Ophthalmoplegia in Sphenoid Sinus Aspergillosis.
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Abstract:
Ophthalmoplegia due to spheniod sinus aspergillosis is rare. We report two cases of sphenoid sinus aspergillosis with diplopia. A diabetic patient presented with complete oculomotor nerve palsy and showed more rapid progression, severe symptoms, and delayed and incomplete recovery from the neurologic deficits. The other patient presented with trochlear nerve palsy and showed slower progression milder symptoms, and more rapid recovery. We suggest that immediate imaging should be performed to diagnose the cause of diplopia in patients with atypical unilateral persistent facial pain with diplopia especially in patients with diabetes mellitus.Keywords:
Oculomotor nerve palsy
Trochlear nerve
Sinus (botany)
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Objective:To investigate the clinic characters and diagnosis of aspergillosis leading to painful ophthalmoplegia(APOP).Methods:One patient was systematically studied and literatures were reviewed by the authors.Results:Aspergillosis was one of the reasons resulting in painful ophthalmoplegia.The onset was urgent and process progress was quick in APOP,It could involve cavernous sinus,accessory nasal cavity,orbital apex and internal carotid artery,showing ophthalmoplegia,retro-orbit pain,peri-orbit pain,vision disorder,hemiparalysis,et al.Biopsy could provide cue to aspergillosis.Conclusion:APOP can be misidentified,but can be diagnosed with history,physical examination,CT,MRI and Biopsy.
Orbit (dynamics)
Sinus (botany)
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Objective To discussion the clinical characteristics and etiology of external ophthalmoplegia. Methods Collected and retrospectively analyzed the etiology and clinical characteristic of 257 external ophthalmoplegia patients. Records of the patient history, clinical manifestations and corresponding neurological department of internal medicine, Ophthalmology, Endocrinology and Radiographic examination. Results Simple ptosis in 80 cases, 131 cases of simple binocular diplopia, ptosis and diplopia in 39 cases, 7 cases of eyeball fixation. 223 cases of unilateral paralysis of extraocular muscle, 32 cases of bilateral extraocular muscle paralysis. The levator paralysis in 119 cases, unilateral put on 98 cases of eyelid muscle paralysis, bilateral put on 21 cases of eyelid muscle paralysis. 84 cases of lateral rectus muscle palsy, 56 cases of unilateral lateral rectus muscle palsy, 6 cases of bilateral lateral rectus paralysis.178 cases of extraocular ophthalmoplegia of oculomotor control, 40 cases with complete paralysis, 117 cases with incomplete paralysis, combined with other extraocular ophthalmoplegia in 21 cases. Superior oblique palsy in 24 cases, alone of superior oblique palsy in 17 cases, combined with other extraocular ophthalmoplegia in 7 cases. 82 cases with orbital local pain, 12 cases with mydriasis. In 163 cases of ocular motor neuropathy patients, single oculomotor nerve palsy in 148 cases, accounting for 90.8%, 15 cases of multiple oculomotor nerve paralysis, 9.2%. Eye movement nerve injury in 110 cases, accounting for 67.5%, 16 cases, nuclear damage was 9.8%, between nuclear damage in 13 cases, accounting for 8%, nuclear damage 24 cases accounted for 14.7%.There are 14 kinds of external ophthalmoplegia etiology in this group. including myasthenia gravis, diabetic oculomotor nerve injury, atherosclerosis and ischemic ocular motor nerve injury, local nonspecific inflammatory, traumatic, local space-occupying lesions, thyroid disease, Increased intracranial pressure, intracranial posterior communicating artery aneurysm, Mitochondrial myopathy, carotid cavernous fistula, distant parts of the tumor, multiple sclerosis, local injection of botulinum toxin, progressive muscular dystrophy. In 86 cases with hypertension, 72 cases with diabetes, 22 cases of diabetes is found for the first time, 15 cases had paralysis of external ophthalmoplegia. Conclusions The main symptoms of ocular muscle paralysis is binocular diplopia and ptosis, The incidence of unilateral external ophthalmoplegia was higher than bilateral extraocular muscle paralysis, Oculomotor nerve innervation of extraocular ophthalmoplegia was the highest, followed by lateral rectus paralysis, paralysis of the superior oblique lower. Orbital pain and pupil change is paralysis of extraocular muscle common accompanied symptoms. Oculomotor nerve paralysis was the highest. Oculomotor nerve palsy with peripheral lesion was the highest. Patients with oculomotor nerve ophthalmoplegia in patients with a higher proportion of hypertension and Diabetes,. Extraocular muscle paralysis patients need regular inspections of fasting and postprandial 2 hour blood glucose, Underwent thyroid function, orbital CT, head CT and /or MRI examination, neostigmine test for external ophthalmoplegia patients in routine. For the extraocular ophthalmoplegia patients with dilated pupil, suggest underwent the DSA to exclusion the intracranial aneurysm.
External ophthalmoplegia
Etiology
Lateral rectus muscle
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Ophthalmoplegia or ophthalmoparesis are the terms given to paralysis or paresis of one or more of the extraocular muscles in one or both eyes. It may be representative of serious neurological or systemic disease. Other mechanisms may cause limitation of eye movement, including restrictive or myasthenic conditions, or combinations of several etiologies. Evaluating and differentiating the mechanisms causing ophthalmoplegia is important in determining the correct diagnosis and selecting the appropriate management in these complex cases.
Ophthalmoparesis
Paresis
Etiology
External ophthalmoplegia
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Sphenoid sinus aspergillosis is notorious for its serious complications, such as permanent cranial nerve deficits and possible death. The most common associated symptoms are headache, followed by visual changes, and cranial nerve palsies. Because of an insidious onset, frequently resulting in missed and delayed diagnosis, sphenoid sinus aspergillosis is a potentially lethal medical condition. We report a case of visual loss secondary to isolated sphenoid sinus aspergillosis. A 69-year-old man presented to our hospital with the complaint of headache. The headache started one year previously and was described as severe dull pain localized bilaterally to the temporo-orbital region. The patient took daily NSAIDs for the pain. The neurological examination was normal. The MRI of the brain showed a left sphenoid sinusitis. A transnasal endoscopic superior meatal sphenoidotomy was performed. Aspergillosis was confirmed after a surgical biopsy was obtained. The patient was discharged from hospital without antifungal therapy. One month later, the patient complained of headache and loss of vision bilaterally. The orbital MRI showed a left cavernous sinus and bilateral optic nerve invasion. The loss of visions was permanent. In our case, the diagnosis was delayed; antifungal agents were not administered after surgery and the patient lost his vision as a result. Therefore, early diagnosis and proper treatment are important. Although the treatment of an invasive type of aspergillus has not been established, surgical removal of a nidus and aggressive antifungal therapy are recommended.
Sinus (botany)
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Oculomotor nerve
Oculomotor nerve palsy
Abducens nerve
Trochlear nerve
External ophthalmoplegia
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Although isolated cranial nerve palsies are common in patients with diabetes mellitus, multiple simultaneous cranial neuropathies are rare. We report a 48-year-old man, a known case of diabetes mellitus, who presented with facial palsy, foot drop and painful ophthalmoplegia of the left eye. The initial differential diagnosis included diabetic polyneuropathy, septic cavernous sinus thrombosis, mucormycosis and the Tolosa Hunt syndrome. Magnetic resonance (MR) imaging findings were consistent with those of the Tolosa Hunt syndrome. The patient had a remarkable complete resolution of his ophthalmoplegia after four weeks of steroid treatment, with repeat MR imaging showing resolution of the initial changes.
Tolosa–Hunt syndrome
Cavernous sinus thrombosis
Cranial nerve disease
Cranial nerves
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Fungus infection of the leptomeninges is uncommon. Aspergillosis is known to occur in patients with debillitating disease, drug addiction, chemotherapy and following prolonged steroid treatment (Dayal et al.,1974). It presents predominantly as proptosis and associated sinus disease due to involvement of the orbit and base of the skull. The diagnosis of aspergillosis of the central nervous system is rarely established pre-operatively and this case report highlights some of the difficulties. A 22-year-old housewife first complained of headache during the eighth month of pregnancy. This was followed by retrobulbar pain and blurring of vision 22 days after delivery necessitating admission to the Department for Neurological Services. Clinical examination revealed proptosis of the left eye with complete ophthalmoplegia in a patient in obvious pain. The EEG, ultrasound and brain scan were all normal. Radiographic examination showed widening of the left superior orbital fissure with reactive basal sclerosis of the sphenoid (FIG. 1). The optic foramen was normal. Angiography revealed narrowing of the internal carotid artery with complete interruption of flow at the level of the sella (Fig. 2). A biopsy of the naso-pharynx was not conclusive. Her condition deteriorated with worsening of the pain and proptosis. Repeat skull examination one month later showed further destruction of the orbital fissure, erosion of the optic foramen and opacity of the ethmoids. Angiograplvy revealed more extensive narrowing of the internal carotid artery on the left. The right remained normal.
Superior orbital fissure
Foramen
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Ophthalmoplegia occurred in 7 of 14 patients with biopsy proved temporal arteritis. Only one patient had diplopia. In six of the seven patients, the pattern of ophthalmoplegia did not conform to the distribution of one of the ocular motor nerves. Impairment of upward gaze was most common. In five patients the ophthalmoplegia was accompanied by ptosis, and in five it was accompanied by a miotic pupil. Ophthalmoplegia and ptosis were the major manifestations of temporal arteritis in one patient. Oculomotor signs and symptoms responded to corticosteroid therapy in all seven patients, but in two patients prolonged therapy was necessary. Ophthalmoplegia or ptosis may be early manifestations and may precede visual loss, so that frequent examination is recommended in patients suspected of temporal arteritis, with prompt administration of adequate doses of corticosteroid as soon as any ocular manifestations of temporal arteritis are noted.
Miosis
Arteritis
External ophthalmoplegia
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The atypical clinical presentations of three patients with an oculomotor (III) nerve palsy are outlined. The first patient is a 49-year-old with a painful, pupil-sparing ophthalmoplegia of sudden onset due to a pituitary adenoma which had eroded into the cavernous sinus. The second patient is a 7-year-old with a traumatic III nerve palsy who despite full recovery of her oculomotility, has been symptomatic due to a permanent internal ophthalmoplegia. The third patient is an 8-year-old who has undergone prolonged optometric therapy for an "atypical esotropia," but in fact has a congenital III nerve palsy with oculomotor synkinesis and deep amblyopia.
Oculomotor nerve palsy
Oculomotor nerve
Esotropia
Presentation (obstetrics)
Abducens nerve
Synkinesis
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Ophthalmoplegia is common cranial neuropathy of Diabetes. In case of 3rd nerve involvement, usually unilateral extra ocular muscles are affected. However, ptosis is very rare in patients with diabetic neuropathy. In this report, we describe bilateral ptosis with ophthalmoplegia in diabetes. In ophthalmoplegia associated with diabetes, ischemic nerve infarction was reported. We treated this patient with Lipo prostaglandin (PG) E1. Since then, increased platelet aggregation activity was found in this patient. After two months, the symptoms of this patient were improved.
External ophthalmoplegia
Diabetic Neuropathy
Oculomotor nerve
Trochlear nerve
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