Background: The sphenoid sinus occupies a strategically central position at the base of the skull, in close proximity to critical neurovascular structures including the pituitary gland, optic nerves, internal carotid arteries, and the cavernous sinus. Its complex anatomical configuration and pronounced individual variability render it a structure of paramount clinical importance in transsphenoidal approaches to the sellar and parasellar regions. Methods: A narrative review of the literature was conducted in accordance with the SANRA (Scale for the Assessment of Narrative Review Articles) guidelines for narrative reviews. A comprehensive search was performed across four electronic databases—PubMed/MEDLINE, Scopus, Web of Science, and Google Scholar—covering publications from January 2000 through March 2026, with the final search update completed in March 2026. An initial pool of 826 articles was identified. Following title and abstract screening, 421 articles were retained for full-text assessment; of these, 307 contributed to the conceptual synthesis, and 100 are directly cited in the manuscript. The literature selection process followed a structured flow diagram consistent with PRISMA reporting principles for identification and screening stages. Results: We synthesise current evidence on the embryological development, macroscopic and microscopic anatomy, morphological classifications, and epidemiological distribution of anatomical variations in the sphenoid sinus, with emphasis on radiological assessment and surgical relevance. The spectrum of pneumatization patterns—from the conchal type through presellar and sellar variants to the postsellar, clival, and lateral types—is reviewed alongside population-level prevalence data. Common and rare variations are examined, including intrasinus septation, Onodi cells, and bony dehiscences overlying the internal carotid artery and optic nerve. The comparative diagnostic capabilities of computed tomography and magnetic resonance imaging are evaluated, alongside emerging modalities such as three-dimensional reconstruction, virtual reality, and augmented reality. Conclusions: Detailed morphological knowledge of the sphenoid sinus plays an important role in surgical strategy, instrument selection, and risk mitigation in skull base surgery. Individualised preoperative imaging—integrating CT, MRI, and, where available, immersive digital technologies—is essential for safe transsphenoidal planning and cannot be replaced by standard anatomical templates.
Bechev et al. (Thu,) studied this question.