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Injury of the internal carotid artery (ICA) during endonasal sinus surgery is rare but a life-threatening situation for the patient. For adequate treatment endovascular therapy as embolization or balloon occlusion is usually performed although there is a high risk of irreversible neurological deficits.We report on a twenty-five-year-old female patient with acute exacerbated chronic polyposis nasi suffering from an injury of the ICA during endonasal sinus surgery. After intraoperative identification of the site of hemorrhage the massive bleeding could temporarily be controlled by a nasal pack. The woman was immediately transferred to a neuroradiological department. After angiographic localization of the vessel defect the bleeding could be stopped by application of a vascular stent without any neurological deficits during or after the procedure. Anatomical characteristics of the ICA in the sphenoid sinus, and recommended emergency treatment and preventive measures are discussed.Although vascular stents are difficult to place in the intrasphenoidal course of the ICA, it provides an effective closure of the vascular injury and above all a sufficient cerebral perfusion, therefore, the risk of neurological defects can be reduced.

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.

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.

Complications after endoscopic sinus surgery are rare and occur in about 0.5 % of all cases. However postoperative symptoms such as severe cephalgia and nasal discharge of clear fluids indicate a cerebrospinal fluid leakage.A 64 year-old-patient presented to our clinic four months after an endoscopic sinus surgery complaining of the two above mentioned symptoms for about 4 weeks. In a computed tomography study of the frontobasis there was no evidence of an osseous defect. An MRI of the head revealed a bilateral temporal fluid collection as seen in bilateral chronic subdural hematoma. Therefore the present illness was no consequence of the preceding surgery.Significant symptoms of severe postoperative complications after endoscopic sinus surgery can still be misleading. Therefore accurate diagnostic and imaging procedures are always crucial to support the initial diagnosis.

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.

To determine the value of MRI in the preoperative evaluation of chronic paranasal sinusitis and to compare the results with CT and intraoperative findings.42 patients with clinical signs of chronic paranasal sinusitis underwent MRI after CT evaluation on one day, with subsequent functional endoscopic sinus surgery on the next day. Coronary CT was obtained with 5-mm slices and table-feed in the prone position, while MRI was performed in the supine position with coronary T2-TSE + pd and coronary and transverse HASTE, each with 5-mm slice thickness. Aquisition time in MRI was less than 8 minutes. Two radiologists reviewed the CT and MRI scans for signs of sinusitis and detection of anatomical landmarks. The results were correlated with the intraoperative findings.MRI offered no artifacts of dental work and showed more often high quality pictures than CT. CT and MRI demonstrated a good correlation in the detection of mucosal pathologies (kappa = 0.46-0.87) and anatomic variants (kappa = 0.55-0.86). All important anatomical structures could be evaluated sufficiently with MRI for preoperative management. Both diagnostic tools showed an unsatisfactory correlation with intraoperative findings in the ethmoidal complex and maxillary sinus (tau = -0.08-0.3).MRI is a fast and reliable alternative to preoperative CT in examining paranasal sinuses and offers a good visualization of mucosal changes. CT and MRI both give an unreliable representation of the ethmoidal complex.

A 14-year-old boy suffered from an acute bilateral blindness which occurred in 24-h time, accompanied by headache and raised temperature, with inconspicuous optic nerve head and fundus. After diagnosis of empyema with magnet resonance tomography (MRT) the sphenoid sinus was fenestrated and streptococcus pneumoniae isolated. Liquor and serology being inconspicuous, there was no evidence of leucaemic or autoimmune disease, intoxication or intracranial tumor.The condition of the patient improved under systemic antibiotic therapy. The bilateral amaurosis remained and opticus atrophy developed.A bilateral amaurosis with descending opticus atrophy as a consequence of a sphenoiditis and spreading inflammation to the meninges and the optic nerve in the area of the chiasm is a rare event. The imaging technique of the MRT offers new opportunities for an early and more pointed diagnosis and therapy.

The clinical occurrence of isolated sphenoid sinusitis is rare. Due to a long history and few initial symptoms, diagnosis of this potentially fatal infections can be difficult. Radiological aspects in 10 patients are presented (e.g. type and design of examination and whether inflammatory or destructive changes could be shown), as well as clinical aspects (cranial nerve palsy, concurrent inflammation, duration of disease and therapy). CT proved to be superior in diagnosing the extent of any bony changes, while MRI was more useful in detecting inflammation.

The renaissance of endonasal microsurgery is not only based on a deeper knowledge of the mucociliar clearance and better operation instruments but depends as well as on the improved radiological diagnosis provided by computed tomography. Since 1986, high-resolution computed tomography in two plains has been part of the authors' preoperative routine diagnostic program for paranasal sinus diseases at their clinic. One hundred and fifty-eight computed tomograms of patients with chronic rhinosinusitis, complicated acute rhinosinusitis, and polyposis nasi were reexamined. The involvement of the paranasal sinuses and abnormalities of the lateral nasal wall were analyzed. The anterior ethmoid is the most frequently affected area in all of the diseases. The computed tomogram is most important for the rhinosurgeon. The ethmoid cell system can be visualized without superimposing structures. Therefore even circumscript pathologic mucosa alterations and the extent of the disease can be defined. All this enables the surgeon to put forward an exact diagnosis and to plan a safe operation as regards important physiological structures of the nose and paranasal sinuses.