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Título

Multiple cranial nerve palsies secondary to sphenoid sinus mucocele: a case report

RESUMO

Case presentation: An 83-year-old male, with previous medical history of hypertension, reported frontal headache with nausea and vomiting of sudden onset, lasting 48 hours, that evolved with bilateral eyelid ptosis, restriction of eye movement and worsening of visual acuity. The ocular motricity deficit progressed with complete bilateral ophthalmoplegia. On physical examination, the following findings were observed: non-photoreactive mydriatic pupils, complete palsy of III, IV and VI cranial nerves bilaterally, with absent oculocephalic reflex. There were no significant visual fields changes and fundoscopic examination showed no abnormalities. Facial sensitivity and motricity, as well as corneal reflex, were preserved. Cranial MRI showed an expansive lesion, with marked spontaneous hyperintensity on T1-weighted images and a fine peripheral contrast-enhancement, centered on the topography of the sphenoid sinuses, measuring approximately 4.2 x 3.4 x 2.8 cm. The lesion determined compression and cranial displacement of the pituitary gland and stalk and was in close proximity with the intracranial internal carotid arteries, without signs of vascular invasion. Laboratory evaluation demonstrated leukocytosis, with no significant change in pituitary function. The patient was, then, diagnosed with sphenoid mucocele. He underwent endoscopic endonasal surgery, with evidence of a purulent collection in the sphenoid sinus. After surgical drainage, the patient evolved with gradual improvement of the neurological deficits, maintaining only bilateral ocular abduction deficit and right eye adduction restriction.

Discussion: Sphenoid sinus mucoceles are uncommon lesions, representing only 1-2% of all paranasal sinus mucoceles. The condition may cause severe neurological sequelae, including amaurosis and intracranial spread of the infection, if there is a delay in diagnosis or treatment. Symptoms are nonspecific and result from direct mechanical pressure on adjacent structures or nerve involvement in the inflammatory process. The most common signs and symptoms are headache, visual loss, and III and VI cranial nerves palsies.

Final comments: The case presented demonstrates a rare condition that may evolve with multiple cranial nerves palsies, and should be considered as a differential diagnosis when identifying expansive lesions in the topography of the sphenoid sinuses.

Palavras Chave

Sphenoid sinus mucocele, cranial nerve palsies