A Case Report of Inflammatory Myofibroblastic Tumor of the Sphenoidal Sinus

Inflammatory myofibroblastic tumor (IMT) is a tumor composed of differentiated myofibroblastic spindle-shaped cells. It occurs in the soft tissues of the abdomen and lungs, and is very rare in the sphenoid sinus. The diagnosis depends on histopathology and immunohistochemistry, and is easily misdiagnosed. Although metastasis is rare, the recurrence rate is high. Surgical resection is the treatment of choice, and where complete resection is difficult, radiation therapy, hormonal therapy, or molecular targeted drug therapy can be administered. We report a rare case of IMT with a primary origin in the sphenoid sinus, which was entirely resected by nasal endoscopy and confirmed by histological examination.

Locoregional Extension Patterns of Nasopharyngeal Carcinoma Detected by FDG PET/MR

PurposeWe sought to define the locoregional extension patterns of nasopharyngeal carcinomas (NPCs) by positron emission tomography (PET)/magnetic resonance imaging (MRI) and to improve clinical target volume (CTV) delineation.MethodsBetween May 2017 and March 2021, 331 consecutive patients with nonmetastatic NPCs who underwent pretreatment, simultaneous whole-body PET/MRI for staging were included in this study.ResultsThe high-risk regions included the base of the sphenoid bone, the prestyloid compartment, prevertebral muscle, foramen lacerum, medial pterygoid plate, sphenoidal sinus, clivus, petrous apex, and foramen ovale. When the high-risk regions were invaded, the incidence rates of tumor invasion into the medium-risk regions increased. In contrast, when the high-risk regions were not involved, the incidence rates of tumor invasion into the medium-risk regions were mostly less than 10%, excluding the post-styloid compartment and oropharynx. According to the updated consensus guidelines of the neck node levels for head and neck tumors from 2013, level IIa (77.3%, 256/331), level IIb (75.8%, 251/331), and level VIIa (71.3%, 236/331) were the most frequently involved levels, followed by levels III (42.6%), Va (13.9%), IVa (8.8%), IVb (3.6%), Ib (3.6%), Vb (2.4%), VIIb (2.4%), VIII (1.8%), Vc (0.9%), and Xa (0.3%). Skip lymph node metastasis occurred in only 1.9% of patients.ConclusionsFor NPCs, primary disease and regional lymph node spread follow an orderly pattern, and a skip pattern of lymph node metastasis was unusual. Involved level radiotherapy might be feasible for cervical lymph node levels below the caudal border of cricoid cartilage and level VIIb.

Aspergillus sphenoiditis growth on long cut ends of a non-absorbable sellar floor dura closure suture

Background: Cerebrospinal fluid (CSF) rhinorrhea is a common complication after transsphenoidal surgery (TSS). Suturing of sellar dura is effective in the prevention of postoperative CSF rhinorrhea, but it may cause rare postoperative infections. Herein, we report a case of Aspergillus sphenoiditis with the growth noted on cut ends of a polyvinylidene fluoride (PVDF) suture used for dural closure. Case Description: A previously healthy 51-year-old woman complained of abnormal odor 5 years after TSS for null cell adenoma. A white mass in the sphenoidal sinus was detected on rhinoscopy. Fungal balls were found clustered around the ends of a PVDF suture used for dural closure at the initial surgery. She underwent removal of both the fungal ball and dural suture. The pathological diagnosis was Aspergillus hyphae. It is thought that a dural suture protruding out of the sphenoid sinus mucosa can cause Aspergillus infection even in immunocompetent patients. A rapid and accurate diagnosis followed by surgical removal of the fungal ball and follow-up with oral antimycotic drugs result in good clinical outcomes. Conclusion: It is crucial to cut short the suture end and cover it with sphenoid sinus mucosa to avoid such complications.

Endonasal endoscopic surgery for temporal lobe epilepsy associated with sphenoidal encephalocele

Background: Temporal lobe epilepsy (TLE) associated with temporal lobe encephalocele is rare, and the precise epileptogenic mechanisms and surgical strategies for such cases are still unknown. Although the previous studies have reported good seizure outcomes following chronic subdural electrode recording through invasive craniotomy, only few studies have reported successful epilepsy surgery through endoscopic endonasal lesionectomy. Case Description: An 18-year-old man developed generalized convulsions at the age of 15 years. Despite treatment with optimal doses of antiepileptic drugs, episodes of speech and reading difficulties were observed 2–3 times per week. Long-term video electroencephalogram (EEG) revealed ictal activities starting from the left anterior temporal region. Magnetic resonance imaging revealed a temporal lobe encephalocele in the left lateral fossa of the sphenoidal sinus (sphenoidal encephalocele). Through the endoscopic endonasal approach, the tip of the encephalocele was exposed. A depth electrode was inserted into the encephalocele, which showed frequent spikes superimposed with high-frequency oscillations (HFOs) suggesting intrinsic epileptogenicity. The encephalocele was resected 8 mm from the tip. Twelve months postoperatively, the patient had no recurrence of seizures on tapering of the medication. Conclusion: TLE associated with sphenoidal encephalocele could be controlled with endoscopic endonasal lesionectomy, after confirming the high epileptogenicity with analysis of HFOs of intraoperative EEG recorded using an intralesional depth electrode.

Anatomical peculiarities of the sphenoidal sinus based on computed tomography data: structural types and correlation with maxillary sinuses

Detailed knowledge of anatomy and topography of sphenoidal and maxillary sinuses may help to improve surgical approaches, better predict postoperative complications, increase safety of surgical techniques, and, consequently, avoid inflammatory reactions. This also helps to determine the cause of inflammatory changes. Aim. This study aimed to analyze structural types of sphenoidal and maxillary sinuses by examining computed tomography (CT) images of the paranasal sinuses, to determine the frequency of the interposition of the internal carotid artery, and to identify sex- and age-related peculiarities and regularities in the extent of pneumatization and contents in the sphenoidal and maxillary sinuses. Materials and Methods. CT images of 50 patients who were receiving treatment in the otolaryngology unit of the Clinic of SamSMU were analyzed. Toshiba Aquilion 32 CT scanner was used. Results. Patients were divided into three groups according to Hamberger classification of the pneumatization of the sphenoidal sinus by taking into account the topographic relation to the sella turcica using CT data: the presellar type was identified in 10% (n=5) of the cases, the sellar type in 22% (n=11), and the postsellar type in 68% (n=34). The postsellar type is the most common structural type of the sphenoidal sinus. Moreover, patients were divided into groups by the type of pneumatization of the maxillary sinuses. No correlation was found between the pneumatizations of sphenoidal and maxillary sinuses. Moderate negative correlation was observed between age and structural type of the sinuses, and moderate positive correlation was found between the contents of the sinuses. Interposition of the internal carotid arteries was identified in 3 (6%) patients. Conclusions. Our data revealed that the postsellar type is the most common structural type of sphenoidal sinuses. The extent of pneumatization of the sphenoidal and maxillary sinuses is independent of each other. Anatomical peculiarities of the sphenoidal sinus in the form of the interposition of the internal carotid arteries are not very rare and should be taken into account in planning surgical interventions.

NEUROIMAGING DATA OF THE STUDY OF THE CHIASMAL-SELLAR REGION STRUCTURES

Background: Sphenoid sinus (SS) is separated by a septum with various position, therefore sizes of two sinus cavities are variable [2]. In addition, sphenoid sinus differs in pneumatization type, ranging from its absence to extensive forms.Knowledge of the linear size and shape of the skull, the structure of the sphenoid sinus and its interconnection with nearby structures will help to avoid complications when performing surgical endoscopic interventions in the chiasmal-sellar region. Currently, the transsphenoid approach is the most optimal in neurosurgery for intracellar and cranial pathologies treatment. Due to proximity and anatomical interconnection of sphenoid sinus with other anatomical structures, such as anterior knees of intracavernous segments of internal carotid artery (ICA), optic nerve (ON), there is a high risk of complications during surgery [1,2,3,4]. Purpose: Features of skull craniometric parameters, the type sphenoid sinus pneumatization, and its practical value in various ON and ICA positions. Methods: The retrospective research, using magnetic resonance imaging (MRI) scans of head, included 1111 people, with 410 males and 701 females out of them but the scope of the article is limited to 93 of them, including 34 males (37%) and 59 females (63%) aged from 20 to 71 years. The research design complies with the Helsinki Declaration’s provisions and was approved by the Local Ethics Committee of the West Kazakhstan Medical University named after Marat Ospanov №50 from January 17, 2020. The average age of males was 41.6 (20 – 71 years), and for females was 41.7 (20 – 66 years). Inclusion criteria were as the following: 1) age range from 20 to 71 years, 2) patients living in Aktobe region, 3) patients sent for examination with pituitary (hypophysis) pathology, 5) patients referred with CSR vascular pathology, 6) patients referred for verification of CSR pathology diagnosis. Exclusion criteria were as the following: 1) patients with skull bones fractures, 2) patients after skull trepanation, 3) patients having orthodontic and orthognathic research at examination time, 4) patients with congenital skull malformations, having gross skull deformation, 5) patients with brain tumors and hemorrhages with obvious CSR compression at examination time, 6) pregnancy, lactation, long-term use of hormonal drugs by persons of both gender. With the RadiAnt Dicom Viewer 5.5.1 program measured craniological indices: crosslongitudinal skull index, degree of pneumatization of the sphenoidal sinus; protrusion and/or gaping of internal carotid artery canal and optic nerve.Allstatistical analyses were performed using Statistica 8.0. Results: The data we obtained show that the vast majority of older males (60-80 years old) had mesocrane skull shape, in contrast to females, among whom the frequency of brachycrane skull shape prevails. Among 20-40 years aged males, the highest percentage falls on mesocrane skull form, while in females the frequencies of mesocrane and brachycrane skull forms are relatively the same. In males and females with ages of 40-60 years, mesocrane and brachycranean skull forms are almost half of the total number of cases. An interesting fact was that dolichocranous skull shape is absolutely not found in both males and females of 40-80 years old age. The skull structure distribution by gender. Based on the sphenoid sinus types classification by Ossama & Guldner, our research revealed that there is no Conchal type (type I) in both genders. In 20-40 age, type III prevailed among males, while type IV has a maximum among females. Types III and IV predominated among males and females of 40-60 years old age. In 60-80 years category, type III prevails among females, while males have two times less. Type II is absent among 40-60 aged males and 60-80 aged females. As per the research of anatomical structures close to SS, it was found that ON and ICA canals form protrusions on the inner surface of the sphenoid sinus sidewall. The protrusion degree was ranged from a slight depression on the lateral wall to a complete "immersion" of canals into the sinus. No protrusion of ON and ICA canals were found in 60-80 years old males in 80% of cases, while complete absence of protrusion was shown in case of the same age females. However, protrusion of only the ICA canal occurs in 60% of cases with over 60 years old age females, while the same was in only 20% with the same age males. There was no case of ON canal protrusion in males, but ON canal gave a protrusion in sphenoid sinus wall in 49% of 20-40 years old females. ON and ICA canals protrusion in 20-60 years old males was found in about 30%, and the same protrusion was found in 60-80 years old females in 40%. Conclusions: This study is aimed at identifying the features of structure of the sphenoidal sinus, focusing on the absence of a dolichocrane type of skull among the population, on the clear distinction between men and women by the type of skull structure and the features of pneumatization of the sphenoidal sinus. The presellar type of sphenoidal sinus has a virtually low adherence to changes in sinus canals in types II and IV. Thus, careful planning of trans-sphenoid access to the sella is possible with modern imaging methods. Different anatomical variations can be detected so that problems can be predicted to be assessable. In order to avoid morbid consequences during surgery, it is imperative that clinicians determine the location and extent of sphenoid sinus walls and its relation to adjacent vital structures whenever trans-sphenoid pituitary surgery is expected. The few surgical tips related to sphenoid sinus anatomical configuration are important to keep in mind during such an approach. Keywords: MRI; sphenoid sinus; pneumatization; internal carotid artery; optic nerve

Mucosal Melanoma of the Head and Neck: A Retrospective Review and Current Opinion

Introduction: Head and Neck Mucosal Melanoma (HNMM) is an uncommon malignancy that arises in decreasing order in the nasal cavity, the paranasal sinuses, and the oral cavity. Although radical surgery followed by eventual radiotherapy is acknowledged as the mainstay treatment, patients with advanced stages or multi-focal tumors benefit from new systemic therapies. We wish to share our experience with these treatments and review the current literature.Materials and Methods: We present a case review of every patient treated in our center for an HNMM over the past 10 years, including every patient treated in our center for an HNMM over the past 10 years. We analyzed clinical characteristics, treatment modalities, and outcomes.Results: We included eight patients aged from 62 to 85 years old. We found six MM in the nasal cavity, one in the sphenoidal sinus, and one in the piriform sinus. Six patients underwent endoscopic surgery with negative margins, six underwent radiotherapy with variable modalities. Immunotherapy or targeted therapy was given in cases extensive tumors without the possibility of a surgical treatment or in two patient as an adjuvant treatment after R0 surgery. The three-year overall survival was 50%, and three patients (37.5%) are in remission.Conclusions: HNMM is associated with poor oncologic outcomes regarding the concerned patients of our review, as reported in the literature. New treatments such as immunotherapies or targeted therapies have not significantly changed the prognosis, but they may offer new interesting perspectives.Our small series of cases seems to confirm that surgical resection with negative margins improves overall survival.