OBJECTIVE: To elucidate the effectiveness of a 30-degree anteriorly tilted coronal CT in visualizing the anterior wall of the sphenoid sinus.
METHODS: Medical records and CTs of patients who underwent septoplasty, inferior turbinectomy, or endoscopic sinus surgery were reviewed. We evaluated the visibility of the anterior wall of the sphenoid sinus on conventional coronal CT scans and categorized its orientation. We then created anteriorly tilted coronal CT images to evaluate its improved visibility.
RESULTS: A total of 129 patients were evaluated. While conventional coronal CT scans fully visualized the anterior wall of the sphenoid sinus in cases with an Onodi cell, 17.7% remained unidentified when the Onodi cell was absent. However, anteriorly tilted coronal CT scans consistently identified the anterior wall regardless of the presence of an Onodi cell.
CONCLUSIONS: Our study highlights the effectiveness of anteriorly tilted coronal CT scans in consistently visualizing the anterior wall of the sphenoid sinus, regardless of the presence of an Onodi cell. It is possible that some other structures may become less identifiable on anteriorly tilted coronal CT.

Spontaneous cerebrospinal fluid (CSF) leaks are an uncommon clinical entity, often challenging to diagnose accurately. We present a unique case of a patient with symptoms suggestive of an ethmoidal CSF leak, initially supported by radiological findings, but ultimately revealed to be a mid-clival CSF leak (from the posterior wall of the sphenoid sinus). This case underscores the complexities of diagnosing CSF leaks and highlights the importance of surgical exploration in cases where radiological evidence appears contradictory. The patient\'s Computed Tomography scan indicated a CSF leak in the cribriform plate, prompting a surgical approach to address this region. However, intraoperative findings surprisingly revealed no evidence of leak in the cribriform plate but instead a posterior wall of the sphenoid defect as the culprit. This report emphasizes the critical role of interdisciplinary collaboration, meticulous preoperative and intraoperative assessment, and adaptability in managing challenging cases of CSF leaks, ultimately leading to successful surgical repair and improved patient outcomes. It serves as a valuable reminder for clinicians to consider the possibility of a masquerading CSF leak when clinical and radiological findings do not align, thereby facilitating more precise diagnosis and targeted treatment.

UNASSIGNED: Granular cell tumors occur in all ages and many anatomic sites. In the craniofacial region, they typically arise in soft tissue, not bone. We present a primary intra-osseous granular cell tumor of the sphenoid and central skull base arising in a 12- year- old girl.
UNASSIGNED: A 12-year-old female with sickle cell disease and Jeavons syndrome presented with seizures. Imaging and partial resection revealed an expansile benign granular cell tumor (GCT) involving the sphenoid body, pterygoid process, and central skull base. The disease has remained stable after 36-month follow up.
UNASSIGNED: GCT primarily involving the osseous sphenoid/skull base has not been previously reported in a child. Although mostly benign, some are aggressive, with malignant transformation in 1-2%. Surgery is the mainstay of treatment, but in the skull base this may be limited by adjacent critical structures. Decision-making is guided by anatomic extent, histology, and clinical behavior.

UNASSIGNED: A temporo-sphenoidal encephalocoele occurs when temporal lobe herniates through a defect in the greater wing of the sphenoid bone into the sphenoid air sinus. The natural history is not well-understood, though presentation in adulthood with CSF rhinorrhoea and/or meningitis is typical. Lateral pneumatisation of the sphenoid sinus and elevated BMI may be contributory.
UNASSIGNED: We explored the feasibility of a transorbital approach (TOA) for repair, using a combination of 3D modelling and simulation. We then successfully deployed this technique in vivo.
UNASSIGNED: CT imaging for three patients who had previously undergone transcranial repair of lateral temporo-sphenoidal encephalocoele was used to generate data allowing 3D printed models of the skull base to be produced. The transorbital approach was simulated by performing a lateral orbitotomy followed by drilling of the sphenoid wing to expose the antero-basal middle fossa. 3D object scanning was used to create virtual models of the skull base post-surgery, from which surgical access was quantified in two ways: the area (mm2) of the middle fossa exposed by the TOA and the vertical attack angle.
UNASSIGNED: The mean surface area of the cranial access window achieved by simulated TOA was 325mm2. The mean vertical attack angle was 25°. One patient was subsequently treated successfully via TOA with no recurrence of their CSF leak, no orbital morbidity, excellent cosmesis, but resolving V2 numbness (follow-up 7 months).
UNASSIGNED: We have shown that the transorbital approach provides adequate surgical access. In our single case, surgical repair of a lateral temporo-sphenoidal encephalocoele via TOA was feasible, safe, and effective. This approach may offer some advantages compared with transcranial or endonasal approaches.

Basilar invagination (BI) is characterized by rostral dislocation of the cervical spine toward the skull base. The craniometrics of the skull base have shown significant differences among craniocervical junction malformations. The sphenoid bone is the center of the skull base; however, no study has evaluated this bone in cases of BI. This was a cross-sectional study of MRI databanks from two institutions of the author\'s practice between 1985 and 2020. The craniometrics of the sphenoid bone were measured in BI patients and controls. Fifty-eight MRIs were selected, including 28 BI patients and 30 controls. The mean sphenoid crest-clivus length was 32.66 ± 4.7 mm in the BI group and 29.98 ± 3.0 mm in the control group (p = 0.01). The mean sphenoid planum-top of Dorsum sellae length was 28.53 ± 3.7 mm in the BI group and 26.45 ± 3.2 mm in the control group (p = 0.02). The mean tuberculum sellae-sphenoid floor height was 18.52 ± 4.4 mm in the BI group and 21.32 ± 2.9 mm in the control group (p = 0.00). The mean sella turcica-sphenoid floor height was 10.35 ± 3.8 mm in the BI group and 12.24 ± 3.5 mm in the control group (p = 0.05). The mean clivus length was 29.81 ± 6.3 mm in the BI group and 40.86 ± 4.2 mm in the control group (p = 0.00). The mean sphenoid length was 58.34 ± 7.4 mm in the BI group and 67.31 ± 6.0 mm in the control group (p = 0.00). The mean sphenoid angle was 116.33 ± 8.7° in the BI group and 112.36 ± 6.9° in the control group (p = 0.05). The BI sphenoid bone has shorter vertical dimensions and longer horizontal measures. This morphology promotes a flattening of the sphenoid angle. The sphenoid bone is significantly altered in BI, favoring the congenital hypothesis in the pathophysiology of this disease.

Plasmacytoma of the skull base is a rare entity. We present a case of sphenoid plasmacytoma in a 51-year-old woman who had nasal obstruction, intermittent epistaxis, headaches, decreasing visual acuity, and diplopia. Computed Tomography (CT) scan and magnetic resonance imaging (MRI) showed a large heterogeneous, expansile lesion measuring 75 mm × 54 mm, centered on the sphenoidal bone and the clivus. Biopsy confirmed the diagnosis of solitary plasmacytoma after ruling out systemic spread by the initial assessment. The patient was successfully managed by external beam radiotherapy and a complete response was obtained after 12 months of follow-up.

Cavernous sinus thrombosis (CST) is a rare but life-threatening infectious disease whose diagnosis and treatment are challenging. CST can result in ocular and neurologic morbidities, as well as fatal systemic complications due to systemic thrombus. Occasionally, these clinical symptoms can be a result of contralateral sinusitis. A 75-year-old female presented with severe headache and fever. Magnetic resonance imaging revealed a multifocal filling defect in both cavernous sinuses, with heterogeneous enhancement and thrombosis of the right superior ophthalmic vein. Intravenous antibiotic was administered, and endoscopic sinus surgery was performed. The patient was discharged 40 days after admission and there were no neurologic symptoms and no evidence of sequelae during the 10-month follow-up. Symptoms of CST on the contralateral side are often missed, which delays initiation of appropriate treatment. When CST secondary to paranasal sinusitis is diagnosed, clinicians should consider contralateral as well as ipsilateral infection of the paranasal sinus. Preventing disease progression and complications through early and aggressive antibiotic administration along with sinus surgery is crucial.

UNASSIGNED: Restricted access and compression of neurovascular structures at various anatomic variations at the skull base poses a challenge to surgeons, neurologists and anesthetists. The present study was performed with the objective of providing morphometric analysis of innominate foramina, and anomalous bony bars and spurs along the infratemporal surface of the greater wing of the sphenoid and reviewing the practical significance of dealing with this region.
UNASSIGNED: A total of 100 dry-aged human adult skulls from the archives of the osteology library of the Department of Anatomy were studied. A detailed morphometric analysis of such innominate foramina and anomalous osseous structures along the base of the sphenoid was performed using a sliding digital vernier caliper.
UNASSIGNED: Anomalous bony bar was found in 22 skulls (25.28%). A complete bar was observed at eight (9.1%). An innominate foramen was located inferomedial to foramen ovale (5 unilateral and 3 bilateral) with a mean anteroposterior diameter of 3.44 mm and a mean transverse diameter of 3.16 mm.
UNASSIGNED: Neurovascular structures may be compressed by abnormal bony outgrowths or while traversing through such unnamed bony foramina. The latter may also be overlooked and mistaken during radiological interpretation leading to delayed diagnosis. Such unnamed foramina and bony outgrowths need to be documented in the literature due to their surgical, and radiological implications and limited citations.

The rarity of isolated sphenoid sinus disease (ISSD) and the specificity of pediatric populations meant that a separate analysis was required in this study. This study aimed to present and discuss the results of an analysis of clinical manifestations, radiological findings and surgical methods based on a large series of exclusively pediatric patients. The study group covered 28 surgically treated children (aged 5.5-17.5 years). The medical data were retrospectively analyzed and meticulously discussed with regards to presenting signs and symptoms, radiographic findings, surgical approaches, complications, post-op care, histopathological results and follow-ups. The dominant symptom was a persistent headache (78%). Four children presented visual symptoms, diplopia in two cases, visual acuity disturbances in one case and both of these symptoms in one patient. Sixteen children presented chronic isolated rhinosinusitis without nasal polyps, six suffered from mucocele and one presented chronic sphenoiditis with sphenochoanal polyp. Four patients turned out to exhibit neoplastic lesions and developmental bony abnormality was diagnosed in one case. No fungal etiology was revealed. The transnasal approach was used in 86% of patients. A transseptal approach with concurrent septoplasty was used in four patients. The patient with visual acuity disturbances completely recovered after the surgery. All children with visual symptoms reported improvement in the vision immediately after surgery. No postoperative complications were observed. Fungal etiology was extremely rare in the pediatric population with ISSD. The surgical treatment should be a minimally invasive procedure regarding a limited range of the pathology in ISSD. Emergency surgery should be performed if ISSD produces any visual loss.

Non skin malignant melanomas are known to be more aggressive than the skin counterpart. A 50-year lady with recurrent epistaxis, had mass in right sphenoid, which was resected by endoscopic sinus surgery. After histopathological confirmation of malignant melanoma radiotherapy was given. She later developed metastasis in liver.