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Sphenoid Sinusitis

Sinusitides Sphenoid

Sphenoid sinusitis results from inflammation in the sphenoid sinuses that can occur following a viral or a bacterial infection.


Presentation

Characteristic symptoms of sinusitis include pressure and pain around the eyes and are worsened by bending. Sphenoid sinusitis also involves ear and neck pain, pain behind the eyes, in the temples and over the cranium. Sore throat and postnasal drip result from mucus drainage and lead to laryngeal irritation.

Symptoms that are common for both acute and chronic sinusitis are facial pressure and pain, congestion and obstruction of the nose, purulent rhinorrhea, bad breath, hyposmia and nocturnal productive cough. Pain in acute sinusitis tends to be more severe. The affected sinus is usually painful upon palpation, erythematous and edematous. Pain in sphenoid sinusitis is usually more diffuse and refers to the frontal and occipital areas. Other symptoms are fatigue, chills and fever.

Patients can also exhibit yellow or green purulent secretions. Secretions in the sphenoid sinusitis occur in the medial and middle turbinates.

Precocious Puberty
  • We present a case sphenoid sinusitis in ten years old girl where precocious puberty and slight headache were the main symptoms. Surgical drainage and antimicrobial treatment were administered.[ncbi.nlm.nih.gov]
Progressive Ophthalmoplegia
  • METHODS: A 37-year-old HIV-infected man presented with headache, reduced vision and progressive ophthalmoplegia in the right eye. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed sphenoid sinusitis.[ncbi.nlm.nih.gov]
Soft Tissue Mass
  • An enhancing left orbital, intrasellar and parasellar cavernous nodule on magnetic resonance imaging progressed into a right cavernous sinus and orbital apex soft tissue mass.[ncbi.nlm.nih.gov]
Parotid Swelling
  • A case of occult sphenoid sinusitis was diagnosed by an MRI scan in a patient who presented clinically with meningism and unilateral parotid swelling.[ncbi.nlm.nih.gov]
Chemosis
  • A 40-year-old male with left-sided headaches, ptosis, proptosis and extra-ocular muscle paralysis developed right-sided headaches, proptosis, chemosis, diplopia, extra-ocular muscle paralysis and trigeminal sensory loss.[ncbi.nlm.nih.gov]
  • Physical examination revealed an ipsilateral paresis of the superior division of the oculomotor nerve with chemosis. CT scan of the paranasal sinuses showed ipsilateral sphenoid sinusitis with cavernous sinus involvement.[ncbi.nlm.nih.gov]
  • A 33-year-old female visited our hospital for severe, right-sided, temporal headache, chemosis, periorbital edema, and proptosis.[ncbi.nlm.nih.gov]
  • Patients may present with preseptal inflammation, lid edema, chemosis, or ophthalmoplegia. We report a case of acute sphenoid sinusitis in a 10-year-old child who presented to the Emergency Department with essentially painless vision loss.[ncbi.nlm.nih.gov]
Abnormal Eye Movement
  • Worrisome findings include orbital proptosis, periorbital and malar edema, abnormal eye movements, disturbances in the visual fields and certain neurologic signs. Laboratory tests can be sometimes employed but are not critical for diagnosis.[symptoma.com]
Meningism
  • While the administration of meropenem and dexamethasone ameliorated the meningitis, right third and sixth nerve palsy suddenly developed 10 days after admission.[ncbi.nlm.nih.gov]
  • We demonstrated that early diagnosis is required for the successful treatment of pneumococcal meningitis. [Indexed for MEDLINE] Free full text[ncbi.nlm.nih.gov]
  • A case of occult sphenoid sinusitis was diagnosed by an MRI scan in a patient who presented clinically with meningism and unilateral parotid swelling.[ncbi.nlm.nih.gov]
  • Isolated sphenoid sinusitis is a rare disease with potentially devastating complications such as cranial nerve involvement, brain abscess, and meningitis. It occurs at an incidence of about 2.7% of all sinus infections.[ncbi.nlm.nih.gov]
  • A 64-year-old woman was initially seen unconscious with bacterial meningitis and cerebrospinal fluid (CSF) fistula. Imaging suggested sphenoid sinusitis with intracranial extension.[ncbi.nlm.nih.gov]
Vertex Headache
  • headache is common, but pain can be localized in frontal, temporal, periorbital, or occipital regions or can be vague or occur anywhere in the craniofacial region. 1 , 3 , 5 , 7 , 11 , 12 Visual changes indicating imminent complications are common, being[jamanetwork.com]
Ataxia
  • Miller Fisher syndrome (MFS), a variant of Guillain-Barré syndrome, is a rare disorder typically characterized by a triad of ataxia, areflexia, and ophthalmoplegia, which may have a highly variable clinical presentation.[ncbi.nlm.nih.gov]
Paresis
  • Physical examination revealed an ipsilateral paresis of the superior division of the oculomotor nerve with chemosis. CT scan of the paranasal sinuses showed ipsilateral sphenoid sinusitis with cavernous sinus involvement.[ncbi.nlm.nih.gov]
Guillain-Barré Syndrome
  • Miller Fisher syndrome (MFS), a variant of Guillain-Barré syndrome, is a rare disorder typically characterized by a triad of ataxia, areflexia, and ophthalmoplegia, which may have a highly variable clinical presentation.[ncbi.nlm.nih.gov]

Workup

Sphenoid sinusitis is diagnosed primarily after taking history and performing the physical exam. Additional lab testing is not recommended, particularly in the absence of complications. The latter tend to occur more frequently in children.

History begins with an assessment for the presence of risk factors such allergic rhinitis and viral infections targeting the upper respiratory tracts. Patients with these risk factors are more vulnerable for acute sinusitis in the setting of migraine or asthma. Viral and bacterial sinusitis can be differentiated based on progression and duration of the symptoms. Symptoms of viral infections tend to last less than 10 days, peak early and progressively become better [4] [5]. Bacterial infections, on the other hand, do not improve and last longer than 10 days. They may also become worse after a period of initial improvement. This phenomenon is called "double sickening" and is classical for bacterial infections.

Viral and bacterial sinusitis may also be differentiated by particular symptoms that present differently. Bacterial sinusitis is more strongly associated with obstruction of the nose, pain in the teeth, purulent nasal discharge, facial pain and pressure and headaches. Viral sinusitis occurs more commonly with muscle pain, sore throat, fever and a clear nasal discharge. The color of the mucus is usually not sufficient to distinguish between the two forms of sinusitis. Cough occurs both in bacterial and viral sinusitis and generally follows asthma exacerbations and postnasal discharge.

Head and neck exam is critical to establish the diagnosis. The physician should assess for facial tenderness, middle ear effusion, mucosal erythema and purulent discharge in the nasal cavity, tender maxillary dentition and postnasal pharyngeal exudates and secretions. The exam is usually performed after administration of a decongestant spray, utilizing a nasal speculum, head light and an otoscope [6]. Bacterial sinusitis is associated with facial tenderness, unilateral purulent secretions and mucosal redness and swelling. Viral etiologies are more strongly related with non-purulent secretions. Nasal endoscopy is also employed in specific patients, especially patients with an infection resistant to antibiotics, in populations where resistance is frequent and in patients suffering from immunodeficiency. It may also be used in patients where nasal exams are difficult to perform.

Endoscopy is available in two types, flexible and rigid. Both forms allow for better visualization of the nasal mucosa, although each has specific advantages over the other. Rigid endoscopy has higher resolution and can be operated with only one hand. Flexible endoscopy is usually more appreciated by patients, but needs the use of both hands. In children, flexible endoscopy is preferable but both types can be employed. Usually, an Ear, Nose and Throat specialist performs endoscopy and preference for either type varies with the personal experience of the specialist.

Some cases may require urgent referral to specialists because of a high risk of potential complications. Worrisome findings include orbital proptosis, periorbital and malar edema, abnormal eye movements, disturbances in the visual fields and certain neurologic signs.

Laboratory tests can be sometimes employed but are not critical for diagnosis. Cultures may help identify the involved organism and select antibiotic treatments, particularly in case of non-response, resistance or immunodeficiency. Cultures are better taken through endoscopy rather than sinus puncture. This is because pain is not common with endoscopy. Nonetheless, both methods yield similar results, particularly when purulence is involved [7] [8]. Cultures are usually not taken through swabs from the nasopharynx or the nasal mucosa without endoscopic visualization because they rarely identify the responsible organism.

Uncomplicated acute sinusitis seldom requires imaging tests and cannot distinguish between viral and bacterial etiologies. Complicated acute sinusitis with facial cellulitis and intracranial or orbital infections, nonetheless, are diagnosed with radiography [9]. Recurrent and chronic acute sinusitis may also require imaging studies. The two imaging modalities of choice are computed tomography (CT) and X-ray. CT scanning is usually administered without any contrast injections and suggestive findings are the presence of air-fluid level, sinus opacification and mucosal thickening. X-rays are only performed when CT scanning is not available or contraindicated. In children, lateral X-rays are preferred and can help to rule out hypertrophy of the adenoid glands in patients with nasal obstruction. Sensitivity and specificity of plain X-rays in the lateral, anterior-posterior and occipito-mental views are approximately 90% and 80%, respectively.

Clostridium Perfringens
  • We present what is believed to be the first reported case of Clostridium perfringens presenting as the causative pathogen in paranasal sinusitis.[ncbi.nlm.nih.gov]

Treatment

Treatment of acute sinusitis is targeted at removing the infection as well as resolving the symptoms associated with the disease. Acute sinusitis can also lead to serious complications that require prevention. 

Treatment is usually performed in the outpatient department by a general health practitioner. However, examination by a specialist is advised in cases of symptom worsening despite antibiotic administration, persistence of the disease after two courses of antibiotics treatment, recurrence of the disease, immunodeficiency or the presence of complications.

According to the Joint Task Force on Practice Parameters for Allergy and Immunology, response to antibiotic therapy is evaluated 3 to 5 days after initial administration, and then for 7 days if the patient exhibits improvements in their conditions. A combination of an antibiotic and intranasal corticosteroid is usually more effective in improving symptoms than antibiotics alone [10]. Nonetheless, overuse of antibiotics is common particularly in cases of mild acute sinusitis. Pyronnen et al found in a large retrospective cohort study that antibiotic administration in 66% of patients with mild acute sinusitis varies with the physician himself, his specialty and the presence of a medical trainee [11].

In addition to antibiotics, drainage is very important in select cases, and can be performed both surgically and medically. It is mostly recommended in the inpatient setting as a prevention method for severe sepsis

Surgical procedures are helpful in draining purulent discharge, improve flow and provide samples for bacterial culture and sensitivity measurements. Drainage can also be conducted with endoscopy and has several advantages that include decompression of the orbit when complications occur and permitting access for the surgeons for the ostia of the infected sinuses [12].

Prognosis

Sphenoid sinusitis has in general a good prognosis, with resolution achieved within one month. Antibiotics are still recommended in appropriate patients and they decrease severity, the infection period and the risk for complications.

Etiology

The majority of cases of bacterial sphenoid sinusitis is caused by Streptococcus pneumoniae and Haemophilus influenzae [3]. Haemophilus influenzae is transmitted through airborne droplets or direct contact with secretions containing the organisms. It is exclusively found in humans, can grow in both aerobic and anaerobic environments and normally colonizes the upper respiratory tract in 75% of healthy individuals.

Epidemiology

Sphenoid sinusitis is a rare form of sinusitis and accounts for only 2.7% of all cases of sinusitis. Nonetheless, it can have severe complications such as brain abscess formation, meningitis and involvement of the cranial nerves.

Sex distribution
Age distribution

Pathophysiology

Pain in sinusitis results from increased negative pressure due to elevated oxygen absorption into blood vessels present within the mucous membrane. The latter results from obstruction of the nasal mucosa that is common in upper respiratory infections. Increased negative pressure can ultimately lead to the formation of a transudate that eventually accumulates in the sinus. The transudate can further act as a nidus for bacterial infections that penetrate the sinus either from adjacent infections, such as thrombophlebitis or cellulitis in the mucous membranes, or directly through the bone. The presence of foreign organisms triggers an intense inflammatory reaction, manifesting with increase in serum in the sinus along with the presence of leukocytes. This, in turn, can elevate positive pressure causing pain, in addition to swelling and hyperemia of the mucous membranes.

Prevention

Prevention can be targeted at limiting infections with viral upper respiratory infections, in addition to treating allergic reactions, avoiding first and second hand smoking or deep diving in swimming pools. Dry nasal airways can also increase the risk of bacterial infection. This occurs especially in winter and can be treated with the use of humidifiers. Nasal sprays are additionally beneficial in limiting the inflammation that takes place in case of allergies.

Summary

Sphenoid sinusitis is an infection of the sphenoid sinuses that can be either bacterial or viral [1]. The most common bacterial pathogens involved are Streptococcus pneumoniae and Haemophilus influenzae. The pathophysiological mechanisms involved include increased negative pressure in the sinuses due to elevated oxygen absorption in the blood vessels. Increased oxygen absorption occurs due to obstruction of the nasal cavity. This is in turn can lead to pain and to extravasation of fluid within the sinus, that later may become a nidus for infection for a number of organisms. Patients usually present with periorbital pain and pressure as well as pain in the ears, in the temples and over the cranium. Other symptoms include nasal congestion, purulent discharge, fever, halitosis, cough, sore throat and laryngeal irritation. Diagnosis of sphenoid sinusitis is mostly established with history and physical exam. Viral sinusitis is generally characterized with rapid improvement and a duration of less than 10 days. Bacterial sinusitis generally exhibits worsening of symptoms after a short period of improvement or progressive worsening. Sinusitis is also more likely to be viral when it is associated with fever, sore throat, clear nasal discharge and myalgia. On the other hand, headaches, facial pain, purulent discharge and pain in the teeth are more strongly associated with bacterial sinusitis. Physical exam will show mucosal erythema, facial tenderness, purulent discharge as well as pharyngeal exudates and secretions. Laboratory tests are limited to bacterial cultures to identify the organism involved and assess antibiotic sensitivity. Treatment is with antibiotics, although current recommendations advise for a combination of antibiotics and a nasal steroid spray [2].

Patient Information

Acute sphenoid sinusitis describes an infection of spaces within the facial bones. The infection generally follows an upper respiratory infection and can either be viral or bacterial. The most common bacterial pathogens are Streptococcus pneumoniae and Haeomophilus influenzae. Patients usually present with headaches and pain in the face, over the head, in the ears and temples. Bacterial and viral sinusitis can be differentiated based on the course of the disease. Viral sinusitis usually resolves within 10 days and peaks early whereas bacterial sinusitis can worsen after a period of initial improvement or can progressively worsen. Some symptoms tend to occur more commonly with viral sinusitis such as muscle pain, fever, sore throat and clear nasal discharge. On the other hand, bacterial sinusitis is more strongly associated with thick, greenish unilateral discharge, facial pain, headaches and pain in the teeth. History and physical exam are critical for diagnosis. Extensive laboratory testing is not recommended and is limited to bacterial cultures. This can aid in identifying the responsible organisms as well as assess sensitivity of the bacterium to antibiotics. Sinusitis is best treated with antibiotics in addition to a steroidal nasal spray. In some cases, surgical or medical drainage are necessary to avoid the development of complications. Prognosis is excellent if the disease is treated early and extensively before complications occur.

References

Article

  1. Shpilberg KA, Daniel SC, Doshi AH, Lawson W, Som PM. CT of Anatomic Variants of the Paranasal Sinuses and Nasal Cavity: Poor Correlation With Radiologically Significant Rhinosinusitis but Importance in Surgical Planning. AJR Am J Roentgenol. 2015 Jun. 204 (6):1255-60.
  2. Gwaltney JM Jr. Acute community-acquired sinusitis. Clin Infect Dis 1996;23:1209–25.
  3. Ng YT, Butler IJ. Sphenoid sinusitis masquerading as migraine headaches in children. J Child Neurol 2001;16(12):882–4.
  4. Rosenfeld RM, Andes D, Bhattacharyya N, et al. Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg. 2007;137(suppl 3):S1-S31.
  5. Gwaltney JM Jr, Hendley JO, Simon G, et al. Rhinovirus infections in an industrial population. II. Characteristics of illness and antibody response. JAMA. 1967;202:494-500.
  6. Benninger MS, Ferguson BJ, Hadley JA, et al. Adult chronic rhinosinusitis: definitions, diagnosis, epidemiology, and pathophysiology. Otolaryngol Head Neck Surg. 2003;129(suppl 3):S1-S32.
  7. Young J, De Sutter A, Merenstein D, et al. Antibiotics for adults with clinically diagnosed acute rhinosinusitis: a meta-analysis of individual patient data. Lancet. 2008;371:908-914.
  8. Dubin MG, Ebert CS, Coffey CS, et al. Concordance of middle meatal swab and maxillary sinus aspirate in acute and chronic sinusitis: a meta-analysis. Am J Rhinol. 2005;19:462-470.
  9. Gendo K. Evidence-based diagnostic strategies for evaluating suspected allergic rhinitis. Ann Intern Med. 2004;140:278-289.
  10. Georgy MS, Peters AT. Chapter 8: Rhinosinusitis. Allergy Asthma Proc. 2012 May-Jun. 33 Suppl 1:S24-7.
  11. Pynnonen MA, Lynn S, Kern HE, et al. Diagnosis and treatment of acute sinusitis in the primary care setting: A retrospective cohort. Laryngoscope. 2015 Oct;125(10):2266-72.
  12. Patel RG, Daramola OO, Linn D, et al. Do you need to operate following recovery from complications of pediatric acute sinusitis?. Int J Pediatr Otorhinolaryngol. 2014 Jun. 78(6):923-5. 

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Last updated: 2018-06-22 05:34