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Patient of The Month. Bakhshaee M, MD Rhinologist Azar 1388. Presentation. 45 man complain from diplopia and headache. History. Headache : Six months ago Diplopia: One month ago Trauma: Three years ago from car accident. Background Diseases: Neg Recurrent URTI: Neg Epistaxis: Neg

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Patient of the month l.jpg

Patient of The Month

Bakhshaee M, MD

Rhinologist

Azar 1388


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Presentation

  • 45 man complain from diplopia and headache


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History

  • 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


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Examination

  • 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


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Paraclinic

Lab

Imaging

  • CBC: Ok

  • FBS: Ok

  • Biochemistry : Ok

  • Conventional

  • CT Scan

  • MRI





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What is the Best?

  • Diagnostic Endoscopy

  • Angiograghy

  • Theraputic Endoscopy



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Diagnosis

  • Chordoma


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Management

  • Surgery

  • Radiotherapy

  • Chemotherapy



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  • The 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.


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Classification neglected sinus because of its isolated position and difficult accessibility.

  • Isolated sphenoid sinus disease can be broadly divided

  • Inflammatory

  • Neoplastic

  • Miscellaneous categories


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Inflammatory lesions neglected sinus because of its isolated position and difficult accessibility.

  • Sinusitis

  • Acute

  • Chronic

  • Fungal infections

  • Invasive: Mucormycoses, disseminated Aspergillosis

  • Noninvasive: Mycetoma, Aspergilloma

  • Mucoceles

  • Pyoceles


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Neoplastic lesions neglected sinus because of its isolated position and difficult accessibility.

Benign

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


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Miscellaneous neglected sinus because of its isolated position and difficult accessibility.

  • Cerebrospinal leaks

  • Traumatic

  • Spontaneous

  • Encephaloceles


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Clinical signs and symptoms neglected sinus because of its isolated position and difficult accessibility.

  • 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


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Evaluation neglected sinus because of its isolated position and difficult accessibility.

  • CT Scan:

  • Air-fluid level

  • Acute & Chronic sinusitis

  • Polyp

  • Aneurism

  • Thining & Expansion

  • Mucocel

  • tumor

  • Sclerosis

  • Fungal

  • Fibroossous

  • Bone erosion

  • Malignant Tumor


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Chordomas neglected sinus because of its isolated position and difficult accessibility.

  • 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


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Symptoms neglected sinus because of its isolated position and difficult accessibility.

  • 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


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Evaluation neglected sinus because of its isolated position and difficult accessibility.

  • 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


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Management neglected sinus because of its isolated position and difficult accessibility.

  • Current and historical management of skull base chordomas has involved :

  • Surgical excision

  • Radiation therapy

  • Both