International Journal of Pediatric Otorhinolaryngology 78 (2014) 684–686
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Case report
Combined endoscopic transnasal and intrasphenoidal septal approach for the drainage of sphenoid sinusitis with cleft lip: Technical note So Young Choi a, Myoung Su Choi b,* a b
Department of Radiology, Eulji University Medical Center, Eulji University, Daejeon, South Korea Department of Otolaryngology-Head and Neck Surgery, Eulji University Medical Center, Eulji University, Daejeon, South Korea
A R T I C L E I N F O
A B S T R A C T
Article history: Received 2 October 2013 Received in revised form 20 December 2013 Accepted 21 December 2013 Available online 8 January 2014
Isolated sphenoiditis is an uncommon disease, particularly in children. Immediate antibiotic therapy and/or endoscopic transnasal sphenoidotomy should be performed to avoid fatal complications. However, the commonly used transnasal route is not always available in children with a cleft lip and deviated nasal septum. We report a case of acute isolated sphenoid sinusitis in a 12-year-old boy with a cleft lip and deviated nasal septum. This patient underwent combined endoscopic transnasal and intrasphenoidal septal surgery and improved without septoplasty, which may affect the later growth of the nose ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Isolated sphenoid sinusitis Intrasphenoidal septum
1. Introduction Acute isolated sphenoiditis (IS) is an uncommon, potentially dangerous disease that frequently presents with headache, visual symptoms, and minimal nasal symptoms [1]. Immediate antibiotic therapy is required to avoid fatal complications. Endoscopic transnasal sphenoidotomy is a widely used surgical therapy for IS [1]. However, septal deviation or craniofacial anomaly may hinder binasal endoscopic sphenoidotomy. In such cases, septoplasty or bypass surgery is necessary. However, many investigators recommend that septoplasty should be delayed until the patient’s growth has ceased [2]. In this paper, we report a successful case of sphenoiditis treated by endoscopic transnasal sphenoidotomy with a perforation of the intrasphenoidal septum without septoplasty which may affect the later growth of the nose. 2. Case report A 12-year-old-boy was initially admitted to the Pediatric Department of Eulji University Medical Center. He had suffered from a progressive left-side headache, vomiting, and left-side eyeball pain for 4 days prior to admission. The patient was referred to ophthalmic examination, which revealed no ophthalmic lesions. A brain magnetic resonance image (MRI) with contrast enhancement
* Corresponding author at: Eulji hospital medical center, Department of Otolaryngology-Head & Neck Surgery, Dunsanseoro 95, Daejeon 302-799, South Korea. Tel.: +82 42 611 3133; fax: +82 42 611 3136. E-mail address: [email protected] (M.S. Choi). 0165-5876/$ – see front matter ß 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijporl.2013.12.040
was performed at the pediatric department. The MRI suggested isolated sphenoid sinusitis. The right side of the sphenoid sinus contained collected fluid without complications, but the left side showed collected fluid with complications (Fig. 1a). The patient was referred to the Department of Otolaryngology and was given empirical intravenous ceftriaxone (2 g per day). After 48 h of antibiotic therapy, the symptoms were not improved. Therefore, we planned an endoscopic sphenoidotomy. The patient had a left-side cleft lip and had undergone cheiloplasty three times in the past. The left-side nostril of the patient was markedly narrow due to a septal deviation. Paranasal sinus computed tomography (CT) with contrast enhancement was performed. The intrasphenoidal septum, which completely divided the sinuses into the left and right sides, was not related with the internal carotid artery and optic canal (Fig. 1b). First, an endoscope was inserted between the nasal septum and right middle turbinate. The lower one-third of the superior turbinate was cut and an ostium of the sphenoid sinus was probed approximately 1 cm above the posterior end of the superior turbinate. After opening the sphenoid sinus, we aspirated the mucoid discharge for microbiologic culture and widened the ostium inferiorly and medialy. Through the widened opening, the mid-portion of the intrasphenoidal septal mucosa was removed using a curette. The exposed bony septum was carefully perforated with a drill and currets (Fig. 2). A mucopurulent discharge from the left sphenoid sinus was drained through the perforation site of the intrasphenoid septum. The aspiration of the discharge from the left sphenoid sinus was sent for microbiologic culture. After packing into the right sphenoidal recess, the operation was complete. After the operation, the left-side headache and eyeball pain immediately disappeared. The microbiological culture from the
S.Y. Choi, M.S. Choi / International Journal of Pediatric Otorhinolaryngology 78 (2014) 684–686
685
Fig. 1. (a) Axial T2WI of the MRI showed collected fluid within the sphenoid sinuses. The signal intensity of the fluid collection in the left sphenoid sinus was heterogeneous to that of the right side. (b) The preoperative post-contrast axial CT scan showed collected fluid in both sphenoid sinuses, and paramedian intrasphenoidal septum, which divides the sinuses completely and is not related to the parasellar carotid prominence.
left sphenoid sinus demonstrated the presence of Streptococcus pyogenes. The patient was discharged after packing removal and was followed for three months. Three months later, a follow-up paranasal sinus CT detected well-aerated sphenoid sinuses and patent opening of the intrasphenoidal septum (Fig. 3).
3. Discussion The complications that occur during IS are due to the association of the sphenoid sinus with important surrounding structures. The cranially adjacent structures of the sphenoid sinus are the pituitary gland, the middle cranial fossa, and the optic nerve and chiasm. The laterally adjacent structures of the sphenoid sinus are the cavernous sinus, the internal carotid artery, and cranial nerves III through VI [3]. The most common symptoms of IS are headache and visual symptoms [1]. In cases of persistence or worsening of symptoms, or when the infection is refractory to
Fig. 2. Intraoperative view of perforation of the sphenoid intersinus septum. The black arrow indicates a perforation site of the intersinus septum, and the white arrow indicates the margin of a widened ostium of the right side sphenoid sinus.
antibiotic therapy, immediate surgery should be performed to avoid life-threatening complications. The prognosis is very poor after severe neurologic deficits, such as vision loss and opthalmoplegia, have occurred [4]. There are transnasal, transethmoid, and transseptal routes for approaching the sphenoid sinus [1]. An endoscopic transnasal approach is widely used for easy access to the sphenoid ostia and a short operating time. The endoscopic transethmoidal approach is useful for making a wide opening in the sphenoid sinus of narrow noses [1]. The transseptal route is seldom used for endoscopic sphenoidotomy [1]. A posterior septectomy is an alternative approach for accessing the contralateral sphenoid ostium through a unilateral transnasal endoscopic approach [5]. A posterior septectomy is a part of transsphenoidal endoscopic skull base surgery and can expose the anterior face of the sphenoid sinus. It can open the sphenoid sinus widely by removing a rostrum and connecting the two natural ostia. In our case, the endoscopic transnasal route was chosen for locating the sphenoid sinus ostium, and a perforation of the intersinus septum was created to drain the contralateral sphenoid
Fig. 3. Three months later, the postoperative axial CT scan image showed wellaerated sphenoid sinuses and patent opening of the intrasphenoidal septum.
686
S.Y. Choi, M.S. Choi / International Journal of Pediatric Otorhinolaryngology 78 (2014) 684–686
sinus (lesion side). The safest location to create an intersinus perforation would be antero-inferiorly, away from the skull base and the carotid protuberance. Special care was required to manipulate the intersinus septa because they were inserted at the parasellar or paraclival carotid prominence, and the connectivity between the septa and the internal carotid artery was approximately 48–89% [6]. For these reasons, one should not shake or pull the intersinus septa with forceps during the operation. Careful review of the preoperative CT scans to determine the relationship between the internal carotid artery and the intersinus septa is mandatory when removing these septa. In our case, the patient was 12-year old. It was important to operate conservatively to avoid disturbing the growth of the nose. The patient had a caudal septal deviation involving the L-strut. A reduction manipulation of the caudal cartilaginous septum could weaken the structural support or disturb the later growth of the nose. There is much debate regarding pediatric septoplasty. One report suggested that operating in the first 10 years of life might change the cartilage growth centers [2]. Other studies have provided evidence that pediatric septoplasty can be performed without affecting the nasal and facial growth [6]. In those studies,
conservative septoplasty, not wide cartilage resection, was recommended out of the concern for nasal growth [7]. We successfully treated a patient with cleft lip for IS without using septoplasty. This approach is useful and is minimally invasive for access to the sphenoid sinus in cases of severe septal deviation. References [1] M.G. Gu¨venc¸, A. Kaytaz, G. Ozbilen Acar, M. Ada, Current management of isolated sphenoiditis, Eur. Arch. Otorhinolaryngol. 266 (2009) 987–992. [2] C.D. Verwoerd, H.L. Verwoerd-Verhoef, Rhinosurgery in children: developmental and surgical aspects of the growing nose, Laryngorhinootologie 89 (2010) S46–S71. [3] M. Ada, A. Kaytaz, K. Tuskna, M.G. Gu¨venc¸, H. Selc¸uk, Isolated sphenoid sinusitis presenting with unilateral VIth nerve palsy, Int. J. Pediatr. Otorhinolaryngol. 68 (2004) 507–510. [4] S.C. Reynolds, E.M. Evans, Acute sphenoid sinusitis induced blindness: a case report, J. Emergency Med. 43 (2012) e123–e124. [5] H.F. Ramos, T.A. Monteiro, C.D. Pinheiro Neto, P.P. Mariani, F.S. Fortes, L.U. Sennes, Endoscopic anatomy of the approaches to the sella area and planum sphenoidale, Arq. Neuropsiquiatr. 69 (2011) 232–236. [6] J.C. Fernandez-Miranda, D.M. Prevedello, R. Madhok, V. Morera, J. Barges-Coll, K. Reineman, Sphenoid septations and their relationship with internal carotid arteries: anatomical and radiological study, Laryngoscope 119 (2009) 1893–1896. [7] R. Lawrence, Pediatric septoplasty: a review of the literature, Int. J. Pediatr. Otorhinolaryngol. 76 (2012) 1078–1081.
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Case report
Combined endoscopic transnasal and intrasphenoidal septal approach for the drainage of sphenoid sinusitis with cleft lip: Technical note So Young Choi a, Myoung Su Choi b,* a b
Department of Radiology, Eulji University Medical Center, Eulji University, Daejeon, South Korea Department of Otolaryngology-Head and Neck Surgery, Eulji University Medical Center, Eulji University, Daejeon, South Korea
A R T I C L E I N F O
A B S T R A C T
Article history: Received 2 October 2013 Received in revised form 20 December 2013 Accepted 21 December 2013 Available online 8 January 2014
Isolated sphenoiditis is an uncommon disease, particularly in children. Immediate antibiotic therapy and/or endoscopic transnasal sphenoidotomy should be performed to avoid fatal complications. However, the commonly used transnasal route is not always available in children with a cleft lip and deviated nasal septum. We report a case of acute isolated sphenoid sinusitis in a 12-year-old boy with a cleft lip and deviated nasal septum. This patient underwent combined endoscopic transnasal and intrasphenoidal septal surgery and improved without septoplasty, which may affect the later growth of the nose ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Isolated sphenoid sinusitis Intrasphenoidal septum
1. Introduction Acute isolated sphenoiditis (IS) is an uncommon, potentially dangerous disease that frequently presents with headache, visual symptoms, and minimal nasal symptoms [1]. Immediate antibiotic therapy is required to avoid fatal complications. Endoscopic transnasal sphenoidotomy is a widely used surgical therapy for IS [1]. However, septal deviation or craniofacial anomaly may hinder binasal endoscopic sphenoidotomy. In such cases, septoplasty or bypass surgery is necessary. However, many investigators recommend that septoplasty should be delayed until the patient’s growth has ceased [2]. In this paper, we report a successful case of sphenoiditis treated by endoscopic transnasal sphenoidotomy with a perforation of the intrasphenoidal septum without septoplasty which may affect the later growth of the nose. 2. Case report A 12-year-old-boy was initially admitted to the Pediatric Department of Eulji University Medical Center. He had suffered from a progressive left-side headache, vomiting, and left-side eyeball pain for 4 days prior to admission. The patient was referred to ophthalmic examination, which revealed no ophthalmic lesions. A brain magnetic resonance image (MRI) with contrast enhancement
* Corresponding author at: Eulji hospital medical center, Department of Otolaryngology-Head & Neck Surgery, Dunsanseoro 95, Daejeon 302-799, South Korea. Tel.: +82 42 611 3133; fax: +82 42 611 3136. E-mail address: [email protected] (M.S. Choi). 0165-5876/$ – see front matter ß 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijporl.2013.12.040
was performed at the pediatric department. The MRI suggested isolated sphenoid sinusitis. The right side of the sphenoid sinus contained collected fluid without complications, but the left side showed collected fluid with complications (Fig. 1a). The patient was referred to the Department of Otolaryngology and was given empirical intravenous ceftriaxone (2 g per day). After 48 h of antibiotic therapy, the symptoms were not improved. Therefore, we planned an endoscopic sphenoidotomy. The patient had a left-side cleft lip and had undergone cheiloplasty three times in the past. The left-side nostril of the patient was markedly narrow due to a septal deviation. Paranasal sinus computed tomography (CT) with contrast enhancement was performed. The intrasphenoidal septum, which completely divided the sinuses into the left and right sides, was not related with the internal carotid artery and optic canal (Fig. 1b). First, an endoscope was inserted between the nasal septum and right middle turbinate. The lower one-third of the superior turbinate was cut and an ostium of the sphenoid sinus was probed approximately 1 cm above the posterior end of the superior turbinate. After opening the sphenoid sinus, we aspirated the mucoid discharge for microbiologic culture and widened the ostium inferiorly and medialy. Through the widened opening, the mid-portion of the intrasphenoidal septal mucosa was removed using a curette. The exposed bony septum was carefully perforated with a drill and currets (Fig. 2). A mucopurulent discharge from the left sphenoid sinus was drained through the perforation site of the intrasphenoid septum. The aspiration of the discharge from the left sphenoid sinus was sent for microbiologic culture. After packing into the right sphenoidal recess, the operation was complete. After the operation, the left-side headache and eyeball pain immediately disappeared. The microbiological culture from the
S.Y. Choi, M.S. Choi / International Journal of Pediatric Otorhinolaryngology 78 (2014) 684–686
685
Fig. 1. (a) Axial T2WI of the MRI showed collected fluid within the sphenoid sinuses. The signal intensity of the fluid collection in the left sphenoid sinus was heterogeneous to that of the right side. (b) The preoperative post-contrast axial CT scan showed collected fluid in both sphenoid sinuses, and paramedian intrasphenoidal septum, which divides the sinuses completely and is not related to the parasellar carotid prominence.
left sphenoid sinus demonstrated the presence of Streptococcus pyogenes. The patient was discharged after packing removal and was followed for three months. Three months later, a follow-up paranasal sinus CT detected well-aerated sphenoid sinuses and patent opening of the intrasphenoidal septum (Fig. 3).
3. Discussion The complications that occur during IS are due to the association of the sphenoid sinus with important surrounding structures. The cranially adjacent structures of the sphenoid sinus are the pituitary gland, the middle cranial fossa, and the optic nerve and chiasm. The laterally adjacent structures of the sphenoid sinus are the cavernous sinus, the internal carotid artery, and cranial nerves III through VI [3]. The most common symptoms of IS are headache and visual symptoms [1]. In cases of persistence or worsening of symptoms, or when the infection is refractory to
Fig. 2. Intraoperative view of perforation of the sphenoid intersinus septum. The black arrow indicates a perforation site of the intersinus septum, and the white arrow indicates the margin of a widened ostium of the right side sphenoid sinus.
antibiotic therapy, immediate surgery should be performed to avoid life-threatening complications. The prognosis is very poor after severe neurologic deficits, such as vision loss and opthalmoplegia, have occurred [4]. There are transnasal, transethmoid, and transseptal routes for approaching the sphenoid sinus [1]. An endoscopic transnasal approach is widely used for easy access to the sphenoid ostia and a short operating time. The endoscopic transethmoidal approach is useful for making a wide opening in the sphenoid sinus of narrow noses [1]. The transseptal route is seldom used for endoscopic sphenoidotomy [1]. A posterior septectomy is an alternative approach for accessing the contralateral sphenoid ostium through a unilateral transnasal endoscopic approach [5]. A posterior septectomy is a part of transsphenoidal endoscopic skull base surgery and can expose the anterior face of the sphenoid sinus. It can open the sphenoid sinus widely by removing a rostrum and connecting the two natural ostia. In our case, the endoscopic transnasal route was chosen for locating the sphenoid sinus ostium, and a perforation of the intersinus septum was created to drain the contralateral sphenoid
Fig. 3. Three months later, the postoperative axial CT scan image showed wellaerated sphenoid sinuses and patent opening of the intrasphenoidal septum.
686
S.Y. Choi, M.S. Choi / International Journal of Pediatric Otorhinolaryngology 78 (2014) 684–686
sinus (lesion side). The safest location to create an intersinus perforation would be antero-inferiorly, away from the skull base and the carotid protuberance. Special care was required to manipulate the intersinus septa because they were inserted at the parasellar or paraclival carotid prominence, and the connectivity between the septa and the internal carotid artery was approximately 48–89% [6]. For these reasons, one should not shake or pull the intersinus septa with forceps during the operation. Careful review of the preoperative CT scans to determine the relationship between the internal carotid artery and the intersinus septa is mandatory when removing these septa. In our case, the patient was 12-year old. It was important to operate conservatively to avoid disturbing the growth of the nose. The patient had a caudal septal deviation involving the L-strut. A reduction manipulation of the caudal cartilaginous septum could weaken the structural support or disturb the later growth of the nose. There is much debate regarding pediatric septoplasty. One report suggested that operating in the first 10 years of life might change the cartilage growth centers [2]. Other studies have provided evidence that pediatric septoplasty can be performed without affecting the nasal and facial growth [6]. In those studies,
conservative septoplasty, not wide cartilage resection, was recommended out of the concern for nasal growth [7]. We successfully treated a patient with cleft lip for IS without using septoplasty. This approach is useful and is minimally invasive for access to the sphenoid sinus in cases of severe septal deviation. References [1] M.G. Gu¨venc¸, A. Kaytaz, G. Ozbilen Acar, M. Ada, Current management of isolated sphenoiditis, Eur. Arch. Otorhinolaryngol. 266 (2009) 987–992. [2] C.D. Verwoerd, H.L. Verwoerd-Verhoef, Rhinosurgery in children: developmental and surgical aspects of the growing nose, Laryngorhinootologie 89 (2010) S46–S71. [3] M. Ada, A. Kaytaz, K. Tuskna, M.G. Gu¨venc¸, H. Selc¸uk, Isolated sphenoid sinusitis presenting with unilateral VIth nerve palsy, Int. J. Pediatr. Otorhinolaryngol. 68 (2004) 507–510. [4] S.C. Reynolds, E.M. Evans, Acute sphenoid sinusitis induced blindness: a case report, J. Emergency Med. 43 (2012) e123–e124. [5] H.F. Ramos, T.A. Monteiro, C.D. Pinheiro Neto, P.P. Mariani, F.S. Fortes, L.U. Sennes, Endoscopic anatomy of the approaches to the sella area and planum sphenoidale, Arq. Neuropsiquiatr. 69 (2011) 232–236. [6] J.C. Fernandez-Miranda, D.M. Prevedello, R. Madhok, V. Morera, J. Barges-Coll, K. Reineman, Sphenoid septations and their relationship with internal carotid arteries: anatomical and radiological study, Laryngoscope 119 (2009) 1893–1896. [7] R. Lawrence, Pediatric septoplasty: a review of the literature, Int. J. Pediatr. Otorhinolaryngol. 76 (2012) 1078–1081.
