Trombosis del seno cavernoso derecho secundaria a rinosinusitis esfenoidal: reporte de caso / Right cavernous sinus thrombosis secondary to sphenoidal rhinosinusitis: case report

RESUMEN La rinosinusitis bacteriana aguda es la infección de la mucosa nasal y de senos paranasales, que se manifiesta con congestión nasal, rinorrea purulenta y fiebre, de curso generalmente autolimitado. La trombosis del seno cavernoso (TSC) es una complicación poco frecuente, que se asocia a compromiso del seno esfenoidal y etmoidal, manifestándose clínicamente con cefalea, fiebre, alteración de pares craneanos y síntomas oculares. Ante su sospecha el estudio imagenológico es fundamental. En estos exámenes se debe buscar un defecto de llene en el seno cavernoso comprometido. El tratamiento debe iniciarse de forma precoz y contempla: antibioticoterapia, drenaje quirúrgico del seno afectado y anticoagulación. Se presenta a un paciente pediátrico masculino con TSC derecha posterior a una rinosinusitis esfenoidal no tratada, que respondió favorablemente al tratamiento. Se describe la clínica y manejo de esta patología, que presenta alta morbimortalidad, y que puede disminuirse considerablemente con un tratamiento precoz y agresivo.

ABSTRACT Acute bacterial rhinosinusitis is the infection of the nasal and paranasal mucous membrane, with symptoms such as nasal congestion, purulent rhinorrhea and fever, usually self-limiting. Cavernous sinus thrombosis (CST) is a rare complication, which is associated with sphenoid and ethmoid sinus involvement, clinically manifest with headache, fever, cranial nerve involvement and ocular symptoms. When suspected, imaging studies will confirm the clinical impression. They will show abnormal flow parameters in the compromised cavernous sinus. The treatment has to start as soon as possible and consists in broad spectrum intravenous antibiotics, surgical drainage of the site of the infection and anticoagulation. We present a patient with a right CST secondary to a non-treated sphenoidal sinusitis, that responded favorably to treatment. The clinical and management of this pathology is described, which presents a high morbidity and mortality that can be reduced considerably with an early and aggressive treatment.

Comparison of cone-beam computed tomography and panoramic radiography in the evaluation of maxillary sinus pathology related to maxillary posterior teeth: Do apical lesions increase the risk of maxillary sinus pathology?

PURPOSE: The aims of this study were first, to compare panoramic radiography with cone-beam computed tomography (CBCT) for evaluating topographic relationships, such as the classification of maxillary posterior teeth and their distance to the maxillary sinus floor; and second, to determine the relationship between maxillary sinus pathology and the presence of apical lesions. MATERIALS AND METHODS: In total, 285 paired CBCT and panoramic radiography records of patients (570 maxillary sinuses) were retrospectively analyzed. Both imaging modalities were used to determine the topographic relationship of the maxillary posterior teeth to the sinus floor. Mucosal thickening >2 mm was considered a pathological state. Data were analyzed using the chi-square, Wilcoxon, and Mann-Whitney U tests. Odds ratios (ORs) and confidence intervals (CIs) were calculated. RESULTS: The closest vertical distance measurements made between posterior maxillary teeth roots and the maxillary sinus on panoramic radiography and CBCT scans showed statistically significant differences from each other (P<0.05). Compared to panoramic radiography, CBCT showed higher mean values for the distance between the maxillary sinus floor and maxillary posterior teeth roots. The CBCT images showed that at least 1 apical lesion adjacent to the right maxillary sinus increased the risk of maxillary sinus pathology by 2.37 times (OR, 2.37; 95% CI, 1.58-3.55, P<0.05). CONCLUSION: Panoramic radiography might lead to unreliable diagnoses when evaluating the distance between the sinus floor and posterior roots of the maxillary teeth. Periapical lesions anatomically associated with maxillary sinuses were a risk factor for sinus mucosal thickening.

Digital Tomosynthesis for PNS Evaluation: Comparisons of Patient Exposure and Image Quality with Plain Radiography

OBJECTIVE: We investigated low dose digital tomosynthesis (DT) for the evaluation of the paranasal sinus (PNS), and compared its diagnostic accuracy with a PNS radiography series (XR). MATERIALS AND METHODS: We enrolled 43 patients for whom XR, PNS DT, and OMU CT were performed. We measured effective doses (EDs) of XR, DT, and OMU CT using Monte Carlo simulation software. Two radiologists performed independent observation of both XR and DT. For seven PNSs, they scored anatomic conspicuity of sinuses and confidence on the presence of sinusitis using nine point scales. OMU CT was observed by the third radiologist and the findings were regarded as reference standard. We compared scores for conspicuity and sinusitis confidence between XR and DT. RESULTS: Mean EDs were 29 +/- 6 microSv, 48 +/- 10 microSv, and 980 +/- 250 microSv, respectively, for XR, DT, and CT. Mean scores for conspicuity were 6.3 and 7.4, respectively, for XR and DT. Sensitivity per patient basis for sinusitis detection were 52% and 96%, respectively, for XR and DT in observer 1 (p = 0.001) and 80% and 92% for observer 2 (p = 0.25). Specificities for sinusitis exclusion were 100% for both XR and DT for observer 1 and 89% and 100% for observer 2 (p = 0.50). Accuracies for sinusitis diagnosis were 72% and 98%, respectively, for XR and DT for observer 1 (p = 0.001) and 84% and 95% for observer 2 (p = 0.125). CONCLUSION: Patient radiation dose from low dose DT is comparable with that of PNS XR. Diagnostic sensitivity of DT for sinusitis was superior to PNS XR.

Post-Operative Maxillary Cyst after Maxillary Orthognathic Surgery: Report of an Unusual Case

Postoperative maxillary cyst is a rare complication of surgical intervention associated with maxillary sinuses. The present paper describes a 25-year-old man presenting with a lump sensation in the left cheek area after Le Fort I osteotomy and mandibular sagittal split osteotomy. The orthopantomograph revealed a bony defect in the left maxillary alveolus. On the computerized tomography, a 1x2x3cm sized, lower density mass, between the left paramedian side of the maxillary alveolar process and hard palate was observed. The cyst was drained and enucleated. More frequent post-operative maxillary cysts may occur with an increase of Le Fort I osteotomies.

Aspergilloma of the maxillary sinus: report of a case / 대한구강악안면방사선학회지

Aspergilloma of the paranasal sinus is a non-invasive form of aspergillosis, most often in the maxillary sinus. This case presents an 86-year-old female with aspergilloma of the left maxillary sinus. The patient's chief complaint was intermittent pain on the left maxillary first premolar area. A radiopacification of the left maxillary sinus was observed on the panoramic radiograph. Cone-beam computed tomography revealed complete radiopacification of the left maxillary sinus and scattered multiple radiopaque mass inside the lesion. Biopsy was performed under local anesthesia. On microscopic examination, numerous fungal hyphae, which branch at acute angle, were observed. The diagnosis was made as an aspergilloma based on the histopatholgic examination.

Comparison of Clinical Characteristics between Primary and Secondary Paranasal Mucoceles

PURPOSE: Paranasal sinus mucocele is a benign, expansile mass which can occur as a result of trauma or spontaneous obstruction of a sinus tract. The purpose of this study was to describe and compare the clinical characteristics of primary mucoceles occurring in patients with no previous sinus surgery history or known cause of mucoceles and secondary mucoceles resulting as a complication following endoscopic sinus surgery or the Caldwell-Luc operation. MATERIALS AND METHODS: We performed a retrospective chart review of 33 cases of primary mucoceles and 60 cases of secondary mucoceles which were diagnosed and surgically corrected between 1996 and 2008. RESULTS: The most common presenting symptoms in primary mucoceles were nasal obstruction (19.4%) and rhinorrhea (17.7%). In secondary mucoceles, the most common symptoms were cheek pain (31.7%) and nasal obstruction (18.3%). The most common origins of primary mucoceles were the ethmoid sinus (45.5%) and the maxillary sinus (18.2%). In secondary mucoceles, the maxillary sinus was the most common site (86%), followed by the ethmoid sinus (7.1%). All patients with secondary mucoceles had a history of sinus surgery. CONCLUSION: The maxillary sinus was the most common site of secondary mucoceles while the ethmoid sinus was the most common origin of primary mucoceles. Cases of secondary mucoceles that occurred following sinus endoscopic surgery developed more frequently in the ethmoid sinus than in those following the Caldwell-Luc procedure, therefore, we suggest that the incidence of maxillary sinus mucoceles in the Asian population would decrease as the rate of endoscopic sinus surgery increases.

Visual Loss due to Inflammatory Sinus Diseases

PURPOSE: Visual loss secondary to inflammatory sinus diseases is an infrequent but disastrous complication. We analyzed the clinical features of patients with paranasal sinusitis who had signs of optic nerve dysfunction. METHODS: Medical records of 10 patients (11 eyes), who presented with visual loss associated with inflammatory sinus diseases, were reviewed retrospectively. RESULTS: The mean age was 53.7 years (range, 33-68 years). Involved sinuses were the sphenoid (10 eyes) and posterior ethmoid (7 eyes). The radiological evidence of orbital apex infiltration was shown in 8 eyes. Headache was the most common presenting symptom. The mean symptom duration before their first visit was 51.4 days. The underlying sinus pathology included fungal infection (5) and mucoceles (5). Fungal sinusitis and initially lower visual acuity were associated with poor visual prognosis, while mucocele showed good prognosis. CONCLUSIONS: The inflammatory sinus disease could leave a permanent visual deficit, especially in cases of fungal sinusitis and initially lower visual acuity. Multidisciplinary diagnostic and therapeutic approaches are essential to prevent serious ophthalmic complications such as permanent visual loss.

Clinicopathological Characteristics of Eosinophilic Fungal Rhinosinusitis / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Since allergic fungal sinusitis (AFS) has been described in 1983, only a few cases have been reported in the domestic scientific journals. This leads to alleviate the strict criteria because many patients with allergic mucin and fungal hyphae reveal negative results of allergic skin test or serologic tests for fungal antigens. To classify these patients, the term `eosinophilic fungal rhinosinusitis (EFS)' was first coined in 1999. The objective of this study was to evaluate the clinicopathological features of EFS. SUBJECTS AND METHOD: The authors retrospectively reviewed medical records of 21 patients who had been diagnosed as EFS between June 2002 and November 2003 at the department of otolaryngology, Asan medical center. RESULTS: Chief complaints at first visits were in the order of nasal obstruction, postnasal drip, headache, foul odor, and rhinorrhea. Nasal endoscopic findings showed nasal polyp, purulent discharge, and fungal debris. 14.2% of patients revealed no abnormal findings. All patients had increased intrasinus attenuation at non-contrast media-enhanced CT. 47.6% of patients had complete opacification of maxillary sinus predominantly. No patients had the evidence of type I hypersensitivity for fungal antigens. Twenty patients had undergone endoscopic sinus surgery and surgical specimens proved to have allergic mucin with fungal hyphae. Postoperatively, four patients (20%) had recurrent symptoms and polypoid mucosal changes, which showed responses to short term oral steroid therapy. CONCLUSION: EFS is a frequent type of fungal sinusitis if surgical specimens are carefully examined histologically. Out of patients who received endoscopic sinus surgery, bi-meatal approach for the maxillary sinus lesions, and local steroid therapy, 80% were cured with no sign of relapse. The existence of eosinophilic infiltration and allergic mucin leads us to believe that focal allergic reaction occurs inside the sinus.

Delayed Ischemic Optic Neuropathy after Endoscopic Sinus Surgery: A Case Report / 대한이비인후과학회지

The intimate relation between the paranasal sinuses and the orbit places the orbital contents at risk of injury during ESS (endoscopic sinus surgery). This injury may cause severe postoperative orbital complications. These have been widely reported from mild orbital hematoma to devastating visual loss. Despite technological advances with a skillful surgeon, ESS still carries potential risks of direct injury to the orbital contents and optic nerve, which may cause blindness. In our case, the disturbance in visual acuity developed 14 days after ESS without intraoperative orbital complications. And we report a rare case of posterior ischemic optic neuropathy following ESS, which may be presumed to cause the delayed onset blindness postoperatively.

Prognostic Factors of Pediatric Endoscopic Sinus Surgery / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Pediatric endoscopic sinus surgery (ESS) is performed for refractory cases of sinusitis that do not respond to medical management. However, studies evaluating the prognostic factors affecting outcomes of pediatric ESS have not been reported much. The aim of this study is to investigate the prognostic factors affecting the outcomes of pediatric ESS. MATERIALS AND METHOD: A retrospective review of medical records was carried out on 71 patients, 15 years or younger, who had undergone ESS from February, 1995 through January, 2002 at our institution. We classified them into two groups, one with good outcome, and the other with poor outcome, according to the postoperative endoscopic findings. We compared the following 8 parameters between the two groups: presence of allergy, bronchial asthma, adenotonsillar hypertrophy, previous sinus surgery, degree of polyposis, preoperative disease extent scored with OMC CT finding, blood eosinophil count, and eosinophil infiltration in nasal mucosa. RESULT: There were no statistical differences between the two groups on the presence of allergy, bronchial asthma, adenotonsillar hypertrophy, previous sinus surgery, degree of polyposis, preoperative disease extent scored with OMC CT finding, blood eosinophil count, and eosinophil infiltration in nasal mucosa. CONCLUSION: Prognostic factors affecting the outcome of pediatric ESS are not clear. We assume that postoperative care, including appropriate postoperative medication, debridement and irrigation, etc., is more important in pediatric ESS.

Orbital Abscess in a 2-month-old Neonate: 1 Case Report

Although orbital abscess may originate from a number of sources, acute paranasal sinus disease is the most common source of infection. The clinical presentation is eyelid swelling, proptosis, conjunctival chemosis, diplopia, and decreased visual acuity. Diagnostic methods available for evaluating orbital abscess include sinus X-ray, ultrasound, computed tomography(CT), and bacterial culture of abscess content. Orbital abscess is treated with systemic antibiotics, or surgical draining followed by intravenous antibiotic therapy. Prompt diagnosis and treatment are necessary to prevent meningitis, subdural abscess, cavernous sinus thrombosis, frontal sinus thrombosis, visual loss from increased intraorbital pressure, even death. The authors exprienced a 2-month-old female neonate who presented with eyelid swelling, erythema, propotsis, eyeball deviation on right eye. Her orbital CT disclosed orbital abscess and only systemic intravenous antibiotics and topical antibiotic eyedrop instillation improved the symptoms.