63 year old man with severe headache and new sudden onset diplopia, and ptosis and proptosis of the

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63 year old man with severe headache and new
sudden onset diplopia, and ptosis and proptosis
of the right eye.
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HPI

• 63 yo man with a history of bone marrow
  transplant 11 years ago for leukemia was seen at
  the ED with intense headache of 6 days duration.
  CT scan in the ED showed isolated sphenoid sinus
  opacification. The patient was febrile and felt
  tired, but had no neurologic signs at the time.
  The patient was admitted for IV antibiotics to
  the internal medicine service. On hospital day
  2, the patient had acute onset of right eye
  ptosis, proptosis, and diplopia on binocular
  vision with mental status change.

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History

• No medications
• NKDA
• PMH leukemia
• PSH bone marrow transplant

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CT Scans
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Paranasal Sinuses
Development of the paranasal sinuses begins in
the fetal stage. The newborn is born with
maxillary sinuses with minimal ethmoid cell
pneumatization. The frontal sinus begins
development at 4 years and is complete after age
12.
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Paranasal Sinuses
The sphenoid sinus begins to develop at age 5,
and is completed after age 12. The sphenoid
sinus approaches the sella turcica and cavernous
sinus as it pneumatizes. The two sides are
asymmetric because of a twisted intersinus
septum. The sphenoid sinus drains into the
sphenoethmoid recess medial to the posterior
attachment of the superior turbinate.
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Sphenoid Sinus

• Indentations in the walls of the sphenoid sinus
  may be seen
• Optic nerve superolateral
• Internal carotid artery - posterolateral
• Vidian nerve
• Maxillary nerve
• Sphenopalatine ganglion
• As many as 8 may have dehiscent carotid arteries
  in the sphenoid sinus. 6 of optic nerves may
  have dehiscence, and up to 75 can have less than
  5mm bony covering over the optic nerve.

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Isolated Shpenoid Sinusitis

• Only 1-3 of sinus infections
• Microbes are different from other sinuses
• Acute S. Aureus, S. Pneumoniae
• Chronic gram-negatives, gram-positives,
  anaerobes
• Fungal Aspergillus Sp., Mucor Sp.,
  Pseudallescheria Sp., Paecilomyes Sp. Alternaria
  Sp.
• Considered an emergency because of its ability to
  progress rapidly, and the possibility of
  intracranial complications if not aggressively
  managed.

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Treatment

• Initial treatment in uncomplicated cases is
  conservative
• Broad-spectrum IV antibiotics and hydration
• Close monitoring with visual and neural checks
• Surgical drainage and removal tissue or debris
  blocking the ostia.

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Complications of Sinusitis

• MucocelesMaxillary, frontoethmoid, sphenoid.
• Can expand slowly and cause bone erosion
• Orbital (Chandlers 5)
• 1. Inflammatory edema
• 2. Orbital cellulitis
• 3. Subpeiriosteal abscess
• 4. Orbital abscess
• 5. Cavernous sinus thrombosis
• Intracranial
• Subdural / epidural abscess
• Meningitis
• Brain abscess
• Specific to sphenoid sinusitis
• Orbital apex syndrome
• Cranial neuropathies
• Carotid artery thrombosis
• Hypopituitarism

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Cavernous Sinus
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Cavernous Sinus Thrombosis

• Causes
• Most commonly sphenoid and ethmoid sinus
  infections
• Face danger area
• Nose
• Tonsils and soft palate
• Teeth
• Ears
• Most common pathogen S. Aureus
• S. Pneumoniae, Gram-negatives, anaerobes,
  Aspergillus, Mucor

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Cavernous Sinus Thrombosis

• Signs
• Fever, ptosis, proptosis, chemosis,
  ophthalmoplegia, lethargy.
• Neuropathies including sympathetic (ica) and
  parasympathetic (cn III)
• Retinal engorgement, papilledema
• Visual impairment
• Spread of signs to opposite side is ominous
• Pituitary necrosis
• Global neurologic compromise

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Studies

• CT
• MRI
• Angiography

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Mortality

• 80-100 prior to antibiotic era
• Now 20-30
• Sequelae
• Up to 77 can have long term sequelae
• Occulomotor neuropathy
• Visual impairment
• Pituitary insufficiency
• Hematogenous spread of infection.