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Sphenoid sinusitis: Medical management
SPHENOID SINUSITIS: MANAGEMENT JESSICA
MEDICAL
W. LIM, MD
Sphenoid sinusitis may present with nonspecific symptoms, particularly when other sinuses are also inflamed. Diagnosis can be made with a combination of history, physical examination, and imaging. Prompt treatment is essential to avoid possible complications. Medical therapy focused on infection, inflammation, and obstruction may be adequate for resolution, but surgical intervention may be required in certain situations.
The location of the sphenoid sinus in the posterosuperior aspect of the nasal cavity is thought to provide protection against most irritants and organisms inhaled through the nose. Infection usually results from obstruction of the sinus outflow, whether by swelling, polyps, or neoplasm. The accurate diagnosis and appropriate treatment of sphenoid sinusitis are essential to provide symptomatic relief for the patient and to prevent complications. The medical management of inflammatory disease of the sphenoid sinus is briefly reviewed.
nostic tool to assess the sphenoid.2 A sphenoid air-fluid level or opacification with new onset symptoms indicates acute infection. In chronic inflammation, mucosal thickening or partial/complete opacification is seen. Heterogeneous opacification and calcifications may indicate allergic fungal sinusitis. An inferiorly or laterally based rounded opacity represents a polyp or mucus retention cyst, while a superiorly based opacity suggests a possible encephalocele. A careful review of the CT is essential to note sinus expansion, bone erosion, and indications of invasive infection, neoplasm, or complications. In cases of complete
DIAGNOSIS
sinus
Headache is the most common symptom of acute and chronic sphenoid sinusitis. Pain is classically retro-orbital but can be frontal or temporal, with radiation along trigeminal nerve distribution or to the occiput. Posterior nasal drainage may be noted. However, because the sphenoid is often not the only paranasal sinus affected alone, other symptoms, such as nasal congestion, rhinorrhea and facial pressure, may be rep0rted.i Acute, severe headache and fever should be presumed sphenoid sinusitis until proven otherwise. Patients with acute sphenoid sinusitis may be very ill at presentation and require immediate hospitalization. Visual disturbances and cranial nerve palsies (usually optic and abducens nerves) are associated more often with isolated sphenoid disease. Symptoms associated with complications are determined by the adjacent structures affected. Nasal endoscopy provides an assessment of the mucosa and septal position, along with visualization of the middle meat-us and the sphenoethmoid recess. Discharge from the posterior drainage pathway may be indicative of sphenoid involvement and can be cultured for pathogen identification. The presence of polyps or other intranasal masses can be detected. Endoscopy is usually not diagnostic in chronic sphenoid sinusitis unless an obvious obstruction is present. Imaging with noncontrast computerized tomography (CT’) of the paranasal sinuses is the most accurate diag-From the Department of Otolaryngology, SUNY Health Sciences Center at Brooklyn, Brooklyn, NY. Address reprint requests to Jessica W. Lim, MD, Assistant Professor, Department of Otolaryngology, SUNY Health Sciences Center at Brooklyn, 450 Clarkson Avenue, Box 126, Brooklyn, NY 11203. 0 2003 Elsevier Inc. All rights reserved. 1043-l 81 O/03/1403-0003$30.00/O dci:l O.l053/S1043-1810(03)00086-1 OPERATIVE
TECHNIQUES
IN OTOLARYNGOLOGY-HEAD
AND
NECK
opacification
and
complications,
follow-up
CT
should be performed to evaluate treatment response. Magnetic resonance imaging of the sinuses and surrounding structures can distinguish between a mass within the sinus and inspissated secretions, and is essential for assessing orbital and intracranial complications.
TREATMENT The treatment of sphenoid sinusitis should address likely pathogenic organisms, decrease mucosal inflammation, and facilitate drainage. Antimicrobial therapy should cover Streptococcus pneumoniae, Hemophilus influenzae, and Moraxella catarrhalis in acute sinusitis.3 In chronic sinusitis, Staphylococcus aureus and anaerobes are more often implicated. In the immunocompromised patient, Pseudomonas species must be considered, particularly with
isolated
sphenoid
infection.
Other
inflammatory
pro-
cesses, such as allergic fungal sinusitis, invasive fungal sinusitis, and polyps, require surgery and medical treatment. Topical nasal decongestants reduce swelling of the nasal mucosa. A decongestant-soaked pledget placed briefly in the sphenoethmoid recess and followed by nasal decongestant spray is ideal in the acute infection. Nasal steroids sprays are more appropriate in chronic sinusitis but are helpful with the acute infection when allergic rhinitis is a precipitating factor. A short course of oral steroids is an excellent anti-inflammatory tool for acute and chronic sinusitis, but judicial use should be exercised in patients with comorbidities such as diabetes. In the patient with symptoms of acute sphenoid sinusitis, treatment should be instituted immediately and the patient followed closely. If there is no change after 24 hours or there is deterioration in the patient’s condition, surgical drainage is indicated. Otherwise, the infectious process may progress to bacterial meningitis or cavernous sinus thrombosis. SURGERY,
VOL
14, NO 3 (SEPT),
2003:
PP 173-174
173
Allergic fungal sinusitis is a chronic condition that is suspected based on CT findings, typically opacified pansinusitis with heterogenous density, calcifications, and bone erosion. Diagnosis is made at surgery with allergic mucin populated with eosinophils, fungus identification (eg, stain, culture, or immunoassay), and no evidence of invasion. Bent and Kuhn proposed criteria for allergic fungal sinusitis that include the previously mentioned, in addition to the CT findings, allergy to fungus, and nasal polyps4 Treatment involves surgery for polyp removal and aeration of the sinuses, immunotherapy5, and postoperative medications. Medications that have been used to control or prevent allergic fungal sinusitis recurrence include topical and systemic steroids, and antifungal agents. However, no standard successful regimen has been established at this time. Invasive fungal sinusitis is the disease of the immunocompromised host. Mucor is the most common pathogen in this rapidly spreading infection that requires immediate surgical resection of the infected, devitalized tissues as well as intravenous amphotericin B. To confirm, the fungi can be identified in the tissue specimen on biopsy. Resection may be disfiguring but is essential to survival. Polypoid sinus disease is treated with combination therapy. Medical treatment should include nasal steroid
174
sprays, immunotherapy, and systemic steroids when appropriate. Certainly, preoperative oral steroids cause polyp shrinkage, allowing for less bleeding and for landmark identification. Antimicrobial agents are given in acute infection, but surgical resection of polyps is eventually needed. Care must be taken when following patients with polyps to look for bony erosion and mucoceles on CT. In conclusion, sphenoid sinusitis can vary in presentation, but proper diagnostic tools will lead the otolaryngologist-head and neck surgeon to the correct diagnosis and treatment.
REFERENCES 1. Lew D, Southwick FS, Montgomery WW, et al: Sphenoid sinusitis: A review of 30 cases. N Engl J Med 309:1149-1154, 1983 2. Lawson W, Reino AJ: Isolated sphenoid sinus disease: An analysis of 132 cases. Laryngoscope 107:1590-1595, 1997 3. Sinus and Allergy Health Partnership: Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Executive summary. Otolaryngol Head Neck Surg 123:1-32, 2000 (suppl 1) 4. Bent JP, Kuhn FA: Diagnosis of allergic fungal sinusitis. Otolaryngol Head Neck Surg 111:580-588, 1994 5. Mabry RL, Manning SC, Mabry CS: Immunotherapy in the treatment of allergic fungal sinusitis. Otolaryngol Head Neck Surg 116:31-35, 1997
SPHENOID
SINUSITIS:
MEDICAL
MANAGEMENT
MEDICAL
W. LIM, MD
Sphenoid sinusitis may present with nonspecific symptoms, particularly when other sinuses are also inflamed. Diagnosis can be made with a combination of history, physical examination, and imaging. Prompt treatment is essential to avoid possible complications. Medical therapy focused on infection, inflammation, and obstruction may be adequate for resolution, but surgical intervention may be required in certain situations.
The location of the sphenoid sinus in the posterosuperior aspect of the nasal cavity is thought to provide protection against most irritants and organisms inhaled through the nose. Infection usually results from obstruction of the sinus outflow, whether by swelling, polyps, or neoplasm. The accurate diagnosis and appropriate treatment of sphenoid sinusitis are essential to provide symptomatic relief for the patient and to prevent complications. The medical management of inflammatory disease of the sphenoid sinus is briefly reviewed.
nostic tool to assess the sphenoid.2 A sphenoid air-fluid level or opacification with new onset symptoms indicates acute infection. In chronic inflammation, mucosal thickening or partial/complete opacification is seen. Heterogeneous opacification and calcifications may indicate allergic fungal sinusitis. An inferiorly or laterally based rounded opacity represents a polyp or mucus retention cyst, while a superiorly based opacity suggests a possible encephalocele. A careful review of the CT is essential to note sinus expansion, bone erosion, and indications of invasive infection, neoplasm, or complications. In cases of complete
DIAGNOSIS
sinus
Headache is the most common symptom of acute and chronic sphenoid sinusitis. Pain is classically retro-orbital but can be frontal or temporal, with radiation along trigeminal nerve distribution or to the occiput. Posterior nasal drainage may be noted. However, because the sphenoid is often not the only paranasal sinus affected alone, other symptoms, such as nasal congestion, rhinorrhea and facial pressure, may be rep0rted.i Acute, severe headache and fever should be presumed sphenoid sinusitis until proven otherwise. Patients with acute sphenoid sinusitis may be very ill at presentation and require immediate hospitalization. Visual disturbances and cranial nerve palsies (usually optic and abducens nerves) are associated more often with isolated sphenoid disease. Symptoms associated with complications are determined by the adjacent structures affected. Nasal endoscopy provides an assessment of the mucosa and septal position, along with visualization of the middle meat-us and the sphenoethmoid recess. Discharge from the posterior drainage pathway may be indicative of sphenoid involvement and can be cultured for pathogen identification. The presence of polyps or other intranasal masses can be detected. Endoscopy is usually not diagnostic in chronic sphenoid sinusitis unless an obvious obstruction is present. Imaging with noncontrast computerized tomography (CT’) of the paranasal sinuses is the most accurate diag-From the Department of Otolaryngology, SUNY Health Sciences Center at Brooklyn, Brooklyn, NY. Address reprint requests to Jessica W. Lim, MD, Assistant Professor, Department of Otolaryngology, SUNY Health Sciences Center at Brooklyn, 450 Clarkson Avenue, Box 126, Brooklyn, NY 11203. 0 2003 Elsevier Inc. All rights reserved. 1043-l 81 O/03/1403-0003$30.00/O dci:l O.l053/S1043-1810(03)00086-1 OPERATIVE
TECHNIQUES
IN OTOLARYNGOLOGY-HEAD
AND
NECK
opacification
and
complications,
follow-up
CT
should be performed to evaluate treatment response. Magnetic resonance imaging of the sinuses and surrounding structures can distinguish between a mass within the sinus and inspissated secretions, and is essential for assessing orbital and intracranial complications.
TREATMENT The treatment of sphenoid sinusitis should address likely pathogenic organisms, decrease mucosal inflammation, and facilitate drainage. Antimicrobial therapy should cover Streptococcus pneumoniae, Hemophilus influenzae, and Moraxella catarrhalis in acute sinusitis.3 In chronic sinusitis, Staphylococcus aureus and anaerobes are more often implicated. In the immunocompromised patient, Pseudomonas species must be considered, particularly with
isolated
sphenoid
infection.
Other
inflammatory
pro-
cesses, such as allergic fungal sinusitis, invasive fungal sinusitis, and polyps, require surgery and medical treatment. Topical nasal decongestants reduce swelling of the nasal mucosa. A decongestant-soaked pledget placed briefly in the sphenoethmoid recess and followed by nasal decongestant spray is ideal in the acute infection. Nasal steroids sprays are more appropriate in chronic sinusitis but are helpful with the acute infection when allergic rhinitis is a precipitating factor. A short course of oral steroids is an excellent anti-inflammatory tool for acute and chronic sinusitis, but judicial use should be exercised in patients with comorbidities such as diabetes. In the patient with symptoms of acute sphenoid sinusitis, treatment should be instituted immediately and the patient followed closely. If there is no change after 24 hours or there is deterioration in the patient’s condition, surgical drainage is indicated. Otherwise, the infectious process may progress to bacterial meningitis or cavernous sinus thrombosis. SURGERY,
VOL
14, NO 3 (SEPT),
2003:
PP 173-174
173
Allergic fungal sinusitis is a chronic condition that is suspected based on CT findings, typically opacified pansinusitis with heterogenous density, calcifications, and bone erosion. Diagnosis is made at surgery with allergic mucin populated with eosinophils, fungus identification (eg, stain, culture, or immunoassay), and no evidence of invasion. Bent and Kuhn proposed criteria for allergic fungal sinusitis that include the previously mentioned, in addition to the CT findings, allergy to fungus, and nasal polyps4 Treatment involves surgery for polyp removal and aeration of the sinuses, immunotherapy5, and postoperative medications. Medications that have been used to control or prevent allergic fungal sinusitis recurrence include topical and systemic steroids, and antifungal agents. However, no standard successful regimen has been established at this time. Invasive fungal sinusitis is the disease of the immunocompromised host. Mucor is the most common pathogen in this rapidly spreading infection that requires immediate surgical resection of the infected, devitalized tissues as well as intravenous amphotericin B. To confirm, the fungi can be identified in the tissue specimen on biopsy. Resection may be disfiguring but is essential to survival. Polypoid sinus disease is treated with combination therapy. Medical treatment should include nasal steroid
174
sprays, immunotherapy, and systemic steroids when appropriate. Certainly, preoperative oral steroids cause polyp shrinkage, allowing for less bleeding and for landmark identification. Antimicrobial agents are given in acute infection, but surgical resection of polyps is eventually needed. Care must be taken when following patients with polyps to look for bony erosion and mucoceles on CT. In conclusion, sphenoid sinusitis can vary in presentation, but proper diagnostic tools will lead the otolaryngologist-head and neck surgeon to the correct diagnosis and treatment.
REFERENCES 1. Lew D, Southwick FS, Montgomery WW, et al: Sphenoid sinusitis: A review of 30 cases. N Engl J Med 309:1149-1154, 1983 2. Lawson W, Reino AJ: Isolated sphenoid sinus disease: An analysis of 132 cases. Laryngoscope 107:1590-1595, 1997 3. Sinus and Allergy Health Partnership: Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Executive summary. Otolaryngol Head Neck Surg 123:1-32, 2000 (suppl 1) 4. Bent JP, Kuhn FA: Diagnosis of allergic fungal sinusitis. Otolaryngol Head Neck Surg 111:580-588, 1994 5. Mabry RL, Manning SC, Mabry CS: Immunotherapy in the treatment of allergic fungal sinusitis. Otolaryngol Head Neck Surg 116:31-35, 1997
SPHENOID
SINUSITIS:
MEDICAL
MANAGEMENT