Sphenoidotomy

The sphenoid sinuses are small (hypoplastic) in 13% of cases, or absent in 1.25% (aplasia or agenesis). Present from birth, they develop mainly between the ages of 4 and 15 within the sphenoid bone, which is located in the middle of the skull behind the ethmoid. The main reasons for opening a sphenoid sinus are antibiotic-resistant bacterial sinusitis that cannot drain naturally, mycoses, mucoceles, diagnostic biopsies and closure of spontaneous or traumatic osteomeningeal breaches.

Find out more about endonasal sphenoidotomy from Dr. Delagranda, ENT and cervico-facial surgeon in La Roche sur Yon.

The sphenoid sinuses are small (hypoplastic) in 13% of cases, or absent in 1.25% (aplasia or agenesis). Present from birth, they develop mainly between the ages of 4 and 15 within the sphenoid bone, which is located in the middle part of the skull behind the ethmoid. They drain into the posterior and medial part of the nasal cavity. The optic nerve and internal carotid artery are two very important elements located laterally to the sphenoid.

Occasionally, the drainage zone is very narrow and, as a result of persistent inflammation, becomes totally blocked, with or without the presence of a sentinel polyp in front of the ostium. This can lead to acute or chronic sinusitis, which may not resolve despite antibiotic, anti-inflammatory and vasoconstrictive treatment.

Mucoceles are hermetic mucous pockets originating from sinuses that can no longer drain. Not specific to the sphenoidal sinuses, mucoceles most often develop in people with previously operated nasal polyposis. Filled with mucus permanently secreted by the mucocele walls, they tend to grow inexorably, as the mucus cannot evacuate. The rate of growth of mucoceles varies from person to person, but it can lead to progressive deformation of the bone over months or years, until rupture occurs, sometimes with serious consequences (meningitis, brain abscess, exophthalmos, double vision (diplopia), loss of sight). Antibiotic and corticosteroid treatments can be used on an ad hoc basis in the event of early complications, before surgery is performed very rapidly. Mucoceles are merely the translation of an underlying problem that may never be resolved, so they can recur, sometimes years later. Mucoceles are monitored by MRI, that should be done regularly. Any change in the mucocele should be booked promptly.

Spontaneous or traumatic neuromeningeal breaches can occur in the sphenoid. Some require surgical coverage, while others may resolve spontaneously or with the help of appropriate measures. A persistent symptomatic breach requires surgical coverage. Vaccination against pneumococcus and haemophilus is recommended.

Endonasal opening of the sphenoid sinus is recommended in cases of :

Bacterial frontal sinusitis resistant to several lines of usually effective antibiotics. Intense, pulsatile facial pain, median between the eyes or at the top of the skull, increased when the head is tilted forward, with or without fever, runny nose or not (rhinorrhea) and which may or may not be blocked (nasal obstruction).

Sphenoidal mucocele. Mucocele is usually initially asymptomatic. Pain is rare, but double vision, paralysis of one eye, and progressive or abrupt, partial or total loss of visual acuity can also occur. These last 2 signs constitute an urgent need for consultation.

Fungal sinusitis. Asymptomatic at first, most of the time. Signs can therefore vary widely, from no signs at all and a chance discovery on a skull scan, for example, to pain between the eyes or at the top of the skull, to a blocked nose (nasal obstruction) or runny nose (rhinorrhea).

Benign or malignant tumor of the frontal sinus, often not limited to this single sinus. Signs can therefore be highly variable: cranial or facial pain, blocked nose (nasal obstruction), runny nose (rhinorrhea) or bleeding (epistaxis) on one side only.

Drainage of cerebrospinal fluid through an osteomeningeal breach. In the absence of meningitis, signs are limited to a permanent or intermittent discharge of clear, sweet fluid from one side only, increased by exertion (abdominal thrust) or tilting the head forward.

With no visible external scar, the procedure is performed through the nasal cavity. Under general anaesthetic in the operating theatre, the nasal cavity is filled with an anaesthetic-retractant, and the ostium of the sphenoidal sinus is located by gentle upward palpation along the nasal septum behind the nasal fossa. The ostium is then enlarged with special forceps that remove the bone from the anterior wall of the sphenoid, under visual control via rigid optics inserted into the nose.  We then penetrate the sphenoid to clean it, take samples, biopsy and close a breach if necessary.

In the case of outpatient surgery for a simple sphenoidotomy, the patient is usually discharged home the same day, but in the case of breach closure, the hospital stay may last several days.
After hospitalization, the patient should remain at home for 7-14 days, resting and checking for bleeding from the nose or throat.
If necessary, the surgeon will give you 7 to 21 days’ leave from work, depending on the procedure.
Sport is not recommended for the first 21 days, and recovery should be gradual.
Pain is minimal. It is controlled by class II analgesics.
Post-operative care at home: nosewash with saline, analgesics, antibiotics if required by your doctor.
Scarring: no visible scar

Here is a selection of questions frequently asked by Dr Delagranda’s patients during a sphenoidotomy consultation in La Roche-sur-Yon.