Bilateral consecutive blindness due to sphenoid sinus mucocele with unilateral partial recovery

Nasal Sinus Mucoceles Manifesting Ocular Symptoms

INTRODUCTION

To describe the ocular symptoms in a series of patients with nasal sinus mucoceles of different locations.

METHODS

The authors analyzed the diagnosis and treatment of patients with sinus mucoceles and ocular symptoms who presented to the hospital from February 2010 to April 2020. A total of 61 patients were included in the study. The locations of the mucoceles were the frontal sinus (8 patients), ethmoid sinus (25 patients), and sphenoid sinus (28 patients). The authors selected 1 typical mucocele case from each of the sinuses, including the frontal, ethmoid, and sphenoid sinuses, and analyzed the history, diagnosis, and treatment of mucoceles in each location.

RESULTS

The main clinical manifestations were ophthalmic symptoms, such as exophthalmos or displacement, eye pain, blindness or decreased vision, blepharoptosis, and diplopia; no obvious nasal symptoms were noted. Most patients with these symptoms went to an ophthalmologist first. All lesions in this study were found through imaging examinations. Most symptoms improved after surgical interventions. Only 2 of the 61 patients had no improvement in vision because of the long period of vision loss.

CONCLUSIONS

Although sinus mucoceles are located in the sinuses, ocular symptoms are more prevalent than nasal symptoms. The earlier the imaging examinations are performed; the sooner lesions are detected, and the patients can be treated.

Frontoethmoidal mucocele causing proptosis and visual loss

Mucoceles are benign mucus-containing cysts formed due to the obliteration of sinus ostium. They are most commonly found in the frontal sinus. Mucoceles can spread both intraorbitally and intracranially causing complications such as meningitis, brain abscess, and loss of vision. Radiological investigations are required for diagnosis, with both computed tomography (CT) and magnetic resonance imaging (MRI) being useful. Surgical approaches for management have changed from external to endonasal these days. We report a case where a 54-year-old patient presented to us with a 14 days' history of loss of vision and complete closure of eyes over 2 days. Contrast-enhanced CT scan and MRI confirmed the diagnosis of frontoethmoidal mucocele breaching the left frontal sinus floor. Endoscopic orbital decompression with functional endoscopic sinus surgery was done. Eye movements and ptosis recovered completely after the surgery, but the vision did not. Although the etiology of mucocele is multifactorial, obstruction of sinus ostium is the most plausible cause. Increasing pressure on adjacent structures by the expanding mucocele can cause intraorbital and intracranial complications. MRI is superior to CT in differentiating mucocele from soft-tissue neoplasms, although CT gives a more detailed information on bone structure. Endoscopic approaches have become the most preferred way to access frontoethmoidal mucoceles, with external approaches being reserved for mucoceles in certain inaccessible locations. Timely intervention is imperative to prevent undesirable complications.

Sphenoid sinus barotrauma in diving: case series and review of the literature

About 50% of scuba divers have suffered from barotrauma of the ears and about one-third from barotrauma of paranasal sinuses. The sphenoid sinuses are rarely involved. Vital structures, as internal carotid artery and optic nerve, adjoin the sphenoid sinus. Thus, barotrauma could lead to serious neurologic disorders, including blindness. After searching the literature (Medline) and other sources (Internet), we present some cases of sphenoid sinus barotrauma, because these injuries may be underreported and misdiagnosed due to the lack of awareness and knowledge. Therefore, information is provided, e.g. on anatomical and pathophysiological features. Divers and physicians should have in mind that occasional headache during or after diving sometimes signals serious neurological disorders like vision loss. We show that injuries can develop from both negative and positive pressures in the sinuses. Because visual recovery depends on prompt diagnosis and proper therapy, physicians like otolaryngologists, ophthalmologists and neurologists need to closely collaborate.

Spheniodal mucocele causing bilateral optic neuropathy and ophthalmoplegia

Sphenoid sinus mucocele comprises only 2% of all paranasal sinus mucoceles. In literature, there is a case report on sphenoidal mucocele causing bilateral optic neuropathy, with unilateral partial recovery and cranial nerve palsy, but we did not come across any literature with bilateral optic neuropathy and ophthalmoplegia together caused by spheno-ethmoidal mucocele. We present such a rare case of spheno-ethmoidal mucocele causing bilateral optic neuropathy and unilateral sixth nerve palsy who had postsurgery, unilateral good vision recovery, and complete resolution of sixth nerve palsy.

Sphenoidal sinus mucocele presenting with acute visual loss in a scuba diver

A 43-year-old male scuba diver presented with an acute history of painful unilateral visual loss after scuba diving. He had right-sided retrobulbar pain and headache. He was known to have sinusitis and had transient visual loss in two previous episodes after scuba diving. His visual acuity was hand motions and 20/20 in the right and left eye, respectively. There was no proptosis. He had a right relative afferent pupillary defect. Colour vision was normal in the left eye and absent in the right eye. Fundal examination revealed healthy discs and macula bilaterally. He was assessed as a right optic neuropathy, possibly secondary to compression. An MRI of the brain revealed a large sphenoidal mucocele extending into the right optic foramen. He was treated with oral steroids, antibiotics and nasal decongestants. He underwent endoscopic intranasal sphenoidectomy and marsupialisation with return of his visual acuity to 20/25 in that eye.

A sphenoid sinus mucocele simulating as retro bulbar optic neuritis

A 25-year-old male presented with complaints of sudden diminution of vision with pain on eye movement in the left eye which was diagnosed clinically as retro bulbar optic neuritis. However, magnetic resonance imaging (MRI) showed lesion consistent with sphenoid sinus mucocele. Early surgical removal of mucocele led to complete recovery of vision, contrast and visual field. A high index of suspicion is necessary for intracranial lesions in all cases of retro bulbar neuritis, especially those with atypical symptoms.

Sphenoethmoidal mucocele presenting with unilateral visual loss

BACKGROUND

Sphenoethmoidal sinus mucocele causing uniocular progressive vision loss is a rare entity and was first described by Bery in 1985. It is generally diagnosed in its advanced stage when the patients develop subjective ophthalmic symptoms.

CASE

A 43-year-old male presented to our institute for further evaluation and treatment of progressive visual deterioration in his left eye. The patient complained of visual impairment in his left eye for the past three months, in the form of a dark area in his left side of the visual field.

OBSERVATIONS

Magnetic resonance imaging (MRI) revealed a large expansile lesion in the left sided posterior ethmoidal air cells, abutting on the left optic nerve and displacing it in the region of the orbital apex. The patient underwent an urgent endoscopic sinus surgery by an Ear-Nose-Throat surgeon which resulted in stable visual acuity in the sixth postoperative month.

CONCLUSIONS

Sphenoethmoidal mucocele can cause irreversible blindness. Progressive vision loss with a neurological visual field defect should raise a high index of suspicion and computed tomography and MRI are to be performed to confirm the diagnosis. Collaboration between radiologists, ENT specialists, and ophthalmologists is essential for treating such cases.

Optic neuritis is nothing to sneeze at

A 36-year-old man developed acute visual loss, mimicking an optic neuritis in the left eye. Cranial magnetic resonance imaging revealed a sphenoid sinus mucocele with extension into the anterior clinoid process abutting the left optic nerve. Endoscopic marsupialization of the mucocele led to marked improvement of vision. Sphenoid sinus mucocele is discussed, as is the differential diagnosis of optic neuritis.

Mucocele of the sphenoid sinus

The sphenoid sinus is the least common site of mucocele of all paranasal sinuses. It is very rare in children, especially in those younger than 12 years when pneumatization of the sphenoid sinus is completed. We report a case of histologically proven sphenoidal mucocele in a 5-year-old child. The child presented with an acute onset of significant visual impairment and headache. His vision gradually improved after trans-nasal sphenoidotomy and drainage of the sinus content with return of complete normal baseline vision after 2 months.