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Diplopia Due to Frontal Sinus Mucocele

Diplopia Due to Frontal Sinus Mucocele A 63-year-old man presented with a 5-month history of diplopia, described variably as horizontal, vertical, or skewed. This complaint appeared in the setting of anosmia for 4 years and right ptosis for 2 years. Results of physical examination showed mild right hypophthalmos, right proptosis, and fusion deficits in all cardinal fields of gaze on Maddox rod testing. Computed tomographic and magnetic resonance imaging revealed a large right frontal sinus mucocele with erosion inferiorly into the orbit, displacing the globe laterally and impinging on the superior and medial rectus muscles (Figure). The mucocele extended posteriorly into the right frontal lobe. There was also evidence of a pansinus inflammatory process with polypoidal thickening. The diplopia seen in this patient was due to mass effect in the orbit. His chronic anosmia was a clue to the possibility of mucocele as an etiology. After successful surgical intervention, the patient continues to remain asymptomatic. Figure. View LargeDownload A, Unenhanced coronal computed tomographic scan. The mucocele has rarefied the supramedial bony orbital wall (asterisk) to invade the orbit. B, Gadolinium-enhanced T1-weighted fat-saturated coronal magnetic resonance imaging. A peripherally enhancing hypointense right frontal mucocele, extending posteriorly into the frontal fossa (long arrow) and inferiorly into the orbit (short arrow), laterally displacing the globe is seen. Also note extension of the mucocele into the upper nasal cavity with pansinus fluid and polypoidal thickening. Sinus mucocele is a benign epithelium-lined accumulation of poorly draining mucosal secretions that can rarely become locally invasive.1 It may arise from obstruction of the nasofrontal duct and/or via an underlying inflammatory process. Obstructive etiologies include trauma, polyps, neoplasm, or prior surgery. Inflammatory causes include allergy, hypersecretion of mucus, and infection. It affects males and females equally, most commonly in the third to seventh decades. The frontal sinus is most often involved, followed by the ethmoid sinus. As it enlarges, the mucocele may extend intracranially, extracranially, or into the orbit, allowing an array of potential presentations. Some report diplopia as a presenting symptom in 12% to 95% of patients,2 variably accompanied by proptosis, periorbital swelling, pain, and/or loss of vision.3 Most of these signs and symptoms are attributable to mass effect on the globe and extraocular muscles. Rarely, oculomotor nerve palsy may occur, which can present with isolated ptosis.4 The diagnosis is made with computed tomography, magnetic resonance imaging, and most definitively with surgical exploration. Computed tomography is useful in defining the extent of bony erosion and distinguishing mucocele from etiologies such as ossifying fibroma and fibrous dysplasia. Magnetic resonance imaging with gadolinium can help differentiate among malignant neoplasm, granulomatous disease, and infection. Treatment often includes surgical removal of the mucocele with sinus cranialization and obliteration of the nasofrontal duct. Sinus mucocele represents another item to consider in the neurological differential diagnosis of diplopia. Back to top Article Information Correspondence: Dr Login, University of Virginia, Department of Neurology, PO Box 800394, Charlottesville, VA 22908 (ISL@hscmail.mcc.virginia.edu). Author Contributions:Study concept and design: Login. Analysis and interpretation of data: Lockman. Drafting of the manuscript: Lockman. Critical revision of the manuscript for important intellectual content: Login. Study supervision: Login. Financial Disclosure: None reported. Additional Contributions: Lubdha Shah, MD, provided guidance in preparing the computed tomographic and magnetic resonance images in this article. References 1. Galiè MMandrioli STieghi RClauser L Giant Mucocele of the Frontal Sinus. J Craniofac Surg 2005;16 (5) 933- 935PubMedGoogle ScholarCrossref 2. Lund VJ The orbit. In: Mackay I, Bull TR, eds. Scott-Brown's Otolaryngology. Vol 4. 6th ed. Oxford, England: Butterworth Heinemann; 1997:24/1–24/19Google Scholar 3. Muneer AJones NSBradley PJDownes R ENT pathology and diplopia. Eye 1998;12672- 678PubMedGoogle ScholarCrossref 4. Lin CJKao CKang BWang H Frontal sinus mucocele presenting as oculomotor nerve palsy. Otolaryngol Head Neck Surg 2002;126 (5) 588- 590PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Neurology American Medical Association

Diplopia Due to Frontal Sinus Mucocele

Archives of Neurology , Volume 64 (11) – Nov 1, 2007

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Publisher
American Medical Association
Copyright
Copyright © 2007 American Medical Association. All Rights Reserved.
ISSN
0003-9942
DOI
10.1001/archneur.64.11.1667
pmid
17998453
Publisher site
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Abstract

A 63-year-old man presented with a 5-month history of diplopia, described variably as horizontal, vertical, or skewed. This complaint appeared in the setting of anosmia for 4 years and right ptosis for 2 years. Results of physical examination showed mild right hypophthalmos, right proptosis, and fusion deficits in all cardinal fields of gaze on Maddox rod testing. Computed tomographic and magnetic resonance imaging revealed a large right frontal sinus mucocele with erosion inferiorly into the orbit, displacing the globe laterally and impinging on the superior and medial rectus muscles (Figure). The mucocele extended posteriorly into the right frontal lobe. There was also evidence of a pansinus inflammatory process with polypoidal thickening. The diplopia seen in this patient was due to mass effect in the orbit. His chronic anosmia was a clue to the possibility of mucocele as an etiology. After successful surgical intervention, the patient continues to remain asymptomatic. Figure. View LargeDownload A, Unenhanced coronal computed tomographic scan. The mucocele has rarefied the supramedial bony orbital wall (asterisk) to invade the orbit. B, Gadolinium-enhanced T1-weighted fat-saturated coronal magnetic resonance imaging. A peripherally enhancing hypointense right frontal mucocele, extending posteriorly into the frontal fossa (long arrow) and inferiorly into the orbit (short arrow), laterally displacing the globe is seen. Also note extension of the mucocele into the upper nasal cavity with pansinus fluid and polypoidal thickening. Sinus mucocele is a benign epithelium-lined accumulation of poorly draining mucosal secretions that can rarely become locally invasive.1 It may arise from obstruction of the nasofrontal duct and/or via an underlying inflammatory process. Obstructive etiologies include trauma, polyps, neoplasm, or prior surgery. Inflammatory causes include allergy, hypersecretion of mucus, and infection. It affects males and females equally, most commonly in the third to seventh decades. The frontal sinus is most often involved, followed by the ethmoid sinus. As it enlarges, the mucocele may extend intracranially, extracranially, or into the orbit, allowing an array of potential presentations. Some report diplopia as a presenting symptom in 12% to 95% of patients,2 variably accompanied by proptosis, periorbital swelling, pain, and/or loss of vision.3 Most of these signs and symptoms are attributable to mass effect on the globe and extraocular muscles. Rarely, oculomotor nerve palsy may occur, which can present with isolated ptosis.4 The diagnosis is made with computed tomography, magnetic resonance imaging, and most definitively with surgical exploration. Computed tomography is useful in defining the extent of bony erosion and distinguishing mucocele from etiologies such as ossifying fibroma and fibrous dysplasia. Magnetic resonance imaging with gadolinium can help differentiate among malignant neoplasm, granulomatous disease, and infection. Treatment often includes surgical removal of the mucocele with sinus cranialization and obliteration of the nasofrontal duct. Sinus mucocele represents another item to consider in the neurological differential diagnosis of diplopia. Back to top Article Information Correspondence: Dr Login, University of Virginia, Department of Neurology, PO Box 800394, Charlottesville, VA 22908 (ISL@hscmail.mcc.virginia.edu). Author Contributions:Study concept and design: Login. Analysis and interpretation of data: Lockman. Drafting of the manuscript: Lockman. Critical revision of the manuscript for important intellectual content: Login. Study supervision: Login. Financial Disclosure: None reported. Additional Contributions: Lubdha Shah, MD, provided guidance in preparing the computed tomographic and magnetic resonance images in this article. References 1. Galiè MMandrioli STieghi RClauser L Giant Mucocele of the Frontal Sinus. J Craniofac Surg 2005;16 (5) 933- 935PubMedGoogle ScholarCrossref 2. Lund VJ The orbit. In: Mackay I, Bull TR, eds. Scott-Brown's Otolaryngology. Vol 4. 6th ed. Oxford, England: Butterworth Heinemann; 1997:24/1–24/19Google Scholar 3. Muneer AJones NSBradley PJDownes R ENT pathology and diplopia. Eye 1998;12672- 678PubMedGoogle ScholarCrossref 4. Lin CJKao CKang BWang H Frontal sinus mucocele presenting as oculomotor nerve palsy. Otolaryngol Head Neck Surg 2002;126 (5) 588- 590PubMedGoogle ScholarCrossref

Journal

Archives of NeurologyAmerican Medical Association

Published: Nov 1, 2007

References