SPHENOID SINUSITIS Richard A. Hill, MD, Lenworth N. Johnson, MD, and Robert Parnes, MD Hershey, Pennsylvania
Significant morbidity and mortality can result if early detection and treatment of sphAenoid sinusitis is not provided. A case is presented in which the diagnosis of sphenoid sinusitis was delayed because a routine computerized tomographic scan was normal. This case underscores the importance of specifically requesting views of the paranasal sinuses in suspected cases of sinusitis. Key words * sphenoid sinusitis * neurodiagnostic imaging
Complications from sphenoid sinusitis, such as irreversible visual loss, cranial nerve palsies, orbital or intracranial abscess, meningitis, cavernous sinus or carotid artery thrombosis, and even death, may be prevented by early detection and treatment of sphenoid sinusitis. 1-4 However, the diagnosis of isolated sphenoid sinusitis is often delayed because of misdiagnosis. In the following case, the diagnosis was considered but was initially missed because the physician ordered a routine cranial computerized tomographic (CT) scan, which did not provide adequate views of the paranasal sinuses.
CASE REPORT A 13-year-old boy received a 1-week course of oral
From the Neuro-Ophthalmology Division, Department of Ophthalmology, Pennsylvania State University, Hershey, Pennsylvania. Requests for reprints should be addressed to Dr Lenworth N. Johnson, Neuro-Ophthalmology Division, Mason Institute of Ophthalmology, University of Missouri-Columbia, Columbia, MO 65212. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 1
erythromycin for severe, right, retro-orbital and frontal pain thought to be due to sinusitis. Radiologic studies of the paranasal sinuses were not obtained prior to antibiotic initiation. Despite the antibiotic, the pain persisted, and the patient developed a low grade fever and horizontal diplopia. His examination was normal apart from his ill appearance, low grade fever, and right abducens nerve paresis. Laboratory studies showed increased Westergren sedimentation rate to 38 mm/hr and elevated leukocyte count to 14 000 cu/mm. A routine, cranial CT scan was normal. Opening pressure on lumbar puncture and cerebrospinal fluid analysis were normal. Neuro-ophthalmologic consultation, obtained one day after the above studies, confirmed the right abducens nerve paresis. On review of the initial, routine CT scan, it was noted that views of the paranasal sinuses were not provided. A second CT scan with coronal views of the paranasal and cavernous sinuses was then performed. This scan demonstrated opacified sphenoid sinuses without airfluid level and possible extension of inflammation to the right cavernous sinus (Figs I & 2). Intravenous ceftriaxone was instituted. The patient became asymptomatic, with complete resolution of the abducens nerve paresis occurring within 1 week. Intravenous ceftriaxone was discontinued and treatment with oral amoxicillin/clavulanate potassium was continued for 3 weeks. A follow-up CT scan of the paranasal sinuses following cessation of antibiotics showed marked improvement of the sphenoid sinus opacification.
DISCUSSION Neurodiagnostic imaging is not indicated for all cases of sinusitis. Plain radiographs of the paranasal sinuses may be helpful in documenting sinus opacifica85
SPHENOID SINUSITIS
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Figure 1. Coronal computerized tomography scan demonstrating bilateral sphenoid sinus opacification (arrows) suggestive of sphenoid sinusitis.
tion or air-fluid level suggestive of sinusitis. However, plain sinus radiographs are not as sensitive for detecting paranasal sinusitis as the CT scan.5 Hence, in patients with neurologic signs, such as the abducens palsy our patient showed, a CT scan is indicated. When CT scans are ordered, clinicians should be aware that routine, cranial CT scans may not provide adequate views of the paranasal sinuses.6 The clinicians ordering these studies should specifically request axial and direct coronal views of the paranasal sinuses. Sinus opacification may suggest sinusitis with diffuse mucosal thickening or fluid, chronic osteitis, soft tissue mass, or may also be seen in clinically normal individuals.7 Thus, following the administration of appropriate antibiotics, persistence of clinical signs or symptoms may warrant a second CT scan or magnetic resonance imaging of the paranasal sinuses.8,9
Figure 2. Coronal computerized tomography scan demonstrating suspected extension of inflammation to the right cavernous sinus (arrow) accounting for the right abducens nerve paresis. 2. Slavin ML, GlaserJS. Acute severe irreversible visual loss with sphenoethmoiditis-"posterior" orbital cellulitis. Arch Ophthalmol. 1 987; 1 05:345-348. 3. Sofferman RA. Cavernous sinus thrombophlebitis secondary to sphenoid sinusitis. Laryngoscope. 1983;93:797-800. 4. Marks PV, Furneaux CE. Pituitary abscess following asymptomatic sphenoid sinusitis. J Laryngol Otol. 1984;98:1 151-1155. 5. Sanborn GE, Kivlin JD, Stevens M. Optic neuritis secondary to sinus disease. Arch Otolaryngol. 1984;1 10:816-819. 6. Johnson LN, Krohel GB, Yeon EB, Parnes SM. Sinus tumors invading the orbit. Ophthalmology. 1984;91 :209-217. 7. Diament MJ, Senac MD, Gilsanz V, et al. Prevalence of incidental paranasal sinuses opacification in pediatric patients: a CT study. J Comput Assist Tomogr. 1987;1 1:426-43 1. 8. Moore J, Potchen M, Sierra A, Waldenmaier N, Potchen EJ. High-field magnetic resonance imaging of paranasal sinus inflammatory disease. Laryngoscope. 1986;96:267-271. 9. Slamovits TL, Gardner TA. Neuroimaging in neuroophthalmology. Ophthalmology. 1989;96:555-568.
Literature Cited 1. Holt GR, Standefer JA, Brown WE, Gates GA. Infectious diseases of the sphenoid sinus. Laryngoscope. 1 986;94:330335.
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JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 1
Significant morbidity and mortality can result if early detection and treatment of sphAenoid sinusitis is not provided. A case is presented in which the diagnosis of sphenoid sinusitis was delayed because a routine computerized tomographic scan was normal. This case underscores the importance of specifically requesting views of the paranasal sinuses in suspected cases of sinusitis. Key words * sphenoid sinusitis * neurodiagnostic imaging
Complications from sphenoid sinusitis, such as irreversible visual loss, cranial nerve palsies, orbital or intracranial abscess, meningitis, cavernous sinus or carotid artery thrombosis, and even death, may be prevented by early detection and treatment of sphenoid sinusitis. 1-4 However, the diagnosis of isolated sphenoid sinusitis is often delayed because of misdiagnosis. In the following case, the diagnosis was considered but was initially missed because the physician ordered a routine cranial computerized tomographic (CT) scan, which did not provide adequate views of the paranasal sinuses.
CASE REPORT A 13-year-old boy received a 1-week course of oral
From the Neuro-Ophthalmology Division, Department of Ophthalmology, Pennsylvania State University, Hershey, Pennsylvania. Requests for reprints should be addressed to Dr Lenworth N. Johnson, Neuro-Ophthalmology Division, Mason Institute of Ophthalmology, University of Missouri-Columbia, Columbia, MO 65212. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 1
erythromycin for severe, right, retro-orbital and frontal pain thought to be due to sinusitis. Radiologic studies of the paranasal sinuses were not obtained prior to antibiotic initiation. Despite the antibiotic, the pain persisted, and the patient developed a low grade fever and horizontal diplopia. His examination was normal apart from his ill appearance, low grade fever, and right abducens nerve paresis. Laboratory studies showed increased Westergren sedimentation rate to 38 mm/hr and elevated leukocyte count to 14 000 cu/mm. A routine, cranial CT scan was normal. Opening pressure on lumbar puncture and cerebrospinal fluid analysis were normal. Neuro-ophthalmologic consultation, obtained one day after the above studies, confirmed the right abducens nerve paresis. On review of the initial, routine CT scan, it was noted that views of the paranasal sinuses were not provided. A second CT scan with coronal views of the paranasal and cavernous sinuses was then performed. This scan demonstrated opacified sphenoid sinuses without airfluid level and possible extension of inflammation to the right cavernous sinus (Figs I & 2). Intravenous ceftriaxone was instituted. The patient became asymptomatic, with complete resolution of the abducens nerve paresis occurring within 1 week. Intravenous ceftriaxone was discontinued and treatment with oral amoxicillin/clavulanate potassium was continued for 3 weeks. A follow-up CT scan of the paranasal sinuses following cessation of antibiotics showed marked improvement of the sphenoid sinus opacification.
DISCUSSION Neurodiagnostic imaging is not indicated for all cases of sinusitis. Plain radiographs of the paranasal sinuses may be helpful in documenting sinus opacifica85
SPHENOID SINUSITIS
'! ....
:......
~ ~ ~ ~ . . .,;e it.
.... ~~~~~~~~~~~~~~~~~~:,: g~
:. :.E..j::: .............. :.::
^~~~~~~~~~~~~~~~~~.. it. . ....fi
FiuE 2. Cooa copteid toorah
Figure 1. Coronal computerized tomography scan demonstrating bilateral sphenoid sinus opacification (arrows) suggestive of sphenoid sinusitis.
tion or air-fluid level suggestive of sinusitis. However, plain sinus radiographs are not as sensitive for detecting paranasal sinusitis as the CT scan.5 Hence, in patients with neurologic signs, such as the abducens palsy our patient showed, a CT scan is indicated. When CT scans are ordered, clinicians should be aware that routine, cranial CT scans may not provide adequate views of the paranasal sinuses.6 The clinicians ordering these studies should specifically request axial and direct coronal views of the paranasal sinuses. Sinus opacification may suggest sinusitis with diffuse mucosal thickening or fluid, chronic osteitis, soft tissue mass, or may also be seen in clinically normal individuals.7 Thus, following the administration of appropriate antibiotics, persistence of clinical signs or symptoms may warrant a second CT scan or magnetic resonance imaging of the paranasal sinuses.8,9
Figure 2. Coronal computerized tomography scan demonstrating suspected extension of inflammation to the right cavernous sinus (arrow) accounting for the right abducens nerve paresis. 2. Slavin ML, GlaserJS. Acute severe irreversible visual loss with sphenoethmoiditis-"posterior" orbital cellulitis. Arch Ophthalmol. 1 987; 1 05:345-348. 3. Sofferman RA. Cavernous sinus thrombophlebitis secondary to sphenoid sinusitis. Laryngoscope. 1983;93:797-800. 4. Marks PV, Furneaux CE. Pituitary abscess following asymptomatic sphenoid sinusitis. J Laryngol Otol. 1984;98:1 151-1155. 5. Sanborn GE, Kivlin JD, Stevens M. Optic neuritis secondary to sinus disease. Arch Otolaryngol. 1984;1 10:816-819. 6. Johnson LN, Krohel GB, Yeon EB, Parnes SM. Sinus tumors invading the orbit. Ophthalmology. 1984;91 :209-217. 7. Diament MJ, Senac MD, Gilsanz V, et al. Prevalence of incidental paranasal sinuses opacification in pediatric patients: a CT study. J Comput Assist Tomogr. 1987;1 1:426-43 1. 8. Moore J, Potchen M, Sierra A, Waldenmaier N, Potchen EJ. High-field magnetic resonance imaging of paranasal sinus inflammatory disease. Laryngoscope. 1986;96:267-271. 9. Slamovits TL, Gardner TA. Neuroimaging in neuroophthalmology. Ophthalmology. 1989;96:555-568.
Literature Cited 1. Holt GR, Standefer JA, Brown WE, Gates GA. Infectious diseases of the sphenoid sinus. Laryngoscope. 1 986;94:330335.
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