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Epidural hematoma accompanied by oculomotor nerve palsy due to sphenoid sinusitis
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American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 355 – 357 www.elsevier.com/locate/amjoto
Epidural hematoma accompanied by oculomotor nerve palsy due to sphenoid sinusitis Kyu-Sup Cho, MD, PhDa , Won-Ho Cho, MD, PhDb , Hak-Jin Kim, MD, PhDc , Hwan-Jung Roh, MD, PhDd,⁎ a
Department of Otorhinolaryngology and Medical Research Institute, Busan, South Korea Department of Neurosurgery, Pusan National University School of Medicine, Busan, South Korea c Department of Radiology, Pusan National University School of Medicine, Busan, South Korea d Department of Otorhinolaryngology, Pusan National University School of Medicine Yangsan Hospital, Yangsan, South Korea Received 25 January 2010 b
Abstract
Spontaneous epidural hematoma (EDH) is rarely mentioned in the literature as an intracranial complication of sinusitis. We report a 17-year-old female patient who developed spontaneous EDH accompanied by isolated oculomotor nerve palsy as a complication of sphenoid sinusitis. Sphenoid sinusitis could be considered as the causative disease in a patient with spontaneous EDH accompanied by isolated oculomotor nerve palsy without history of head trauma. © 2011 Elsevier Inc. All rights reserved.
1. Case report A 17-year-old adolescent girl with no history of any preceding head trauma presented with headache, vomiting, and high fever for 1 day after upper respiratory tract infection. She attended the emergency department and was found to be neurologically normal. Result of cerebrospinal fluid analysis and other laboratory findings were normal. Computed tomography (CT) of the brain revealed soft tissue density in both sphenoid sinus, but no abnormal finding in the brain parenchyma. One day later, she showed a rapid decline in consciousness and ptosis in right eye. In the neurologic examination, she had markedly decreased sensation on the right cheek, limitation of medial gaze, and diplopia. Right pupil was dilated without reaction to light. A right oculomotor nerve palsy was diagnosed. Brain CT showed a right-sided temporal lenticular-shaped hyperdense lesion with midline shifting to the left and total opacification in both sphenoid sinuses with no evidence of skull fracture (Fig. 1). Magnetic ⁎ Corresponding author. Department of Otorhinolaryngology, Pusan National University School of Medicine Yangsan Hospital, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 626-770, South Korea. Tel.: +82 55 360 1013; fax: +82 55 360 1027. E-mail address: [email protected] (H.-J. Roh). 0196-0709/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.amjoto.2010.07.003
resonance imaging of the brain was performed, which confirmed the epidural hematoma (EDH) with heterogenous signal intensity in T2-weighted image and intermediate high signal intensity in T1-weighted image. On hemorrhagic
Fig. 1. Preoperative paranasal CT. Coronal paranasal CT shows total opacification in both sphenoid sinus.
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K.-S. Cho et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 355–357
sequence images, there was associated signal dropout confirming the presence of hemorrhage (Fig. 2). The patient underwent emergent transnasal endoscopic sphenoidotomy and evacuation of hematoma via craniotomy under general anesthesia. After partial superior turbinectomy, sphenoid ostium was widened using sphenoid punch forceps. Pulsating pus-like discharge and inflammation-induced edematous sinus mucosa were
noted. Neurosurgeon performed a right frontotemporal craniotomy for the evacuation of hematoma. The blood clot sample from lesion was sent for histologic examination and revealed a hemorrhage containing clusters of polymorphonuclear cells. There was neither skull fracture nor bony defect in the sphenoid sinus. No organism was seen on gram, acid fast bacilli (AFB), and fungus stain; and culture yielded no growth in the pus from sphenoid sinus. The
Fig. 2. Preoperative brain magnetic resonance images. Lenticular lesion is shown in the right temporal region with intermediate high signal at T1 (A) and heterogenous signal at T2 images (B, C). Hemorrhagic sequence (D) means hemorrhage has low signal.
K.-S. Cho et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 355–357
Fig. 3. Postoperative brain CT. Brain CT at postoperative day 20 shows no abnormal findings in brain parenchyma and sphenoid sinus.
patient received a 3-week course of intravenous ceftriaxone and metronidazole and recovered fully without any neurologic deficit. One month following the operation, endoscopic finding showed no remarkable finding in the sphenoid sinus; and brain CT revealed no evidence of residual lesion (Fig. 3).
357
Firstly, arteritis is believed to cause weakening of meningeal vessels. Once the middle meningeal vessels adjacent to the sphenoid sinus become inflamed by retrograde infection through diploic vascular channels, the vessel walls may weaken and become prone to rupture even after subclinical trauma. Secondly, the accumulation of exudates, pus, or air causes progressive detachment of the dura mater from the inner table of the skull. The third, fourth, fifth, and sixth cranial nerve can be compressed in the cavernous sinus by expanding hematoma, thereby producing various degrees of ophthalmoplegia. However, isolated oculomotor nerve palsy is very rare. In the present case, considering the findings of magnetic resonance imaging and her acute presentation, the most likely explanation of the isolated oculomotor nerve palsy is the direct compression of the cavernous sinus by sudden enlargement of hematoma. Anatomically, the oculomotor nerve travels through the superior, lateral aspect of the cavernous sinus. Because of this location, the oculomotor nerve is a relatively more susceptible to the transmitted pressure generated by an expanding hematoma abutting the cavernous sinus [6]. Although spontaneous EDH accompanied by isolated oculomotor nerve palsy is a rare intracranial complication of sinusitis, sinusitis could be considered as the causative disease in a patient with spontaneous EDH accompanied by isolated oculomotor nerve palsy without a history of head trauma. If the sinusitis and EDH are correlated, prompt surgery of endoscopic sinus surgery and craniotomy and a course of antibiotics should lead to complete recovery. References
2. Discussion The occurrence of spontaneous EDH is rare, and its incidence has not been known [1]. Typically, there is no history of any head trauma. Although it is associated with coagulation disorders such as hypofibrinogenemia or thrombocytopenia and dural vascular malformation, infection is another common cause [1,2]. Male adolescence is predominant, and the frontal area is the most common EDH site [3-4]. All the patients, including our patient, had no history of head trauma or bleeding tendency [1-5]. There was no vascular anomaly found at the bleeding sites. Two possible mechanisms could be proposed to account for the development of spontaneous EDH in patients with infection.
[1] Ng WH, Yeo TT, Seow WT. Non-traumatic spontaneous acute epidural haematoma—report of two cases and review of the literature. J Clin Neurosci 2004;11:791-3. [2] Papadopoulos MC, Dyer A, Hardwidge C. Spontaneous extradural hematoma with sinusitis. J R Soc Med 2001;94:588-9. [3] Raiput AJ, Rozdilsky B. Extradural hematoma following frontal sinusitis. Report of a case and review of the literature. Arch Otolaryngol 1971;94:83-6. [4] Chaiyasate S, Halewyck S, Van Rompaey K, et al. Spontaneous extradural hematoma as a presentation of sinusitis: case report and literature review. Int J Pediatr Otorhinolaryngol 2007;71:827-30. [5] Moonis G, Granados A, Simon SL. Epidural hematoma as a complication of sphenoid sinusitis and epidural abscess: a case report and literature review. Clin Imaging 2002;26:382-5. [6] Rossitch Jr E, Carrazana EJ, Black PM. Isolated oculomotor nerve palsy following apoplexy of a pituitary adenoma. J Neurosurg Sci 1992;36: 103-5.
American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 355 – 357 www.elsevier.com/locate/amjoto
Epidural hematoma accompanied by oculomotor nerve palsy due to sphenoid sinusitis Kyu-Sup Cho, MD, PhDa , Won-Ho Cho, MD, PhDb , Hak-Jin Kim, MD, PhDc , Hwan-Jung Roh, MD, PhDd,⁎ a
Department of Otorhinolaryngology and Medical Research Institute, Busan, South Korea Department of Neurosurgery, Pusan National University School of Medicine, Busan, South Korea c Department of Radiology, Pusan National University School of Medicine, Busan, South Korea d Department of Otorhinolaryngology, Pusan National University School of Medicine Yangsan Hospital, Yangsan, South Korea Received 25 January 2010 b
Abstract
Spontaneous epidural hematoma (EDH) is rarely mentioned in the literature as an intracranial complication of sinusitis. We report a 17-year-old female patient who developed spontaneous EDH accompanied by isolated oculomotor nerve palsy as a complication of sphenoid sinusitis. Sphenoid sinusitis could be considered as the causative disease in a patient with spontaneous EDH accompanied by isolated oculomotor nerve palsy without history of head trauma. © 2011 Elsevier Inc. All rights reserved.
1. Case report A 17-year-old adolescent girl with no history of any preceding head trauma presented with headache, vomiting, and high fever for 1 day after upper respiratory tract infection. She attended the emergency department and was found to be neurologically normal. Result of cerebrospinal fluid analysis and other laboratory findings were normal. Computed tomography (CT) of the brain revealed soft tissue density in both sphenoid sinus, but no abnormal finding in the brain parenchyma. One day later, she showed a rapid decline in consciousness and ptosis in right eye. In the neurologic examination, she had markedly decreased sensation on the right cheek, limitation of medial gaze, and diplopia. Right pupil was dilated without reaction to light. A right oculomotor nerve palsy was diagnosed. Brain CT showed a right-sided temporal lenticular-shaped hyperdense lesion with midline shifting to the left and total opacification in both sphenoid sinuses with no evidence of skull fracture (Fig. 1). Magnetic ⁎ Corresponding author. Department of Otorhinolaryngology, Pusan National University School of Medicine Yangsan Hospital, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 626-770, South Korea. Tel.: +82 55 360 1013; fax: +82 55 360 1027. E-mail address: [email protected] (H.-J. Roh). 0196-0709/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.amjoto.2010.07.003
resonance imaging of the brain was performed, which confirmed the epidural hematoma (EDH) with heterogenous signal intensity in T2-weighted image and intermediate high signal intensity in T1-weighted image. On hemorrhagic
Fig. 1. Preoperative paranasal CT. Coronal paranasal CT shows total opacification in both sphenoid sinus.
356
K.-S. Cho et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 355–357
sequence images, there was associated signal dropout confirming the presence of hemorrhage (Fig. 2). The patient underwent emergent transnasal endoscopic sphenoidotomy and evacuation of hematoma via craniotomy under general anesthesia. After partial superior turbinectomy, sphenoid ostium was widened using sphenoid punch forceps. Pulsating pus-like discharge and inflammation-induced edematous sinus mucosa were
noted. Neurosurgeon performed a right frontotemporal craniotomy for the evacuation of hematoma. The blood clot sample from lesion was sent for histologic examination and revealed a hemorrhage containing clusters of polymorphonuclear cells. There was neither skull fracture nor bony defect in the sphenoid sinus. No organism was seen on gram, acid fast bacilli (AFB), and fungus stain; and culture yielded no growth in the pus from sphenoid sinus. The
Fig. 2. Preoperative brain magnetic resonance images. Lenticular lesion is shown in the right temporal region with intermediate high signal at T1 (A) and heterogenous signal at T2 images (B, C). Hemorrhagic sequence (D) means hemorrhage has low signal.
K.-S. Cho et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 32 (2011) 355–357
Fig. 3. Postoperative brain CT. Brain CT at postoperative day 20 shows no abnormal findings in brain parenchyma and sphenoid sinus.
patient received a 3-week course of intravenous ceftriaxone and metronidazole and recovered fully without any neurologic deficit. One month following the operation, endoscopic finding showed no remarkable finding in the sphenoid sinus; and brain CT revealed no evidence of residual lesion (Fig. 3).
357
Firstly, arteritis is believed to cause weakening of meningeal vessels. Once the middle meningeal vessels adjacent to the sphenoid sinus become inflamed by retrograde infection through diploic vascular channels, the vessel walls may weaken and become prone to rupture even after subclinical trauma. Secondly, the accumulation of exudates, pus, or air causes progressive detachment of the dura mater from the inner table of the skull. The third, fourth, fifth, and sixth cranial nerve can be compressed in the cavernous sinus by expanding hematoma, thereby producing various degrees of ophthalmoplegia. However, isolated oculomotor nerve palsy is very rare. In the present case, considering the findings of magnetic resonance imaging and her acute presentation, the most likely explanation of the isolated oculomotor nerve palsy is the direct compression of the cavernous sinus by sudden enlargement of hematoma. Anatomically, the oculomotor nerve travels through the superior, lateral aspect of the cavernous sinus. Because of this location, the oculomotor nerve is a relatively more susceptible to the transmitted pressure generated by an expanding hematoma abutting the cavernous sinus [6]. Although spontaneous EDH accompanied by isolated oculomotor nerve palsy is a rare intracranial complication of sinusitis, sinusitis could be considered as the causative disease in a patient with spontaneous EDH accompanied by isolated oculomotor nerve palsy without a history of head trauma. If the sinusitis and EDH are correlated, prompt surgery of endoscopic sinus surgery and craniotomy and a course of antibiotics should lead to complete recovery. References
2. Discussion The occurrence of spontaneous EDH is rare, and its incidence has not been known [1]. Typically, there is no history of any head trauma. Although it is associated with coagulation disorders such as hypofibrinogenemia or thrombocytopenia and dural vascular malformation, infection is another common cause [1,2]. Male adolescence is predominant, and the frontal area is the most common EDH site [3-4]. All the patients, including our patient, had no history of head trauma or bleeding tendency [1-5]. There was no vascular anomaly found at the bleeding sites. Two possible mechanisms could be proposed to account for the development of spontaneous EDH in patients with infection.
[1] Ng WH, Yeo TT, Seow WT. Non-traumatic spontaneous acute epidural haematoma—report of two cases and review of the literature. J Clin Neurosci 2004;11:791-3. [2] Papadopoulos MC, Dyer A, Hardwidge C. Spontaneous extradural hematoma with sinusitis. J R Soc Med 2001;94:588-9. [3] Raiput AJ, Rozdilsky B. Extradural hematoma following frontal sinusitis. Report of a case and review of the literature. Arch Otolaryngol 1971;94:83-6. [4] Chaiyasate S, Halewyck S, Van Rompaey K, et al. Spontaneous extradural hematoma as a presentation of sinusitis: case report and literature review. Int J Pediatr Otorhinolaryngol 2007;71:827-30. [5] Moonis G, Granados A, Simon SL. Epidural hematoma as a complication of sphenoid sinusitis and epidural abscess: a case report and literature review. Clin Imaging 2002;26:382-5. [6] Rossitch Jr E, Carrazana EJ, Black PM. Isolated oculomotor nerve palsy following apoplexy of a pituitary adenoma. J Neurosurg Sci 1992;36: 103-5.