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 Table of Contents  
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 193-194

Compression optic and oculomotor neuropathy caused by misdiagnosed sphenoid sinus mucocele

Department of Otorhinolaryngology Head and Neck Surgery, Affiliated Hospital, Clinical Medical College of Chengdu University, Chengdu, China

Date of Submission12-Mar-2021
Date of Acceptance06-Jul-2021
Date of Web Publication07-Jan-2022

Correspondence Address:
Dr. Jie Zhang
Address: No. 82, Section 2, 2nd Ring Road North, Chengdu, Sichuan - - 610 081
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_573_21

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We herein describe the case of a 60-year-old man who complained of headache and inability to open his left eye. Four years ago, he was admitted to a hospital because of the loss of vision in his left eye. Without adequate radiological examination, he was misdiagnosed with ischemic optical neuropathy and treated with glucocorticoid and neurotrophic drugs, but his vision did not improve. After sphenoidostomy under local anesthesia in time, his headache disappeared and his left eye could be opened immediately. We herein report this case to emphasize the relationship between the optic and oculomotor neuropathy and paranasal sinus disease.

Keywords: Blindness, ischemic optical neuropathy, mucocele, oculomotor neuropathy, sphenoid sinus

How to cite this article:
Zhang J, Lan D, Hong Y, Wei X. Compression optic and oculomotor neuropathy caused by misdiagnosed sphenoid sinus mucocele. Indian J Ophthalmol Case Rep 2022;2:193-4

How to cite this URL:
Zhang J, Lan D, Hong Y, Wei X. Compression optic and oculomotor neuropathy caused by misdiagnosed sphenoid sinus mucocele. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 14];2:193-4. Available from: https://www.ijoreports.in/text.asp?2022/2/1/193/334960

It is not uncommon for sphenoid sinus lesions to compress the optic nerve and cause vision loss or blindness.[1] The optic canal is located in the anterior superior part of the lateral wall of the sphenoid sinus. When there is a mass in the sphenoid sinus, it may compress the optic nerve and cause progressive vision loss with progressive enlargement of the mass.[2] It is not difficult for experienced ophthalmologists to make a definite diagnosis, but delayed diagnosis is not rare, and the lack of severe and specific symptoms is responsible for the delayed diagnosis and treatment.[3] It is very rare for sphenoid sinus mucocele to cause oculomotor neuropathy. Making an accurate diagnosis and giving timely treatment are particularly important for the prognosis of patients. We report a case of oculomotor neuropathy after misdiagnosis of optic nerve compression caused by sphenoid sinus mucocele. We believe that this case can not only provide guidance for general practitioners but also provide a reference for specialists.

  Case Report Top

Four years ago, a 60-year-old man was admitted to a hospital because of the loss of vision in his left eye. He was diagnosed with ischemic optical neuropathy and treated with glucocorticoid and neurotrophic drugs, but unfortunately, his vision did not improve. Since then, although blindness in his left eye did not improve, he never sought further treatment. More than 10 days before admission, the patient had a headache and could not open his left eye. He went to the local county hospital for treatment. Computed tomography (CT) examination of the sinus showed that there was a mass of soft tissue density in the left sphenoid sinus [Figure 1]a, [Figure 1]b, [Figure 1]c.
Figure 1: (a-c) CT scan of each view showing the mass arising from the left sphenoid sinus

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The physical examination revealed left eye ptosis, covering the whole cornea, unable to open the eye [Figure 2]a, with disc pale and no light sensitivity. The intraocular pressure of both eyes was normal, and the movement of eyeballs in all directions was normal. We made a diagnosis of left sphenoid sinus mucocele with optic nerve and oculomotor nerve injury. After careful preoperative evaluation, we finally performed left sphenoid sinus surgery under local anesthesia, and we found that a large amount of pus sac fluid flowed out from the left sphenoid sinus. After the surgery, the left eye of the patient could be opened immediately, which was slightly worse than that of the contralateral side, and the vision of the left eye did not improve [Figure 2]b. Two weeks after the surgery, there was no significant difference between the two eyes in opening the eyes. The patient provided informed consent for publication of this case and the associated images.
Figure 2: Physical examination findings. (a) The left eye of the patient cannot open before the surgery. (b) After the surgery, the left eye can be opened immediately, which is slightly worse than that of the opposite side

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  Discussion Top

Sphenoid sinus mucoceles often have no nasal symptoms in the early stage, but the headache, visual changes, and neurological symptoms only appear when the mucoceles gradually increase. It is not uncommon for a giant sphenoid sinus mucocele to compress the optic nerve and cause vision loss or blindness. However, it is very rare that a sphenoid sinus mucocele oppresses the oculomotor nerve and causes ptosis.[1] The patient had obvious symptoms of optic nerve compression at the time of the first attack. Without the CT examination, he was misdiagnosed with ischemic optic neuropathy for the first time in the ophthalmology department. Ophthalmologists' lack of understanding of the nasal cavity and paranasal sinus lesions may lead to the neglect of nose-eye related diseases, resulting in delayed treatment of some patients.[4] With the progress of the disease, the patient had a headache and was unable to open his left eye, and was finally diagnosed by CT.

In 2004, Sundar et al.[5] reported a case with sphenoid sinus mucocele, which manifested as mono-ocular painless loss of vision. Fortunately, the patient was diagnosed in time and underwent an emergency sphenoidostomy, and his vision improved 1 day after the surgery. Long time compression of optic nerve may cause irreversible optic nerve damage and bad improvement of visual acuity. Visual loss from sphenoid sinus mucoceles is usually associated with a poor prognosis if surgical treatment is delayed for more than 7 to 10 days.[6] In our case, the patient's left optic nerve was compressed for too long, and the visual acuity did not improve after the surgery. However, the oculomotor nerve compression was relieved in time through surgery, and the patient was able to open his eyes. In clinical practice, we should strengthen lateral thinking and pay attention to differential diagnosis in the process of disease diagnosis and treatment.[7] If ophthalmic symptoms such as eye pain, diplopia, vision loss, and so on are unknown or the treatment effect is not good, the eye and head CT scan or magnetic resonance imaging should be performed in time to facilitate early diagnosis and treatment.

There were two reasons for blindness in his left eye. The doctor's misdiagnosis was the first reason, and the second one was the lack of further treatment when his symptoms were not relieved. This may be related to the insufficient allocation of health resources in China's rural areas.[8] Some patients in remote rural areas do not pay enough attention to their personal health. For example, when the treatment of blindness in the left eye was ineffective, he thought that the right eye could see clearly, so he did not seek further treatment. There are still many such patients with lack of health knowledge and economic backwardness. We often see the elderly with only one hearing aid in China. In the future, it is very helpful to reduce the misdiagnosis by suggesting the patients to reexamine in time or take the initiative to follow up the patients by telephone.

  Conclusion Top

In conclusion, once the symptoms of ocular nerve compression appear, an imaging examination should be arranged shortly. If space-occupying lesions are found, it is necessary to relieve the ocular nerve compression by surgery in time.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Chen K, Cao Y, Wu J, Xiang H, Huang XF, Chen B. Clinical analysis of sphenoid sinus mucocele with initial neurological symptoms. Headache 2019;59:1270-8.  Back to cited text no. 1
Nerurkar NK, Bradoo R, Muranjan S, Khare M. Sphenoid sinus mucocele with unilateral blindness. Annals Otol Rhinol Laryngol 2004;113:294-6.  Back to cited text no. 2
Sieskiewicz A, Lyson T, Olszewska E, Chlabicz M, Buonamassa S, Rogowski M. Isolated sphenoid sinus pathologies--the problem of delayed diagnosis. Med Sci Monit 2011;17:R180-4.  Back to cited text no. 3
Chen C, Cui Y, Huang X. [Clinical analysis of isolated sphenoid disease first manifesting headache and/or ophthalmic symptoms]. Lin Chuang Er Bi Yan Hou Ke Za Zhi 2006;20:628-9, 633.  Back to cited text no. 4
Sundar U, Sharma AL, Yeolekar ME, Pahuja V. Sphenoidal sinus mucocoele presenting as mono-ocular painless loss of vision. Postgrad Med J 2004;80:40.  Back to cited text no. 5
Johnson LN, Hepler RS, Yee RD, Batzdorf U. Sphenoid sinus mucocele (anterior clinoid variant) mimicking diabetic ophthalmoplegia and retrobulbar neuritis. Am J Ophthalmol 1986;102:111-5.  Back to cited text no. 6
Kösling S, Hintner M, Brandt S, Schulz T, Bloching M. Mucoceles of the sphenoid sinus. Eur J Radiol 2004;51:1-5.  Back to cited text no. 7
Chen Y, Yin Z, Xie Q. Suggestions to ameliorate the inequity in urban/rural allocation of healthcare resources in China. Int J Equity Health 2014;13:34.  Back to cited text no. 8


  [Figure 1], [Figure 2]


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