Web case

Case presentation:
An 8 year old boy presented to the emergency department with few days
history of severe headache. Pain is described as fronto-occipital, continuous
and not relieved by pain medications. It’s associated with nausea, vomiting
and high grade fever. No blurred vision, no dizziness, no diarrhea and no
other associated symptoms. Physical findings were pertinent for fever of
39°C and facial tenderness over the frontal area with no meningeal signs.
His pediatrician asked for a CT scan of brain and sinuses which revealed
right isolated sphenoid opacification (fig. 1).
fig.1: CT scan of sinuses: Right isolated sphenoid sinus opacification
He was sent home on Amoxicillin-Clavulanic acid and antipyretics.
However the patient presented to the emergency unit 3 days later because of
persistent severe occipital headache. The ENT team was consulted at this
moment to evaluate the patient.
On physical exam, he was awake and oriented, afebrile, no meningeal or
focal neurological signs. His nose was congested otherwise his exam was
within normal limits.
Blood studies revealed a white blood cells count of 7000 with 67%
segmented and CRP = 71.4 mg/L.
CT scan of sinuses was repeated and revealed same findings (fig.2)
fig. 2: Persistent right sphenoid sinus opacification.
The patient was admitted for intravenous antibiotics and started on
Ceftriaxone and Clindamycin, nasal decongestant and pain medications.
Patient improved and became free of pain and fever after 48 hours.
He was discharged home after few days on Cefpodoxime and Clindamycin
for a total of 3 weeks.
He stayed free of symptoms until completion of treatment, then follow up
CT scan revealed clearance of his sphenoid disease (fig.3)
Fig. 3: Follow up CT sinuses showing minimal mucosal thickening of the right sphenoid
sinus.
DIAGNOSIS: Isolated acute sphenoid sinusitis.
Discussion:
Sphenoid sinusitis is an uncommon entity in children. Van Alyea described
the sphenoid sinus as the most neglected sinus [1].
Sphenoid sinusitis affects children in their pre-adolescent and adolescent
age, since its formation started to be clinically apparent between the age of 5
and 15 years [5], it reaches its adult size by puberty. The low incidence of
isolated sphenoiditis is due to its deep position away from the current of
nasal secretions, irritants and pathogens [2].
The low rate of sphenoiditis is also explained by the low secretion rate of its
lining mucosa and therefore decreased drainage problems as compared to
other paranasal sinuses [13].
In its anatomical position, the sphenoid sinus is surrounded by 13 important
structures that may be involved by the diseased sinus. These structures
include: the pituitary gland, the optic nerve and chiasm, the dura mater, the
cavernous sinus, the internal carotid artery, the third, fourth, and sixth
cranial nerves, the ophthalmic and maxillary nerves, the sphenopalatine
ganglion, the sphenopalatine artery, and the pterygoid nerve.
The clinical presentation of isolated sphenoiditis is usually vague and nonspecific making the diagnosis often delayed [7]. The presentation ranges
from the non-severe form with headache being the most common, to the
severe form with headache, fever and any manifestation related to
involvement of adjacent structures [14].
Persistent headache, not responding to medical treatment and awakening
patients at night should prompt the diagnosis of isolated sphenoid sinusitis
among other cranial pathologies [8,11]. The location of headache is variable
and inconsistent [7]. Headache is often associated with facial and orbital
pain as well as visual symptoms including blurred vision, photophobia and
diplopia [8,11].
Other presenting symptoms are related to complications that can be serious
and these include blindness, ophtalmoplegia, cavernous sinus thrombosis,
meningitis, cerebral infarction and cranial nerves palsy (III, IV, V and VI)
[7,14].
Predisposing factors are those related to anatomical obstruction to sphenoid
drainage (septal deviation, large superior and middle turbinate), traumatic or
surgical injury, history of sinusitis and/or allergic rhinitis.
Swimming and diving were related to isolated sphenoiditis in children due to
forceful introduction of pathogens [6,7, 14].
High resolution CT and MRI are the main diagnostic tools to assess the
extent of the disease as well as the presence eventual complication [3,12].
Nasal endoscopy , although not well tolerated by children, can be helpful to
visualize the sphenoethmoid recess [4].
The most common organisms found in acute sphenoiditis is Staphylococcal
Aureus, followed by Streptococcal species and less frequently Gramnegative and anaerobs. Fungal infection, mainly Aspergillus, should be
considered in immunocompromised patients [7,10,11].
Uncomplicated acute sphenoiditis can be treated with 3-4 weeks of
antibiotics directed against the most common pathogens. Surgical drainage
should be considered if no clinical improvement in 24-48 hours or in case of
emergence of complication [8,9].
In conclusion, acute isolated sphenoid sinusitis in children is a rare but
serious condition. Its unspecific presentation may delay the diagnosis and
can lead to devastating complications. Acute isolated sphenoiditis should be
considered in the differential diagnosis of persistent and refractory headache.
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