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A Boy with Acute Strabismus
A Boy with Acute Strabismus
A
12-year-old boy was admitted to the hospital with a 3-day history of strabismus, diplopia, and worsening of a headache of which he had been complaining for 3 months, without nocturnal awakenings. The headache worsened during the previous 2 weeks, after an upper respiratory tract infection, such that the analgesic therapy (paracetamol and codeine) was not effective anymore. There was no history of vomiting. In the previous period, he never had been febrile. On neurologic examination, we found a left esotropia without alterations of ocular movements (Figure 1), a faltering walk probably due to diplopia, and a bilateral papilledema; visual acuity was normal. Blood tests revealed only a mildly elevated erythrocyte sedimentation rate. A magnetic resonance imaging scan ruled out a brainstem tumor but showed homogeneous semifluid material completely occupying half the sphenoid sinus, with no enhancement after contrast, in keeping with a flogistic event (Figure 2). A computerized tomography scan of the paranasal sinuses highlighted a well-delineated cystic formation with loss of bone continuity next to the sella turcica, a radiologic image compatible with a mucocele (Figure 3; available at www.jpeds.com). This diagnostic suspect was confirmed by surgery (endoscopic sphenoidotomy). Sphenoid sinus mucocele is a rare condition accounting for 1%-2% of paranasal sinus mucoceles.1 The etiology is unknown; it could be due to sinus ostium obstruction following chronic sinus inflammation, polyposis, infections, or tumors. The highest incidence of sphenoid sinus mucocele is reported during the fourth decade of life, whereas it is rare in childhood when cystic fibrosis must be ruled out.2 Useful for
Figure 2. Magnetic resonance imaging shows a lesion occupying one-half of the sphenoidal sinus with no involvement of other sinuses.
the diagnosis are both computerized tomography and magnetic resonance imaging.3 It is important to recognize this condition because the persistence and worsening of neurologic symptoms (headache and optical impairment) warrants urgent surgical drainage followed by wide-range antibiotic therapy to prevent iatrogenic infection.4 Generally, no complications are described after surgery.5 n Federico Poropat, MD Giovanna Ventura, MD Department of Pediatrics Institute for Maternal and Child Health IRCCS “Burlo Garofolo” University of Trieste
Flora M. Murru, MD Eva Orzan, MD Massimo Maschio, MD Figure 1. Esotropia of the left eye due to sixth nerve palsy.
Institute for Maternal and Child Health IRCCS “Burlo Garofolo” Trieste, Italy
J Pediatr 2012;161:1178. 0022-3476/$ - see front matter. Copyright ª 2012 Mosby Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2012.06.055
1178
References available at www.jpeds.com
Vol. 161, No. 6 December 2012
References 1. Soon SR, Lim CM, Suingh H, Sethi DS. Sphenoid sinus mucocele: 10 cases and literature review. J Laringol Otol 2010;124:44-7. 2. Lui YW, Dasari SB, Young RJ. Sphenoid masses in children: radiologic differential diagnosis with pathologic correlation. Am J Neuroradiol 2011;32:617-26.
3. Lee TJ, Li SP, Fu CH, Huang CC, Chang PH, Chen YW, et al. Extensive paranasal sinus mucoceles: a 15 year review of 82 cases. Am J Otolaryngol 2009;30:234-8. 4. Elden LM, Reinders ME, Kazahaya K, Tom LW. Management of isolated sphenoid sinus disease in children: a surgical perspective. Int J Pediatr Otorhinolaryngol 2011;75:1594-8. 5. Har-El G. Endoscopic management of 108 sinus mucoceles. Laringoscope 2001;111:471-3.
Figure 3. Computerized tomography of sinus shows a welldelineated cystic formation with sinus roof fracture. 1178.e1
A
12-year-old boy was admitted to the hospital with a 3-day history of strabismus, diplopia, and worsening of a headache of which he had been complaining for 3 months, without nocturnal awakenings. The headache worsened during the previous 2 weeks, after an upper respiratory tract infection, such that the analgesic therapy (paracetamol and codeine) was not effective anymore. There was no history of vomiting. In the previous period, he never had been febrile. On neurologic examination, we found a left esotropia without alterations of ocular movements (Figure 1), a faltering walk probably due to diplopia, and a bilateral papilledema; visual acuity was normal. Blood tests revealed only a mildly elevated erythrocyte sedimentation rate. A magnetic resonance imaging scan ruled out a brainstem tumor but showed homogeneous semifluid material completely occupying half the sphenoid sinus, with no enhancement after contrast, in keeping with a flogistic event (Figure 2). A computerized tomography scan of the paranasal sinuses highlighted a well-delineated cystic formation with loss of bone continuity next to the sella turcica, a radiologic image compatible with a mucocele (Figure 3; available at www.jpeds.com). This diagnostic suspect was confirmed by surgery (endoscopic sphenoidotomy). Sphenoid sinus mucocele is a rare condition accounting for 1%-2% of paranasal sinus mucoceles.1 The etiology is unknown; it could be due to sinus ostium obstruction following chronic sinus inflammation, polyposis, infections, or tumors. The highest incidence of sphenoid sinus mucocele is reported during the fourth decade of life, whereas it is rare in childhood when cystic fibrosis must be ruled out.2 Useful for
Figure 2. Magnetic resonance imaging shows a lesion occupying one-half of the sphenoidal sinus with no involvement of other sinuses.
the diagnosis are both computerized tomography and magnetic resonance imaging.3 It is important to recognize this condition because the persistence and worsening of neurologic symptoms (headache and optical impairment) warrants urgent surgical drainage followed by wide-range antibiotic therapy to prevent iatrogenic infection.4 Generally, no complications are described after surgery.5 n Federico Poropat, MD Giovanna Ventura, MD Department of Pediatrics Institute for Maternal and Child Health IRCCS “Burlo Garofolo” University of Trieste
Flora M. Murru, MD Eva Orzan, MD Massimo Maschio, MD Figure 1. Esotropia of the left eye due to sixth nerve palsy.
Institute for Maternal and Child Health IRCCS “Burlo Garofolo” Trieste, Italy
J Pediatr 2012;161:1178. 0022-3476/$ - see front matter. Copyright ª 2012 Mosby Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2012.06.055
1178
References available at www.jpeds.com
Vol. 161, No. 6 December 2012
References 1. Soon SR, Lim CM, Suingh H, Sethi DS. Sphenoid sinus mucocele: 10 cases and literature review. J Laringol Otol 2010;124:44-7. 2. Lui YW, Dasari SB, Young RJ. Sphenoid masses in children: radiologic differential diagnosis with pathologic correlation. Am J Neuroradiol 2011;32:617-26.
3. Lee TJ, Li SP, Fu CH, Huang CC, Chang PH, Chen YW, et al. Extensive paranasal sinus mucoceles: a 15 year review of 82 cases. Am J Otolaryngol 2009;30:234-8. 4. Elden LM, Reinders ME, Kazahaya K, Tom LW. Management of isolated sphenoid sinus disease in children: a surgical perspective. Int J Pediatr Otorhinolaryngol 2011;75:1594-8. 5. Har-El G. Endoscopic management of 108 sinus mucoceles. Laringoscope 2001;111:471-3.
Figure 3. Computerized tomography of sinus shows a welldelineated cystic formation with sinus roof fracture. 1178.e1