Abstract
Objective
We describe a patient who presented with recurrent, contralateral abducens nerve palsy resulting from acute sphenoiditis.
Methods
Patient medical record and imaging studies were reviewed. A literature review of complications of sphenoiditis was performed.
Results
Our patient presented with symptoms consistent with an upper respiratory tract infection, as well as severe headache, disequilibrium, and diplopia. Physical examination demonstrated left-sided sixth cranial nerve palsy. Imaging studies were consistent with right sphenoid sinus inflammatory disease. Her medical history was significant for a similar episode 9 years previously, which was managed medically. The current episode was treated acutely with antibiotics and prednisone. Upon resolution of her symptoms, she underwent an endoscopic sphenoidotomy.
Conclusions
Although cranial nerve palsies associated with isolated sphenoiditis have been reported, we describe a unique case of recurrent isolated sphenoiditis causing contralateral abducens nerve palsy. Acute management can be medical, with surgical therapy reserved for refractory cases or to prevent future episodes.
1
Introduction
Isolated sphenoiditis is an uncommon disease. Typically, inflammatory disease of the sphenoid sinus is seen in association with disease in other paranasal sinuses. Unlike other sinuses, the sphenoid is located in proximity to many important structures including the pituitary gland, cavernous sinus, internal carotid artery, cranial nerves (CNs) II to VI, sphenopalatine artery and nerve, and pterygoid canal and nerve. The most common symptom of an isolated sphenoid sinusitis is headache, which is nonspecific and can be misdiagnosed. Sometimes, the inflammation of the nearby structures gives rise to more specific signs or symptoms, and sphenoid pathology should be considered. If suspected, appropriate workup and management to diagnose and treat the sphenoiditis is necessary. Recurrent complicated sphenoiditis is unusual and is rarely reported in the literature. We present an atypical case of recurrent, isolated, sphenoiditis with ocular complications. We also present a literature review of complications of sphenoiditis.
2
Case report
A 45-year-old woman presented to our institution with a chief complaint of double vision and headaches. She reported a 2-week history of an upper respiratory tract infection. She was initially seen by her primary care provider and given azithromycin. Four days before presentation, she was seen at an outside emergency department for acute worsening of her symptoms, including dizziness, diplopia, and difficulty standing. A computed tomography (CT) scan of the head showed no intracranial pathology; however, the right sphenoid sinus was completely opacified. She was discharged with a prescription of amoxicillin/clavulanate and prednisone (60 mg daily for 5 days) for treatment of her sinus disease. She noted no improvement in her symptoms in the 4 days after this encounter and, therefore, presented to our hospital. Her medical history was significant for an episode of right sphenoiditis with the same manifestations 9 years earlier. That episode was managed medically with a prolonged course of antibiotics and prednisone. Her other medical history was noncontributory. Her past surgical history was significant for sinus surgery approximately 15 years ago. She was a nonsmoker and occasionally used alcohol.
On presentation, the patient was afebrile. Physical examination demonstrated diplopia on left lateral gaze and palsy of the left lateral rectus muscle. Visual acuity was grossly intact. She did not suffer from purulent rhinorrhea. Nasal endoscopy demonstrated diffuse mucosal inflammation and erythema throughout. A large rightward septal spur was appreciated. The right middle turbinate remnant was diffusely edematous. There was no mucopurulence emanating from the common final pathway, the superior meatus, or the sphenoethmoidal recess on the right. There was polypoid edema in the region of the natural ostium of the sphenoid sinus. The nasopharynx was unremarkable.
Computed tomography examination of the sinonasal cavities demonstrated mucosal thickening and fluid nearly opacifying the right sphenoid sinus with scant mucosal thickening in the right maxillary and ethmoid sinuses ( Fig. 1 ). The right sphenoid sinus was dominant in size and crossed the midline posteriorly with extension to the left cavernous sinus. Postsurgical changes were noted, consistent with a previous ethmoidectomy. Of note, a significant right-sided septal deviation was present with a rightward bony septal spur. No bony dehiscence of the sphenoid walls was appreciated.
Magnetic resonance (MR) imaging of the brain, orbits, and sinuses demonstrated no intracranial pathology and no evidence of orbital pathology or inflammation. The cavernous sinuses were of normal morphology and enhanced symmetrically and homogeneously. There was no evidence of CN involvement. The right sphenoid sinus demonstrated peripheral hyperintense mucosal thickening on T2-weighted images consistent with mucosal edema and central hypointense material consistent with inspissated secretions ( Fig. 2 ). Enhancement of the inflamed mucosa was noted on postgadolinium T1-weighted images with fat suppression ( Fig. 3 ).
The patient was admitted to the hospital for intravenous antibiotics and steroid therapy. She was started on decadron and ertapenam. An ophthalmology consult was obtained, and a left sixth CN (CN VI) palsy was confirmed. Her orbital pain and headache steadily improved and were under control by the time of discharge 3 days later. Her diplopia gradually improved but was still present at the time of discharge. The patient was discharged with 3 weeks of oral amoxicillin/clavulanate and a prednisone taper. She was followed closely with serial office visits, and her symptoms were noted to gradually improve.
Within 2 months of this acute episode, all of her symptoms had completely resolved. The patient elected to undergo endoscopic sinus surgery directed at opening the sphenoid ostium in an attempt to prevent future episodes. She underwent a directed septoplasty followed by an endoscopic right sphenoidotomy. The patient tolerated the procedures well and has had no recurrence of symptoms.
2
Case report
A 45-year-old woman presented to our institution with a chief complaint of double vision and headaches. She reported a 2-week history of an upper respiratory tract infection. She was initially seen by her primary care provider and given azithromycin. Four days before presentation, she was seen at an outside emergency department for acute worsening of her symptoms, including dizziness, diplopia, and difficulty standing. A computed tomography (CT) scan of the head showed no intracranial pathology; however, the right sphenoid sinus was completely opacified. She was discharged with a prescription of amoxicillin/clavulanate and prednisone (60 mg daily for 5 days) for treatment of her sinus disease. She noted no improvement in her symptoms in the 4 days after this encounter and, therefore, presented to our hospital. Her medical history was significant for an episode of right sphenoiditis with the same manifestations 9 years earlier. That episode was managed medically with a prolonged course of antibiotics and prednisone. Her other medical history was noncontributory. Her past surgical history was significant for sinus surgery approximately 15 years ago. She was a nonsmoker and occasionally used alcohol.
On presentation, the patient was afebrile. Physical examination demonstrated diplopia on left lateral gaze and palsy of the left lateral rectus muscle. Visual acuity was grossly intact. She did not suffer from purulent rhinorrhea. Nasal endoscopy demonstrated diffuse mucosal inflammation and erythema throughout. A large rightward septal spur was appreciated. The right middle turbinate remnant was diffusely edematous. There was no mucopurulence emanating from the common final pathway, the superior meatus, or the sphenoethmoidal recess on the right. There was polypoid edema in the region of the natural ostium of the sphenoid sinus. The nasopharynx was unremarkable.
Computed tomography examination of the sinonasal cavities demonstrated mucosal thickening and fluid nearly opacifying the right sphenoid sinus with scant mucosal thickening in the right maxillary and ethmoid sinuses ( Fig. 1 ). The right sphenoid sinus was dominant in size and crossed the midline posteriorly with extension to the left cavernous sinus. Postsurgical changes were noted, consistent with a previous ethmoidectomy. Of note, a significant right-sided septal deviation was present with a rightward bony septal spur. No bony dehiscence of the sphenoid walls was appreciated.
