"Diplopia and Headache: A Case Presentation by Dr. Bakhshaee M, MDRhinologist Azar 1388"
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Slide1Bakhshaee M, MDRhinologist Azar 1388
Slide2Presentation 45 man complain from diplopia and headache
Slide3History Headache : Six months ago Diplopia: One month ago Trauma: Three years ago from car accident. Background Diseases: Neg Recurrent URTI: Neg Epistaxis: Neg Rhinorrhea: Neg Nasal Obstruction: Neg Visual Disturbance: Neg Smoking: Pos Job: Driver Smell: Ok Facial pain: three months ago Dizziness: Pos Hoarseness: Neg Other cranial nerve: Neg Long tract sign
Slide4Examination Nasal Endoscopy: Mild SD Visual acuity: 9/10 Eye movement: Right eye limitation to most lateral gaze Ptosis & Proptosis: Neg Neck Mass: Neg Sinus palpation: No tenderness Blood Pressure: 13/9 Craniofacial deformity: Neg Ear, Throat and oral cavity: No noticible point Retinal Examination: Ok
Slide5ParaclinicLab Imaging CBC: Ok FBS: Ok Biochemistry : Ok Conventional CT Scan MRI
Slide6CT Scan
Slide9MRI
Slide11What is the Best? Diagnostic Endoscopy Angiograghy Theraputic Endoscopy
Slide12Diagnostic Endoscopy
Slide13Diagnosis Chordoma
Slide14Management Surgery Radiotherapy Chemotherapy
Slide16The sphenoid sinus has often been referred to as the neglected sinus because of its isolated position and difficult accessibility. Disease restricted to the sphenoid sinus is rare and often manifests with nonspecific or subtle signs and symptoms. Typically, patients are referred to the otolaryngologist because of a finding of isolated sinus opacification on CT scans ordered by the patient’s primary care physician or neurologist to evaluate vague symptoms such as headache.
Slide17Classification Isolated sphenoid sinus disease can be broadly divided 1. Inflammatory 2. Neoplastic 3. Miscellaneous categories
Slide18Inflammatory lesions Sinusitis Acute Chronic Fungal infections Invasive: Mucormycoses, disseminated Aspergillosis Noninvasive: Mycetoma, Aspergilloma Mucoceles Pyoceles
Slide19Neoplastic lesionsBenign Malignant Intrinsic: 1. Inverting papillomas 2. Myofibroma 3. Schwannoma 4. Osteochondroma 5. Fibro-osseous disorders (fibrous dysplasia, ossifying fibroma) Extrinsic: 1. Meningioma 2. Paraganglioma 3. Pituitary macroadenomas Primary: 1. Squamous cell carcinoma 2. Adenocarcinoma 3. Adenoid cystic carcinoma 4. Mucoepidermoid carcinoma 5. Undifferentiated carcinoma 6. Transitional cell carcinoma Metastatic: 1. Renal cell carcinoma 2. Thyroid carcinoma 3. Prostate adenocarcinoma 4. Breast carcinoma 5. Lung carcinoma 6. Melanoma 7. Multiple myeloma and lymphoma
Slide20Miscellaneous Cerebrospinal leaks 1. Traumatic 2. Spontaneous Encephaloceles
Slide21Clinical signs and symptoms The most common symptom of sphenoid sinus disease is headache Visual disturbance is the second most frequently reported symptom Nasal obstruction Smell and taste Cranial nerve palsies Dizziness
Slide22Evaluation CT Scan: Air-fluid level 1. Acute & Chronic sinusitis 2. Polyp 3. Aneurism • Thining & Expansion 1. Mucocel 2. tumor Sclerosis 1. Fungal 2. Fibroossous Bone erosion 1. Malignant Tumor
Slide23Chordomas Relatively rare tumors deriving from rests of embryonal notochord tissue located in the skull base, spine, and sacrococcygeal regions. Skull base chordomas are typically located in the midline, in the clival and basisphenoid regions
Slide24Symptoms Slow-growing tumors; therefore, most patients will relate a fairly long history of symptoms on initial presentation. Symptoms in a given patient will depend on the exact location of the tumor. Most commonly, the patient will report headaches and visual changes Diplopia secondary to cranial nerve (CN)VI paresis, Facial numbness, facial droop, Dysphagia, Hoarseness CN XII paresis
Slide25Evaluation CT Scan • Reveal destruction of bone in a lytic pattern MRI • T1 : Isointense or hypointense lesion • T2 : bright signal that may appear heterogeneous. • Gd : Enhancement is typically moderate to high
Slide26Management Current and historical management of skull base chordomas has involved : 1. Surgical excision 2. Radiation therapy 3. Both