"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

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