CASE REPORT

Niger J Paed 2014; 41 (2): 144 –146

Akubuilo UC

Ayuk AC

Eze JN

Unilateral ptosis: an uncommon

presentation of chronic sinusitis - A

case report

Oguonu T

DOI:http://dx.doi.org/10.4314/njp.v41i2,15

Accepted: 23rd November 2013

Abstract Chronic sinusitis is an

inflammatory lesion that involves

the paranasal sinuses with symp-

toms and signs that are beyond 12

weeks in duration. It commonly

presents with nasal stuffiness,

mouth breathing, purulent nasal

discharge, post natal drip, snoring,

cough, headache, facial fullness,

hyposmia, sore throat and halito-

sis. Features of ocular and cere-

bral complications may be present

at diagnosis but are uncommon

and can thus result in misdiagno-

sis. A 15 year old male presented

with sudden onset ptosis and other

symptoms that initially suggested

an intracranial SOL or a Cavern-

ous sinus thrombosis. A CT scan

of the head and neck structures

identified chronic sinusitis as the

only likely pathology. We present

this case to highlight an unusual

ocular complication of chronic

sinusitis.

(

)

Akubuilo UC

Ayuk AC, Eze JN, Oguonu T

Department of Paediatrics,

University of Nigeria Teaching

Hospital, Enugu, Nigeria

Tel: +2348035442644

Email: kuzzy3006@yahoo.com

Introduction

bing temporal headache, right eye swelling and pain,

with drooping of the right upper eyelid. There was asso-

ciated rhinorrhea of thick yellow mucus draining from

the right nostril. Coexisting constitutional symptoms

included high grade fever, and vomiting. There was no

neck pain and consciousness was preserved. There was

feeling of facial fullness but no facial pain, photophobia,

redness nor discharge from either eye. There was no

antecedent trauma to the face or history of foreign body

inhalation through the right nostril. He had a past history

of recurrent nasal stuffiness in the preceding 4 months

with occasional fetid breath. Symptoms were progres-

sive over 5 days before presenting to the emergency

unit.

Chronic sinusitis is an inflammatory lesion that involves

the paranasal sinuses with symptoms and signs that are

beyond 12 weeks in duration. It occurs in₁a_,₂ll ages with

no gender, racial or ethnic predilection. Chronic si-

nusitis is a common disease worldwide, particularly in

3

places with high levels of atmospheric pollution. In

pediatric population the term rhinosinusitis is more com-

monly used to include both acute and chronic infection

which can be both viral and bacterial in origin. The com-

mon occurrence in pediatric population is likely secon-

dary to an increased frequency of exposure to upper

3

respiratory tract infections in this age group. The illness

is associated with loss of productivity and missed school

days with pat₄ients suffering a comparable decrease in

quality of life.

He was fully conscious. His body temperature was

39.5 C with pulse rate of 90 per minute and blood pres-

0

sure of 100/60 mm Hg supine. Examination of the eye

revealed: ptosis of the right upper eyelid with normal

vertical eye movements and both pupils were of normal

size but reacted sluggishly to light. There were no other

neurological deficits elicited on further examination.

Nasal examination revealed a narrow right nasal cavity

with enlarged pale turbinates. Pharyngeal examination

showed thick yellow exudate on the right posterior pha-

ryngeal space.

The common clinical features of chronic sinusitis are

nasal stuffiness, nasal discharge, postnasal drip, facial

pain/pressure, persistent dry cough, mouth breathing and

snoring. Others include fever, fatigue and halitosis. Un-

commonly it may present with features of ocular and

cerebral complications₅_-s₇uch as ptosis, intracranial infec-

tions, orbital cellulitis.

The objective of this report is to highlight these uncom-

mon presentations, broaden our differentials of these

presentations with a guide to diagnosis and treatment.

Our initial diagnosis included intracranial space occupy-

ing lesion to rule out a cavernous sinus thrombosis

Case Presentation

(CST).

A

coronal CT scan of the head

showed inflammatory changes in the right ethmoidal

and maxillary sinuses (fig 1) suggesting a chronic rhino-

sinusitis. It further confirmed that there were no SOL or

CST and no foreign body was seen. Complete blood

A 15 year old male presented in the Emergency Unit of

the University of Nigeria Teaching Hospital (UNTH)

Enugu Nigeria with a sudden onset of right sided throb-

1

45

count and electrolyte studies were normal with ESR of

2mm/hr.

Parenteral ceftriaxone was commenced and within 72

hours of admission ma_t_hjor presenting symptoms had re-

solved and by the 10 day the right sided ptosis had

complications include preseptal cellulitis, orbital

cellulitis, su₅_-b₁p₂ eriosteal abscess, and cavernous sinus

thrombosis. Ptosis as a complication especially as a

7

unilateral presentation is not as₅_,₆c_,₈ommon and may usu-

5

ally be discovered incidentally. Swift and colleagues

completely resolved.

He was subsequently dis-

in Liverpool reported a case of ptosis due to chronic

sinusitis detected by incidental CT finding. The patient

presented with painful ophthalmoplegia of the right eye

and ptosis. The CT scan finding revealed opacification

of the right ethmoid, frontal and maxillary sinus. All

symptoms resolved with sinus irr₁i₃gation and antibiotic

charged on oral third generation cephalosporin, nasal

decongestants and steroid nasal spray. On review 4

weeks following discharge he had remained stable with

no further recurrence of headache, nasal discharge and

ptosis.

4

treatment. Suzuki and colleagues in Tokyo reported

Fig 1: Coronal CT scan showing inflammatory changes and

occlusion in the right maxillary and ethmoidal sinuses (1 and

second arrows respectively)

another case of a patient who presented with fever, neck

rigidity, ophthalmoplegia and ptosis, with CT scan and

MRI results that revealed a shadow in the sphenoid si-

nus and cavernous sinuses. The symptoms improved

with sphenoidectomy and antibiotics.

st

The involved sinuses in our patient, the ethmoidal and

maxillary receive some innervation from the seventh and

1

4

third cranial nerves. Partial pressure compression of a

superior rami branch of the occulomotor nerve by the

surrounding inflamed sinuses may be a li₆k_,₁e₄ly explana-

tion for the ptosis our patient experienced, as vertical

eye movements were not affected thus excluding entire

third nerve involvement. Distal to the cavernous sinus

and maxillary sinus, the micro branches of the occulo-

motor nerve such as the superior ramus which supplies

the super₄ior rectus and the Levatorpalpebral muscles of

1

the eye may have thus been compressed by the in-

flamed sinuses.

Even though the risk factors for cavernous sinus throm-

bosis are infections of the paranasal sinuses and mid-

face as well as bac₉teremia, trauma, infection of the ear

or maxillary teeth, thrombosis of the cavernous sinus

almost always progresses to involve the contra late₇ral

1

eye as well within 24-48hrs which is pathognomic in

addition to other common signs such as periorbital oe-

dema and pain which worsen overtime, facial fullness

without facial pain, visual disturbanc₅_.es major cranial

1

nerve signs in addition to headache. The sixth cranial

nerve is commonly the first affected owing to its course

directly through the cavernous sinus followed by the

third and fourth nerves involvement in more extensive

disease as these nerves are protected in th₁₈eir course in

the lateral wall of the cavernous sinus. Our patient

presented with headache, eye swelling, and ptosis that

remained confined to the right eye and he did not have

major cranial nerve deficits. Orbital cellulitis is the com-

monest complication of maxillary sinusitis and may p₁ re-

5,16.

sent with fever, headache just like in our patient

However proptosis and ophthalmoplegia₉are the cardinal

1

Discussion

signs and symptoms of orbital cellulitis both of which

were absent in our patient as well as other symptoms

such as blurred vision and reduced visual acuity. In

other intracranial SOL such as tumors and abscesses,

one would have expected extensive lateralizing signs but

these were also not present in the index case.

The invaluable use of CT scan as a diagnostic tool to

help narrow the diagnosis cannot be overemphasized as

the patient’s acute presentation had these as possible

Chronic sinusitis is an inflammatory lesion that involves

the paranasal sinuses with symp_,₃toms and signs that are

1

beyond 12 weeks in duration. It commonly presents

with nasal stuffiness, mouth breathing, purulent nasal

discharge, postnatal drip, snoring, cough, headache, fa-

cial fullness, hyposmia, sore throat, halitosis. Features of

ocular and₄ cerebral complications may be present at

diagnosis Documented and commoner orbital

1

46

differential diagnosis. There is therefore a need to

strengthen our health system so as to easily access nec-

essary supportive diagnostic investigations even when

patients are unable to pay out-of-pocket.

Conclusion

Ptosis could complicate chronic sinusitis and the latter

must be excluded in cases of ptosis.

The goal of medical therapy is to reduce mucosal

oedema, promote sinus drainage, eradicate infections

and prevent complications. Oral antibiotics for two

weeks, topical nasal steroids, decongestants and saline

Conflict of interest: None

Funding: None

1

0,11,12

.

nasal sprays have been employed satisfactorily

Our patient did well on this therapy. He did not require

surgical intervention or follow-up physiotherapy.

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