Lateral rectus muscle palsy secondary to sphenoid sinusitis

Abstract

Isolated sphenoid sinus disease is a rare, often misdiagnosed condition of the paranasal sinus. If left untreated, it can lead to complications involving pituitary gland, cavernous sinus, neurological and vascular structures nearby. Early recognition and treatment are critical to prevent the progression of the disease. We present a case of a 60-year-old woman with a history of severe left-sided headache, facial pain, diplopia and left lateral rectus palsy. She was initially referred to ophthalmology and rheumatology for possible giant cell arteritis. Magnetic resonance imaging revealed opacification in left sphenoid sinus with cavernous sinus/superior orbital fissure involvement consistent with left sphenoid sinusitis. She was then referred to the ear, nose and throat department and had endoscopic transnasal sphenoidotomy in theatre. Culture results showed Haemophilus influenza and fungal pseudohyphae. She recovered three months later after a course of antibiotics and antifungals. The onset of isolated sphenoid sinus disease is often insidious and the diagnosis of this condition remains a challenge. Magnetic resonance imaging and computed tomography remain the best diagnostic tools to recognise and manage this condition.

Identifying the Risk Factors for Orbital Complications in Isolated Sphenoid Rhinosinusitis

“…Regarding the orbital complications secondary to isolated sphenoid rhinosinusitis, previous case reports have demonstrated cavernous sinus thrombophlebitis and optic neuritis [10][11][12][13][14]18,19]. The sixth cranial nerve (abducens nerve) and optic nerve were consequently affected, which resulted in ophthalmologic symptoms including diplopia, extraocular motility limitation, orbital pain, and visual impairment.…”

“…The sixth cranial nerve (abducens nerve) and optic nerve were consequently affected, which resulted in ophthalmologic symptoms including diplopia, extraocular motility limitation, orbital pain, and visual impairment. In two of the cases mentioned above, the orbital symptoms improved after receiving intravenous antibiotic treatment and prompt endoscopic sinus surgery [13]. However, visual impairment deterioration was found in the other case due to delayed surgical drainage [14].…”

“…Furthermore, isolated sphenoid rhinosinusitis may have devastating consequences such as orbital complications due to its anatomical contiguity with vital structures including the cranial nerves and cavernous sinus [10][11][12][13][14]. For the orbital complications secondary to isolated sphenoid rhinosinusitis, previous case reports have demonstrated cavernous sinus thrombophlebitis and optic neuritis [10][11][12][13][14].…”

“…Furthermore, isolated sphenoid rhinosinusitis may have devastating consequences such as orbital complications due to its anatomical contiguity with vital structures including the cranial nerves and cavernous sinus [10][11][12][13][14]. For the orbital complications secondary to isolated sphenoid rhinosinusitis, previous case reports have demonstrated cavernous sinus thrombophlebitis and optic neuritis [10][11][12][13][14]. The sixth cranial nerve (abducens nerve) and optic nerve were consequently affected, which resulted in ophthalmologic symptoms including diplopia, extraocular motility limitation, orbital pain, and visual impairment.…”

Isolated Abducens Nerve Palsy in the Setting of Isolated Sphenoid Sinusitis: A Case Report

“…Most cases had some variations of associated symptoms, including progressively worsening headaches, often hemi-cranial-disequilibrium, orbital or ocular pain, blurred vision, fever, and/or nasal congestion [11][12][13][14][15]. In addition, some cases required more extensive treatment beyond conservative and antibiotic measures, such as transnasal sphenoidotomy [13,19] or sphenoid drainage [11]. Although our patient did have unilateral left palsy with significant sphenoid sinusitis, our case was unique in that she did not present with any of the typical associated symptoms one would expect with acute sphenoid sinusitis, namely, headaches radiating to the vertex or occiput of the skull.…”