Acute sphenoiditis involving the second branch of the

QJM Advance Access published September 10, 2016
Title: Acute sphenoiditis involving the second branch of the trigeminal nerve
Author names: Yuta Hirose, Yusuke Hirota, Daiki Yokokawa, Yoshiyuki Ohira, Masatomi Ikusaka
Department of General Medicine, Chiba University Hospital, Chiba city, Chiba, Japan
Correspondence to: Yuta Hirose, Department of General Medicine, Chiba University Hospital, 1-8-1
Inohana, Chuo-ku, Chiba city, Chiba, Japan, 260-8677
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Tel.: +81-43-224-4758
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E-mail: [email protected]
© The Author 2016. Published by Oxford University Press on behalf of the Association of Physicians.
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Learning point for clinicians
Acute sphenoiditis may affect the second branch of the trigeminal nerve because of anatomical reasons
and should be included in differential diagnoses in patients with headache accompanied by facial
numbness.
Case report
side of the face. He noted preceding transient upper respiratory tract symptoms seven days before his visit.
The headache that occurred two days before his visit was the most severe he had ever experienced and
worsened. On the day before his visit, it was accompanied by vomiting and numbness on the right side of
the face. Physical examination showed a temperature of 36.6°C, blood pressure of 167/83 mmHg, pulse
rate of 72 beats per minute, and oxygen saturation as measured using pulse oximetry (SpO2) of 99%.
Neither neck stiffness nor papilledema of the eyeground was observed. Both tactile sense and thermal
nociception were impaired in areas corresponding to the second branch of the trigeminal nerve, such as
the upper lip, lateral side of the ala of the nose, buccal region, and maxillary gingiva in the right side of
the face. Hematologic tests showed a white blood cell count of 10000 /µL and a C-reactive protein level
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A 67-year-old man visited our hospital with complaints of headache, vomiting, and numbness on the right
of 3.8 mg/dL, indicating an inflammatory response. The spinal fluid test showed no abnormal finding.
Head computed tomography (CT) (Figure 1a) showed fluid accumulation without bone destruction in the
right sphenoidal sinus. Right sphenoid sinusitis was diagnosed.
Intravenous infusion of sulbactam/ampicillin (SBT/AMPC) was started at a dose of 6 g/day. When a plug
of pus that was revealed at the right sphenoid ostium with a nasal endoscope was removed, a large
amount of pus was drained. Simultaneously, the headache was markedly relieved. On hospital day 6,
clavulanate 125 mg/day), and the patient was discharged. No pathogenic bacterium was isolated from pus
or identified by blood culture (two sets).
Discussion
Sinusitis that occurs in the sphenoidal sinus alone is a relatively rare condition, accounting for less than
3% of all cases of sinusitis.1 Lawson et al reported that headache, which is observed in 100% of the cases,
is the most common symptom, followed by visual loss in 13% and cranial neuropathy in 8%, in
descending order.2 Headache is nonspecific in terms of features and can occur in any part of the
craniofacial area. Frequency of nasal symptoms is considered to be lower than that of headache and visual
3
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treatment was changed to oral administration of antimicrobial agents (amoxicillin 500 mg/day +
disturbance. In cases without complications, resolution can be achieved by conservative treatment with
antimicrobial agents alone. However, endoscopic drainage should be performed in cases resistant to
conservative treatment and those with complications.1
The structures associated with complications of sphenoiditis include cranial nerves II, III, IV, V1, V2, and
VI, the dura mater, pituitary body, cavernous sinus, internal carotid artery, sphenopalatine ganglion,
sphenopalatine artery, pterygoid canal, and pterygoid nerve.1,
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The most common type of cranial
However, we have found no case report of sphenoiditis affecting only the second branch of the trigeminal
nerve, as seen in our case. On CT images taken in our case (Figure 1b), the right foramen rotundum (red
arrow), through which the second branch of the right trigeminal nerve passes, appears adjacent to the
sphenoidal sinus, and the bone separating between the right foramen rotundum and the sphenoidal sinus
is unclear, compared to the bone on the left side (blue arrow). It was assumed that inflammation in the
sphenoidal sinus had spread to the foramen rotundum and the second branch of the trigeminal nerve
passing through the foramen.
Conflict of interest: None declared.
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neuropathy is abducens nerve disorder because of the nerve running closest to the sphenoidal sinus.1, 2
References
1. Tan HKK, Ong YK. Acute Isolated Sphenoid Sinusitis. Ann Acad Med Singapore 2004; 33: 656-9.
2. Lawson W, Reino AJ. Isolated sphenoid sinus disease: an analysis of 132 cases. Laryngoscope 1997;
107: 1590-5.
3. Proetz AW. The sphenoid sinus. Br Med J 1948; 2: 243-5.
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(a) Computerized tomography of the head is revealed a shadow without bone destruction observed in the
right sphenoidal sinus (red arrow).
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Figure 1a: Head CT showing sphenoid sinusitis
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Figure 1b: Head CT showing sphenoid sinusitis
(b) Computerized tomography of the head is revealed that the bone separating between the right
sphenoidal sinus and the adjacent right foramen rotundum (red arrow) is unclear, compared to the bone on
the left side (blue arrow).
2