Title: Acute sphenoiditis involving the second branch of the trigeminal nerve

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Eugenia Walker
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1 QJM Advance Access published September 10, 2016 Title: Acute sphenoiditis involving the second branch of the trigeminal nerve Author names: Yuta Hirose, Yusuke Hirota, Daiki Yokokawa, Yoshiyuki Ohira, Masatomi Ikusaka Department of General Medicine, Chiba University Hospital, Chiba city, Chiba, Japan Correspondence to: Yuta Hirose, Department of General Medicine, Chiba University Hospital, Inohana, Chuo-ku, Chiba city, Chiba, Japan, Tel.: Fax: The Author Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please 1

2 Learning point for clinicians Acute sphenoiditis may affect the second branch of the trigeminal nerve because of anatomical reasons and should be included in differential diagnoses in patients with headache accompanied by facial numbness. Case report A 67-year-old man visited our hospital with complaints of headache, vomiting, and numbness on the right side of the face. He noted preceding transient upper respiratory tract symptoms seven days before his visit. The headache that occurred two days before his visit was the most severe he had ever experienced and worsened. On the day before his visit, it was accompanied by vomiting and numbness on the right side of the face. Physical examination showed a temperature of 36.6 C, blood pressure of 167/83 mmhg, pulse rate of 72 beats per minute, and oxygen saturation as measured using pulse oximetry (SpO 2 ) of 99%. Neither neck stiffness nor papilledema of the eyeground was observed. Both tactile sense and thermal nociception were impaired in areas corresponding to the second branch of the trigeminal nerve, such as the upper lip, lateral side of the ala of the nose, buccal region, and maxillary gingiva in the right side of the face. Hematologic tests showed a white blood cell count of /µl and a C-reactive protein level 2

3 of 3.8 mg/dl, indicating an inflammatory response. The spinal fluid test showed no abnormal finding. Head computed tomography (CT) (Figure 1a) showed fluid accumulation without bone destruction in the right sphenoidal sinus. Right sphenoid sinusitis was diagnosed. Intravenous infusion of sulbactam/ampicillin (SBT/AMPC) was started at a dose of 6 g/day. When a plug of pus that was revealed at the right sphenoid ostium with a nasal endoscope was removed, a large amount of pus was drained. Simultaneously, the headache was markedly relieved. On hospital day 6, treatment was changed to oral administration of antimicrobial agents (amoxicillin 500 mg/day + clavulanate 125 mg/day), and the patient was discharged. No pathogenic bacterium was isolated from pus or identified by blood culture (two sets). Discussion Sinusitis that occurs in the sphenoidal sinus alone is a relatively rare condition, accounting for less than 3% of all cases of sinusitis. 1 Lawson et al reported that headache, which is observed in 100% of the cases, is the most common symptom, followed by visual loss in 13% and cranial neuropathy in 8%, in descending order. 2 Headache is nonspecific in terms of features and can occur in any part of the craniofacial area. Frequency of nasal symptoms is considered to be lower than that of headache and visual 3

4 disturbance. In cases without complications, resolution can be achieved by conservative treatment with antimicrobial agents alone. However, endoscopic drainage should be performed in cases resistant to conservative treatment and those with complications. 1 The structures associated with complications of sphenoiditis include cranial nerves II, III, IV, V1, V2, and VI, the dura mater, pituitary body, cavernous sinus, internal carotid artery, sphenopalatine ganglion, sphenopalatine artery, pterygoid canal, and pterygoid nerve. 1, 3 The most common type of cranial neuropathy is abducens nerve disorder because of the nerve running closest to the sphenoidal sinus. 1, 2 However, we have found no case report of sphenoiditis affecting only the second branch of the trigeminal nerve, as seen in our case. On CT images taken in our case (Figure 1b), the right foramen rotundum (red arrow), through which the second branch of the right trigeminal nerve passes, appears adjacent to the sphenoidal sinus, and the bone separating between the right foramen rotundum and the sphenoidal sinus is unclear, compared to the bone on the left side (blue arrow). It was assumed that inflammation in the sphenoidal sinus had spread to the foramen rotundum and the second branch of the trigeminal nerve passing through the foramen. Conflict of interest: None declared. 4

5 References 1. Tan HKK, Ong YK. Acute Isolated Sphenoid Sinusitis. Ann Acad Med Singapore 2004; 33: Lawson W, Reino AJ. Isolated sphenoid sinus disease: an analysis of 132 cases. Laryngoscope 1997; 107: Proetz AW. The sphenoid sinus. Br Med J 1948; 2:

6 Figure 1a: Head CT showing sphenoid sinusitis (a) Computerized tomography of the head is revealed a shadow without bone destruction observed in the right sphenoidal sinus (red arrow). 1

7 Figure 1b: Head CT showing sphenoid sinusitis (b) Computerized tomography of the head is revealed that the bone separating between the right sphenoidal sinus and the adjacent right foramen rotundum (red arrow) is unclear, compared to the bone on the left side (blue arrow). 2

fig.1: CT scan of sinuses: Right isolated sphenoid sinus opacification

fig.1: CT scan of sinuses: Right isolated sphenoid sinus opacification Case presentation: An 8 year old boy presented to the emergency department with few days history of severe headache. Pain is described as fronto-occipital, continuous and not relieved by pain medications.