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Sphenoid sinusitis, a cause of debilitating headache
Printed in the USA * Copyright 8 1990 Pergamon Press plc
The Journal of Emergency Medicine, Vol. 8, pp. 557459, 1990
SPHENOID
SINUSITIS,
A CAUSE OF DEBILITATING
Linda Nordeman,
MD,
and Emily Jean Lucid,
HEADACHE
MD
Department of Emergency Medicine, Medical College of Pennsylvania, Allegheny Campus, Pittsburgh, Pennsylvania Reprint address: Linda Nordeman, MD, Division of Emergency Medicine, Allegheny General Hospital, 320 E. North Avenue, Pittsburgh, PA 15212
intracranial hemorrhage or mass effect. A lumbar puncture was performed, and evaluation of the cerebral spinal fluid (CSF) was unremarkable. No organisms were seen on Gram’s stain, cell count revealed two red blood cells and one white blood cell, and glucose and protein were within normal limits. The patient was discharged with the diagnosis of cephalgia with a prescription for Fiorinal . He had persistent pain, and the following day he saw his dentist who ruled out any intraoral etiology of his headache. That evening he returned to the emergency department with persistent headache unresponsive to Fiorinal. He had no change in the character of the pain. He had no associated fever, chills, or nasal discharge. His examination was again unremarkable. The official report (from the CT scan performed the previous night) was obtained during this visit and revealed opacification of the sphenoid sinus. CSF culture from the previous night was negative. The patient received intramuscular Demerol and Vistaril with minimal relief. He was discharged on antibiotics and a decongestant with the diagnosis of sinusitis. The following day he saw his private physician. Despite oral antibiotics and analgesics his headache had increased in intensity. He had gone without sleep for two nights and appeared extremely fatigued and in obvious discomfort. He was admitted to the hospital for further evaluation. Sinus radiographs and a CT scan of the sinuses revealed opacification of the maxillary, ethmoid, and sphenoid sinuses bilaterally. He was treated with a IO-day course of intravenous (IV) antibiotics; (eight days of Ampicillin and two days of Claforan) with moderate pain relief. He was discharged on oral Keflex. He subsequently developed increasingly severe headaches necessitating readmission and surgical drainage of the
0 Abstract - We present a case of sphenoid sinusitis resulting in a debilitating headache refractory to both oral and intramuscular analgesics. Despite an aggressive evaluation in the emergency department, the correct diagnosis and appropriate treatment were delayed. Recognition of sphenoid sinusitis, the complications associated with it, and the need for aggressive management are addressed. 0 Keywords - headache; sphenoid sinusitis
INTRODUCTION Sphenoid sinusitis, an uncommon cause of headache, is associated with significant morbidity and mortality and requires aggressive management. Because the incidence of this disease is low and the initial symptoms are nonspecific, it is often misdiagnosed. In addition, routine sinus x-ray studies may fail to reveal opacification of the sphenoid sinus.
CASE REPORT A 35-year-old white male presented to the emergency department with a 2-day history of severe headache, described as a tight band encircling his head and radiating down his neck. The pain had increased in intensity since the onset two days prior to presentation. The patient complained of an inability to sleep or concentrate. He had no relief after taking aspirin or acetaminophen. He had experienced no associated fever, chills, nausea, photophobia, or visual changes. His physical examination was entirely within normal limits. His evaluation included unenhanced computed tomography (CT scan) of the head, which revealed no evidence of
RECEIVED: 30 ACCEPTED:
October 1989; FINALSUBMISSIONRECEIVED:2 March 1990 12 March 1990 557
0736-4679/90 $3.00 + .OO
Linda Nordeman and Emily Jean Lucid
558
Cribiform Optic Carotid A.
Sphtkoid Sinuses
A
B
Figure 1. Sagittal and coronal sections of the sphenold sinus. The sagittal section (A) demonstrates the relationship of the sphenold sinus to the sella turcica, nasophatynx, and cribriform plate. The coronal section through the posterior aspect of the sphenoid sinus (B) demonstrates the relationship of the sinus to multiple adjacent structures.
sphenoid sinuses. At operation a large amount of purulent material was evacuated from the sphenoid sinuses. Cultures were sterile. The patient had immediate relief of his headache and an unremarkable postoperative course. DISCUSSION Headache is a frequent presenting complaint in the emergency department. The challenge to the emergency physician is to identify patients with a potentially life threatening etiology of their pain. Included in the differential is an uncommon and an infrequently considered disease - sphenoid sinusitis. The sphenoid sinus has been described as the “neglected sinus” (1) due to its location and often nonspecific symptoms when inflamed. However, sphenoid sinusitis is associated with significant morbidity and requires early recognition and aggressive management. The purpose of this report is to review the pathology of sphenoid sinusitis so that it will be aggressively sought in the patient with severe headache of unknown etiology. The sphenoid sinus develops during childhood and becomes clinically significant between the ages of 3 to 5 years. It is located adjacent to many critical vascular and neurologic structures (Figure l), and it is these anatomic relationships that make inflammation of this sinus clinically significant. The sinus walls are directly adjacent to the dura mater, the pituitary gland, the optic nerve and chiasm, and the cavernous sinus, through which travel the carotid artery and cranial nerves III, IV, V and VI (1,2). Fugil et al. (3) examined these relationships in 25 cadavers. He found that in over 75% of cases, the sinus walls were less than 0.5 mm thick and that in several
cases only the mucosa separated the sinus from the dura. With such close approximation of the sinus to these structures, it is not surprising that untreated sphenoid sinusitis can result in significant morbidity and mortality. In a series of 30 cases (15 acute and 15 chronic), Lew et al. (4) found that delay in treatment was always associated with serious morbidity and occasional mortality. In the 15 cases of acute sphenoid sinusitis, he reported the occurrence of cavernous sinus thrombosis in 5, meningitis in 6 (4 of whom also had cavernous sinus thrombosis), orbital cellulitis in 1, and cortical vein thromboses in 1. Other authors have reported similar findings (5-8). Abscesses of the pituitary gland (8-lo), nasal septum (1 l), epidural, subdural, and intracerebral spaces have been described (8) as has severe, debilitating pain (6,12-14). It is clear that a process associated with such morbidity requires early diagnosis and treatment. This frequently is difficult, however. The incidence of this disorder is low (4), the initial signs and symptoms are often nonspecific, and routine sinus films may be inadequate (4,7). The literature contains scattered isolated reports and few large reviews. Of 950 cases of sinus disease treated at the Mayo Clinic from 1935 through 1972, Wyllie et al ( 12) found only 2 1 cases involving isolated inflammation of the sphenoid sinus. Involvement of contiguous sinuses is more commonly found. Of 31 cases of infectious disease involving the sphenoid sinus, Holt et al (16) found that 65% involved the adjacent sinuses. In a large, 12-year review from Massachusetts Eye and Ear Infirmary and Massachusetts General Hospital, Lew (4) reported 30 cases of sphenoid sinusitis. He
Sphenoid Sinusitis
559
found an equal number of acute and chronic cases. In addition, he found that 60% of acute cases were initially misdiagnosed resulting in a delay in treatment. All of the patients with delayed treatment had serious complications or died. Misdiagnosis is most likely due to the early nonspecific symptoms. The most common presenting complaint is headache (4,15-16). This may vary in both location (retro-orbital, vertex, frontal, or parietal-occipital) (7) and quality (sharp, boring, throbbing) (12). It is usually severe, interfering with sleep and not relieved by aspirin. Patients may have fever and purulent nasal discharge (4). This is not universal, however (7). As the process extends and involves contiguous structures, patients present with meningeal signs, cranial neuropathies involving cranial nerves III, IV, V, or VI (7,17), periorbital swelling, lethargy, and increasing mental status changes (16). Laboratory evaluation may reveal a leukocytosis (14). Lumbar puncture and CSF examination may be normal (6), or may be consistent with a parameningeal infection (18-19), or consistent with frank meningitis (7,16). Routine sinus x-ray studies may be diagnostic. The sphenoid sinus is best visualized on the lateral and submentovertex views (6,16), and these views should be examined carefully for opacification. Sinus films may be inadequate, however (4,7). Normal sinus films are not uncommon in surgically documented cases of sphenoid sinusitis (12). Therefore, further radiologic evaluation
may be necessary if sinus views are normal. CT scan is a sensitive test for sphenoid sinus disease. Routine, unenhanced head CT is usually adequate, but at times thin sections through the base of the skull are necessary (20-21). A CT scan is frequently ordered in patients presenting with severe headaches to rule out an intracranial bleed or mass lesion. As in this case, a CT scan ordered for these reasons, may reveal opacification of the sphenoid sinus. Treatment involves both a medical and surgical approach (16,22). The number of undiagnosed cases associated with maxillary or frontal sinusitis and treated successfully with oral antibiotics is unknown. Most documented cases, however, have required both surgical drainage and intravenous antibiotics (16). The most common organisms involved are Staphylococcus aureus, Streptococcus pneumoniae, and occasionally gram-negative organisms (4). Antibiotic therapy is based on culture results in surgically treated cases. If cultures are not available, appropriate coverage of the above organisms is necessary. Sphenoid sinusitis, an uncommon disorder, should be considered in the differential of severe debilitating headache. The diagnosis may become apparent if the patient is evaluated for an intracranial bleed, meningitis, or sinusitis. It is important to recognize opacification of the sphenoid sinus and initiate aggressive treatment, as a delay in treatment is associated with a high incidence of serious complications or death.
REFERENCES 1. Levine H. The sphenoid sinus, the neglected nasal sinus. Arch Otolaryngol. 1978;104:585-7. 2. Van Alyea OE. Sphenoid sinus: anatomic study, with consideration of the clinical significance of the structural characteristic of the sphenoid sinus. Arch Otolaryngol. 1941;34:225-53. 3. Fujii K, Chambers SM. Rhoton AL. Neurovascular relationships of the sphenoid sinus. J Neurosurg. 1979;50:31-9. 4. Lew D, Southwick FS, Montgomery WW, Weber AL, Baker AS. Sphenoid sinusitis: a review of 30 cases. N Engl J Med. 1983;309: 1149-54. 5. Quick CA, Payne E. Complicated acute sinusitis. Laryngoscope. 1972;1248-63. 6. Dale BAB, Mackenzie II. The complications of sphenoid sinusitis. J Laryngol Otol. 1983;97:661-70. S, Smelt GJC. Acute sphenoiditis, alone and in 7. Abramovich concert. J Laryngol Otol. 1982;96:751-7. 8. Teed RW. Meningitis from the sphenoid sinus. Arch Otolaryngol. 1938;589-619. 9. Marks PV, Fumeaux CE. Pituitary abscess following asymptomatic snhenoid sinusitis. J Larvngol Otol. 1984;98:1151-5. SC, Goldenberg HI. 10. Nelson DA, Holloway WJ: KaraEneff Neurological syndromes produced by sphenoid sinus abscess. Neurol. 1967;17:981-7. isolated 11. Collins MP. Abscess of the nasal septum complicating acute sphenoiditis. J Laryngol Otol. 1985;99:715-9. 12. Wyllie JW III, Kern EB, Djalilian M. Isolated sphenoid sinus
lesions. Laryngoscope. 1973;1252-65. 13. Sellars BL, De Villiers JC. Clinical records: the sphenoid sinus mucocoele. J Laryngol Otol. 1981;95:493-502. 14. Myer CM, III, Herwig SO, Seid AB, Cotton RT, Towbin RB. Acute sphenoid sinusitis in children. Am J Otolaryngol. 1982;3: 223-6. 15. Harrington P. Complications of sinusitis. Ear Nose Throat J. 1984;63:163-71. 16. Holt GR, Strandefer JA, Brown WE, Gates GA. Infectious diseases of the sphenoid sinus. Laryngoscope. 1984;94:330-5. 17. Weisberger EC, Dedo HH: Cranial neuropathies in sinus disease. Laryngoscope. 1976;35763. 18. Brook I, Overturf GD, Steinberg EA, Hawkins DB. Acute sphenoid sinusitis presenting as aseptic meningitis: a pachymeningitis syndrome. Int J Pediatr Otorhinolatyngol. 1982;4:77-81. 19. Finkelstein R, Honigman S, Doron Y, Braun Y. Sphenoid sinusitis presenting as &tonic meningitis. Eur Neurol. 1986;25: 183-7. 20. Yune HY. Holden RW, Smith JA. Normal variations and lesions of the sphenoid sinus. AJR. 1975;124:129-38. 21. Mac Rae D, Lampe H. Use of computer assisted tomography in the diagnosis of lesions in and around the sphenoid sinus. J Otolaryngol. 1980;9:412-18. 22. Ramsey PG, Weymuller EA. Complications of bacterial infection of the ears, paranasal sinuses, and oropharynx in adults. Emerg Med Clinic N Am. 1985;3: 143-61.
The Journal of Emergency Medicine, Vol. 8, pp. 557459, 1990
SPHENOID
SINUSITIS,
A CAUSE OF DEBILITATING
Linda Nordeman,
MD,
and Emily Jean Lucid,
HEADACHE
MD
Department of Emergency Medicine, Medical College of Pennsylvania, Allegheny Campus, Pittsburgh, Pennsylvania Reprint address: Linda Nordeman, MD, Division of Emergency Medicine, Allegheny General Hospital, 320 E. North Avenue, Pittsburgh, PA 15212
intracranial hemorrhage or mass effect. A lumbar puncture was performed, and evaluation of the cerebral spinal fluid (CSF) was unremarkable. No organisms were seen on Gram’s stain, cell count revealed two red blood cells and one white blood cell, and glucose and protein were within normal limits. The patient was discharged with the diagnosis of cephalgia with a prescription for Fiorinal . He had persistent pain, and the following day he saw his dentist who ruled out any intraoral etiology of his headache. That evening he returned to the emergency department with persistent headache unresponsive to Fiorinal. He had no change in the character of the pain. He had no associated fever, chills, or nasal discharge. His examination was again unremarkable. The official report (from the CT scan performed the previous night) was obtained during this visit and revealed opacification of the sphenoid sinus. CSF culture from the previous night was negative. The patient received intramuscular Demerol and Vistaril with minimal relief. He was discharged on antibiotics and a decongestant with the diagnosis of sinusitis. The following day he saw his private physician. Despite oral antibiotics and analgesics his headache had increased in intensity. He had gone without sleep for two nights and appeared extremely fatigued and in obvious discomfort. He was admitted to the hospital for further evaluation. Sinus radiographs and a CT scan of the sinuses revealed opacification of the maxillary, ethmoid, and sphenoid sinuses bilaterally. He was treated with a IO-day course of intravenous (IV) antibiotics; (eight days of Ampicillin and two days of Claforan) with moderate pain relief. He was discharged on oral Keflex. He subsequently developed increasingly severe headaches necessitating readmission and surgical drainage of the
0 Abstract - We present a case of sphenoid sinusitis resulting in a debilitating headache refractory to both oral and intramuscular analgesics. Despite an aggressive evaluation in the emergency department, the correct diagnosis and appropriate treatment were delayed. Recognition of sphenoid sinusitis, the complications associated with it, and the need for aggressive management are addressed. 0 Keywords - headache; sphenoid sinusitis
INTRODUCTION Sphenoid sinusitis, an uncommon cause of headache, is associated with significant morbidity and mortality and requires aggressive management. Because the incidence of this disease is low and the initial symptoms are nonspecific, it is often misdiagnosed. In addition, routine sinus x-ray studies may fail to reveal opacification of the sphenoid sinus.
CASE REPORT A 35-year-old white male presented to the emergency department with a 2-day history of severe headache, described as a tight band encircling his head and radiating down his neck. The pain had increased in intensity since the onset two days prior to presentation. The patient complained of an inability to sleep or concentrate. He had no relief after taking aspirin or acetaminophen. He had experienced no associated fever, chills, nausea, photophobia, or visual changes. His physical examination was entirely within normal limits. His evaluation included unenhanced computed tomography (CT scan) of the head, which revealed no evidence of
RECEIVED: 30 ACCEPTED:
October 1989; FINALSUBMISSIONRECEIVED:2 March 1990 12 March 1990 557
0736-4679/90 $3.00 + .OO
Linda Nordeman and Emily Jean Lucid
558
Cribiform Optic Carotid A.
Sphtkoid Sinuses
A
B
Figure 1. Sagittal and coronal sections of the sphenold sinus. The sagittal section (A) demonstrates the relationship of the sphenold sinus to the sella turcica, nasophatynx, and cribriform plate. The coronal section through the posterior aspect of the sphenoid sinus (B) demonstrates the relationship of the sinus to multiple adjacent structures.
sphenoid sinuses. At operation a large amount of purulent material was evacuated from the sphenoid sinuses. Cultures were sterile. The patient had immediate relief of his headache and an unremarkable postoperative course. DISCUSSION Headache is a frequent presenting complaint in the emergency department. The challenge to the emergency physician is to identify patients with a potentially life threatening etiology of their pain. Included in the differential is an uncommon and an infrequently considered disease - sphenoid sinusitis. The sphenoid sinus has been described as the “neglected sinus” (1) due to its location and often nonspecific symptoms when inflamed. However, sphenoid sinusitis is associated with significant morbidity and requires early recognition and aggressive management. The purpose of this report is to review the pathology of sphenoid sinusitis so that it will be aggressively sought in the patient with severe headache of unknown etiology. The sphenoid sinus develops during childhood and becomes clinically significant between the ages of 3 to 5 years. It is located adjacent to many critical vascular and neurologic structures (Figure l), and it is these anatomic relationships that make inflammation of this sinus clinically significant. The sinus walls are directly adjacent to the dura mater, the pituitary gland, the optic nerve and chiasm, and the cavernous sinus, through which travel the carotid artery and cranial nerves III, IV, V and VI (1,2). Fugil et al. (3) examined these relationships in 25 cadavers. He found that in over 75% of cases, the sinus walls were less than 0.5 mm thick and that in several
cases only the mucosa separated the sinus from the dura. With such close approximation of the sinus to these structures, it is not surprising that untreated sphenoid sinusitis can result in significant morbidity and mortality. In a series of 30 cases (15 acute and 15 chronic), Lew et al. (4) found that delay in treatment was always associated with serious morbidity and occasional mortality. In the 15 cases of acute sphenoid sinusitis, he reported the occurrence of cavernous sinus thrombosis in 5, meningitis in 6 (4 of whom also had cavernous sinus thrombosis), orbital cellulitis in 1, and cortical vein thromboses in 1. Other authors have reported similar findings (5-8). Abscesses of the pituitary gland (8-lo), nasal septum (1 l), epidural, subdural, and intracerebral spaces have been described (8) as has severe, debilitating pain (6,12-14). It is clear that a process associated with such morbidity requires early diagnosis and treatment. This frequently is difficult, however. The incidence of this disorder is low (4), the initial signs and symptoms are often nonspecific, and routine sinus films may be inadequate (4,7). The literature contains scattered isolated reports and few large reviews. Of 950 cases of sinus disease treated at the Mayo Clinic from 1935 through 1972, Wyllie et al ( 12) found only 2 1 cases involving isolated inflammation of the sphenoid sinus. Involvement of contiguous sinuses is more commonly found. Of 31 cases of infectious disease involving the sphenoid sinus, Holt et al (16) found that 65% involved the adjacent sinuses. In a large, 12-year review from Massachusetts Eye and Ear Infirmary and Massachusetts General Hospital, Lew (4) reported 30 cases of sphenoid sinusitis. He
Sphenoid Sinusitis
559
found an equal number of acute and chronic cases. In addition, he found that 60% of acute cases were initially misdiagnosed resulting in a delay in treatment. All of the patients with delayed treatment had serious complications or died. Misdiagnosis is most likely due to the early nonspecific symptoms. The most common presenting complaint is headache (4,15-16). This may vary in both location (retro-orbital, vertex, frontal, or parietal-occipital) (7) and quality (sharp, boring, throbbing) (12). It is usually severe, interfering with sleep and not relieved by aspirin. Patients may have fever and purulent nasal discharge (4). This is not universal, however (7). As the process extends and involves contiguous structures, patients present with meningeal signs, cranial neuropathies involving cranial nerves III, IV, V, or VI (7,17), periorbital swelling, lethargy, and increasing mental status changes (16). Laboratory evaluation may reveal a leukocytosis (14). Lumbar puncture and CSF examination may be normal (6), or may be consistent with a parameningeal infection (18-19), or consistent with frank meningitis (7,16). Routine sinus x-ray studies may be diagnostic. The sphenoid sinus is best visualized on the lateral and submentovertex views (6,16), and these views should be examined carefully for opacification. Sinus films may be inadequate, however (4,7). Normal sinus films are not uncommon in surgically documented cases of sphenoid sinusitis (12). Therefore, further radiologic evaluation
may be necessary if sinus views are normal. CT scan is a sensitive test for sphenoid sinus disease. Routine, unenhanced head CT is usually adequate, but at times thin sections through the base of the skull are necessary (20-21). A CT scan is frequently ordered in patients presenting with severe headaches to rule out an intracranial bleed or mass lesion. As in this case, a CT scan ordered for these reasons, may reveal opacification of the sphenoid sinus. Treatment involves both a medical and surgical approach (16,22). The number of undiagnosed cases associated with maxillary or frontal sinusitis and treated successfully with oral antibiotics is unknown. Most documented cases, however, have required both surgical drainage and intravenous antibiotics (16). The most common organisms involved are Staphylococcus aureus, Streptococcus pneumoniae, and occasionally gram-negative organisms (4). Antibiotic therapy is based on culture results in surgically treated cases. If cultures are not available, appropriate coverage of the above organisms is necessary. Sphenoid sinusitis, an uncommon disorder, should be considered in the differential of severe debilitating headache. The diagnosis may become apparent if the patient is evaluated for an intracranial bleed, meningitis, or sinusitis. It is important to recognize opacification of the sphenoid sinus and initiate aggressive treatment, as a delay in treatment is associated with a high incidence of serious complications or death.
REFERENCES 1. Levine H. The sphenoid sinus, the neglected nasal sinus. Arch Otolaryngol. 1978;104:585-7. 2. Van Alyea OE. Sphenoid sinus: anatomic study, with consideration of the clinical significance of the structural characteristic of the sphenoid sinus. Arch Otolaryngol. 1941;34:225-53. 3. Fujii K, Chambers SM. Rhoton AL. Neurovascular relationships of the sphenoid sinus. J Neurosurg. 1979;50:31-9. 4. Lew D, Southwick FS, Montgomery WW, Weber AL, Baker AS. Sphenoid sinusitis: a review of 30 cases. N Engl J Med. 1983;309: 1149-54. 5. Quick CA, Payne E. Complicated acute sinusitis. Laryngoscope. 1972;1248-63. 6. Dale BAB, Mackenzie II. The complications of sphenoid sinusitis. J Laryngol Otol. 1983;97:661-70. S, Smelt GJC. Acute sphenoiditis, alone and in 7. Abramovich concert. J Laryngol Otol. 1982;96:751-7. 8. Teed RW. Meningitis from the sphenoid sinus. Arch Otolaryngol. 1938;589-619. 9. Marks PV, Fumeaux CE. Pituitary abscess following asymptomatic snhenoid sinusitis. J Larvngol Otol. 1984;98:1151-5. SC, Goldenberg HI. 10. Nelson DA, Holloway WJ: KaraEneff Neurological syndromes produced by sphenoid sinus abscess. Neurol. 1967;17:981-7. isolated 11. Collins MP. Abscess of the nasal septum complicating acute sphenoiditis. J Laryngol Otol. 1985;99:715-9. 12. Wyllie JW III, Kern EB, Djalilian M. Isolated sphenoid sinus
lesions. Laryngoscope. 1973;1252-65. 13. Sellars BL, De Villiers JC. Clinical records: the sphenoid sinus mucocoele. J Laryngol Otol. 1981;95:493-502. 14. Myer CM, III, Herwig SO, Seid AB, Cotton RT, Towbin RB. Acute sphenoid sinusitis in children. Am J Otolaryngol. 1982;3: 223-6. 15. Harrington P. Complications of sinusitis. Ear Nose Throat J. 1984;63:163-71. 16. Holt GR, Strandefer JA, Brown WE, Gates GA. Infectious diseases of the sphenoid sinus. Laryngoscope. 1984;94:330-5. 17. Weisberger EC, Dedo HH: Cranial neuropathies in sinus disease. Laryngoscope. 1976;35763. 18. Brook I, Overturf GD, Steinberg EA, Hawkins DB. Acute sphenoid sinusitis presenting as aseptic meningitis: a pachymeningitis syndrome. Int J Pediatr Otorhinolatyngol. 1982;4:77-81. 19. Finkelstein R, Honigman S, Doron Y, Braun Y. Sphenoid sinusitis presenting as &tonic meningitis. Eur Neurol. 1986;25: 183-7. 20. Yune HY. Holden RW, Smith JA. Normal variations and lesions of the sphenoid sinus. AJR. 1975;124:129-38. 21. Mac Rae D, Lampe H. Use of computer assisted tomography in the diagnosis of lesions in and around the sphenoid sinus. J Otolaryngol. 1980;9:412-18. 22. Ramsey PG, Weymuller EA. Complications of bacterial infection of the ears, paranasal sinuses, and oropharynx in adults. Emerg Med Clinic N Am. 1985;3: 143-61.