PMC3404477_01
Preoperative (A) axial and (B) coronal CT scan showing an aggressive mass within the sphenoid sinus. There is bony destruction of the anterior wall of the sphenoid sinus and the anterior portion of inferior wall, in addition to destruction of the posterior aspect of the planum sphenoidale and the anterior wall and floor of the sella turcica.
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F1
Her preoperative CT scan showed aggressive bony destruction of the sphenoid sinus involving the ventral and anterior portion of the inferior wall, the posterior aspect of the planum sphenoidale, and anterior wall and floor of the sella (Fig. 1).
Preoperative (A) coronal T1, (B) axial T1, and (C) T2 MRI. The mass lesion in the sphenoid sinus is isointense to gray matter on T2-weighted imaging with diffuse enhancement on T1-weighted images. The pituitary gland is distinctly visualized and separate from the mass.
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F2
T1-weighted images (Fig. 2). There was no other evidence of head and neck involvement after review of the MRI and CT scan. The patient underwent a right-sided sphenoidotomy with debridement and biopsy of the sphenoid mass.
(A) Hematoxylin and eosin (H & E) stain showing acute and chronic inflammation with fibrosis present throughout the tissue sample. Plasma cells were CD138+ with a mixture of kappa- and lambda-light chain-bearing cells. (B) Dense plasmacytic infiltrate with >150 IgG4+ cells/high-power field (hpf).
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F3
(A) Axial and (B) coronal 2-month postoperative CT scan showing partial opacification and recurrence of IgG4 sclerosing disease in the sphenoid sinus. This imaging corresponded to the patient's 2 month postoperative nasal endoscopy with sphenoid antrostomy obstruction and polypoid-like mucosal changes (Fig. 5 B).
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F4
However, at her 2-month postoperative visit she showed evidence of disease recurrence in the sphenoid sinus with partial opacification of the sphenoid sinuses on CT imaging and occlusion of the sphenoid antrostomy (Figs. 4 and Fig. 5 B).
(A) One-month postoperative nasal endoscopy showing a wide sphenoid antrostomy. (B) Two-month postoperative nasal endoscopy with sphenoid antrostomy obstruction and polypoid like mucosal changes. (C) Five-month postoperative nasal endoscopy after starting a nasal corticosteroid shows an improved and widely patent sphenoid antrostomy.
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F5
One-month postoperative evaluation showed a patent sphenoid antrostomy without evidence of recurrence (see Fig. 5 A). She was subsequently started on fluticasone, a nasal corticosteroid, which improved the patency of the sphenoid antrostomy (Fig. 5 C).