Sphenoid sinus organized hematoma with cranial neuropathies masquerading as a malignancy: A case report

Sinonasal organized hematoma (SNOH) is rarely encountered in clinical practice. The disease demonstrates a high tendency for occurrence in East Asian individuals, and in the majority of cases, is located in the maxillary sinus. The current report presents the case of an 81-year-old female who developed a space-occupying lesion, which masqueraded as a skull base malignancy, following surgery for the treatment of isolated sphenoid sinus aspergilloma. Subsequent endoscopic endonasal surgery confirmed the diagnosis of an OH of the sphenoid sinus. The patient recovered from all neurological deficits within two months, with the exception of the loss of visual perception. Although SNOH presents a diagnostic challenge, when physicians possess knowledge of its typical imaging features, this facilitates the achievement of a correct diagnosis and the prescription of optimal treatment.

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abstract: Organizing hematomas of the paranasal sinuses are diagnostic dilemmas clinically and radiographically, mimicking benign or malignant neoplastic processes and causing patients and clinicians undue worry regarding these diagnoses. Diagnostic criteria for correctly identifying these lesions are not well known.

title: Organized hematoma in the paranasal sinus and nasal cavity--imaging diagnosis and pathological findings.
abstract: The "organized hematoma" is a non-neoplastic, hemorrhagic lesion, which can develop in the paranasal sinus and nasal cavity. This is the first report on the relationship between the imaging and pathological findings.



We diagnosed organized hematoma, based on three criteria: no existence of neoplastic cells; consistency of hematoma and fibrosis; and development from the paranasal sinus and nasal cavity. We retrospectively investigated six cases from the patients' medical records.



On the imaging findings, the central part of the lesion was enhanced more strongly than the lesion periphery. All of the pathological findings were hematoma at the center, and fibrosis at the periphery. In three of the cases, dilated vessels were found but not in the other three.



We found that the biphasic appearance of the imaging findings correlated with that of the pathological findings. There are two pathological types--the dilated vessel type and the non-dilated vessel type.

title: Organised haematoma of the sphenoid sinus mimicking a pituitary tumour
abstract: We report an extremely rare case of an organised haematoma arising in the sphenoid sinus.  An 85-year-old woman presented with an expansile soft tissue mass in the left sphenoid sinus, with bony destruction of the sella turcica, which mimicked the extrasellar extension of a pituitary tumour. The tumour was excised using an endoscopic, transsphenoidal approach. Histopathological examination revealed an organised haematoma.  To our knowledge, this is the first report of an organised haematoma arising in the sphenoid sinus. This case indicates that organised haematoma should be included in the differential diagnosis of extensive sphenoid lesions; it also emphasises the importance of correct pre-operative diagnosis for therapeutic planning, as complete surgical resection by an endoscopic approach is curative.

title: Sinonasal Organized Hematoma: CT and MR Imaging Findings
abstract: Sinonasal organized hematoma (OH) is an uncommon, nonneoplastic benign condition that can be locally aggressive. The purpose of this work was to characterize the CT and MR imaging findings of sinonasal OH.  CT (n = 11) and MR (n = 10) images of 12 patients (9 men and 3 women; mean age, 41 years; range, 12–76 years) with pathologically proved sinonasal OH were retrospectively reviewed. Particular attention was put on the location, shape, size, extent, internal architecture, and enhancement pattern of the lesion and associated sinus wall change.  The lesions were seen as an expansile (n = 9) or nonexpansile (n = 3) mass, ranging in size from 2.2 to 6.0 cm (mean, 4.2 cm), primarily involving the maxillary sinus (n = 11) or nasal cavity (n = 1) unilaterally. The ipsilateral nasal cavity was also involved in 9 of 11 maxillary sinus lesions. Smooth sinus wall erosion other than the medial maxillary sinus wall was noted in 8 lesions. The internal architecture was best displayed on T2-weighted MR images on which all of the lesions were seen as a mixture of marked heterogeneous hypointensity and isointensity, surrounded by a hypointense peripheral rim, reflecting histologic heterogeneity of the lesion composed of hemorrhage, fibrosis, and neovascularization. Marked irregular nodular, papillary, or frondlike enhancement at the areas of neovascularization was also a typical finding seen in all of the lesions.  An expansile soft tissue mass, smooth sinus wall erosion, marked heterogeneous signal intensity with a hypointense peripheral rim on T2-weighted MR images, and marked irregular nodular, papillary, or frondlike enhancement are characteristic CT and MR imaging findings of sinonasal OH.

title: Prolonged Visual Disturbance Secondary to Isolated Sphenoid Sinus Disease
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title: Isolated sphenoid sinus disease: differential diagnosis and management
abstract: review the current literature on isolated disease of sphenoid sinus, and to describe the various approaches to the sphenoid sinus. Recent findingsDue to its posterior location and subtle presenting symptoms, sphenoid lesions, in the past, have often been missed and were reported as rare occurrences. However, with the availability of current diagnostic modalities such as endoscopy and imaging techniques such as computed tomography (CT) and magnetic resonance imaging (MRI), diseases of the sphenoid sinus are now more frequently diagnosed. Since the introduction of endoscopic techniques in the mid 1980s, various endoscopic approaches to the sphenoid sinus, depending on the extent and type of disease, have been described. These approaches were subsequently ‘extended’ to remove pituitary tumours, and certain diseases of the parasellar region and the petrous apex. More recently, further extension of these approaches has led to the development of endoscopic skull base surgery, using the sphenoid sinus as the ‘gateway’ to the anterior, middle and the posterior cranial fossa. These approaches require a clear understanding of the anatomy of the sphenoid sinus and its surrounding regions. SummaryThis paper presents a review of the various diseases of the sphenoid sinus and describes the approaches to the sinus with special emphasis on the transpterygoid approach to the lateral recess of the sphenoid sinus.

title: Fungal rhinosinusitis
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title: MR Evaluation of Sinonasal Angiomatous Polyp
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title: Angiectatic nasal polyps that clinically simulate a malignant process: report of 2 cases and review of the literature.
abstract: Approximately 5% of inflammatory or allergic sinonasal polyps develop extensive vascular proliferation and ectasia with deposition of pseudoamyloid. These so-called angiectatic nasal polyps (ANPs) can grow rapidly and exhibit an aggressive clinical behavior that could simulate malignancy preoperatively.



To systematically address the differential histologic diagnosis of ANPs.



We evaluated by light microscopy, immunohistochemistry, and electron microscopy biopsy and resection specimens from 2 large ANPs (8 and 10 cm in diameter) that presented in 2 adult men with life-threatening epistaxis and facial deformity, respectively.



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These 2 cases represent extreme examples of ANPs that clinically simulate a malignant process. Awareness of the histological features of ANPs should prevent confusion of such lesions with other vascular or spindle cell lesions of the nasopharynx that would require different treatment and carry a different prognosis.

title: Endoscopic endonasal skull base surgery: past, present and future
abstract: Endoscopic techniques have undergone tremendous advancement in the past years. From the management of phlogistic pathologies, we have learned to manage skull base lesions and even selected intracranial diseases. Current anatomical knowledge plus computer-aided surgery has enabled surgeons to remove large lesions in the paranasal sinuses extending beyond the boundaries of the sinuses themselves. In this sense, management of benign diseases via endoscopic routes is nowadays well accepted whilst the role of endoscopic techniques in sinonasal malignancies is still under investigation. Nowadays, it is possible to tackle different pathologies placed not only in the ventral skull base, but also extended laterally (infratemporal fossa and petrous apex) and even, in really selected cases, within the orbit. The ability to resect and reconstruct has improved significantly. At the moment, the improvement in surgical techniques, like the four-handed technique, has rendered endoscopic procedures capable of managing complex pathologies, according the same surgical principles of the open approaches. From now onwards, frameless neuronavigation, modular approaches, intraoperative imaging systems and robotic surgery are and will be an increasingly important part of endonasal surgery, and they will be overtaken by further evolution.