Left Sphenoid Sinus Research Articles

A Case of Malignant Lymphoma with Superior Orbital Fissure Syndrome

The superior orbital fissure syndrome (SOFS) is caused by impaired functions of the cranial nerves (III, IV, V1, VI) that enter the orbit through the superior orbital fissure. SOFS associated with malignant lymphoma is rare.We present the case of an 88-year-old female patient who presented with left-sided ptosis and total ophthalmoplegia, with pain in the left eye. Examination revealed small tumors in the left lower eyelid and a nodule in the left leg. CT of the orbits and the nasal sinus area showed mass lesions in the ethmoid sinuses of both sides and the left sphenoid sinus. We suspected infection or autoimmune disorder and performed endoscopic sinus surgery for the purpose of histopathologic diagnosis and treatment.Both frozen-section and permanent section diagnosis of the resected specimen revealed features consistent with malignant lymphoma (diffuse large B-cell lymphoma (DLBCL)). Biopsy of the skin nodule in the left leg performed at the same time also revealed features consistent with the diagnosis of DLBCL.Although the standard treatment for DLBCL is combination chemotherapy (R-CHOP), this patient and her family decided against aggressive chemotherapy in favor of best supportive care, in view of her age and performance status.A large variety of disease processes are known to underlie the etiopathogenesis of SOFS, such as infections and autoimmune diseases. When the onset of symptoms is slow, a neoplastic cause should be considered.The greater the degree of disease progression, the higher the risk of vision loss from optic neuropathy. Therefore, the condition should be diagnosed early and treated promptly to avoid blindness.

A conservative surgical strategy for spontaneous cerebrospinal fluid leakage: a rare case report

A 59-year-old male with no history of trauma or surgery presented with clear rhinorrhea occurring when he bent his head forward. A CT scan revealed localized fluid accumulation and a lateral wall defect involving the left sphenoid sinus. Using the transpterygoid approach, we widened the anterior wall of the sphenoid sinus inferolaterally to expose the lesion as much as possible. Reconstruction involved placing an interposition graft between the dura and the bony defect using the underlay technique, followed by free mucosal grafting. Histopathological examination revealed neuroglial cells, confirming the diagnosis of spontaneous cerebrospinal fluid rhinorrhea due to a meningoencephalocele.

ANTROCHOANAL POLYP: AN UNCOMMON CAUSE OF CHRONIC NASAL CONGESTION IN PEDIATRIC PATIENTS

<h3>Introduction</h3> Chronic nasal congestion is a common pediatric problem, caused most frequently by viral infections and environmental allergies. We describe a rare case of pediatric antrochoanal polyp causing nasal obstruction. <h3>Case Description</h3> A 10-year-old female with chronic nasal congestion, allergic rhinitis, snoring, recurrent sinus infections, and hyposmia was found to have a left-sided nasal mass after several years of progressive symptoms, despite treatment with nasal corticosteroids and anti-histamines. CT scan showed opacification of the left maxillary and sphenoid sinuses, bilateral ostiomeatal obstruction, and a small, lobulated mass obstructing the left nasal cavity. She had no other recurrent infections or family history of cystic fibrosis; immunoglobulin levels and sweat testing were normal. After otolaryngological evaluation, the mass was resected and found to be an antrochoanal polyp filling the entire chonae and left maxillary sinus. After surgery, her sense of smell returned, nasal congestion resolved, and she had no further infectious sinusitis episodes or polyp recurrence after four years. <h3>Discussion</h3> Pediatric nasal polyps are rare but should be considered in cases of chronic nasal congestion/obstruction. While antrochoanal polyps (arising from the maxillary sinuses) are most common in children, nasal polyps may also originate in the ethmoid/sphenoid sinuses (choanal polyps). Polyps can develop from prolonged mucosal inflammation in the setting of both eosinophilic and non-eosinophilic chronic rhinosinusitis. Lastly, pediatric nasal polyps can be associated with systemic diseases (including cystic fibrosis, primary ciliary dyskinesia, and immunodeficiency) and should prompt additional testing including sweat test and serum immunoglobulin levels.

ODP317 Hypophysitis or No? A Rare Case of Bipolaris Fungal Sinusitis Causing Severe Pituitary Inflammation.

Abstract Clinical case: A 28 year old male with uncontrolled diabetes mellitus presented to the hospital with severe, worsening holo-cephalic headache associated with fevers, light sensitivity which was unresponsive to pain medications. Initial CT of the brain showed severe paranasal sinus disease. Lumbar puncture was significant for elevated protein and cell count with neutrophilic predominance and negative CSF culture. Patient was empirically treated for meningitis. Due to no improvement in his symptoms, MRI brain with contrast was done that showed complete opacification of the left sphenoid sinus with partial opacification of the ethmoid sinus. Of note, heterogeneous enlargement and enhancement of pituitary gland including portion of distal infundibulum was seen with mild compression of optic chiasm. High dose dexamethasone was initiated. Pituitary workup revealed preservation of all axes including AM cortisol 36.5 mcg/dL (6.6mcg/dl- 33 mcg/dl), prolactin 2.9 ng/ml (2.1ng/ml-17.7ng/ml), TSH 1.4 uIU/mL (0.34-5.6 uIU/mL), FT4 0.99 uIU/mL (0.80-1.80 uIU/mL) with normal serum chemistry and hemodynamics. Repeat MRI brain showed sphenoid pyomucocele with infection extending to the sella, cavernous sinuses and anterior/middle cranial fossas. ENT surgery was emergently performed with surgical debridement of the sphenoid and ethmoid sinuses revealing green cement like debris causing posterior septal perforation from the pressure. Interestingly, ethmoid sinus fluid culture grew Bipolaris fungal species. Patient's condition gradually improved and he was discharged on oral itraconazole with steroid taper. The patient did not develop signs or symptoms of hypophysitis during his hospital course. Presentation: No date and time listed

P266 A case of mixed fungal infection causing invasive fungal Rhinosinusitis in a post-COVID patient

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PMObjectivesTo identify the fungal etiology of invasive nasal sinusitis in a patient of post-COVID.MethodsA 34-year-old non-diabetic man, who had mild coronavirus disease (COVID) infection 2 months back presented with left-sided nasal obstruction, headache accompanied by malodorous, thick, mucopurulent discharge for the last 2 weeks.A CT scan of sinuses revealed opacification of left posterior ethmoid and sphenoid sinus without bony erosion or calcification.The patient underwent unilateral functional endoscopic sinus surgery (FESS) and debridement of tissue from the affected sinuses.ResultsA KOH preparation of the debrided tissue showed thin septate hyphae. Gram-stained smear of the debrided material showed thin septate fungal hyphae with clamp-like connections (Fig. 1). Histopathological examination revealed features of the inflammatory polyp. In Sabouraud dextrose agar the fungal colony grew fast and its aerial mycelium is white and cotton-like. The fungus was phenotypically identified as Schizophyllum communae (identification was confirmed at the National Reference Centre).He continued to do well but about 2 months later he started experiencing headaches and pain behind the eyes. He also complained of nasal stuffiness (left greater than right) and yellowish nasal discharge. At this point, a CT scan revealed soft tissue density with interspersed hyperdensity in sphenoid sinus bilateral ethmoid, and bilateral maxillary sinuses with associated bony erosion and possible extension into the right cavernous sinus and extrachonal compartment of right orbit suggestive of invasive fungal sinusitis (Fig. 2).Bilateral FESS was done. Extensive fungal material was observed in the sphenoid sinus and thorough debridement was performed.Mycological studies of the debrided tissue showed thin septate hyphae. Schizophyllum communae was again isolated in culture.Histopathological section showed inflammatory cells and several slender, branching septate fungal hyphae.The invasive nature of the infection prompted reexamination of the histopathology slides and cultures for the presence of other fungi particularly of the Mucorales group but no other fungus could be identified.The patient was started on liposomal amphotericin B and the tissue blocks were sent for fungal identification to the National Reference Centre through sequencing following DNA extraction from the paraffin blocks. Amplification of the 18 S rDNA region (coding for the 18 S RNA) using ZM primers followed by sequencing revealed the presence of R. arrhizus.The patient was continued on amphotericin B. The patient was discharged after 2 weeks with oral isuvuconazole. At six months follow up he is doing well with no evidence of active infectionConclusionAs the novel COVID‐19 continues to rampage, an abrupt increase in the number of opportunistic fungal infections has been observed.Invasive and often fatal rhino-cerebral Mucormycosis is now been increasingly reported in patients who have had COVID-19 infection in the recent past. In this case, there was a dual fungal infection causing rhino-sinusitis which was established through conventional culture and PCR assays from paraffinized tissue sections. Increased awareness of the existence of dual mold infections in at-risk patients is necessary for optimum management. PCR methods in tissue sections increase the diagnosis of dual mold infections.

Life-Threatening Sinonasal Invasive Aspergillosis Easily Misdiagnosed

Background and Objectives Invasive fungal sinusitis is extremely rare. Yet the consequences of this infection may be fatal if not diagnosed correctly at an early stage. We discuss three cases of Aspergillosis sphenoid sinusitis that were misdiagnosed and have led to fatal consequences.Subjects and Method This is a retrospective analysis of cases diagnosed as invasive fungal sinusitis of sphenoid sinus.Results All three cases were of men who had immunocompromised medical histories that included leukemia and diabetes mellitus. The patients presented symptoms that included fever, chronic headache, weakness on one side, and facial edema. In the first case, CT showed no suspicious lesions that indicated fungal infection. However, five days after being prescribed antibiotics, the patient suffered obstruction of the right internal carotid artery (ICA) and right cavernous sinus. In the second case, CT showed total obstruction in the left ICA and a soft tissue mass in the left sphenoid sinus that extended and involved the left cavernous sinus. In the last case, CT showed soft density progression in the right sphenoid sinus with bone erosion when compared to images taken eight days earlier. In each of these cases, we performed emergency endoscopic sinus surgery. One case was confirmed to be invasive aspergillosis by histology whereas the other two cases were suspected to be invasive aspergillosis based on their past medical histories, clinical findings and image studies.Conclusion Clinicians must take great care to rule out invasive aspergillosis in immunocompromised patients with sinusitis.

464 Local Extension of a Solitary Extra Medullary Nasal Plasmacytoma into the Orbit

AimExtramedullary plasmacytoma are rare neoplasms, which mainly occur in the head and neck, the most common site being the nasal cavity or septum. Patients may present with epistaxis, nasal obstruction, or rhinorrhoea. Extension into the orbit is rare but can lead to visual disturbances.MethodThis case report pertains to a 69-year-old female patient who initially presented with a 6-week history of recurrent sinusitis, with left sided cheek pain and diplopia.ResultsA CT and MRI scan was performed, which showed opacification of the left maxillary, ethmoid and sphenoid sinuses with bony destruction of the medial and anterior maxillary walls and into the anterior soft tissues. The mass was completely obstructing the left nasal cavity extending into the inferomedial orbit. Staging CT scans also showed nodal disease in the neck.Biopsy with histology was positive for CD138, with diffuse proliferation of plasma cells of varying maturity and atypia. Additionally, mono IgG kappa was also positive as was CD45 suggestive of a lymphoid neoplasm. Bone marrow biopsy and PET scan confirmed there was no systemic involvement.Radiotherapy was initiated after the patient recovered from COVID -19. A repeat MRI scan 6 weeks post radiotherapy showed a partial response with reduction in the size of the tumour, resolution of the intra-orbital extension and disappearance of paraprotein.ConclusionsThis case report illustrates need for earlier consideration of EMP diagnostically to reduce the risk of conversion of the plasmacytoma to multiple myeloma, which is a known possibility and to ensure minimal delay in the commencement of treatment.

714. Invasive Fungal Infection Caused by Curvularia Species in a Patient with Intranasal Drug Use: A Case Report

Abstract Background Invasive fungal infections (IFIs) are uncommon infections that account for approximately 27.2/100,000 cases per year in the United States. One form of IFI is chronic invasive fungal sinusitis (CIFS). If untreated, invasion into neighboring structures may cause altered mental status, seizures, strokes, proptosis, and intracranial complications. Case Report An afebrile 43-year-old female with a history of polysubstance abuse presented to the ED due to altered mental status, left sided facial droop, right sided hemiparesis, and slurred speech. The patient was somnolent but arousable to stimuli and appeared acutely ill. The patient’s mother reported a history of cocaine abuse, which was confirmed on urine toxicology. A CT head and neck with contrast revealed subacute basal ganglia lacunar infarcts and a left sphenoid opacity with scattered hyperintensities and erosive changes [Figure 2]. One month prior, she had been diagnosed with a left superior pole kidney mass and a left-sided enlarged periaortic lymph node containing multiple noncaseating granulomas and GMS stains positive for fungal hyphae [Figure 1]. The patient underwent nasal endoscopy with tissue biopsy. Tissue showed necrotizing invasive fungal sinusitis with granuloma formation and foreign-body giant cell reaction. Fungal speciation of the tissue culture showed Curvularia species was placed on IV voriconazole. While the infection stabilized, her neurologic deficits did not significantly improve. She was discharged to inpatient rehabilitation. Figure 1. Coronal and axial view of left upper pole kidney mass with perinephric fat stranding. Figure 2. MRI brain CTA Head and Neck with contrast in axial plane showing multifocal infarcts likely represent complications of fungal basilar meningitis secondary to the left sphenoid sinus disease. Imaging also shows irregular erosive change at the anterior aspect of the sella turcica, through the planum sphenoidale, and bony defect of the sphenoid sinus. Methods Results Conclusion Intranasal use of cocaine causes vasoconstriction to elicit sinonasal tissue ischemia. With extended use, chronic mucosal inflammation can occur that can result in sinonasal osteocartilaginous necrosis and potential for infection. CIFS is infrequently diagnosed and its indolent nature with progression over weeks or months can make diagnosis and treatment difficult. The most frequent fungal species identified are the Aspergillus species, but Curvularia species have been found as well. CT and MRI scanning can be suggestive, but are not sufficiently specific or sensitive. The main forms of interventional modalities include surgical debridement and antifungal therapy to maximize survival Disclosures All Authors: No reported disclosures

Novel pediatric granulomatosis with polyangiitis with a marked bloody pericardial effusion and bloody stool: a case report

BackgroundGranulomatosis with polyangiitis (GPA) is a syndrome of refractory vasculitis involving the upper respiratory tract, lungs, kidneys, and systemic small and medium-sized arteries that affects all age groups. No pediatric case with a bloody pericardial effusion resulting in cardiac tamponade and co-existing hematochezia has been reported.Case presentationA 14-year-old boy was referred for evaluation of prolonged fever, chest pain, and intermittent hematochezia. Diagnostic imaging showed a prominent pericardial effusion. Immediately after admission, his systolic blood pressure decreased. Emergent pericardiocentesis resulted in aspiration of a massive amount of bloody pericardial fluid. This was diagnosed as cardiac tamponade because his blood pressure recovered immediately after the drainage. The patient had an elevated serine proteinase 3-anti-neutrophil cytoplasmic antibody (PR3-ANCA) level on serological examination. Head MRI showed thickening of nasal and sinusoidal mucosa and a cystic mass in the left sphenoid sinus. After ruling out malignancy based on the cytology of the effusion, chest MRI, and gallium scintigraphy, total colonoscopy showed multiple irregular-shaped aphthae from the right transverse colon to the cecum on the contralateral side of the mesenteric attachments. Biopsy specimens of aphthous lesions confirmed necrotizing granulomatous inflammation. A diagnosis of GPA was made based on these findings, and oral prednisolone (PSL) and azathioprine were started. The hematochezia disappeared rapidly, and no recurrence of pericardial effusion was seen after PSL tapering was completed. The PR3-ANCA level decreased into the normal range immediately after the initial therapy.ConclusionsPericarditis is a common cardiac complication of GPA, but there have been no reports of resultant cardiac tamponade. This is the first case of pediatric GPA with cardiac and gastrointestinal complications preceding the common symptoms such as respiratory or renal symptoms. A case of pediatric GPA with hematochezia is also extremely rare. In conclusion, serial measurement of ANCA levels is important in patients with persistent fever and bloody stool, such as in inflammatory bowel disease, to make the diagnosis of a vasculitic syndrome.

Management of cerebrospinal fluid leak in the lateral recess of the sphenoid sinus with transpterygoid approach: A case report.

BackgroundCerebrospinal fluid (CSF) leak that occurred in the lateral sphenoid sinus is a rare and difficult case. This paper aims to report a case of defect closure in the lateral recess of the sphenoid sinus endoscopically with a transpterygoid approach.Case presentationA 38-year-old Indonesian woman reported a CSF leak, and identified a defect in the lateral recess of the left sphenoid sinus. CSF leak was repaired with endoscopic transethmoid-pterygoid or transpterygoid endoscopic surgery and no CSF leak was found. The surgical procedure was successful even though it was only performed by an otorhinolaryngologist.DiscussionEndoscopic transethmoid-pterygoid or transpterygoid endoscopic surgery is effective in repairing defects in the lateral recess of the sphenoid sinus in which surgical procedure is performed by a single otorhinolaryngologist.ConclusionEndoscopic transpterygoid approach gained access to lateral site of sphenoid sinus was an effective approach in managing CSF leak of lateral sphenoid recess. Closure of the defect using a bone graft and mucosa of the middle turbinate was proven to be effective. It had been carried out successfully in Indonesia.

Ocular Manifestations of Sphenoid Meningioma : A Case Report

Background: Approximately 46.8% to 88.6% patient with brain tumor experienced ophthalmology manifestations and most patients went to ophthalmologist in the first time with ocular symptoms. Sphenoid meningioma are often asymptomatic in the early stage of the disease. The ocular manifestations mentioned above could appear as the disease progresses, therefore a careful clinical evaluation is needed in order to retain neurological function. Case: A 40 years old female patient was presented with main complaint of headache. This symptom was felt since 6 months ago on the left side of the head accompanied by visual disturbance on the left eye since 3 months ago. Head magnetic resonance imaging (MRI) with contrast showed broad base meningioma on the left sphenoid wing measuring about 3,62 x 3,08 x 2,24 cm. The mass extended to left cavernous sinus and encased left carotid artery as well as pushing the right carotid artery laterally; the mass also extended to left sphenoid sinus and encased left optical nerve; the mass also extended to intrasellar and compressed the hypophysis. Optical coherence tomography (OCT) examination showed retinal nerve fiber layer (RNFL) thinning on the temporal quadrant of the left eye, reduced macular thickness of the left eye, and optic papilla atrophy of the left eye. Conclusion: Ophthalmic examinations and evaluation could assist in early diagnosis of tumor in order to adequately treat the disease. The prognosis is better if the cranial lesion could be recognized early and hence managed well, therefore decreasing morbidity and mortality.

Protrusion of the carotid canal into the sphenoid sinuses: evaluation before endonasal endoscopic sinus surgery.

Many reports have previously indicated the vast number of anatomical variations of the sphenoid sinuses, e.g. presence of the recesses. Notwithstanding, there are a few crucial neurovascular structures directly neighbouring with the sinuses. The following research aimed to evaluate frequency prevalence of the carotid canal's protrusion into the sphenoid sinuses in adult population. Computed tomography (CT) scans of the paranasal sinuses of 296 patients (147 females, 149 males) were analysed in this retrospective study. The patients did not present any pathology in the sinuses. Spiral CT scanner Siemens Somatom Sensation 16 was used in the standard procedure in the option Siemens CARE Dose 4D. Protrusion of the carotid canal was found in the majority of the patients - 55.74%, more frequently in males (65.1% of the patients) than in females (46.26% of the patients). The said variant - regardless of gender - was noted more often bilaterally (41.55% of the cases: 29.93% females, 53.02% males) than unilaterally (14.19% of the cases: 16.33% females, 12.08% males). In the unilateral type (regardless of gender), the protrusion was more common for the left sphenoid sinus - 10.81% of the patients (12.24% females, 9.4% males) than for the right - 3.38% of the patients (4.08% females, 2.68% males). Complicated structure of the paranasal sinuses, derived from the high prevalence of their anatomical variations, may perplex routine surgical interventions. Henceforth, referral for a CT scan is imperative in order to abate the risks associated with an invasive procedure in the said region.

501 Lateral Rectus Muscle Palsy Secondary to Sphenoid Sinusitis: A Case Report and Literature Review

Abstract Background Isolated sphenoid sinus disease (ISSD) is a rare, often misdiagnosed condition of the paranasal sinus. If left untreated, it can lead to complications involving pituitary gland, cavernous sinus, neurologic, and vascular structures nearby. Case report We present a case of a 60-year-old female with a history of severe left-sided headache, facial pain, diplopia, and left lateral rectus palsy. She was initially referred to ophthalmology and rheumatology for possible giant cell arteritis. MRI scans revealed opacification in left sphenoid sinus consistent with left sphenoid sinusitis. There were no signs of cavernous sinus thrombosis. She was then referred to ENT and underwent endoscopic transnasal sphenoidotomy procedure. Culture results showed Haemophilus Influenza and fungal pseudohyphae. Her palsy and headaches recovered completely 3 months later with a course of antibiotics and antifungals. Literature review for lateral rectus palsy secondary to sphenoid sinusitis without cavernous sinus thrombosis showed it is not a common condition and this case report should serve as a reminder to consider paranasal sinus disease when assessing these patients. Conclusions The onset of ISSD is often insidious and diagnosis of this condition remains a challenge. MRI and CT imaging remain the gold standard for recognising and managing this condition.

Cerebrospinal Fluid Leak After Medical Management of Prolactinoma

Introduction: Dopaminergic agonists such as cabergoline are commonly used to treat prolactinomas, and often lead to significant adenoma shrinkage. Rarely, macroprolactinomas may invade the sphenoid sinus and pose a therapeutic challenge, as treatment with dopamine agonists and subsequent tumor shrinkage can lead to a cerebrospinal fluid (CSF) leak.Clinical Case: A 32-year-old female with no prior medical history presented to the emergency room of an outside hospital for headaches and visual changes. MRI demonstrated a 4.3 x 4.0 x 3.0 cm sellar mass with extension into the right cavernous sinus and sphenoid sinus, and prolactin was elevated to 1,859 ng/ml (3.4 - 21.4). Cabergoline was initiated at a dose of 0.25 mg twice a week with a decrease in her prolactin to 646 ng/ml one month later. Six months after initiation of therapy she transferred her care to our institution and presented for a routine endocrinology visit. She complained of rhinorrhea worse when upright that had begun two weeks prior to this encounter. Urgent MRI of the sella revealed an interval decrease in the size of the sellar mass to 2.1 x 2.7 x 1.5 cm and a fluid collection extending from the sella turcica to the left sphenoid sinus consistent with a CSF leak, and labs showed a prolactin level of 169 ng/ml. Cabergoline was discontinued and the patient was admitted to the hospital for treatment with antibiotics and acetazolamide. She underwent lumbar drain placement while awaiting definitive surgical management, which was delayed due to the COVID-19 pandemic. While off cabergoline, the sellar mass increased in size and her prolactin rose to 1,449 ng/ml, with no effect on the optic chiasm and visual fields. Three months later, she underwent transsphenoidal debulking of the pituitary mass with repair of the sellar floor and removal of lumbar drain. Her postoperative course was uncomplicated and she resumed cabergoline 0.25 mg twice weekly. A prolactin measured two weeks postoperatively was 337 ng/ml. Tumor histopathology revealed a 1.3 x 0.4 x 0.3 cm pituitary adenoma. Immunohistochemistry stained positive for chromogranin A, synaptophysin, and prolactin only. An MRI of the sella and prolactin level will be repeated at her next endocrinology visit.Conclusions: CSF leak is a rare but serious complication from tumor shrinkage after medical management of large invasive prolactinomas, and patients with such tumors should be monitored closely for its development. CSF leaks can increase a patient’s risk for meningitis and subsequent morbidity and mortality. The management of patients with large prolactinomas with local invasion should involve a multidisciplinary approach for decision making, extensive patient education, and close follow up in order to identify and treat a CSF leak should it develop.

Ruptured infectious ICA pseudoaneurysm into the sphenoid sinus after maxillofacial infection, successfully treated by selective embolization

Background: Intracranial infectious aneurysms are cerebral aneurysms caused by pathogen-induced inflammation undermining the arterial wall. We present a rare case of inflammatory pseudoaneurysm of cavernous internal carotid artery (ICA).Case Description: A 51-year-old female with a recent diagnosis of acute lymphoblastic leukemia developed maxillofacial infection with Pseudomonas and Acinetobacter after chemotherapy onset. Initial plain computed tomography (CT) revealed bony dehiscence of the left ICA canal, as well as bilateral protrusion of the vessel within the sphenoid sinus. Following infection spread into the left sphenoid sinus, she presented with episodes of intermittent epistaxis, without any profound vascular abnormalities on postcontrast CT. CT angiography that was performed 15 days later, due to refractory epistaxis, illustrated a large narrow necked irregular shape pseudoaneurysm of the left paraophthalmic ICA, extending into the ipsilateral sphenoid sinus. The aneurysm was completely occluded by selective embolization without parent or adjacent vessel sacrifice, documented on both intraoperative and follow-up angiogram, with no recurrence of epistaxis.Conclusion: Conclusively, ruptured internal carotid infectious aneurysms are rare but potentially fatal causes of epistaxis when extended into the sphenoid sinus. Selective coiling is feasible and can provide definitive treatment of these lesions.

First report of chronic invasive fungal rhinosinusitis in a patient with ovarian cancer caused by Didymella pedeiae and successful treatment with voriconazole: A case report.

Background and Purpose:Didymella pedeiae is a dematiaceous fungus that belongs to the Coelomycetes class. While species within this class are known to cause human infection, D. pedeiae had previously only been known as phytopathogens and had never been isolated from a human sample.Case report: A 51-year-old Iranian female patient with ovarian cancer was admitted with unilateral lesions in paranasal sinuses and a five-month history of nasal obstruction, headache, postnasal drainage, swelling on the left side of the face, and orbital pain. Paranasal sinus computerized tomography scan revealed a soft tissue mass that filled the left nasal cavity, ethmoid, sphenoid, and frontal sinuses with more involvement in the maxillary and ethmoid sinuses. Antifungal treatment was simultaneously initiated with itraconazole+prednisolone 15 mg/day, and levofloxacin. Due to poor clinical response, IV voriconazole and amphotericin B were added to the treatment as well. The patient recovered completely after 10 weeks of therapy.Conclusion: Here, we report the first case of human D. pedeiae infection in a patient with ovarian cancer.

A rare metastatic follicular thyroid carcinoma masquerading as primary sinonasal carcinoma presentation with unusual orbit, skull base and brain metastases

Tumour involving the sinonasal tract account for only 1% of all malignancies. The large majority of tumours affecting sinonasal tract are mainly primary neoplasm or from direct extension of adjacent region; metastatic tumour affecting sinonasal tract are extremely rare. Most of the metastases are originate from carcinoma inferior to the clavicle, including renal, breast, lung, and prostate. The incidence of metastases to sphenoid sinus are even rare. We describe a rare case of metastases of FTC to sinonasal tract, mimicking primary sinonasal carcinoma presentation, with unusual orbit, skull base and brain metastases.A 66-year-old lady with history of subtotal thyroidectomy for FTC presented with epistaxis associated with proptosis of left eye. Nasal endoscopy revealed vascularised mass occupying the entire left nasal cavity. Endoscopic transnasal biopsy was performed which showed metastatic FTC with positive immunochemical staining for thyroglobulin, and thyroid transcription factor-1. Computed tomography angiography demostrated a large vascular tumour involving the left maxillary sinus, bilateral ethmoid and sphenoid sinuses. The mass causing erosion of nasal septum and pterygoid plates and left temporal bone, with extension to left orbit, infratemporal fossa and intracranial. Patient received thyroid stimulating hormone suppression therapy followed by radio-iodine ablation.As surprisingly rare, the purpose of our study is to raise the awareness regarding the possibility of FTC metastatizing to sinonasal tract, orbit, skull base and intracranial. The completion thyroidectomy intervention is crucial for better future prognosis. Thyroid carcinoma should be considered in differential diagnosis of epistaxis and potential primary neoplasm in patient with orbital metastases.

A Case of Painful Post-Traumatic Trigeminal Neuropathy after Endoscopic Sinus Surgery

Painful post-traumatic trigeminal neuropathy (PPTTN) is a distinctive facial pain syndrome characterized by facial and/or oral pain along the sensory distribution of the fifth cranial nerve with a clear history of a traumatic event. To our knowledge, PPTTN after endoscopic sinus surgery (ESS) has not been reported in the literature. We present a case of an elderly woman who experienced unilateral neuralgic pain after undergoing ESS. Following ESS of the left sphenoid sinus to remove suspicious fungus balls, the patient complained of intermittent facial pain occurring in the left periorbital and forehead area. Clinical diagnosis of PPTTN was established after a comprehensive multidisciplinary assessment. The pain disappeared completely after a 5-week medical treatment with gabapentin. Since PPTTN cases associated with ESS are extremely rare, our case demonstrates that PPTTN should be considered in the differential diagnosis of facial pain developing after ESS and can be successfully treated with medical therapy.

Cholesterol Granuloma as a Late Complication of Endoscopic Sinus Surgery

Introduction: To date there are five reports referring to cholesterol granuloma of the sphenoid sinus. This is the first case where cholesterol granuloma is presented as a late complication after successful removal of a mucocele through functional endoscopic sinus surgery (FESS) and associated with convergence insufficiency. Case Report: A 67-year-old carpenter presented with binocular diplopia and frontal headache. A mucocele of the left sphenoid sinus was removed endoscopically leading to the resolution of his symptoms. Eight months later he presented with similar symptoms and findings. Following a revision FESS, cholesterol granuloma was diagnosed. Discussion: Haemorrhage within the sphenoid sinus, obstruction in the sinus ostium and fibrous tissue formation may explain the postoperative formation of cholesterol granuloma. Convergence insufficiency could be attributed to mechanical failure or denervation of eye muscles. Conclusion: Cholesterol granuloma should be included in the differential diagnosis, when recurrence of a sphenoid sinus mucocele is suspected.

MON-237 Primary Pituitary Lymphoma - an Unusual Guest in the Sella!

BackgroundPrimary Pituitary Lymphoma (PPL) is a rare differential diagnosis for a sellar / suprasellar lesion. Less than 40 cases have been reported.Case presentationA 75-year old Chinese lady with known subclinical hypothyroidism presented with 3-day history of dull frontal headache, giddiness and diplopia. Incomplete left cranial nerve (CN) III palsy was noted with no other neurological deficit or hemodynamic instability. MRI brain and pituitary showed a T1- and T2 isointense, 2.0 x 1.1 x 1.3 cm enhancing mass arising from the left sellar region, extending to the left sphenoid and cavernous sinuses, displacing the pituitary stalk towards the right, with no optic chiasm compression. There was no imaging evidence of apoplexy.Evaluation of anterior pituitary hormones revealed hypocortisolism (peak cortisol post 1mcg Synacthen 344 nmol/L, ACTH 3.5 ng/L [10 - 60]), subclinical hypothyroidism (free T4 9.6 pmol/L [8.8 - 14.4], TSH 7.19 mU/L [0.65 - 3.70]), normal prolactin 7.4 ug/L [5.0-27.7], mildly elevated IGF-1 193.7 mcg/L [67.0 - 189.0] with normal GH 1.0 ng/ml, and elevated FSH appropriate for menopause. Glucocorticoid replacement was started.Though the clinical presentation was not typical of a pituitary macroadenoma, in view of symptomatic improvement and neurological stability, she was conservatively managed with plans for early repeat imaging outpatient.Patient was readmitted 1 month later for headache and decreased left-sided visual acuity. A complete CN III palsy, and new CN II, IV and VI deficits were noted (orbital apex syndrome). Repeat MRI showed increase in the size of the sellar lesion to 2.6 x 2.1 x 1.3 cm, surrounding the optic nerve and with left cavernous and sphenoid sinus invasion. Again, there was no suggestion of apoplexy. Biopsy of the lesion was performed, and histology was consistent with Diffuse Large B-cell Lymphoma and Grade 3A Follicular Lymphoma with high proliferative index (Ki67 70%). Immunohistochemistry excluded carcinoma, meningioma and pituitary tumor. PET-CT and bone marrow aspirate confirmed the diagnosis of PPL without metastasis.After 3 cycles of chemotherapy (Methotrexate, Rituximab, Cyclophosphamide, Doxorubicin, Vincristine and Prednisolone), significant decrease in the size of the lesion was noted on repeat MRI. Only mild asymmetric soft tissue thickening remained noticeable over the left sella and cavernous sinus. Cranial nerve deficits had since completely resolved. Glucocorticoid replacement was continued in the meantime while awaiting the completion of chemotherapy.ConclusionPPL may present in a similar manner as pituitary apoplexy. Absence of typical imaging characteristics of apoplexy in patients with rapid symptom progression and CN involvement should alert clinicians to consider alternative diagnosis including aggressive neoplastic, inflammatory and infective lesions.