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I 15 case report _ cavernous sinus infection I roots4_2010 Sphenoidalsinuses The sphenoidal sinuses are located in the body of the sphenoid bone and may extend into its wings. They are unevenly divided and separated by a bony septum. Because of this extensive pneumatisation (formation of air cells or sinuses), the body of the sphenoid is fragile. Only thin plates of bone separate the sinuses from several important structures: the optic nerves and optic chiasm, pituitary gland, inter- nal carotid arteries and cavernous sinuses. The sphe- noidalsinusesarederivedfromaposteriorethmoidal cell that begins to invade the sphenoid, giving rise to multiple sphenoidal sinuses that open separately into the sphenoidal recess. The posterior ethmoidal arteries and posterior ethmoidal nerve supply the sphenoidal sinuses. Complications of sphenoidal sinusitis (diplopia in childhood) The most common complication of sphenoidal sinusitis is meningitis. Any surrounding tissue adja- cent to sphenoid sinus may be infected. As a result of thecloseanatomicalrelationshipwiththesphenoidal sinuses, cranial nerves II to IV, the dura mater, pitu- itary gland, cavernous sinus, internal carotid artery, spheno-palatine artery and pterygopalatine nerve have been reported to be infected by dissemination. Complications such as orbital cellulitis, orbital abscess,orbitalapexsyndrome,blindness,meningitis, epidural and subdural abscesses, cerebral infarcts, pituitary abscess, cavernous sinus thrombosis and internal carotid artery thrombosis have been de- scribed in literature. Clinical suspicion is very important for determin- ing the diagnosis because the symptoms, history and physical examination do not specifically indicate sphenoidal sinusitis. High-resolution axial and coro- nal CT is recommended for the diagnosis of sphe- noidal sinusitis and potential intracranial complica- tions. However, cranial magnetic resonance imaging issuperiortoCTintermsofdetectingtheinvolvement of cranial nerves, cavernous sinus, surrounding neu- rovascular tissue and the presence of a tumour. The most common pathogens in the aetiology of sphenoidal sinusitis are Staphylococcus aureus, Streptococcus pneumonia and some aerobic and anaerobic Streptococcus spp. fungi, particularly As- pergillusspp., should be kept in mind in immunosup- pressed patients. Uren and Berkowitz reported eight children with Idiopathic subglottic stenosis, five out of which had been treated successfully with medical therapy. The remaining three children, either unre- sponsivetomedicaltherapyorcomplicatedcases,had undergone endoscopic sphenoidotomy. At the begin- ning,parenteralantibiotictherapyshouldbeadminis- tered, since this infection may cause serious, even fatal, complications. A three- to four-week antibiotic therapy should be completed. Topical decongestants and irrigation with saline solution are recommended as adjunctive therapy. Since the sphenoid sinus has anatomical relation- shipswithseveralvitalstructures,anydelayincorrect diagnosis and, therefore, in prompt and adequate treatment, can result in severe and life-threatening complications1, such as meningitis, pituitary abscess, peri-orbital cellulitis, orbital cellulitis, optic neuritis, carotidarterythrombosisandcavernoussinusthrom- bosis. Sphenoiditis is generally associated with in- flammation of the maxillary and ethmoidal sinuses. Whencomplicationsoccur,patientsalsocomplain offacialpain,paraesthesiaattheleveloftheV1,V2,V3 areas, sixth nerve palsy, ocular signs and symptoms (blurred vision, diplopia, eye tearing, proptosis, visual loss,ptosis)andmentalstatuschanges.Thesecompli- cations are due to the anatomical relationship of the sphenoid sinuses with nearby vital structures such as the middle cranial fossa, hypophysis, superior orbital fissure,opticalcanalandcavernoussinus,whichcon- taintheinternalcarotidarteryandcranialnervesIIIto VI.Thus,whenasinusinfectionspreadstothesestruc- tures, it may mimic other neurological disorders, thus delayingcorrectdiagnosisandappropriatetreatment. Maxillarysinuses Embryologically, the maxillary sinus is first to ap- pear, initially, as a depression of the nasal wall below themiddleturbinate.Thegrowthofthesinusisrelated tothedevelopmentanderuptionofthemaxillarymo- larteeth,anddoesnotreachfullsizeuntiltheeruption Fig. 6 Fig. 6_Immediate post-op X-ray.