Acute and chronic sphenoid sinusitis (sphenoiditis)

Diagnosis of Sphenoiditis

The diagnosis of sphenoiditis is based on a combination of clinical manifestations identified during an ENT examination, imaging studies, and sometimes diagnostic procedures like probing or puncture (though the latter are less commonly performed as primary diagnostic tools today).

1. Clinical Evaluation: A thorough history focusing on the nature of headaches, post-nasal drip, and any associated neurological or visual symptoms. Nasal endoscopy performed by an ENT doctor is crucial to visualize the sphenoethmoidal recess (where the sphenoid sinus ostium is located) for signs of inflammation or purulent discharge.
2. Imaging Studies:
   • Computed Tomography (CT) of the Paranasal Sinuses: This is the gold standard for diagnosing sphenoiditis. CT scans provide detailed images of the sphenoid sinus anatomy, showing mucosal thickening, air-fluid levels, opacification, or bony erosion. Axial, coronal, and sagittal views are important.
   • Magnetic Resonance Imaging (MRI): MRI may be used if complications such as intracranial extension, optic nerve involvement, or cavernous sinus thrombosis are suspected, or to differentiate soft tissue inflammation from tumors.
   • Plain X-ray Examination: Lateral skull X-rays can sometimes show opacification of the sphenoid sinus, but they have limited sensitivity and specificity compared to CT.
3. Diagnostic Probing and Puncture of the Sphenoid Sinus (Historical and Current Context):
   • Probing: To diagnose sphenoiditis, the sphenoid sinus can be probed, ideally under direct vision using an endoscope or operating microscope, especially if the olfactory cleft is wide. If anatomical conditions are unfavorable (e.g., narrow olfactory cleft, obstructing middle turbinate), thorough anesthesia and anemization of the olfactory area are necessary. The middle nasal concha might need to be gently displaced medially (e.g., with a Killian's nasal speculum) to visualize the natural ostium located near the roof of the nose. Probing is performed with a probe slightly curved at the end or a cannula probe at least 10 cm long. The distance from the nasal entrance to the anterior wall of the sphenoid sinus in older children and adults is approximately 8 cm, and about 3 cm from the posterior edge of the nasal septum.

     The probing technique for sphenoiditis involves using a self-retaining nasal dilator. With the patient's head tilted back, the end of the probe is placed on the lower edge of the nasal entrance and guided along the nasal septum (without deviating laterally) towards the middle of the lower edge of the middle nasal concha, aiming for the natural sphenoid ostium. A characteristic sensation is often felt upon entering the sinus. The sphenoid sinus can then be flushed using a graduated cannula or a thin ear catheter (no more than 2 mm in diameter).

     Challenges in probing arise because the natural sphenoid ostium is small (about 1 mm in diameter), and the probe may not easily penetrate it. If the probe is directed too superiorly from the anterior part of the middle turbinate, there is a risk of penetrating the cribriform plate and entering the cranial cavity. It is generally safer to aim slightly lower and more posteriorly than this landmark. Failures can also occur due to the highly variable shape of the sphenoid sinus, which may have additional septa, ridges, be rudimentary, or even completely absent on one side.

   • Puncture: An original method involving puncture of the sphenoid sinus by accurately determining the angle using a sighting device is generally not used in children due to its technical difficulty and feasibility issues. When performed, sinus puncture allows for aspiration of contents for culture and cytology, and for therapeutic lavage.

Treatment of sphenoiditis is most often conservative. However, in cases of complicated pansinusitis, or if orbital or intracranial symptoms related to sphenoiditis arise, surgical intervention is typically required.

Treatment of Acute and Chronic Sphenoiditis

The management of sphenoiditis depends on whether it is acute or chronic, the severity of symptoms, and the presence of any complications.

 

Conservative Medical Management

For most cases of uncomplicated acute sphenoiditis and as initial therapy for chronic sphenoiditis, conservative medical management is the first line of approach:

• Antibiotics: If a bacterial infection is suspected (especially in acute cases with purulent discharge, fever, or prolonged symptoms), a course of appropriate antibiotics is prescribed. The choice may be empiric initially, covering common sinus pathogens, or guided by culture results if available (e.g., from endoscopic sampling).
• Nasal Decongestants: Topical (sprays/drops) or oral decongestants can help reduce mucosal swelling around the sphenoid ostium and improve drainage. Topical agents should be used for a limited duration (3-5 days).
• Intranasal Corticosteroids: These are crucial for reducing mucosal inflammation in both acute and chronic sphenoiditis. Long-term use is often necessary for chronic conditions.
• Nasal Saline Irrigation: Helps to clear secretions from the nasal passages and nasopharynx, improving comfort and potentially facilitating drainage from the sphenoethmoidal recess.
• Analgesics: For pain relief (e.g., acetaminophen, NSAIDs).
• Mucolytics: May help thin tenacious secretions.
• Management of Underlying Conditions: If allergies or other predisposing factors are present, they should be addressed.

 

Surgical Intervention for Sphenoiditis

Surgical intervention is typically reserved for cases of chronic sphenoiditis unresponsive to maximal medical therapy, recurrent acute sphenoiditis, sphenoid sinus mucocele, fungal sphenoiditis (fungus ball), or if complications arise.

The primary surgical procedure is **endoscopic sphenoidotomy**, performed under local or general anesthesia. The goals are to:

• Create a widely patent opening into the sphenoid sinus to ensure adequate long-term drainage and ventilation.
• Remove any diseased tissue, polyps, or fungal debris from within the sinus.
• Facilitate postoperative topical medication delivery.

The essence of the operation is to create conditions for drainage by removing the anterior wall of the sinus, which is sometimes facilitated by an atrophic process in the nasal cavity where the natural opening of the sinus might be more visible. Various approaches can be used:

• Transnasal Endoscopic Approach: The most common method. The endoscope is passed through the nasal cavity, and the sphenoid ostium is identified in the sphenoethmoidal recess. The ostium is then enlarged, or the anterior wall of the sphenoid sinus is opened. This may be done directly (transostial) or sometimes via a transethmoidal approach if posterior ethmoidectomy is also required.
• Transethmoidal Approach: In some cases, particularly if there is coexisting posterior ethmoiditis, the sphenoid sinus is accessed after performing a posterior ethmoidectomy. This involves sequentially opening all posterior ethmoid cells, after previously (if necessary) resecting the middle turbinate, correcting a deviated nasal septum, or removing nasal polyps to gain access. A hook, probe, or sharp elongated spoon is then inserted into the natural ostium of the sphenoid sinus, or the anterior wall of the sinus is resected using specialized chisels, cutters, or powered instruments (microdebrider). Sometimes, not only the anterior but also part of the lower wall is removed, or the sinus is opened using elongated burs under endoscopic guidance.
• Transseptal Approach: Less commonly, the sphenoid sinus can be approached by traversing the nasal septum.

Extranasal approaches to the sphenoid sinus are rarely used today for inflammatory disease due to the efficacy of endoscopic techniques.

 

Ozone Therapy as an Adjunctive Treatment

Local ozone therapy has been proposed as an adjunctive treatment for purulent sinusitis, including sphenoiditis, particularly for patients with hypersensitivity to standard antibiotics or antiseptics. The proposed regimen involves:

• Sinus Lavage: Washing the inflamed sinuses with a physiological saline solution containing ozone at a concentration of 6-8 mg/L to evacuate purulent discharge.
• Ozone Insufflation: Subsequent saturation of the sinus mucosa with ozone by aerating the sinuses for 15-20 minutes with an ozone-oxygen gas mixture (ozone concentration 6-8 mg/L).
• Concentration Adjustment: As inflammation and pus discharge decrease, it is recommended to reduce the ozone concentration to 3-4 mg/L to potentially stimulate tissue regeneration.
• Hydrocortisone Suspension: Local ozone therapy may be supplemented with the introduction of a hydrocortisone suspension into the affected sinuses to relieve mucosal swelling and inflammation around the anastomosis (opening).
• Parenteral Ozone Therapy: For patients with severe symptoms of intoxication, intravenous administration of ozonated physiological saline (ozone content 0.8-1 mg/L, 400 ml every other day, for a course of 3 to 6 infusions) has been suggested. The duration is determined by the patient's general condition and resolution of intoxication signs. Due to the relative instability of ozone in physiological solution, drip infusion is advisable.

It is important to note that while ozone therapy is explored in some regions, its efficacy and safety for sinusitis are not universally established by robust, large-scale clinical trials, and it is not considered a standard part of mainstream international treatment guidelines for sinusitis. Its use should be considered experimental or adjunctive and undertaken by practitioners experienced in this modality.

 

Differential Diagnosis of Sphenoiditis Symptoms

The often vague and non-specific symptoms of sphenoiditis, particularly headache, require careful differentiation from other conditions:

Condition	Key Differentiating Features
Sphenoid Sinusitis	Deep-seated, often non-localized headache (occipital, vertex, retro-orbital); post-nasal drip; +/- fever, nasal congestion. Diagnosis confirmed by endoscopy (pus in sphenoethmoidal recess) and CT/MRI showing sphenoid sinus inflammation/opacification.
Migraine Headache	Often unilateral, throbbing, associated with nausea, vomiting, photophobia, phonophobia; may have aura. Nasal symptoms can occur ("sinus migraine") but sinus imaging usually normal.
Tension-Type Headache	Bilateral, band-like pressure or tightness; often related to stress/muscle tension. Usually no fever or purulent nasal discharge.
Cluster Headache	Severe, excruciating, unilateral periorbital/temporal pain; occurs in clusters; associated autonomic symptoms (tearing, nasal congestion, ptosis on affected side).
Posterior Ethmoiditis	Very similar symptoms to sphenoiditis due to close proximity and shared drainage. Often coexists. Differentiated by imaging.
Pituitary Apoplexy or Tumor	Severe headache, visual disturbances (bitemporal hemianopsia, ophthalmoplegia), endocrine dysfunction. Requires urgent neuroimaging (MRI).
Cavernous Sinus Thrombosis	Headache, proptosis, ophthalmoplegia (CN III, IV, VI palsies), periorbital edema, fever, sepsis. Life-threatening emergency. Often secondary to facial or sinus infection.
Temporal Arteritis (Giant Cell Arteritis)	Typically in older adults (>50); new-onset headache (often temporal), scalp tenderness, jaw claudication, visual symptoms. Elevated ESR/CRP.
Cervicogenic Headache	Pain referred from cervical spine structures. Often occipital or suboccipital, may radiate to head. Related to neck movement/posture.

 

Potential Complications of Sphenoiditis

Due to the sphenoid sinus's proximity to critical neurovascular structures, untreated or aggressive sphenoiditis can lead to severe complications:

• Orbital Complications:
  • Optic neuritis leading to visual impairment or blindness (due to proximity of optic nerve).
  • Orbital apex syndrome (involvement of CN II, III, IV, V1, VI).
  • Superior orbital fissure syndrome.
• Intracranial Complications:
  • Cavernous sinus thrombosis.
  • Meningitis.
  • Epidural, subdural, or brain abscess (especially temporal or frontal lobes).
  • Pituitary abscess or dysfunction.
  • Carotid artery involvement (aneurysm, vasospasm - very rare).
• Neurological Deficits: Cranial nerve palsies (III, IV, V, VI are most at risk).
• Sphenoid Sinus Mucocele/Pyocele: Can expand and erode surrounding bone, compressing adjacent structures.

These complications are medical emergencies requiring immediate and aggressive management.

 

Prevention and When to Seek Specialist Care

Prevention involves:

• Prompt and effective treatment of acute upper respiratory infections and rhinosinusitis involving other sinuses to prevent spread to the sphenoid.
• Management of underlying predisposing factors like allergies or anatomical issues.

Consultation with an ENT specialist is crucial if sphenoiditis is suspected, especially if experiencing:

• Persistent, severe, or unusual headaches (especially occipital, vertex, or retro-orbital).
• Persistent post-nasal drip unresponsive to standard treatments.
• Any visual disturbances (blurred vision, double vision, decreased vision).
• Pain with eye movements or restricted eye movements.
• Unexplained fever with headache and nasal symptoms.
• Neurological symptoms such as facial numbness, weakness, or altered mental status.

Early diagnosis and treatment of sphenoiditis are vital to prevent potentially devastating complications due to its deep anatomical location and proximity to critical structures.