A Rare Erosive Sphenoid Sinus Organized Hematoma Resulting in Epistaxis and Diplopia: A Case Report and Review of the Literature

Sinonasal organized hematomas (SOH) are rare benign entities that frequently masquerade as malignancies, both clinically and radiographically. They most commonly develop in the maxillary sinus and rarely evolve in the sphenoid sinus. The small capacity of the sphenoid sinus, paired with its anatomic intimacy with the skull base, can portend devastating complications from sphenoid SOH, such as blindness and sentinel bleeding.

We report the case of a 79-year-old male with a remote past medical history of oropharynx carcinoma and renal cell carcinoma, who was actively taking Eliquis for recalcitrant atrial fibrillation. He presented to the emergency department with a 6-month history of sporadic, yet progressive epistaxis, coupled with 3 months of debilitating fronto-occipital headaches, and 1 week of worsening diplopia. Urgent MR and CT imaging demonstrated a destructive mass centered in the left sphenoid sinus with the erosion of the sella, the clivus, with early encroachment into the middle cranial fossa ([Fig. 1]).

Fig. 1 (A–C) Imaging of patient at the time of presentation. (A/C) MR imaging demonstrates a mild enhancing transpacial sphenoid sinus mass with areas of intrinsic T1 hyperintensity. There is focal enhancement along the left lateral aspect of this mass that extends into the middle cranial fossa with focal reactive dural thickening/enhancement. (B) Axial CT imaging demonstrates an expansile, destructive lesion centered in the left sphenoid sinus with extensive erosion/thinning of the walls of the sphenoid sinus, including extension into the adjacent right sphenoid sinus, erosion of the floor of the sella, and remodeling of the posterior wall of the upper clivus.

ENT clinical evaluation with a 30-degree rigid endoscope revealed old blood products and clot emanating from the left sphenoid os. Intraoperatively, a transnasal endoscopic wide-field sphenoidotomy was performed, revealing extensive congealed blood products with mucosal discoloration and bony erosion of the sphenoid floor ([Fig. 2]). Frozen section pathology demonstrated organized hematoma. No feeding vessel was implicated intraoperatively. Postoperatively the patient had immediate complete resolution of his headaches and diplopia, but persistent, though less severe, epistaxis. A subsequent CTA and cerebral angiogram revealed normal bilateral paraclival and cavernous internal carotid arteries without epistaxis source identification. The patient’s dose of Eliquis was reduced and he was started on daily gentamycin nasal irrigations with epistaxis resolution

Fig. 2 Endoscopic wide field left sphenoidotomy revealing congealed blood products.

With the paucity of reports documenting sphenoid organized hematomas, we review the relevant literature, and add our unique case to the skull base annals.

 

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No conflict of interest has been declared by the author(s).

Publication History

Article published online:
07 February 2025