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

1. 63 year old man with severe headache and new sudden onset diplopia, and ptosis and proptosis of the right eye.

2. 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.

3. History No medications NKDA PMH: leukemia PSH: bone marrow transplant

4. CT Scans

5. Paranasal Sinuses

6. Paranasal Sinuses

8. 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.

9. 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.

10. 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.

11. Complications of Sinusitis Mucoceles:Maxillary, frontoethmoid, sphenoid. Can expand slowly and cause bone erosion Orbital (Chandler�s 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

12. Cavernous Sinus

14. 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

15. 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

16. Studies CT MRI Angiography

17. 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.