Abstract
Spontaneous epidural hematoma (EDH) is rarely mentioned in the literature as an intracranial complication of sinusitis. We report a 17-year-old female patient who developed spontaneous EDH accompanied by isolated oculomotor nerve palsy as a complication of sphenoid sinusitis. Sphenoid sinusitis could be considered as the causative disease in a patient with spontaneous EDH accompanied by isolated oculomotor nerve palsy without history of head trauma.
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Case report
A 17-year-old adolescent girl with no history of any preceding head trauma presented with headache, vomiting, and high fever for 1 day after upper respiratory tract infection. She attended the emergency department and was found to be neurologically normal. Result of cerebrospinal fluid analysis and other laboratory findings were normal. Computed tomography (CT) of the brain revealed soft tissue density in both sphenoid sinus, but no abnormal finding in the brain parenchyma.
One day later, she showed a rapid decline in consciousness and ptosis in right eye. In the neurologic examination, she had markedly decreased sensation on the right cheek, limitation of medial gaze, and diplopia. Right pupil was dilated without reaction to light. A right oculomotor nerve palsy was diagnosed. Brain CT showed a right-sided temporal lenticular-shaped hyperdense lesion with midline shifting to the left and total opacification in both sphenoid sinuses with no evidence of skull fracture ( Fig. 1 ). Magnetic resonance imaging of the brain was performed, which confirmed the epidural hematoma (EDH) with heterogenous signal intensity in T2-weighted image and intermediate high signal intensity in T1-weighted image. On hemorrhagic sequence images, there was associated signal dropout confirming the presence of hemorrhage ( Fig. 2 ).
The patient underwent emergent transnasal endoscopic sphenoidotomy and evacuation of hematoma via craniotomy under general anesthesia. After partial superior turbinectomy, sphenoid ostium was widened using sphenoid punch forceps. Pulsating pus-like discharge and inflammation-induced edematous sinus mucosa were noted. Neurosurgeon performed a right frontotemporal craniotomy for the evacuation of hematoma. The blood clot sample from lesion was sent for histologic examination and revealed a hemorrhage containing clusters of polymorphonuclear cells. There was neither skull fracture nor bony defect in the sphenoid sinus. No organism was seen on gram, acid fast bacilli (AFB), and fungus stain; and culture yielded no growth in the pus from sphenoid sinus. The patient received a 3-week course of intravenous ceftriaxone and metronidazole and recovered fully without any neurologic deficit. One month following the operation, endoscopic finding showed no remarkable finding in the sphenoid sinus; and brain CT revealed no evidence of residual lesion ( Fig. 3 ).
