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Hintergrund: Zur operativen Therapie des symptomatischen Hypophysenadenoms, welches 10-15 % aller intrakraniellen Tumore ausmacht, stehen mit dem mikrochirurgischen und dem endoskopischen transnasalen, transsphenoidalen Zugang zwei verschiedene, seit Jahren anerkannte Resektionstechniken zur Verf��gung. Bez��glich der postoperativen Lebensqualit��t (QoL) und sinunasalen Funktion gibt es in der Literatur bisher kaum vergleichende Ergebnisse, insbesondere aus Langzeitstudien. Untersucht wurde, ob sich die beiden etablierten Operationstechniken zur transsphenoidalen Resektion von Hypophysenadenomen bez��glich der postoperativen Lebensqualit��t und der sinunasalen Funktion sowie der Alltagsbelastung im Hinblick auf die Hormoninsuffizienz als gleichwertig erweisen. Methoden: In die retrospektive Fragebogenstudie wurden 52 Patienten mit zur��ckliegender mikrochirurgischer (35 Patienten) bzw. endoskopischer (17 Patienten) transsphenoidaler Resektion eines Hypophysenadenoms eingeschlossen, welche unter Einsatz einer intraoperativen Magnetresonanztomographie zwischen 2008 und 2016 am BKH G��nzburg operiert wurden. Diese wurden mittels vier verschiedener Frageb��gen, dem Sino-Nasal Outcome Test-20 German Adapted Version (SNOT-20 GAV), dem Quality of Life Assessment of Growth Hormone Deficiency in Adults (QoL-AGHDA), dem Addison���s disease-specific Quality-of-Life-30 Fragebogen (AddiQoL-30) und dem EQ-5D three-level version Fragebogen (EQ-5D-3L) zu ihrer postoperativen QoL und sinunasalen Funktion sowie zur durch eine Hormoninsuffizienz ver��nderten Alltagsbelastung befragt. M��gliche Unterschiede sollten ��ber die bisherigen Erkenntnisse hinaus in Abh��ngigkeit von diversen Subgruppen (Geschlecht, Tumorsubtyp, invasives Wachstumsmuster des Adenoms nach Knosp, postoperatives endokrines Ergebnis, Resektionsausma�� und Sch��delbasisrekonstruktion) aufgezeigt werden. Der Nachbeobachtungszeitraum betrug dabei durchschnittlich 59 �� 30 Monate nach Operation. Ergebnisse: Im SNOT-20 GAV wurden in der mikrochirurgischen Gruppe signifikant niedrigere Gesamt- (p=0,001) und Subscores (p

Modern Management of Pituitary Adenomas - Current State of Diagnosis, Treatment and Follow-Up Abstract. Pituitary adenomas (PA) are benign neoplasms originating from parenchymal cells of the anterior pituitary. Tumor mass effect can cause headaches, visual deficits by compression of the optic chiasm, and partial or complete hypopituitarism. Hormone secreting PA can cause several forms of specific syndromes such as Cushing's disease or acromegaly depending on the type of hormone. Endoscopic transsphenoidal resection is the preferred treatment option for most symptomatic or growing PA. Nowadays techniques like high definition intraoperative MRI can assist the surgeon in his goal of maximal safe resection. An exception are prolactinomas which can usually be treated medically with dopamine agonists. Therapy of PA is complex and should be managed in a high-volume center with an interdisciplinary team approach including neurosurgeons and endocrinologists.Zusammenfassung. Hypophysenadenome (HA) sind gutartige Tumoren aus parenchymatösen Zellen des Hypopysenvorderlappens. Es wird zwischen endokrin-inaktiven HA und hormonsezernierenden HA differenziert. Die Symptomkonstellation ist abhängig von der hormonellen Über- oder Unterfunktion und dem durch das HA erzeugten Masseneffekt. Neben Kopfschmerzen präsentieren sich HA häufig mit Visusstörungen sowie Gesichtsfeldausfällen als Folge der Kompression des Chiasma opticum. Die chirurgische Resektion über einen transsphenoidalen Zugang ist die bevorzugte Therapieoption für symptomatische oder grössenprogrediente HA. Moderne Techniken wie intraoperative hochauflösende MR-Bildgebung unterstützen den Chirurgen in der maximal sicheren Resektion. Eine Sonderrolle spielen symptomatische Prolaktinome, die in erster Linie medikamentös mit Dopaminagonisten therapiert werden sollten. Aufgrund der Komplexität der Erkrankung ist eine interdisziplinäre Betreuung der Patienten durch Neurochirurgen und Endokrinologen in einem Zentrum mit hohen Fallzahlen empfohlen.

Spontaneous rhinoliquorrhea with or without meningo-encephaloceles in the region of the sphenoid sinus occurs very infrequently. It is not uncommon that the attempt of transnasal endoscopic duraplasty in this region leads to recurrence of the CSF leak. The existence of a lateral craniopharyngeal canal can be a possible explanation for these failures.Retrospective analysis of 23 patients with rhinoliquorrhea of different pathogenesis in the region of the frontal and central skull base that were treated with transnasal, video-endoscopic surgical procedures in our department between 2006 and 2011.2 of 23 patients with proven rhinoliquorrhea following a transnasal video endoscopic duraplasty procedure showed a recurrence of the CSF leak. The computertomographic analysis with respect to the current literature indicated the presence of a craniopharyngeal canal at the lateral side of the sphenoid sinus. This canal is also known in the literature as Sternberg's canal. In contrast to the other 21 treated cases there were no planar skull base defects of different pathogenesis in these 2 cases, but a ontogenetically bony canal. The canal can reopen spontaneously or due to an external mechanical impact.The closure of this bony canal requires a modified surgical procedure such as sufficient padding of the bony canal and its sealing by a vascularized pedicle flap in contrast to the ordinary planar bony skull base defects.

Endo- and transnasal surgery needs optical support. The use of a microscope allows bimanual manipulation. More often the endoscopic technique is used which needs one hand for endoscope guidance "loosing" it for manipulation or demanding an assistant for endoscope guidance. In this work the use of a miniature endoscope manipulator system for endonasal and transnasal surgery was evaluated.31 FESS with manipulator-assisted endoscope guidance were performed. The used endoscope positions, the number of position changes and conditional interruptions were documented. In addition, a transsphenoidal approach to the pituitary gland was performed in a cadaver trial.Non-inferiority was shown for the use of the endoscope manipulator with reference to time and accuracy of manipulator-assisted endoscope guidance. There were 6.4 position changes for each side. Bimanual manipulation was possible in all cases. In the region of high-risk structures (lamina papyracea, frontal recess) we conceptual switched to manual endoscope guidance.The evaluated endoscope manipulator fulfills the minimum requirements to be integrated into the surgical workflow of endo- and transnasal surgery. The number of required endoscope position changes is small allowing bimanual instrumentation. Still a disadvantage is the need for interrupting the workflow to remote the endoscope manipulator with the joystick console. Further development potential would be a forced-feedback function and hands-free navigated-controlled guidance.

The effective register accuracy in an situs issues a challenge to the employment of instrument navigation in the ENT Surgery. The idea of the initially determined process Dynamic Registration Supply (DRS) is to improve the register accuracy by the automatic, and interoperability of the register.The aim was to determine clinical use of DRS. Opto-electrical system Navigation Panel Unit, vs. 4.0.0 with the functionality DRS was used. Experiments were carried out on 95 patients who had so called FESS. The data of a control group were available to researchers. The measuring log includes among other things following parameters: retooling time, cutting-suture time, frequency of use of the navigated pointer, frequency of additional registration.At least once during the procedure DRS has been activated in 85 of 95 interventions (89.5). The time required increased by 15% accumulated 189 s per intervention. The most frequently used additional registration was in the region of sphenoid sinus. The surgeons underlined that out of 95 surveys in 75 cases the DRS rendered the instrument navigation more precise, while 1% of 93 cases considered this function as unwanted.The first clinical study for use of an automatic algorithm for recognition and reduction of faulty registration of a CT, navigation was successful. The findings suggest that by using automatic intraoperative registration DRS consisting inaccuracy can be reduced. In practice this means an efficient quality improvement of the Navigation.

With the symptom diplopia, in addition to an ocular cause, pathology of the paranasal sinuses must always be taken into consideration. A common differential diagnosis is an acute inflammatory process such as an orbital complication of acute sinusitis. We present the rare case of an initial manifestation of metastasis in the paranasal sinuses originating from a primary ductal carcinoma in situ of the breast. In our case, the metastatic manifestation and its clinical symptoms were the first sign of recurrence and transformation into invasive breast cancer.

We present the case report on a 66-year-old male patient who appeared in our clinic with recurrent epistaxis. Anterior rhinoscopy during acute bleeding yielded no information on the origin of hemorrhage. On renewed epistaxis, angiography was performed on which an arteriovenous malformation in the sphenoid sinus could be identified as the cause of epistaxis. Embolization of afferent vessels successfully reduced the malformation and stopped the bleeding. In cases of recurrent epistaxis, especially in combination with an unremarkable anterior rhinoscopy, angiography is recommended for the detection of life-threatening vessel malformations.

In a retrospective analysis of the autopsy material (n = 5,767) of the Institute of Legal Medicine of the Hanover Medical School covering the period of 1998-2007, all aquatic fatalities were evaluated, categorized and systematically compared under epidemiological and forensic criteria. The total of 156 cases of death by drowning (2.7 % of all autopsies) included 38 bathtub drownings and 28 deaths in the water for which no pathological anatomical cause of death could be reliably demonstrated. A control group (n = 221) was investigated for the presence of aqueous liquid in the sphenoid sinuses and compared with the findings of the drowning cases without signs of putrefaction. About 16 % of the control cases had fluid in the sphenoid sinuses compared with 57.6 % in the drowning group. Most of the drowning victims were men (60.9 %), whereas in the group of bathtub drownings the majority were women. More than half of the drowning cases (n = 89) could be classified as accidents. The individual groups showed a different incidence of findings associated with drowning.

Adenoid cystic carcinomas (ACC) in sinunasal compartments are often not completely resectable. We discuss both, surgical margins and functional results preoperatively and postoperative options for adjuvant therapy. The former opinion of a resistance of ACC towards chemotherapy or irradiation seems to be outdated, even though consensus about therapeutic strategies is still missing.We discuss therapeutic options and compare data from literature regarding the best adjuvant therapy with the case of a 25-year-old patient with an advanced ACC of the left fossa pterygopalatina. Further we discuss alternative therapeutic options like neutron irradiation, chemotherapy or targeted therapy. Following the advice from literature, we performed an eye saving tumor resection by a left transmaxilloethmoidale sphenoidectomy via combined trans- und extranasal approach. We accepted close surgical margins for the benefit of the abandonment of dismembering measures and performed an adjuvant radiochemotherapy with taxol and carboplatin.With the described therapeutic strategy we reached an optimal local tumor control with unlimited visus and without functional and cosmetic restrictions up to now. Periodic staging did not show any local tumor progress or metastatic spread hitherto.Organ preserving surgery and adjuvant radiochemotherapy even in combination with taxol and carboplatin seems to be a sufficient therapeutic option in treating advanced sinunasal ACC, and might not have any prognostic disadvantages to radical surgery.

The diagnostic workup proceeding paranasal sinus surgery routinely includes coronal CT views to get an exact representation of the microanatomy in the region of the lateral nasal wall and the anterior skull base. Axial and sagittal views are often not available, yet they can provide important additional information.It was the aim of the current study to analyse multislice CT data sets in order to determine the incidence of anatomical variants. The investigation was performed as a retrospective, monocentrical study on n = 641 patients. Prior paranasal sinus surgery was defined as the sole exclusion criterion.The analysis of the data showed the following anatomical variants of frontoethmoidal cells: Kuhn Typ I: 17.0 %, Typ II6.8 %, Typ III: 12.5 %, Typ IV: 0.1%. The prevalence for Agger nasicells was 80.0 %, that for supraorbital cells was 10.2 %, that for suprabullar cells was 28.2%, that for frontal bullae was 16.0% and the one for cells of the interfrontal septum was 11.9 %. The incidence of other anatomical variants was as follows: Concha Bullosain 22.2 %, Haller cells in 16.0 %, pneumatised Uncinate Process in 8.8% and Onodi Cells in 8.4 %.A multiplanar reconstruction of the frontoethmoidal complex with its numerous variants is essential in the preoperative workup of patients with conditions of the frontal sinus. This advantage can even be enhanced by using navigation systems, even though they are not available for every rhinosurgeon yet. However, navigation systems should not be considered as a surrogate for lacking anatomical knowledge.

Inverted papillomas are primarily benign neoplasms that occur in the nasal cavity and paranasal sinuses. Many aspects of sinonasal inverted papillomas are still controversial and active fields of research. Inverted papillomas generate considerable interest because they are locally aggressive, have a propensity to recur and are associated with malignancy. However, neither the etiology and pathogenesis of these tumors nor the putative role as a precursor to carcinoma and the factors responsible for associated malignancy have been clarified. Whether carcinomas in inverted papillomas arise meta- or synchronous is also still unknown.In a retrospective study we reviewed the charts of 93 patients with sinonasal inverted papillomas who were treated at our department between 1990 and 2007. Comparison was made between the group of patients with inverted papillomas and associated squamous cell carcinomas and the group of patients with benign inverted papillomas. We undertook a critical analysis of our results compared with the international medical literature.Associated malignancy was found in 11 patients (11.8 %). In each one case a metachronous carcinoma with and without recurrent inverted papilloma was diagnosed, the remaining 9 carcinomas were determined to be synchronous malignancies. Our data suggest, that the association between carcinoma and inverted papilloma is indirect and that the gradual progression from inverted papilloma to a malignant neoplasm is if at all infrequent. Male gender, advanced age and recurrent inverted papilloma do not per se present risk factors for the development of associated malignancies.Sinonasal carcinomas arise in about 10 % of patients with inverted papillomas, but the ratio of metachronous carcinomas has possibly been overrated up to now. Nevertheless, regular follow-up investigations after surgical resection of inverted papillomas are mandatory. The assumption, that carcinomas in inverted papillomas are less aggressive than carcinomas alone and the definition of high-risk groups for the development of carcinomas seems hazardous.

Endoscopic sinus surgery is the procedure of choice for treating chronic rhinosinusitis. This paper describes a new minimally invasive method to restore ostium patency without removing tissue: the balloon sinuplasty technique.Two patients were treated with the new procedure. One patient had her maxillary and sphenoid ostia dilated; the other patient had both frontal ostia, both maxillary ostia, and the right sphenoid ostia dilated.The balloon dilatations of the ostia were achieved successfully without impairing the mucosal circumference. There was no bleeding, and nasal packing was not necessary. The postoperative healing process showed no complications.This paper discusses the advantages and disadvantages as well as the indications and contraindications of this method. The balloon sinuplasty technique is an easily performed surgery; for selected indications, it seems especially suited for opening blocked ostia.

The trigeminocardiac reflex (TCR) is a relatively recently described brainstem reflex in the fields of neurosurgery which leads to a simultaneous drop in mean arterial pressure (MAP) and heart rate of at least 20% from baseline levels after stimulation of a sensible branch of the trigeminal nerve.The purpose of this study was to register prospectively for the first time the rate of TCR during trans-sphenoidal surgery and to describe possible predispositional factors. This was examined by determining selected biomarkers thought to correlate with possible intraoperative ischemic events after occurrence of TCR and furthermore with neuroprotective mechanisms ("ischemic tolerance").Three of the 40 patients included (7.5%) demonstrated intraoperative occurrence of TCR after exposure of the cavernous sinus. One (2.5%) demonstrated a TCR during preparation of the nasal mucosa. Permanent cardiovascular damage or unfavorable postoperative outcome through the appearance of TCR was not found. There was a trend to lower C-reactive protein levels after occurrence of TCR (32 mg/dl vs 14 mg/dl) following normal values before operations in all cases. Considering that no clinical clue of ischemia was detected, this could mean that some neuroprotective cascades are initiated. There was a correlation between tumor necrosis factor A and noradrenalin levels with the size (invasivity) of the pituitary adenoma. The administration of atropine was necessary in only one patient with intraoperative occurrence of TCR.On the basis of this study, it cannot be said to what extent neuroprotective mechanisms after TCR are activated, but a trend is still apparent. Considering the adverse effects and the reflex arc, prophylactic or therapeutic treatment with atropine is not justified.

Prechiasmal lesions of the visual pathway are produced by visual field defects that either affect only one eye or, if both eyes are affected, they are clearly different. Typically, the defects respect the vertical meridian. This report of a case shows that the classical nerve fibre bundle defect must be taken into consideration for differential diagnosis.In a 67-year-old patient, a meningeoma of the sphenoid was diagnosed that had spread into the optic canal. Examination of the visual field showed an inferior altitudinal nerve fibre bundle defect.Apparently the retinal pattern of nerve fibres remains intact even when approaching the optic chiasm. Nerve fibre bundle defects are therefore sometimes found in prechiasmal lesions and should be considered for differential diagnosis (e. g., in the case of a suspected low tension glaucoma).

Computer-assisted surgery (CAS) has found widespread use in functional endonasal sinus surgery (FESS) over the past few years. The present study investigates if CAS leads to a better outcome in FESS.All patients who underwent endonasal sphenoethmoidectomy were enrolled in a prospective, non-randomized study. The procedures were done without CAS (group A) in 2003 and in 2004 with CAS (group B), using a Stryker navigation unit. 62 patients (113 sphenoidectomies) were included in group A and 61 patients (109 sphenoidectomies) in group B. The underlying disease was recurrent chronic sinusitis or polyposis nasi in all patients except for inverted papilloma in one patient of group A and in two patients of group B. The follow-up period was 6 months. Preoperatively and at 6 months postoperatively, a CT-scan was obtained and symptom scores were assessed using a questionnaire.No significant difference was found between group A and B with respect to symptom scores, and CT-scans preoperatively and at 6 months postoperatively. The operation strategy did not change by the introduction of CAS. The frontal sinus was entered in group A and B in 59% and 64%, respectively. All parameters significantly improved postoperatively, compared to the preoperative values. As far as complications are concerned, two anterior orbital injuries and one retrobulbar haematoma occurred in group A and one postoperative lacrimal stenosis in group B.CAS does not lead to a better clinical outcome in FESS. Our data suggest that the rate of complications may be reduced using CAS. However, studies with a much larger number of patients would be necessary for a definite answer to this issue.

Sinonasal undifferentiated carcinoma (SNUC) is a rare tumor of the nasal cavity and paranasal sinuses first described in 1986. Olfactory neuroblastoma and SNUC may appear quite similar on histological examination. Due to the fact that olfactory neuroblastoma has a much better prognosis, a distinction with SNUC has to be drawn. We report a case of SNUC and describe the role of immunohistochemistry in making an accurate histological diagnosis. In addition, potential factors influencing the development of SNUC described in the literature and current treatment modalities are discussed. Despite aggressive and multimodal treatment regimens, the outcomes of patients suffering from SNUC have remained dismal. A randomized controlled clinical study could be the basis for determining the optimal treatment for SNUC.

Fulminant-invasive sinus aspergillosis affects immunocompromised patients and is usually lethal because of intracranial complications. Chronic-invasive and non-invasive types occur in non-immunocompromised patients. In these cases, intracranial extension is possible and life-threatening. The effective management of sinus aspergillosis requires early diagnosis by CT and histological classification, surgery, and if necessary, chemotherapy or steroids in case of allergy. Here we report a successfully treated case in a 29-year-old non-immunocompromised patient with chronic-invasive sinus aspergillosis. He presented a recurrent sphenoid sinus aspergillosis with destruction of the clivus and ophthalmoplegia. Diagnostic and therapeutic procedures are described.

In this case study, we report on a patient complaining of headache who, after CT and MRI, was found to have a neoplasia of the left sphenoid sinus. After a transnasal biopsy and histological examination, a prolactinoma was diagnosed. Based on this case, we discuss important aspects of tumor biology, diagnostic procedures, histology as well as differential diagnosis. Prolactinoma has to be considered as a differential diagnose in all sphenoid sinus neoplasias with close contact to the pituitary gland.

Traumatic lesion to the optic nerve often leads to severe and persistent functional loss.A male patient was transferred to our hospital from the University Eye Clinic of Guadeloupe 5 days after ocular injury caused by a flying fish. Visual function was light perception. The anterior part of the eye and retina were unremarkable. A computer tomography disclosed a fracture of the sphenoid sinus, with a little bone fragment (DD: foreign body) located close to the optic nerve.Therapy had been started with Aminopenicillin combined with clavulan acid (Augmentin) i. v., 500 ml methylprednisolone (Solumedrol) i. v., lysine-acetyl salicylate (Aspegic) and topical application of dexamethasone combined with neomycin/polymyxin B (Maxitrol). We continued this therapy and intensified it by adding nimodipine (Nimotop) 30 1-1-1 and acetazolamide retard (Diamox sustet) 1-0-1. Unfortunately visual function did not recover under therapy.Traumatic lesions of the optic nerve head, especially when due to axial or tangential forces, can lead to severe and irreversible functional loss. Severe traumatic lesions, even bone fractures induced by flying fish are not a seldom encounter in the Caribbean Sea.

A 59-year-old woman was diagnosed as having solitary bone plasmacytoma of the sternum which was resected. Five month later she presented with a pathological fracture of the clavicle. On examination she had a ptosis and an ophthalmoplegia.A mass in the clivus extending into the left sphenoid sinus as well as multiple osteolytic lesions in the skull were shown by cranial MRI. Skeletal survey showed multiple osteolytic lesions. Laboratory test did not show any specific abnormalities.The biopsy taken from the mass at the sphenoid sinus demonstrated plasmacytoma. The diagnosis of multiple myeloma was based on the histological evidence of plasmacytoma and the occurrence of multiple lytic bone lesions although no infiltration of bone marrow and none of the specific laboratory findings were present. The patient underwent local radiotherapy with 30 Gy followed by systemic chemotherapy. The symptoms regressed completely under this therapy.Various cranial nerve syndromes such as the superior orbital fissure syndrome are most often caused by tumors at the skull base. Knowledge of the histological entity is essential for the correct diagnosis and the appropriate therapy because rare tumors like multiple myeloma may also cause such syndromes.

Malignomas of the nasal cavity and the paranasal sinuses count for less than 3 % of the ENT-malignancies.This retrospective chart review reports about 46 patients that were first diagnosed and treated with a nasal cavity or paranasal sinus malignancy between 1998 and 2002 in the ENT department of the Ruhr-Universität Bochum.18 of 46 malignomas were squamous cell carcinomas. At initial diagnose, already 52 % of malignomas were staged T4. Accordingly the origin in 17 % of malignomas could not be determined anymore. Additional 43 % of malignomas originated from the nasal cavity, another 20 % from the maxillary sinus. 11 of 46 patients (24 %) showed histological proven nodal involvement at initial diagnose. 92 % of patients underwent surgical therapy. 25 patients were radiated postoperatively. Over-all 1-year-survival-rate was 75 %, over-all 2-year-survival-rate was 47 %. Beside patients age, tumor free margins at initial surgery and absence of nodal involvement correlated to improved survival. 16 (76 %) of the 21 patients who died had local recurrence. Maxillary sinus malignomas recurred more often than malignomas of the ethmoid and the nasal cavity.Malignancies of the nasal cavity and paranasal sinuses are very often diagnosed in advanced T-stages because of unspecific symptoms. The limited prognosis mainly depends on free surgical margins at the first resection and nodal involvement at the first diagnose. For improvement in outcome of nasal and paranasal sinuses malignancies, prospective multi-center trials are necessary.

Whereas a tubular adenoma is a unique finding within the paranasal sinuses, intestinal adenocarcinomas are especially in patients with long-term exposure to wood dust, common tumours in this location.In a 65 year old joiner endonasal sinus surgery performed to treat suspected chronic pansinusitis brought up by chance the histological finding of a tubular adenoma. As the patient at first refused surgical revision, but magnetic resonance imaging during follow-up revealed evidence for a space occupying lesion affecting the ethmoid and sphenoid sinuses revision surgery took place one year later. Histopathological evaluation now found a papillary adenocarcinoma. Clinical follow-up and magnetic resonance imaging one year after second surgery found no evidence for tumour recurrence.Progression of a tubular adenoma to an adenocarcinoma like in the adenoma-carcinoma model well known for colorectal carcinomas has so far not been observed within the paranasal sinuses. But, an adenocarcinoma already present at the time of first surgery can not be ruled out completely in the presented case as histopathological evaluation may have failed to detect an adenocarcinoma in the available specimens after first surgery. Either malignant transformation of a tubular adenoma had occurred or proof of an adenocarcinoma has failed with misdiagnosis of a tubular adenoma. A tubular adenoma as well as an adenocarcinoma require complete resection and careful clinical and radiological follow-up to avoid adenocarcinoma development from a tubular adenoma or to detect an adenocarcinoma by histological evaluation of the whole specimen.

Angiofibromas are benign, but locally aggressive tumors occurring nearly exclusively in adolescent males. Pathogenesis of this fibrovascular neoplasm is still unknown. Detection of beta-catenin gene mutations and immunohistochemical localization of beta-catenin only in the nuclei of stromal cells has been proposed as evidence for the stromal cells to be the neoplastic cells in angiofibromas (Abraham et al., 2001).Paraffin embedded tissue of 13 angiofibromas was analysed immunohistochemically for expression of E-cadherin, N-cadherin, alpha-catenin, beta-catenin and gamma-catenin.In all angiofibromas stromal cells showed in their cytoplasm and their nuclei strong immunoreaction for beta-catenin. In 10 out of 13 angiofibromas strong immunoreaction was also observed in endothelial cells covering the irregular lined vascular spaces. While gamma-catenin was detected in 7 out of 13 angiofibromas in the stromal cells and endothelial cells, N-cadherin was found only in the stromal cells in 8 out of 13 angiofibromas. No significant immunoreaction in angiofibromas was seen for E-cadherin and alpha-catenin.Proof of strong beta-catenin-expression in stromal cells and endothelial cells stress possible importance of the APC/beta-catenin-pathway in angiofibromas, but gives no certain evidence for the assumption that stromal cells may be the neoplastic cells. As beta-catenin can increase sensitivity of the androgen receptor, it may be assumed that the increased beta-catenin-expression in angiofibromas is involved in the typical growth stimulus of this tumor in adolescent males.

In a multi-center trial, the feasibility of combining remifentanil (RF) and target-controlled infusion of propofol (P) for patients undergoing transsphenoidal resection of the pituitary gland was tested. After IRB approval, 74 patients (29 male/45 female) were included in the study. The concentration of RF and the target concentration of P were recorded as were heart rate (HR) and mean arterial blood pressure (MAP). For intubation the RF dosage was 0.26 +/- 0.06 microgram.kg-1.min-1 and the target concentration of P was 3.16 +/- 0.63 micrograms.ml-1. After induction, HR and MAP decreased significantly. The painful events of the operation were preparation of the nasal mucous membrane and penetration of the sella turcica. By adjusting the RF dose to 0.31 +/- 0.09 microgram.kg-1. min-1 and the target concentration of P to 3.48 +/- 1.49 micrograms.ml-1, an increase of HR and MAP above initial values was avoided at this time. Hypotension and bardycardia were treated in eight patients (10.8%) with a vasopressor, in four patients (5.4%) with atropine and in four more patients (5.4%) with a combination of these drugs. Two patients (2.7%) needed antihypertensive therapy. The average time interval between the end of P-TCI and spontaneous breathing was 6 +/- 3 min (median 6 min) and till patients opened their eyes 9 +/- 4 min (median 9 min). After 13 +/- 4 min (median 13 min) the patients became orientated. The average doses of analgetics were 19.5 +/- 19.9 mg piritramide and 1.8 +/- 1.0 g metamizol during the first 12 hours postoperatively. Eight patients (10.8%) did not need any analgetics. We suggest that the combination of RF and P as a "fast track concept" can supplement the repertoire of anaesthetic managements used for transsphenoidal resection of the pituitary gland.

Chondrosarcomas are rare malignant mesenchymal tumors of unknown etiology. Only 5 to 10 % appear in the head and neck region.We report the case of a 63 year old woman with a chondrosarcoma of the sphenoethmoidal complex extending into the anterior cranial fossa. The tumor was subtotally resected via an osteoplastic lateral rhinotomy. Postoperatively, a fractionated radiation therapy with carbon ions (Schwerionen) was applied. There was no evidence of recurrence one year after therapy.Recent prognostic improvements of skull base chondrosarcomas by combination of skull base surgery and innovative radiation therapy are discussed and the literature is presented.

In the forensic literature the opinion is often held that the presence of aqueous liquid in the paranasal sinuses in conjunction with other findings (plume of froth around the mouth and nostrils, emphysema aquosum, Paltauf's spots, increased haemolysis etc.) can be regarded as a sign of drowning. Especially the sphenoid sinus is easily accessible at autopsy; its content can be aspirated from the base of the skull with a cannula. The valency of the liquid content in the sphenoid sinuses was consecutively investigated in 60 deaths by drowning and 157 other deaths. The results showed that in 92% of the deaths by drowning between 1 ml and 4 ml of aqueous fluid could be found in the sphenoid sinuses. However, a positive result was also obtained in 52% of the other cases autopsied, but in the control group the average volume of the aspirate was smaller than in the group of deaths by drowning.

Acute sinusitis can lead to severe complications. This includes involvement of the optical nerve with visual loss and brain abscess as a life-threatening complication.Empyema of the chiasma opticum region with neuritis nervi optici and bilateral acute amaurosis was observed in a 13 year old boy with sinusitis sphenoidalis and ethmoidalis. In a 11 year old girl, pronounced papilledema was found to be closely associated with sinusitis sphenoidalis. While she recovered completely on appropriate antibiotic therapy, visual loss in the boy was irreversible despite surgical intervention.Sinusitis should always be considered in patients with impaired vision, neuritis nervi optici or unexplained papilledema, especially if occurring in association with an upper respiratory infection. In addition to physical examination, cranial computer tomography or magnetic resonance imaging of the brain including sinuses and chiasma opticum should be applied early. If empyema is found, immediate surgical intervention is of prognostic importance.

The case of an 87-year old man with widespread prostatic cancer is reported. During the autopsy macroscopically visible metastases were found within the frontal sinuses. These tumor masses destroyed the posterior osseous wall of the frontal sinus and formed polypoid bulging masses. In contrast to the macroscopically unaffected mucous membrane of the sphenoid sinus the maceration specimen of the skull base demonstrated a spongious-mossy, osteoplastic metastasis, lining the sphenoid sinus like a tapestry. This affection started from an exhaustive osteoplastic metastasis within the clivus. No metastases could be found in both antrums or the ethmoids. Retrospectively no symptoms from the paranasal sinuses could be eruated, only occasional pain of the frontal bone. The review of the world literature with 123 reports revealed 169 cases. Renal cell carcinomas most frequently metastasize into the paranasal sinuses (67 cases), followed by bronchogenic carcinomas (15 cases). Thyroid cancers and cancers of the mammary gland are responsible for 13 respectively 14 cases. The prostate also adds 12 cases. The paranasal sinuses are affected in diminishing frequency: maxillary sinus (55 cases), sphenoid sinus (37 cases), ethmoidal cells (23 cases) and frontal sinus (15 cases). In 38 cases exhaustive metastases affecting two or more paranasal sinuses are reported. The statement of literature, that metastases affecting the paranasal sinuses are much more frequent than reported, cannot be supported by our study, because the intensive autoptic investigation of 50 skulls of patients suffering from widespread cancers revealed no further cases of metastatic processes of the paranasal sinuses.

Metastatic tumours involving the nose and the paranasal sinuses are rare. Especially metastatic spread to the sphenoid sinus is an extremely rare occurrence. The most common metastatic tumour is the renal cell carcinoma. Only four cases of hepatocellular carcinoma presenting a sphenoid sinus metastasis could be found in a search of the literature. We report on the case of a 59-year-old male who suffered from a sphenoid sinus mass. A biopsy showed the tumour to be a metastatic hepatocellular carcinoma. The suspected primary tumour was then found in the left liver lobe. The early diagnosis of paranasal sinus malignancies is difficult because of the varied and nonspecific symptoms and signs. In cases of late diagnosis, the treatment is usually palliative with a poor prognosis. The importance of endoscopic examination and CT or MRI scan for early detection must be emphasized.

Aim of this study was to evaluate the postnatal growth pattern of the sphenoid sinus.83 cerebral MRI examinations of infants and children aged 5 months to 14 years were retrospectively reviewed for pneumatization and growth of sphenoid sinus.A continuous increase of pneumatization and growth of the sphenoid sinus was demonstrated between infancy and adolescence including considerable individual variations. Even in children less than two years old remarkable spatial extends of this sinus could be found in some cases.Diagnosis of an acute or chronical sinusitis in pediatric patients should alert the clinician to the possibility of a sphenoidal participation.

The inverted papilloma of the nasal cavity and the paranasal sinuses is a benign but locally aggressive neoplasm with a high recurrence rate and an unknown risk of malign transformation. This unsteadiness of biological behaviour requires a permanent control of the outcome of the available surgical treatments to ensure the utmost reliability for the patients.In our investigation we analysed the surgical results in 54 patients with inverted papilloma of the last 30 years with an average followup of 55 months. 25 of them were endoscopically treated. The other group of 29 patients was treated by traditional surgical techniques using an extra-nasal approach.Using the endonasal-endoscopic technique we observed a recurrence rate of 48% whereas the other group treated by an extra-nasal approach reached a recurrence rate of only 24% and did not show any multiple recurrences. A malign transformation was found in two patients (5%) within the first 8 months after the first resection.In consequence patients with inverted papilloma have to be informed of the different surgical techniques and their recurrence rates. Especially an endonasal-endoscopic treatment of the maxillary sinus has to be carefully considered.

An isolated aspergillosis of the sphenoidal sinus is a difficult diagnosis because the often misleading clinical symptoms of this rare disease can develop late and first be presented to the ophthalmologist. Because of this even life-threatening disease in normally immunodeficient patients, fast diagnostics and treatment is indicated.We report about an immunocompetent man to suffer from an invasive aspergillosis involving the sphenoidal sinus after external operation of a mucocele. Aspergillus infiltrated the right orbit by bone erosion and led to an acute loss of vision on his right eye and a pathological visual field (visual acuity 0.1). A systemical antimycotic therapy was performed and the right orbit and the optical channel were operated to remove the mycosis. During operation the optical nerve was found to be completely surrounded by the mycosis. After surgery visual acuity recovered slowly but completely in about two weeks (visual acuity 1.0) and visual field examination revealed normal findings. These findings were stable now for one year.The main findings of unilateral acute visual loss and pre-operations of the paranasal sinuses in combination with persistent headache can lead to the suspect of an aspergillosis infection. It is important to establish correct diagnosis--especially in immunocompetent patients--early to prevent a probably irreversible visual loss and in an advanced stage to handle the life-threatening risk of this disease.

Malignant tumors very seldom establish metastasis in the paranasal sinuses. Renal cell carcinomas (RCC) are one of the possible primary tumors displaying metastases in this location. The incidence of metastasis from the renal cell carcinoma in the paranasal sinuses is higher as would be expected by the incidence of this tumor.We report here about 3 patients from the ENT clinic with metastasis in the paranasal sinus derived from primary RCC. Two of them showed metastases in the maxillary sinus and the third patient had a metastasis in the sphenoid sinus.Further progression of the patients disease exhibited the paranasal sinuses being only a localisation of the generalised tumor disease. 2 of 3 patients developed the metastasis many years after nephrectomy and the third patient displayed a renal cell carcinoma by the diagnosis of a paralysis of the abducens nerve. All patients were treated with radiation of the tumor, but in one case with a metastasis in the maxillary sinus the tumor was also treated surgically. 2 of the 3 patients (one with a metastasis in the maxillary sinus and the other in the sphenoidal sinus) were inoperable due to the expanded tumor size. Nowadays surgical resection of the tumor seems to be the only therapy. In the follow-up all patients developed multiple distant metastasis. With respect to the quality of life of the patients the indication of a radical operation should be discussed very critically. Palliative methods, like interferon-therapy or selective embolisation of tumor, may also reduce the symptoms of the tumor and increase the quality of life for the patients.