Abstract
This 44-year-old patient presented with recurrent vertex headaches, nasal congestion, and “runny nose.” Her symptoms persisted despite multiple antibiotic treatments and a course of oral steroids. This nonsmoking patient had no history of diabetes or allergies, and she had not previously undergone sinus surgery. Preoperative sinus computed tomography (CT) demonstrated significant opacification isolated to the sphenoid sinuses bilaterally; the remainder of the paranasal sinuses were clear (figure, A).
After we discussed medical and surgical treatment options with her, the patient wished to proceed with endoscopic sphenoid sinus surgery. The sinus was approached transnasally, and balloon dilation was selected as the tool for ostial enlargement.
After the nose was decongested and anesthetized, a 0° Wolf telescope was used to view the region of the natural sphenoid sinus ostium between the superior turbinate and the nasal septum. The sphenoid guide was placed just anterior to the natural ostium. The lighted guide wire was passed easily through the natural ostium of the sphenoid sinus, and the sphenoid sinus was noted to transilluminate (figure, B).
A 6 × 16-mm balloon catheter was advanced over the guide wire and inflated to dilate the sphenoid sinus ostium (figure, C). After thick secretions were suctioned and irrigated out of the sinus, the telescope was advanced to view the interior of the sphenoid sinus. A clear image of the illuminated sinus cavity with the lighted guide wire in place was obtained (figure, D).
The contralateral sphenoid sinus ostium was also balloon-dilated with successful eradication of thick sinus secretions. The patient has remained free of vertex headaches for more than 2 years.
Balloon sinus dilation is a safe and effective method for enlarging sinus ostial openings. 1 The safe application and utility of balloon technology using a lighted guide wire in the frontal sinus has been well documented. 2 The sphenoid sinus has been considered a more challenging sinus to view with the lighted guide wire; unlike the other three paranasal sinuses, the sphenoid sinus is “hidden” from view because of its more posterior location. Some believed that fluoroscopy was necessary for the sphenoid sinus, but this raised the burden of bringing in a C-arm for fluoroscopic visualization and concerns about surgeon and patient radiation exposure.
This case demonstrates that sphenoid sinus dilation can be readily accomplished without fluoroscopy. The anterior wall does transilluminate well with the light inside the sphenoid sinus cavity, and twirling the guide wire can confirm that the sinus is cannulated as the light will “dance” or swirl within the sinus. Turning the telescope light down or off (akin to turning off the OR lights when confirming frontal or maxillary sinus lighted guide wire entry) can accentuate the glow of the transilluminated sphenoid sinus.
As this case also demonstrates, the telescope can be advanced through the newly dilated sphenoid sinus ostium, even while the lighted guide wire remains in place, to confirm successful entry into the sphenoid sinus. The lighted guide wire can even be manipulated, utilizing it almost like a flashlight, to provide even brighter illumination to visualize details within recesses of the sphenoid sinus cavity.