VOL. 324, No.

NORMAL VARIATIONS AND LESIONS OF

THE SPHENOID SINUS*
By HEUN Y. YUNE, M.D., ROBERT W. HOLDEN, M.D., and JOHN A. SMITH, M.D.
INDIANAPOLIS, INDIANA

A WIDE range
of normal variation is is of the greater and the lesser wings, which
recognized the development
in of the is associated with pulsating exophthalmus
sphenoid sinus.’-’ On roentgenograms, some on the side of the aplasia. Most of these are
normal variations so closely simulate patho- associated with neurofibromatosis. Aplasia
logic entities that without proper clinical of the sphenoid body is extremely rare, and
correlation they may be a cause of misdiag- this is usually associated with midline
nosis. cleft of the face and the base of the skull.
Various diseases are found in the sphe- As a result, the meningeal structures herni-
noid sinus which may involve the sinus ate through such a cleft and present into
either in primary or in secondary fashion. the nasal or oral cavity (Case i). Such a
A wide spectrum of positive roentgeno- defect is clinically obvious soon after birth,
American Journal of Roentgenology 1975.124:129-138.

graphic signs is associated with many of but roentgenographic demonstration of the

these conditions, some of which are fairly bony defect is much more definitive than
characteristic of the lesion.’ the clinical estimation by observation and
From a collection of material encoun- palpation. The presence or absence of brain
tered during the past several years, a num- substance within the herniated meningeal
ber of illustrative cases were selected to sac can be determined by the pneumoen-
demonstrate the role which radiology plays cephalogram or carotid angiogram.
in the diagnosis of disease of the sphenoid
sinus. CASE I. Nasopharyngeal meningoenceph-
This presentation is not meant to be a alocele associated with aplasia of the sphenoid
complete compendium of all conditions of body and extensive midfacial cleft (Fig. i).
the sphenoid sinus; rather, it is a concise
This is a newborn infant male who soon after
demonstration of developmental van a- birth was noted to have a large bulging cystic
tions of the sphenoid sinus, some of which mass on the roofofthe mouth associated with a
are definite congenital anomalies, others widely cleft lip and palate. The mass filled the
are normal developmental variations, and a oral cavity. Transmitted pulse was felt on the
few are examples of pathologic entities surface of this mass.
which these variations simulate.
Hypoplasia of the sphenoid sinus may be
CLASSIFICATION OF THE DEVELOPMENTAL an isolated condition due to the lack of
VARIATIONS sufficient aeration in the sphenoid body
For convenience, the developmental var- ( Case ii), or a part of a complex mid facial
iation of the sphenoid sinus may be classi- and cranial base hypoplasia, such as Apert’s
fied into 3 categories; (A) aplasia and syndrome (Case III). In isolated hypoplasia,
hypoplasia; (B) variation in septation; and it is quite frequently overdiagnosed as a
(C) variation in aeration. diseased sinus and the patient is often sub-
jected to multiple unnecessary diagnostic
A. APLASIA AND HYPOPLASIA
tests, even surgical exploration. This is be-
Aplasia of the sphenoid bone is rare. cause of a resemblance of a small sphenoid
The most frequently encountered aplasia sinus to a clouded sinus. The key to the

* Presented at the Seventy-fifth Annual Meeting of the American Roentgen Ray Society, San Francisco, California, September 24-
27, 1974.
From the Department of Radiology, Indiana University Medical Center, Indianapolis, Indiana.

129
 130 H. Y. Yune, R. W. Holden and J. A. Smith MAY, 1975
American Journal of Roentgenology 1975.124:129-138.

Fic. I . Nasopharyngeal Meningoencephalocele. Case I.

( A) Anteroposterior, (B) steep Waters’, and (C) lateral roentgenograms of face and anterior skull show
a large “soft tissue mass” in the oral cavity, growing downward from the roof of the mouth (open arrows).
Extensive midline facial and basal cranial cleft is noted on anteroposterior view (solid arrows on A).

proper diagnosis is the roentgenographic tus. There was one episode

of an of vertigo
demonstration of a very small but well- objective nature, lasting mm- approximately 2

aerated sphenoid sinus. This is easily ac- utes. This vertigo was not associated with other
sensory or motor dysfunction or disturbance in
complished by the use of thin-section to-
consciousness. The outside roen tgenographic
mography of the sphenoid body. In this
examination of the sinuses was interpreted as
situation, the ingrowing walls of the sphe-
showing sclerotic disease of the sphenoid sinus
noid sinus which have not expanded far
that could be osteitis, osteoma, or osteochon-
enough to be in apposition with the bony droma. Subsequent complete diagnostic work-
cortex of the body of the sphenoid will be up was essentially negative for organic disease.
demonstrated. When the sphenoid hypo-
plasia is a part of a complex midfacial and CASE III. Apert’s syndrome (Fig. 3).
cranial base anomaly, recognition of the
This is a 17 year old white female who was
condition is facilitated by the presence of born with Apert’s syndrome. Multiple congeni-
multiple deformities in the adjacent struc- tal anomalies, including anomalies of the face
tures. with underdeveloped maxilla, zygoma and fore-
head were noted. As a result, hypertelorism,
CASE II. Isolated hypoplasia of the sphen- proptosis, and cleft palate were present. There
oid sinus (Fig. 2). were multiple syndactylies of the hands and
This is a 33 year old white male who was re- feet. History of multiple surgical procedures
was given; 1956, cranioplasty; 1958, repair of
ferred to us with a tentative diagnosis of either
sinusitis, osteitis, or possible mass in the sphen-
the syndactyly; 1961, palatoplasty. Severe hy-
oid sinus. One year history of intermittent occi- poplasia of the maxilla has resulted in a mod-
erate Class III dental occlusion.
pital headache relieved by analgesics, and a
month history of a mild throbbing right fronto-
temporal headache were given. One month The hypoplasia of the sphenoid body
prior to the examination given by the referring without an equally proportioned reduction
physician, the patient noted the onset of tinni- in the size of the sella may give rise to a
 VOL. 124, No. i Normal Variations and Lesions of the Sphenoid Sinus ‘3’

AJ
American Journal of Roentgenology 1975.124:129-138.

Fic. 2. Isolated Hypoplasia of the Sphenoid Sinus. Case n.

(A and B) Routine lateral and submentovertex views of the sphenoid sinus show either a lack of aeration
or diffuse clouding of the sphenoid sinus. (C and D) Submentovertex tomograms, and (E and F) antero-
posterior tomograms of the sphenoid sinus clearly demonstrate very small but well-aerated sphenoid
sinuses (arrows). An isolated oval loculus is noted on the anterosuperior midline (arrow on D), outlined
by its own cortical walls.

false impression that the sella turcica is en- divides the sphenoid sinus into the right
larged due to an intrasellar mass lesion and left sides. This septum is almost never
( Case iv). on the midline. Occasionally, the septum
may enclose a portion of the sphenoid sinus
CASE iv. Pituitary eosinophi/ic adenoma in such a manner that it may simulate an
(Fig. 4). isolated sinus within the sinus (Case v).
This is a 37 year old white female with acro-
megaly. Initial diagnosis of pituitary eosino- CASE v. Variation in septation-sinus in
philic adenoma was made in 1969. Radiation sinus (Fig. ).

therapy to the pituitary gland was administered

This is a 33 year old white female with chief
in August, 1972. The chief complaint at that complaint of nasal stuffiness associated with
time was macroglossia, rhinorrhea, blurred
frontal headache. This was annually recurrent
vision, and occasional frontal midline headache. and worse in the late spring. The patient was
The patient noted continuous enlargement of
clinically symptomatic at the time ofthis roent-
her hands. The sella was noted be enlarging
to
genographic examination, but clinical examina-
continuously despite radiation therapy. Thy-
tion disclosed no sinus disease.
roid function determination, cortisol, and visual
field tests were all normal. Growth hormone was
An isolated may loculus
be a small
elevated. In January, 1974, subfrontal hypo-
vesicle-like the septum
space withinor on
physectomy wasperformed with removal of a
large quantity of semiliquid debris from the the wall of the sphenoid sinus (see Case ii).
pituitary fossa. The histopathology was necrotic If the isolated spherical or disk-like loculus
eosinophilic adenoma. within the sinus becomes clouded, it may
mimic a large polypoid mass, a cyst (Case
B. VARIATION IN SEPTATION vi), or an expanding floor of the sella (Cases
Ordinarily, there is a bony septum which vii and viii).
 132 H. Y. Yune, R. W. Holden and J. A. Smith MAY, 1975
American Journal of Roentgenology 1975.124:129-138.

Fic. 3. Apert’s Syndrome. Case III.

(A-C) Routine lateral, Caidwell’s, and submentovertex views of the facial region; (D) tomographic
lateral, and (E and F) anteroposterior views show flat, scaphoid face due to hypoplasia of multiple mid-
facial and basal cranial structures. Relatively small sphenoid body makes the sella appear abnormally
large.

CASE vi. Mucous retention cyst (Fig. 6). also noted to have generalized severe arterio-
sclerosis and an abdominal aortic aneurysm. He
This 28 year old woman presented with “in-
was confused, with a flaccid left upper extrem-
tolerable” headache. Physical examination was
ity and had xanthochromic spinal fluid.
not remarkable except for low grade fever. A
brain scan was negative. Routine sinus roent- CASE VIII. Pituitary eosinop/iilic adenoma
genograms revealed a density in the sphenoid (Fig. 8).
sinus. This density was noted to have grown
This is a 46 year old white male who de-
in size during the past 9 months. Tomography
of the sphenoid sinus revealed a homogeneous veloped gradual acromegalic changes of his face
well-marginated mass density within the sinus. and body during the past i to 20 years. Con-
The following day, the patient developed prop- firmation of acromegaly was made by a fasting
growth hormone value of i8 ng./ml., and a
tosis of the right eye. The patient subsequently
had a transnasal sphenoid sinus drainage of a postglucose stimulation value of 13 ng./ml. at
I hour, and I 5 ng.,/ml. at 2 hours. Roentgeno-
retention cyst.
graphic examination revealed an enlarged sella
with mass extending into the sphenoid sinus. He
CASE VII. Variations in septation with
denied any complaint of headache. The patient
sinusitis (Fig. 7).
underwen t transsphenoidal h ypophysectomy
Thisis a 69 year old critically ill white male. which demonstrated extension of the pituitary
He was a tremendously obese, known alcoholic mass into the sphenoid sinus, which was greater
who was admitted with acute renal failure on the left. Histopathology was eosinophilic
week following left above-knee amputation. AK adenom a.
amputation was performed for a thrombosed
popliteal aneurysm. Subsequently, multiple
Infrequently, the persistence of cranio-
complications developed, such as aspiration
pharyngeal canal may be seen, which will
pneumonia, acute and chronic pan-sinusitis, in- mimic an isolated loculus within the sphen-
farction of the right colon, septicemia, and oid sinus on submentovertex view (Case
metabolic encephalopathy. The patient was ix).
 VOL. 124, No. i Normal Variations and Lesions of the Sphenoid Sinus 133
American Journal of Roentgenology 1975.124:129-138.

Pic. 4. Pituitary Eosinophilic Adenoma. Case iv.

(A) Plain lateral view of the sella-sphenoid sinus, (B) lateral midline tomogram, and (C) anteroposterior
brow-up view during pneumoencephalography demonstrate marked expansion of the sella turcica en-
croaching upon the sphenoid sinus, which is due to an intrasellar soft tissue mass causing pressure erosion
on the tuberculum and dorsum sellae. Suprasellar extension of the pituitary mass is well seen on pneumo-
encephalographic examination (arrow on B and C).

Fic. 5. Variation in Septation-I. Case v.

(A) Routine lateral, (B) modified Waters’ (transoral), (C) submentovertex views, and (D) tomographic
lateral and (E) anteroposterior views of the sphenoid sinus demonstrate an oval loculus surrounded by its
cortical walls in the right sphenoid sinus. It has the appearance of the shell of a bird’s egg attached to the
right lateral wall of the spheioid sinus. (Courtesy: John H. Beveridge, M.D., Nashville, Tenn.)
 134 H. Y. Yune, R. W. Holden and J. A. Smith MAY, 1975
American Journal of Roentgenology 1975.124:129-138.

Fic. 6. Mucous Retention Cyst. Case i.

( A) Lateral view of the sphenoid sinus in March, 1971, demonstrates sharply demarcated “water
density” filling the entire floor of the sphenoid sinus. The surface of this demarcation is slightly undulating,
but can be easily mistaken as air-fluid level (arrow). (B) Lateral roentgenogram of sphenoid sinus in De-
cember, 1971. The homogeneous soft tissue density has now a smooth convex surface encroaching more into
the sphenoid sinus space. (C and D) The lateral and anteroposterior tomograms of the sphenoid sinus
demonstrate oval, well-demarcated water density occupying most of the sphenoid sinus space. Note that
there is no destruction of the sinus walls or expansion. (Courtesy of George B. Pratt, M.D., Indianapolis,
Ind.)

Fic. 7. Variation in Septation-Il. Case vii.

(A) Plain film lateral, (B) lateral tomogram on the right, and (C) left
side of mid-sagittal plane, (D) an-
teroposterior plain roentgenogram, and (E and F) a.nteroposterior tomograms of the sphenoid sinus demon-
strate what appears to be a large unilateral expansion of the floor of the sella due to partial loculus of
the right sphenoid sinus into a biconcave disk-like space, and the clouding of this loculated space by
irregular mucoperiosteal thickening of chronic sinusitis (compare with Figure 8). Note intact floor of sella
on F (arrow).
 VOL. ia, No. i Normal Variations and Lesions of the Sphenoid Sinus ‘35
American Journal of Roentgenology 1975.124:129-138.

Fic. 8. Pituitary Eosinophilic Adenoma. Case viii.

( A and B) Routine lateral and submentovertex views demonstrate a well-marginated soft tissue mass
within the sphenoid sinus (arrows on B), with seemingly intact sella. (C-E) Anteroposterior tomograms,
and (F-H) lateral tomograms of the sella show this mass to be due to the unilateral expansion of the sella
depressing and eroding the left floor down into the sphenoid sinus (solid arrows on D and G). Note still
intact right margin of the floor of the sella (open arrows on D and F) and that the mass is not covered by
cortical bone.

- : I A
Fic. 9. Persistent Craniop/taryngeal Canal. Case ix.
( A) Submentovertex and (B) lateral views of the sphenoid sinus demonstate cylindrical bony canal
between the anterior floor of the sella turcica and the bony roof of the nasopharynx. Note that there is no
recognizable pneumatization of the sphenoid body. On submentovertex view alone, one might mistake this
centrally located radiolucency for an isolated, hypoplastic midline sinus (see Figure 2D).
 136 H. Y. Yune, R. W. Holden and J. A. Smith MAY, 1975

C. VARIATION IN AERATION

Variation in aeration ranges from mini-

mal, and consequently a hypoplastic sinus
(see Case ii), to extensive, with extension
into the appendages of the sphenoid body,
such as the anterior clinoid processes, the
lesser wings, the greater wings, the ptery-
goid plates, and the posterior clinoid pro-
cesses (Cases x, xi, and xii).

CASES x, xl, and xii. Variations in aera-

tion (Fig. Jo; i I and 12).

These are cases with complaints unrelated to

the paranasal sinuses. Variations in aeration
demonstrated here are purely incidental obser-
vations.
American Journal of Roentgenology 1975.124:129-138.

Recognition of extensive aeration is clin-

ically important with the involvement of
the sinus by a disease, as aeration of these
appendages increases the chance of exten-

Fic. 10. 1ariation in Aeration. Case x.

Aeration of the sphenoid sinus may extend into
its appendages.
(A and B) Aeration of the anterior clinoid
processes.

CAS E I X. Persistent craniopharyngeal

canal (Fig. 9).
This child was noted shortly after birth to
have difficulty feeding and mild respiratory dis-
tress. Examination of the oropharynx revealed
a cystic mass depressing the soft palate. This
mass was partially resected at weeks
2 of age
and the pathologic diagnosis of fibroid epithelial
cyst was made. Leaking ofclear fluid, presuma-
bly cerebrospinal fluid, was noted for a few days
after the operation. This ceased spontaneously.
One year later the patient was readmitted. A
tubular bony canal connecting the anterior por-
tion of the sella turcica to the nasopharynx was
noted on roentgenograms. On physical exami-
nation, the mass was again apparent on the soft
palate. A second resection of the lesion was then
performed with the same pathologic diagnosis. FIG. II. J”ariation in Aeration. Case xi.
Clinical diagnosis of nasopharyngeal meningo- (A and B) Aeration extension into the base of
cele was not substantiated. the left pterygoid process.
 VOL. 124, No. i Normal Variations and Lesions of the Sphenoid Sinus ‘37

sion of the sinus disease to adjacent struc-

tures. Asymmetric expansion of the sinus
space may yield a false impression that the
smaller side is diseased because of the
relative increase in density due to a smaller
volume of air.

DISCUSSION

Because of its deep location and ana-

tomic relationship with many important
deep facial and intracranial structures, the
sphenoid sinus presents a unique problem
in clinical diagnosis.’’ Roentgenologic cx-
amination is probably the most effective
and definitive method in solving many of
the diagnostic problems arising from dis-
eases of the sphenoid sinus. ‘I
American Journal of Roentgenology 1975.124:129-138.

In the roentgenologic evaluation of the

sphenoid sinus it is essential to analyze the
following points: (i) the location and integ-
rity of the walls of the sinus; (2) the loca-
tion, shape, and integrity of the septum;
(3) the size of the sphenoid sinus and the
presence of any space encroachment; and
(4) the condition of the adjacent and con- B
tiguous structures. Fic. 12. Variation in Aeration. Case xii.
Advantages and limitations of the con- (A and B) Aeration extension into the lesser
ventional roentgenographic views of the wings (upper arrows) and greater wings (lower
arrows on B). Generous aeration of the base of the
sphenoid sinus are well known. Among
pterygoid processes is also seen.
these, modified Waters’ view (transoral
view) and submentovertex view, together
sphenoid sinus is the knowledge of develop-
with the lateral view will provide the essen-
mental variation which will enable the oh-
tial preliminary information, but these will
server to recognize those normal variations
not be sufficient for critical evaluation of
which closely mimic pathologic entities
the sphenoid sinus itself because of the roentgenographically, and separate them
superimposi tion of surrounding structures
from a real disease.”
on the roentgenogram.”2 For this reason,
modern thin-section tomography plays an SUMMARY

indispensable role by enabling an examiner I. A considerable amount of variation

to observe every small part of the sinus exists in the development of the sphenoid
without superimposition of the surrounding sinus. Classification of these variations for
structures. There are instances in which a convenience in roentgenographic analysis is
disease has extended beyond the sphenoid given.
sinus without roentgenographically demon- 2. For a complete evaluation of the sphe-
strable destruction of its walls. In such a noid sinus, the routine sinus roentgeno-
case, especially when it has extended into graphic series is not sufficient. If a lesion in
the cranial cavity, angiography and pneu- the sphenoid sinus is suspected, unless the
moencephalography are very helpful. lesion is quite obvious on routine roent-
Above all, the most important first step genograms, thin-section tomography should
in the roentgenologic examination of the always be obtained.
 138 H. Y. Yune, R. W. Holden and J. A. Smith MAY, 1975

3. Some abnormal and normal develop- 2. ETTER, L. E., and PRIMAN, J. Middle cranial fossa
mental variations of the sphenoid sinus are and paranasal sinuses. Part II. M. Radiol. &
Photog., 1965, 41, 38-60.
presented to emphasize the importance of
3. PENDERGRASS, E. P., SCHAEFFER, J. P., and
recognition of normal variations which H0DE5, P. J. The Head and Neck in Roentgen
mimic disease. Diagnosis. Second edition. Charles C Thomas,
Publisher, 1956.
Heun Y. Yune, M.D.
4. VAN ALYEA, 0. A. Sphenoid sinus: anatomic
Department of Radiology
study with consideration of clinical significance
Indiana University Medical Center
of structural characteristics of sphenoid sinus.
Indianapolis, Indiana 46202
Arch. Otolaryng., 1941,34, 225-253.
5. VuM, B. Postnatal development of sphenoidal
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