Sphenoid Sinus Mucocele

Angela Donaldson and Lee A. Zimmer

History

A 46-year-old black woman arrived at the clinic with a 3-month history of headaches and visual changes. The patient described the headaches as localized to the left frontal region, worsened by lying supine, and constant in nature. The patient denied photophobia, nausea, and vomiting and had no history of migraines. She also complained of diplopia, which had been present for the past month. The diplopia improved when she turned her head to the left. An eye examination 3 months earlier had shown 20/20 vision bilaterally, and she had no current complaints. For the past 2 weeks she had been experiencing pain behind her left eye. The patient denied recent trauma, vertigo, nausea, vomiting, or weight loss.

The patient’s medical history includes hypertension, allergic rhinitis, and chronic sinusitis. She works for an interior design firm. Patient denied the use of tobacco, alcohol, and illicit drugs. Family history is noncontributory.

On physical examination, the patient appears well. Pupils are equal, round, and reactive to light. The left eye has mobility superiorly, medially, and inferiorly, but it does not move laterally. Extraocular movement is intact on the right. There is mild swelling of the inferior tuberinates bilaterally and no septal deviation or polyps. Nasal endoscopy showed a smooth cystic swelling in the area of the sphenoid with no focal ulcerations.

Differential Diagnosis—Key Points

1. Taking a thorough history regarding the patient’s headache is important to the diagnosis. The differential diagnosis of headaches includes, but is not limited to, tension headache, cluster headache, migraine, meningitis, intracranial mass, sinusitis, fungus ball, and temporomandibular joint (TMJ) syndrome. This patient describes her headaches as retro-orbital and worse when lying in the supine position. The patient also denied aura symptoms and has no family history of migraine, therefore making this diagnosis of migraine less likely. Because there is no history of trauma and the headaches have been present for an extended period, the concern for a space-occupying lesion should be high on the differential diagnosis.

2.