Infranuclear opthalmoplegia

CASE :

Young male teenager presented with 1 week history of progressively worsening vision of his left eye. He claims that he cannot see well with that eye. He has fever and headache as well. He has severe facial acne.
Cranial nerve examination noted left sided external and internal opthalmoplegia,and loss of sensation over the left forehead. Other neurological examination is normal. What can be your diagnosis?

DISCUSSION :

All the 3rd, 4th and 6th cranial nerves, together with opthalmic branch (V1) and maxillary branch (V2) run forward in the lateral wall of cavernous sinus.

V2 (maxillary branch of trigeminal nerve) leaves the mid-portion of cavernous sinus to exit the skull through foramen rotundum.

V3 （mandibular branch) langsung not in the lateral wall of cavernous sinus at all. Exits the skull through foramen ovale as soon as it leaves the trigeminal ganglion.

So,
Retrocavernous sinus -> 3 branches of CNV, CNIII, CNIV & CNVI
Posterior portion of cavernous sinus -> CNV1, CNV2, CNIII, CNIV & CNVI
Anterior portion of cavernous sinus -> CNV1, CNIII, CNIV & CNVI

Questions :
1. What is the most likely diagnosis ?

Lesions at the left anterior portion of cavernous sinus, which is most probably due to left cavernous sinus thrombosis secondary to facial acne.

2. What is internal and external opthalmoplegia ?

Internal -> paralysis affecting only the sphincter muscle of the pupil and the ciliary muscle

External -> paralysis affecting one or more of the extrinsic eye muscles

Total opthalmoplegia -> Internal + External

3. Differential diagnosis ?

- Pituitary Tumour (Pituitary gland is situated between the left and right cavernous sinus)
- Intracavernous carotid artery aneurysm
- Cavernous-carotid arteriovenous fistula
- Metastases (eg, nasopharyngeal carcinoma extension)
- Meningioma
- Sphenoidal sinusitis

4. What other condition can present with similar conditions ?

Lesions at superior orbital fissure -> Trauma, Tolosa-Hunt Syndrome (idiopathic granulomatous disease)

Reason : After cavernous sinus, CN3,4,6 and V1 bersama-sama enter superior orbital fissure. That's all.

5. Why facial acne cause Cavernous sinus thrombosis ?

Facial acne -> Acne pecah -> Kebetulan acne burst at the place of danger area of the face -> bacteria enters Facial Vein -> ophthalmic vein connects facial vein and cavernous sinus, and because these connections are valveless, retrograde infections can spread from facial vein to cavernous sinus -> Thrombophlebitis of the cavernous sinus -> haha !

6. Other signs/symptoms of cavernous sinus thrombosis ?
- Swollen eyelids, chemosis and proptosis
- Papilloedema
- Usually involves both eye

7. Name 1 condition very similar to cavernous sinus thrombosis ? State the difference.

Orbital cellulitis. Jawapan dekat Dhingra pg 191.

Summary : Cavernous sinus thrombosis is more acute, involve both eyes.

8. How to confirm cavernous sinus thrombosis ?
CT scan

9. Other source of cavernous sinus thrombosis ?
Dhingra pg 191.

Please correct me if I am wrong, some of these questions is I sendiri fikir punya. Thanks.

Source : Red book of neuro examination, Dhingra, Oxford

Thanks to Dr. Yeoh for asking us this interesting case through facebook. It's very rare but it happens in Teluk Intan.