iodine, 100 MCi. Her lung and spine deposits lysed, and she experienced no further epistaxis. Thyroid carcinoma's ability to metastasize to a paranasal sinus is documented here. Epistaxis after a thyroidectomy for cancer now must be considered an unusual clinical manifestation of metastatic spread, unless otherwise proved. The differential diagnosis of epistaxis must now include thyroid carcinoma metastatic to the sinonasal tract.     

Paranasal sinus mycoses in north India

Recognizing the high incidence of paranasal sinus mycoses in north India, we analysed retrospectively the clinical, mycological and management aspects of 178 patients with proven disease attending our institute. On the basis of clinical, radiological, histopathological and mycological findings, the patients could be categorized into those with allergic (8), non-invasive (92) and invasive (78) disease types. Bony erosion without mucosal invasion by fungi was seen in 16 patients with non-invasive disease. Young men from rural areas were the most commonly affected. Rhinorrhoea with nasal polyposis (45.8%) and proptosis (46.4%) was the most common presentation. Concurrent involvement of the maxillary and ethmoid sinuses was common in these patients, whereas isolated sphenoid and frontal sinuses were involved in the invasive variety only. Orbital and intracranial extensions were detected in 100% and 13.2%, respectively, of patients with the invasive type of disease. Aspergillus flavus (79.7%) was the most common isolate. Surgical debridement and sinus ventilation were adequate for the effective management of the non-invasive disease. However, adjuvant medical therapy was included in treatment of the semi-invasive and invasive varieties of the disease. Itraconazole was found to be most useful in prevention of recurrence in the invasive type. Mortality was highest (33.3%) among patients with zygomycotic infection. Invasive fungal granuloma with orbital and intra-cranial invasion is a distinct entity in terms of its clinical course and treatment compared with non-invasive fungal sinusitis, and it needs to be treated aggressively with surgical excision and postoperative itraconazole.     

New methods of diagnosis and treatment of paranasal sinusitis with "IaMIK" sinus catheters

A new method for the diagnosis and treatment of PNS has been designed. The devices are named sinus-catheters YAMIK and consist of elongated flexible body with two inflatable vessels and three passages. Two of the passages have separate outlets into the vessel cavities and serve for their inflation. The third, working passage, opens on the body surface between the vessels and has an adaptor on the other end. Also a glass model of nasal sinuses has been developed. On the model YAMIK the procedure performs as follows: sinus catheter is inserted into the nasal cavity, the nostril and rhinopharynx are sealed off by inflating the vessels, a syringe is connected to the adaptor of the working passage. It creates controlled negative pressure in the nasal cavity, and this makes pathological secretion come out of the paranasal sinuses through their natural openings. After the evacuation of the pathological contents, medicine is introduced into the sinuses. This glass model is helpful in understanding the principle of YAMIK procedure which provides a good opportunity to evacuate pathological secretion from PNS through natural ostia and introduce medicine into the PNS.     

Case of paranasal sinus osteoma with cerebrospinal rhinorrhea and pneumocephalus

The authors describe a case of osteoma of the paranasal sinuses growing into the anterior cranial fossa with liquorrhoea and aerocele treated successfully surgically from an osteoplastic transsinusal approach.     

The effects of leukotrienes C4 and D4 on ciliary activity of human paranasal sinus mucosa in vitro

The effects of leukotrienes C4 and D4 on ciliary activity of human paranasal sinus mucosa were investigated in vitro. Normal mucosa was surgically obtained from human paranasal sinuses and incubated in the form of tissue culture. Ciliated cells were magnified under an inverted microscope, and ciliary activity was photoelectrically measured. LTD4 progressively inhibited ciliary activity, and showed a more potent effect on ciliary activity compared to LTC4. The concentrations of LTC4 and LTD4 in the incubation medium were determined by radioimmunoassay when the mucosa was incubated with 10(-8) M LTC4. The concentration of LTD4 gradually increased and after 90 min reached the maximum of 0.71 x 10(-8) M, while that of LTC4 was reduced to about 10% of its initial concentration within 60 min. These results suggested the possible conversion of LTC4 to LTD4 on the mucosa, and that LTC4 can inhibit ciliary activity by means of LTD4.     

"Cavernous sinus EEG": a new method for the preoperative evaluation of temporal lobe epilepsy

PURPOSE: In presurgical evaluation of temporal lobe epilepsy (TLE), invasive methods are necessary if results of various noninvasive methods are not sufficiently convergent enough to identify the epileptogenic area accurately. To detect the epileptiform discharges originating specifically from the mesial temporal lobe, we applied the cavernous sinus catheterization technique. METHODS: We placed Seeker Lite-10 guide wire electrodes into bilateral cavernous sinus through the internal jugular veins to record EEG (cavernous sinus EEG) in 6 patients with intractable TLE. Scalp EEG was simultaneously recorded in all 6 and electrocorticogram (ECoG) was also recorded in 4. RESULTS: The cavernous sinus EEG demonstrated clear epileptiform discharges, sometimes even when they were absent on the simultaneously recorded scalp EEG. The epileptiform discharges recorded from the cavernous sinus electrodes were specifically associated with those in the mesial temporal region on ECoG. Ictal EEG pattern originating from mesial temporal lobe was also clearly documented on the cavernous sinus EEG. CONCLUSIONS: This new, semi-invasive method of identifying epileptogenic areas can detect the epileptiform discharges specifically arising from the mesial temporal lobe; it is as useful as or complements the invasive techniques such as foramen ovale or depth recording.     

Radical resection of meningiomas and arteriovenous fistulas involving critical dural sinus segments: experience with intraoperative sinus pressure monitoring and elective sinus reconstruction in 10 patients

OBJECTIVE: Radical resection of meningiomas and dural arteriovenous fistulas involving functional major dural sinuses entails the risk of intracranial hypertension and venous infarction. Surgical reconstruction of dural sinuses and bridging veins increases the spectrum of dural sinus conditions that can be treated by complete resection, but indications for venous reconstructions and associated risks are still not well defined. We report our experience with sinus reconstruction based on the intraoperative assessment of collateral venous flow. METHODS: Radical resection of meningiomas (n = 5) or dural arteriovenous fistulas (n = 5) involving critical segments of dural sinuses was performed in 10 patients. All but two patients were suffering from recurrent disease after incomplete treatment. Tolerance of sinus occlusion was assessed intraoperatively by measuring stump pressure in the superior sagittal sinus during test clamping of the involved sinus segment. RESULTS: In five patients, the results of pressure monitoring suggested that occlusion of the sinus might not be tolerated. In two other patients, major bridging veins entered the diseased segment. In these patients, the resected sinus segment was reconstructed and bridging veins were reinserted as far as possible. Postoperative graft occlusion occurred in two patients. One patient who was managed without reconstruction sustained a transient postoperative neurological deficit resulting from venous congestion in the vein of Labbé. Postoperative imaging confirmed total elimination of the pathological process in all 10 patients. There was no recurrence of disease during follow-up periods of up to 8 years. CONCLUSION: The monitoring of sinus pressure, together with the possible reconstruction of the diseased sinus, allows complete surgical treatment of dural sinus abnormalities and involves acceptable risk.     

Value of B-image ultrasound in diagnosis of paranasal sinus diseases in comparison with computerized tomography

BACKGROUND: In diagnostic imaging of the paranasal sinuses, the A-mode technique is increasingly being substituted by B-mode ultrasonography. To assess the value of B-mode sonography we compared in a double-blind study computed tomography with our ultrasound findings. PATIENTS AND METHODS: Seventy-eight patients were examined by CT and subsequently by ultrasound, two-thirds before endonasal surgery and one-third for diagnosis of serious facial pain and swelling. RESULTS: Among 114 pathological maxillary sinus tomograms, 83 findings could also be diagnosed by ultrasound (sensitivity 72.8%). In the frontal sinuses only 12 of 52 of pathological findings could be detected (23.1%) and only 9 of 80 in the frontal ethmoid (11.3%). Except for circumscribed polyps and moderate general swelling of the mucosa, the detection rate by sonography was 97.4% for the maxillary sinuses, 31.5% for the frontal and 18% for the ethmoid sinuses. CONCLUSIONS: Ultrasound usually only demonstrates the presence of absence or unspecific findings. Differential diagnosis between tumors and sinusitis is generally difficult. The healthy individual is correctly assessed as healthy due to the total reflection of the air-filled healthy sinus. According to our findings ultrasound has a certain value in the diagnosis of maxillary sinuses. It can be used to obtain a preliminary diagnosis and as a screening method although a negative result never excludes a disease of the sinuses. As it does not involve radiation exposure, ultrasonography can be recommended as first step in diagnosis for children, pregnant women, and young women especially in acute sinusitis, because in acute sinusitis the maxillary sinuses are generally affected.     

Traumatic carotid cavernous sinus fistula: serial angiographic studies from the day of trauma

BACKGROUND AND PURPOSE: The purpose of this study was to ascertain the early angiographic features characteristic of traumatic carotid cavernous sinus fistulas (CCFs). METHODS: Eight patients with severe craniofacial injuries underwent emergency diagnostic and therapeutic angiography for intractable oronasal bleeding, starting on an average of 6.7 hours after trauma. Carotid angiograms and the clinical manifestation of traumatic CCFs were then reviewed retrospectively to determine characteristic angiographic features. RESULTS: In four of the eight patients, no arteriovenous fistulas were found in the cavernous sinuses and symptomatic CCF did not occur during the follow-up period. In the remaining four patients, dural CCFs (Barrow type B) were observed, unilaterally in three patients and bilaterally in one. One of these four patients subsequently became symptomatic and required transarterial coil embolization. CONCLUSION: Traumatic dural CCFs are frequently observed in the early stage of severe craniofacial trauma, if investigated. Although their spontaneous disappearance is known, some of these do become symptomatic and need treatment.     

Meningeal architecture of the cavernous sinus: clinical and surgical implications

OBJECTIVE: The meningeal structure of the cavernous sinus (lateral sellar compartment) was anatomically and histologically studied. We discuss the clinical and surgical significance and present clinical examples of cranial base tumors. METHODS: Ten adult cadaveric heads were used for microsurgical dissection or histological studies. Specimens of the cavernous sinus were continuously sectioned in three dimensions and stained by Masson's trichrome method. The findings are anatomically discussed as they pertain to presented clinical cases. RESULTS: The cavernous sinus, located in an interdural space between periosteal and meningeal dura, is properly accessed by detachment of the periosteal bridge between the superior orbital fissure and the middle fossa. The lateral meningeal dura is dissected under minimal hemorrhage from the sinus, with a surgically important cleaving plane between the "deep layer," a semitransparent meningeal sheath with which the cranial nerves are covered and protected. It has various degrees of meningeal pockets, of which Meckel's cave is the largest example. Adventitia of the carotid artery in the sinus, uncovered with protective meninges, is considered to contact directly with tumors of the sinus origin. The meningeal wall of the cavernous sinus anatomically has three weak points as far as tumor invasion and extension are concerned: the venous plexus around the superior orbital fissure, the loose texture of the medial wall around the pituitary body, and dural pockets of the IIIrd and Vth cranial nerves. The dural wall is extremely thin or missing at those points. CONCLUSION: A surgical technique based on the meningeal anatomy is important for cavernous sinus surgery. The cavernous apex and Meckel's cave, which are spaces of convergence of cranial nerves, however, are weak points for surgical dissection. The presence or absence of tumor invasion into those areas may influence the microsurgical results.     

Deflation of detachable balloons in the cavernous sinus by percutaneous puncture

The authors show that percutaneous puncture of balloons within the cavernous sinus is technically feasible and allows further access to the cavernous sinus after balloon detachment. Complete closure of a large carotid cavernous fistula was achieved in the 37-year-old trauma victim they treated using this technique.     

Frontal sinus mucocele mimicking a metastasis of papillary thyroid carcinoma

Radioiodine scans are highly specific for detecting metastases of well-differentiated thyroid carcinomas. However, false-positive 131I whole-body scans may occur as illustrated in the following case report. In a 53-yr-old patient, abnormal 131I uptake was found in the right frontal skull 4 wk after total thyroidectomy and radioiodine therapy for papillary thyroid cancer. Bone scans and planar x-rays of the skull were unremarkable and the serum thyroglobulin level was within normal limits. X-ray CT revealed a small nodule in the right frontal sinus corresponding to the pathological focus of 131I uptake. Surgical removal and histopathological examination of this lesion yielded a mucocele, a slow-growing lesion of the paranasal sinuses accumulating mucous material. The postoperative 131I scan was unremarkable. The possibility of a false-positive finding on radioiodine scans should be considered, particularly when the serum thyroglobulin level is not elevated.