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Ocular Palsies Withnasal Sinusitis

Ocular Palsies Withnasal Sinusitis

J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.13.3.225 on 1 August 1950. Downloaded from

J. Neurol. Neurosurg. Psychiat., 1950, 13, 225.

.. OCULAR PALSIES WITH NASAL BY HELEN DIMSDALE and D. G. PHILLIPS

The diagnosis of nasal sinusitis as a cause of (Rollet, 1933). This patient had, in addition to ocular palsy has recently fallen into disfavour, ocular palsy, an . particularly since the importance of congenital as a cause of third nerve palsy has been Pathological Anatomy recognized. Exhaustive studies of the relation of the ocular It is the purpose of this communication to record to the nasal sinuses have been made by a series of fully investigated cases of ocular palsy Sluder (1913), the Onodis (1914), and Houser (1933). observed over some years, in which the palsies were During the course of these nerves from the associated with the presence of a chronic infection stem through the superior orbital fissure to the Protected by copyright. of the nasal sinuses. We made a short preliminary , there are two sites where the anatomical report of these cases in 1948.* Since then one relationships predispose to palsies as a result of further example has been added to the series. sinus infection. The third nerve emerges Historical Review after it from the anterior end of the cavernous sinus lies in close relation to the The association of ocular palsies with nasal sinus upper part of the lateral wall of the sphenoidal and infection has been recognized for many years. posterior ethmoidal sinuses, especially if pneuma- Trantas (1893) described a patient with left ex- tization has extended into the attached root of the ophthalmos and total left ophthalmoplegia, in whom lesser wing of the sphenoid. It should be noted that recovery from ocular palsy followed drainage of the the is also in close relation here. infected sinuses, though severe visual loss resulted, The fourth and sixth nerves are more laterally with optic atrophy. Trantas mentions the occur- placed, but may be involved by extension of the rence of other cases of sinus disease with blindness infective process from the anterior or posterior and third nerve palsy in the literature. Further groups of sinuses into the superior orbital fissure. early cases in the continental literature are quoted The sixth nerve alone is in relation to the posterior by Onodi (1914) and Rollet In recent (1933). times wall of the sphenoidal sinus in Dorello's canal. http://jnnp.bmj.com/ the relatively few recorded cases include those This canal is bounded by the posterior clinoid with isolated third nerve palsy (Sluder, 1927; process, the apex of the petrous bone, and the Rollet and Parthiot, 1929; Genet, 1929; Rollet, petro-clinoid ligament, and transmits the sixth nerve 1933 ; Yaskin, 1939), isolated fourth nerve and the inferior petrosal sinus. There is much palsy (Sluder, 1927; Redslob and Delbos, 1941), variation in the extension of the sinus cavity back- isolated (Caliceti, 1927 ; Sargnon wards in the body of the sphenoid bone, and in some and Parthiot, 1930; Horgan, 1931 ; Diamant, skulls there may be as little as two millimetres

1937), and multiple ocular palsies (Sargnon, 1923; between Dorello's canal and the interior of the sinus on September 28, 2021 by guest. Sluder, 1927; Stieren and McKee, 1932; Yaskin, cavity (Houser, 1933). 1939; Kretzschmar and Jacot, 1939). Nearly all Involvement of the sixth nerve by a spread of the patients had short histories and rapid and to theb apex of the petrous bone from complete recoveries following treatment of infected an ear infection, as in Gradenigo's syndrome, is sinuses. The only fatal case among these was a well known. Symonds (1944) suggested that in a man who died 40 days after operation of meningitis proportion of cases this syndrome may result from a of the inferior * Communication read at the Congress of the United Kingdom thrombophlebitis petrosal sinus. In Ophthalmological Society in April, 1948. some individuals the sixth nerve reaches the lateral G 225 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.13.3.225 on 1 August 1950. Downloaded from

226 HELEN DIMSDALE AND D. G. PHILLIPS wall of the cavernous sinus by first penetrating the Culture grew haemolytic streptococci. Sulphathiazole inferior petrosal sinus. In view of the relative was given post-operatively. frequency of sixth nerve palsy in association with On September 6 the ocular movements had improved and , it is rather surprising and ten days after operation were full, apart from slight . The of the left eye had expanded that it should not be encountered more frequently and the left was 6/12 corrected. Radiological as a result of sphenoiditis. examination a month after operation showed some re-formation of the dorsum sellhe. Case Material Five years later the patient was well, and the sella The cases are divided into two main groups: turcica was normal apart from slight irregularity of the ocular palsies with sphenoiditis; ocular palsies floor. with inflammation of the superior orbital fissure. Although there were no recent nasal symptoms, Ocular Palsies with Sploiditis (Four Cases).- a sphenoiditis and pansinusitis produced a right These cases form a well-defined group. The patients third nerve palsy complete except for the pupillary presented with and double vision. They fibres. There was interference chiefly with the nasal were apyrexial and did not complain of nasal fibres of the left optic nerve. Recovery resulted symptoms, but radiological examination showed from drainage of the infected sinuses. opacity of the sphenoidal sinuses and extreme Case 2.-Martin W., a man aged 46, was admitted to rarefaction of bone around the sella turcica. Chase Farm Hospital on October 10, 1946, from the Surgical drainage of the infected sphenoidal sinuses Royal London Ophthalmic Hospital. He complained was performed, with immediate improvement in the of attacks of shooting in the right temple for the ocular palsies, progressing to partial or complete past six months. One month before admission he recovery. Radiological examination after some started to see double and the right drooped. months showed regeneration of the decalcified bone There was no history of nasal discharge. about the sella. On examination there was no anosmia. The fundi, Protected by copyright. fields, and visual acuity were normal. The right Case 1.-Mrs. F. B., aged 60 years, was admitted to reacted sluggishly to light and . There Chase Farm Hospital on August 8, 1943, from the Royal was a right partial ptosis with weakness of elevation, London Ophthalmic Hospital. Five months previously adduction, and depression. Two weeks after admission she had noticed double vision on looking to the left; a weakness of the right superior oblique muscle this lasted for two weeks. Three weeks before admission developed. No clinical evidence of sinus infection was the double vision recurred accompanied by in the detected. right side of the forehead and drooping of the right The sedimentation rate was 12 mm. in one hour, the eyelid. About the same time she noticed the sight of blood count normal. The blood Wassermann reaction the left eye was deteriorating. For many years she had was negative, and the cerebrospinal fluid was normal. a nasal discharge with loss of of smell, but about Radiological examination showed that the dorsum and five years ago the discharge had ceased. floor of the sella were destroyed, with an opacity of the On examination there was bilateral anosmia. She sphenoidal sinus. Bilateral carotid arteriography and was myopic, otherwise the fundi were normal. The air encephalography demonstrated no abnormalities. visual field of the left eye showed a slight superior nasal On December 17, 1946, at the Brentwood Annexe of constriction and a hemianopic temporal defect with the London Hospital the sphenoidal sinus was explored to white. The visual field of by Mr. Keogh. The posterior part of the bony roof of sparing of 3/1500 http://jnnp.bmj.com/ the right eye was full. The left visual acuity was 6/36, the sinus felt soft. The sinus was filled with 4 ml. of and the right 6/12 corrected. There was a right partial dark brown fluid under pressure containing pus cells, ptosis, with absence of elevation and adduction; and on culture grew Staphylococcus pyogenes. depression was weak. The superior oblique muscle was Three months after operation some weakness of active. The right pupil was slightly larger than the elevation and depression remained, but the other move- left but reacted normally. The rest of the nervous ments were full, and there was no ptosis. Radiological system was normal. The blood pressure was 180/100 examination a year later showed partial re-formation of mm., and there was moderate peripheral arteriosclerosis. the floor of the sella.

The sedimentation rate was 17 mm. in one hour; on September 28, 2021 by guest. the blood count was normal. The blood Wassermann of the right third and fourth nerves was reaction was negative, and the cerebrospinal fluid was produced by an infected cyst of the sphenoidal normal. Radiological examination showed erosion of sinus. There were no nasal symptoms. Partial the middle of the dorsum sellk, floor and neighbouring recovery occurred after drainage of the sphenoidal parts of the sphenoid, with generalized opacity of the sinus with re-formation of the bone. nasal sinuses. On September 2, 1943, a bilateral Caldwell-Luc Case 3.-J. S., a man aged 60 years, was admitted to operation was performed by D.G.P. with free drainage of the London Hospital on November 10, 1947. Nine pus from the antra, ethmoids, and sphenoidal sinuses. months previously he had noticed double vision for J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.13.3.225 on 1 August 1950. Downloaded from

OCULAR PALSIES WITH NASAL SINUSITIS 227 On October 29, 1947, Mr. Bowen-Davies performed operative drainage of the sinuses. Polypoid mucosa was found in the posterior ethmoidal cells. The left sphenoidal sinus contained some curious material almost of the consistency of dark brown plasticine. The histological changes were those of a ohronic pyogenic inflammation. On November 5, 1947, there was no and the ocular movements were full. On radiological examination two months after operation the sella was seen to be re-forming (Fig. lb). Six months later the patient had remained well. There was a history of catarrh, although there was no clinical evidence of sinus infection. The partial left third nerve paresis recovered after drainage of the infected sphenoidal sinus, and the eroded sella re-formed. FIG. la (Case 3).-Rarefaction of sella turcica; opaccity of Case 4.-Maurice W., a man aged 45, was sphenoidal sinus. admitted to Chase Farm Hospital on Novem- ber 14, 1942, from the London Hospital. He three weeks, and a dull aching pain in the left temple. complained of generalized headache and double vision

The double vision recurred in May and September, 1947, for two months. He had noticed a blood-streaked, Protected by copyright. and lasted three weeks on each occasion. There was a post-nasal discharge for ten years. He was a treated history of chronic nasal discharge since a blow on his diabetic. nose by a cricket ball in 1912. In 1920 a nasal polyp was removed. On examination there was no anosmia. The fundi and were normal. There was diplopia on looking up and to the right, suggestive of a left inferior oblique ..>,. paresis. There was no clinical evidence of sinusitis. Radiological examination showed destruction of the floor of the sella turcica, with opacities of very large sphenoidal sinuses and the maxillary sinuses (Fig. Ia). !1 rwr~~~~~~~~~~:F''>: http://jnnp.bmj.com/

FIG. 2a (Case 4).-Absorption of bone of sella turcica. on September 28, 2021 by guest. On examination there was a right external rectus paresis; otherwise the was normal. There was no clinical evidence of nasal sinus infection. The blood Wassermann reaction was negative, and the cerebrospinal fluid was normal. Radiological examination of the skull and sinuses showed dullness of the sphenoidal sinuses with erosion of the floor of the FiG. lb (Case 3).-Regeneration of sella; clear sphenoidal sella turcica together with the posterior clinoid processes sinus (two months later). suggestiveofa ofthe sphenoidalsiDuses (Fig. 2a). J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.13.3.225 on 1 August 1950. Downloaded from

228 HELEN DIMSDALE AND D. G. PHILLIPS On March 31, 1943, the ethmoidal and sphenoidal Relative sparing of the puplUary fibres in these sinuses were explored by D.G.P.; mucous discharge and patients (Cases 1, 2, and 3) was probably fortuitous. hypertrophied polypoid mucosa were found. On section Hermann and Hall found ptosis and an inactive this showed granulation tissue infiltrated with poly- pupil in their patient. Rollet (1933) and Yaskin morphonuclear and plasma cells. Culture grew (1939) also described internal ophthalmoplegia due Coccobacillus fwtidus ozaene. to sphenoiditis. There was an improvement of abduction of the right Certain clinical features may assist in the differ- eye three days after operation, and by the twelfth due to from post-operative day the diplopia had cleared. Occasional entiation of ocular palsies sphenoiditis diplopia recurred over a year, but during the next those due to supraclinoid . The uni- five years recovery was complete. Radiological exami- lateral frontal pain was aching in character and was nation seven months after operation showed re- not intense. The palsy did not develop simul- calcification of the sphenoid (Fig. 2b). taneously with the pain. There were no symptoms, such as stiffness of the neck, suggestive of a leaking aneurysm. The third nerve palsies were incomplete and other , the second (Case 1) and the fourth (Case 2) were involved. Jefferson (1947) has stated that it is the completeness of an isolated third nerve palsy that is so characteristic of an aneurysm of the pos- terior communicating artery. kThe symptomatology of carcinoma of the naso-pharynx has been studied by

Godtfredsen (1947) who found that the Protected by copyright. sixth nerve was frequently first affected, then the contralateral sixth, and the trigeminal nerve. Palsies of the third and fourth nerves were infrequent. The appearance of an ocular palsy due to disseminated sclerosis in a patient with sinus infection may be misleading. The patients under consideration were old for FIG. 2b (Case 4).-Regeneration of sella (seven months later). the onset of this disease ; other signs of disseminated sclerosis were lacking and Sphenoiditis with destruction of bone was did not develop during the period of observation. present without nasal symptoms apart from Neurosyphilis was excluded by the negative some post-nasal catarrh. It must be admitted that serology. the diagnosis of the cause of the sixth nerve paresis Radiological appearances of a pansinusitis may was complicated by the' presence of , but clarify the diagnosis; but if the sphenoidal sinuses permanent recovery appeared to be related to the only are opaque, with erosion of the sella, ex- http://jnnp.bmj.com/ drainage of the infected sphenoidal sinus. ploration is necessary to determine the nature of the lesion. Discussion The site of the lesion of the third nerve in these Chronic sphenoiditis may be present in the patients was probably at the medial end of the absence of nasal symptoms, although a past history superior orbital fissure, and of the sixth nerve in of a period of nasal discharge was usually obtainable Dorello's canal, associated with erosion of the from these patients. Cessation of discharge was posterior clinoid processes. probably due to blockage of the ostium of the sinus. on September 28, 2021 by guest. The increase of tension in the sinus finally produced Ocular Palsies with Inflammation of the Superior erosion of its bony wall with the development of Orbital Fissure (Six Cases).-These cases corres- ocular' palsies. The palsies might be intermittent ponded generally with the syndrome de la fente at first due to changes in tension of the contents of sphenoidale described by Rollet (1933) and Kretz- the sinus. Hermann and Hall (1944) have des- schmar and Jacot (1939), and orbital periostitis cribed the case of a patient with periodic headache (Cairns, 1938 ; Collier, 1922). The patients presented associated with a partial third nerve palsy due to with unilateral headache, and double vision due mucocele of the sphenoidal sinus. to multiple ocular palsies. Proptosis, generally J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.13.3.225 on 1 August 1950. Downloaded from

OCULAR PALSIES WITH NASAL SINUSITIS 229 slight, was present in all. Unilateral papillcedema, Case 6.-C. C., a boy aged 12, was admitted to the trigeminal nerve involvement, and intracranial London Hospital on August 26, 1946. spread of inflammation were seen in a varying He had complained of for some months. degree. Nasal symptoms were not prominent, Three weeks before admission he became drowsy, and but all showed radiological evidence of sinusitis vomited several times. It was noticed that his right eye at some period of their illness. was prominent, and he began to see double. On examination there was a tender swelling in the Case 5.-Mrs. L. S. aged 46 years was admitted to the right temporal fossa extending over the zygoma anterior Maida Vale Hospital for Nervous Diseases, London, to the pinna. The right side of the face was warm and on April 9, 1947, from the Moorfields, Westminster and flushed. There was papilloedema of the right , Central Eye Hospital (Royal London Ophthalmic the left disc was normal, and the visual fields were full. Hospital). There was proptosis of the right eye with incomplete Nine weeks previously she had noticed protrusion of ptosis, weakness ofelevation and adduction, and absence the right eye and drooping of the lid. She then started of abduction. The rest of the nervous system was to have an aching pain on the right side of the forehead. normal. Although she had a past history of catarrh there was no The sedimentation rate was 36 mm. in one hour. recent nasal discharge. The white count was normal. The cerebrospinal fluid On examination there was no anosmia. The fundi pressure was normal in pressure and contained protein and visual fields were normal. The right visual acuity 50 mg. per 100 c.cm., no pleocytosis; Lange curve was 6/9, left 6/6 uncorrected. The right eye was 12322100. Radiological examination of the skull proptosed downwards and forwards. There was partial showed translucency of the lateral wall of the orbit right ptosis, with weakness of elevation and adduction. on the right side (Fig. 4a), suggesting infection. The pupils were normal. The rest of the nervous system There was extensive loss of bone in the posterior and was normal. The blood pressure was 220/120 mm., lateral walls of the orbit and destruction of the floor. and the heart moderately enlarged. Both maxillary sinuses showed opacities, suggesting The sedimentation rate was 11 mm. in one hour, and thickened mucosa. There was a roughly spherical the white count was normal. The blood Wassermann opacity in the upper part of the right antrum adjacent Protected by copyright. reaction was negative, and the cerebrospinal fluid normal to the localized area of erosion in the lower and in pressure and constituents. outermost part of the greater wing of the sphenoid Radiological examination of the skull showed no (Fig. 5a). abnormality of cranium or orbit. Thickened mucosa or The patient recovered spontaneously during the next fluid was present in the right antrum, and fluid in the two months and a year later passed the left antrum. for a navigation school. Radiological examination 12 On April 12, 1947, an oval mass about 2 cm. and 17 months later showed progressive regeneration x 0 5 cm. was detected in the posterior part of the orbit, which was thought to be inflam- matory and related to sinus infection. Some improvement followed antral puncture and conservative treatment. Subsequently the proptosis increased, and cedema cf the lids appeared. Although the fundus and visual field were normal, the right visual acuity deteriorated to 6/18. Radiological examina- tion now showed a patch of osteitis in the roof of the orbit (Fig. 3). The condition http://jnnp.bmj.com/ was considered to be inflammatory by Mr. Wylie McKissock. A radical frontal sinus operation was performed by Mr. Howells in July, 1947, at Slough Emergency Hospital; chronic frontal sinusitis was found with necrosis of the anterior wall of the sinus. The patient

made a satisfactory recovery. on September 28, 2021 by guest. Maxillary and frontal sinusitis without recent nasal symptoms was diagnosed. There was proptosis, partial right third nerve palsy, and deterioration of right visual acuity due to an inflammatory lesion in the posterior part of the orbit. Recovery took place with drainage of the FIG. 3b(Case 5).-Patch of osteitis in the posterior part of the frontal sinus. roof of the right orbit. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.13.3.225 on 1 August 1950. Downloaded from

2)30 HELEN DIMSDALE AND D. G. PHILLIPS

FIG. 4a (Case 6).-Absorption ofgreater wing ofsphenoid FIG. 4b (Case 6).-Regeneration of greater wing of in right orbit. sphenoid (17 months later). of the orbital wall (Fig. 4b), but the appearances of intracranial extension. Although there were no mucosal thickening in the antra persisted (Fig. 5b). symptoms of nasal infection, the peculiar radio- Protected by copyright. This patient developed a subacute inflammation logical appearance of the right antrum was very of the soft tissues and bony wall of the orbit, suggestive of a connexion between the condition including the outer wall common with the temporal of the antrum and the osteitis of the orbit. The fossa, and the lateral extremity of the superior sinusitis may, however, have been contemporaneous orbital fissure. The second, third, and sixth cranial rather than causative. nerves were involved, probably at the apex of Case 7.-A. L., a man aged 49, was admitted to the orbit. Apart from an increase of protein in Chase Farm Hospital on March 7, 1946. Three the cerebrospinal fluid, there was no evidence of months previously he had had a bad cold, with http://jnnp.bmj.com/ on September 28, 2021 by guest.

FIG. 5a (Case 6).-Patch of osteitis lower and outer part of FIG. 5b (Case 6).-Recovery of osteitis (12 months right orbit, with spherical opacity in upper part ofright later). antrum. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.13.3.225 on 1 August 1950. Downloaded from

OCULAR PALSIES WITH NASAL SINUSITIS 231 pain in the left forehead and behind the eye, radiating examination on February 11 showed opacity of the right over the left side of the head. Two days after the onset maxillary antrum and sphenoidal sinus. of pain he began to see double. The nasal discharge On examination there was no anosmia. The right suddenly ceased but the pain and double vision optic disc was congested; the right visual acuity was J2, persisted. Chronic catarrh had been present since the left visual acuity Jl. There was irreducible proptosis childhood, and four years before he had undergone of the right eye, with partial ptosis, absence of elevation an operation for deflected nasal septum. Radiological and abduction, and impaired depression. The right examination shortly before admission showed a faint pupil was smaller than the left but reacted normally. opacity of the left maxillary sinus. The rest of the nervous system was normal. The right On examination there was no anosmia. The fundi and nasal cavity was congested, but no pus was obtained on pupils were normal. There was slight proptosis of puncture of the right maxillary antrum. Radiological the left eye, with partial ptosis, weakness of elevation examination of the skull showed no abnormality. and absent abduction. Appreciation of pinprick was On March 2 the patient developed severe pain and impaired over the distribution of the first and relative hypalgesia with diminished corneal response in second divisions of the left trigeminal nerve. There the right trigeminal area. The right pupil became was a right lower facial weakness, with increased sluggish. He had a series of fits of an uncinate type reflexes in the right arm and leg, and the right with hallucinations of and smacking of the lips. plantar response was equivocal. At repeated examinations, the cerebrospinal fluid was The sedimentation rate was 22 mm. in one hour. normal in pressure and showed an increase of cells from The cerebrospinal fluid was normal in pressure and 30 to 230 per c.mm. (40% polymorphonuclears and 60% contained red blood cells. Ventriculography showed lymphocytes), protein 40-60 mg. per 100 c.cm. It was some increase in the subarachnoid space but no other sterile on culture. A ventriculogram was normal. abnormality. The ventricular fluids were also slightly The white blood count increased from 5,000 perc.mm. bloodstained. (polymorphonuclears 40%) to 13,800 per c.mm. (poly- Radiological examination on March 30, 1946, morphs 68%). On March 6 several more uncinate showed the right maxillary antrum to be semi-opaque, attacks occurred, and on March 7 a right frontal and an appearance of the right frontal sinus craniotomy and decompression was performed by Mr. Protected by copyright. suggestive of infection. He had complained of Northfield. In the region of the superior orbital fissure extension of pain to the right orbit and eyeball. the dura mater was grossly indurated, and had a granular The patient improved spontaneously, but in June, external surface. Biopsy showed fibrous granulation 1946, he had a recurrence of left-sided pain and tissue, and the culture grew a small clump of Staphylo- nasal discharge. There was still slight left-sided proptosis, coccus albus only. No abscess was found. but the ocular movements were full. The reflexes were On March 17 the right fundus showed a secondary brisk and equal. When the patient was seen 15 months optic atrophy and there was no of light. later there was no proptosis. There was a complete right external and internal ophthalmoplegia. The onset of symptoms was associated with an On May 30 the patient suddenly developed a spastic exacerbation of chronic nasal discharge, which then left hemiplegia associated with pyrexia. Ventriculo- dried up. The left antrum showed radiological graphy showed displacement of the ventricles to the evidence of infection. There was a partial lesion left. The craniotomy was reopened but only much of the left third nerve, involvement of the sensory thickened dura was found in the anterior and middle fibres of the trigeminal, and a complete sixth nerve cranial fossae. He became aggressive with highly organized delusions and was admitted to Napsbury palsy. The cause of the contralateral pyramidal Mental Hospital for five months. signs was obscure. The presence of blood in In the following year he returned to heavy work. He http://jnnp.bmj.com/ cerebrospinal fluid in the lumbar sac and in the had some left-sided fits preceded by an olfactory , ventricles may have been due to an insidious intra- but these were controlled by phenobarbitone. cranial venous thrombosis. The course of the In October, 1943, the right visual acuity was percer- illness was unlike a subarachnoid hmmorrhage due tion of light only, there was a right secondary optic to aneurysm. The patient was considered to be atrophy, the ocular movements were almost full, and the suffering from a low-grade infection of the tissues left hemiplegia had recovered. During the next five around the left superior orbital fissure, and possibly months the visual acuity of the left eye deteriorated from

leptomeningitis. 6/9 to 6/18. On examination there was left anosmia, on September 28, 2021 by guest. left primary optic atrophy with a paracentral , Case 8.-S. F., a man aged 18, was admitted to Chase and an upper left temporal defect. On April 13, 1944, Farm Hospital from the London Hospital on February the chiasmal region was explored through a left frontal 25, 1942. craniotomy by Mr. Northfield. Where the left optic Six weeks earlier he had developed right frontal nerve entered the optic canal dense, fleshy adhesions headache, with swelling of the right , right ptosis were found, binding down the region of the gyri recti, and double vision. He had a , felt shivery, slept the olfactory tract and the optic nerve to the surface of poorly, and sweated at night. Pyrexia was absent, but the dura mater. The adhesions round the optic nerve he had been treated with sulphonamides. Radiological were divided and the optic canal was decompressed. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.13.3.225 on 1 August 1950. Downloaded from

232 HELEN DIMSDALE AND D. G. PHILLIPS

FIG. 6a (Case 8).-Eroded right optic foramen. FIG. 6b (Case 8).-Contracted right optic foramen (four years later).

Radiological examination in March, 1944, showed tosis. Radiological examination showed some enlarge- Protected by copyright. residual destructive changes on the right side, with ment ofthe right superior orbital fissure but the definition erosion of the lesser wing of the sphenoid (Fig. 7a), of its outer border had improved (Fig. 7b). There was upper border of the optic foramen (Fig. 6a), and no deficiency in the outline of the optic foramina but the enlargement of the superior orbital fissure (Fig. 7a). right (Fig. 6b) was smaller than the left (Fig. 6c). In 1948 the patient was working as a packer. He still Radiological evidence of infection of the right had olfactory hallucinations but no fits. The left optic sinuses was present at the disc was pale and the left visual acuity was 6/12 corrected. maxillary and frontal There was a right secondary optic atrophy with P.L. onset of the illness, though clinical effects were only. The ocular movements were full without prop- probably masked by sulphonamides. http://jnnp.bmj.com/ on September 28, 2021 by guest.

FiG. 6c (Case 8).-Left optic foramen (for comparison). FIG. 7a (Case 8).-Destruction of right lesser sphenoidal wing, and erosion of superior orbital fissure. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.13.3.225 on 1 August 1950. Downloaded from

OCULAR PALSIES WITH NASAL SINUSITIS 2)33 The right second, third, fourth, and sixth cranial The cerebrospinal fluid was normal in pressure and nerves, the fifth to a less extent, and possibly the constituents. Radiographs of the skull and an air ocular sympathetic were involved in the inflam- encephalogram showed no abnormality, but on left matory process at the apex of the orbit. Intracranial carotid arteriography there was delay in the passage complications consisted of uncinate and of the opaque medium above the carotid syphon. attacks Exploration was undertaken to exclude the presence of a later mental changes due to the thickened adherent sphenoidal ridge . dura in the middle and anterior cranial fossee. The On June 5, 1946, a left frontal craniotomy was per- sudden onset of a contralateral hemiplegia suggested formed by Mr. Northfield. No abnormality of the a vascular element in the spread of the disease. brain was found. The dura mater was thickened and reddened at the medial part of the sphenoidal ridge, and there were some fine adhesions between the dura and arachnoid. The day following operation the patient had a number of right-sided fits and became unrousable with a pyrexia of 1010 F. Re-exploration revealed some hxmorrhagic swelling of the brain. The fits continued, and two days later she was still deeply unconscious with a right flaccid hemiplegia. On recovery of consciousness she was aphasic. A month later she had slight dysphasia with increased reflexes in the right upper limb. The ocular signs were unchanged. Radiological examination now showed clearing of the left ethmoidal sinuses. Gradual improvement occurred and by November, 1947, though she complained of diplopia, the left ocular movements appzared full. There was slight proptosis.

The right-sided pyramidal signs had recovered. Protected by copyright. In the absence of clinical evidence of sinus infection, the significance of the radiological findings was uncertain. There appeared to have been sinusitis present shortly after the onset of symptoms, which was more marked on the side of FIG. 7b (Case 8).-Partial regeneration of bone around the affected eye. Oedema of the lids, left proptosis, right superior orbital fissure (four years later). and a partial third and sixth nerve paresis developed slowly. Exploration revealed the presence of Extension of the pachymeningitis to the opposite inflammatory changes on the adjacent to side resulted in involvement of the left optic nerve, the left superior orbital fissure. The post-operative relieved by decompression of the optic canal. The of a sudden right hemiplegia preceded eroded bone round the right superior orbital fissure by right-sided fits was thought to be due to a left and optic foramen re-formed, with contraction of venous thrombosis, though the exposed cortical the optic foramen. The condition was subacute or veins appeared normal. chronic with extension over two years.

Case 10.-S. H., a man aged 41, was admitted to Chase http://jnnp.bmj.com/ Case 9.-Mrs. M. T. was admitted to Chase Farm Farm Hospital on October 15, 1942. Fifteen months Hospital on May 4, 1946. previously he developed pain in the right cheek radiating Fourteen months earlier her left eye had become to the forehead and the back of the neck, also drooping prominent, and about this time she began to see double. of the right eyelid and watering of the eye. Radiological She complained of a dull pain in her temple and a examination of the sinuses four months after the onset feeling of "something pushing" behind the left eye. of the pain had shown thickening of the mucosa of the She had no nasal symptoms. She suffered from maxillary antra. For some months he had vomited recurrent polyarthritis affecting the small joints of the daily, and two weeks before admission he first noticed hands and the knees. Radiographs taken four months double vision. on September 28, 2021 by guest. after the onset of symptoms showed well-marked On examination there was no anosmia. The right changes of maxillary sinusitis, more on the left side, optic disc was pinker than the left. The right pupil and left ethmoidal sinusitis. reacted sluggishly to light and accommodation. There On examination there was no anosmia. The fundi was slight proptosis of the right eye with chemosis of the and pupils were normal. The left upper lid was , and weakness of adduction. Power was cedematous ; the left eye was proptosed downwards diminished in the left upper limb, with exaggeration of and forwards. There was weakness of abduction and the tendon jerks. The blood Wassermann reaction was elevation. The rest of the nervous system was normal. negative. The cerebrospinal fluid was normal in J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.13.3.225 on 1 August 1950. Downloaded from

234 HELEN DIMSDALE AND D. G. PHILLIPS pressure and constituents. Radiological examination of partial recovery occurred in every patient. Taylor the skull and sinuses at this time showed no abnormality (1949) has commented on the high natural resistance apart from some absorption of the dental alveoli. to intracranial infection developing from the sinuses On November 5 and 9, the patient had a series of or middle ear. dental extractions, and after the second operation tl erl r jW eo os developed an external rectus palsy of the right eye. for weeks or months with frontal A right carotid arteriogram showed no abnormality. were present Right frontal craniotomy was performed on November headache, pain behind the eye, and double vision. 21 by D.G.P. to exclude the presence of neoplasm in Paralysis of the external ocular muscles on the the middle cranial fossa. A free exposure of the middle affected side, especially of the elevators and abduc- and anterior cranial fossm showed no abnormality of the tors, developed, sometimes with papilloedema pro- brain or adjacent structures except for a definite bulging ceeding to optic atrophy, and slight hypalgesia in of the lateral wall of the cavernous sinus, suggesting the distribution of the first and second divisions of localized thickening of the dura. the trigeminal nerve. The condition might recover By March, 1943, the ocular movements had improved, spontaneously (Case 6), or after drainage of the but the right eye was still displaced downwards. The patient complained of persistent pain in the right cheek nasal sinuses (Case 5). Intracranial extension and in June, 1943, was readmitted to Chase Farm occurred in four patients (Cases 7, 8, 9, 10) with Hospital. severe trigeminal pain in three (Cases 7, 8 10), Examination on June 30 showed papilloedema of the contralateral pyramidal signs, and in one patient right optic disc. The eye was displaced downwards, (Case 8), uncinate attacks. and there was diffuse swelling of the right upper lid The portal ofentry ofthe infection was speculative and of the outer two-thirds of the superior orbital in five patients (Cases 6, 7, 8, 9, 10). There were no margin. The ocular movements were full apart from symptoms or signs of acute nasal infection, but the right ptosis. On July 22, 1943, the right gasserian onset of double vision in one patient (Case 7) was ganglion was injected with alcohol. Unusually tough with sudden of a chronic resistance was detected on passage of the needle through associated Protected by copyright. the foramen ovale. There was considerable relief of nasal discharge. Radiological evidence of antral pain. Radiological examination in July, 1944, showed a infection was difficult to assess when it consisted of slight haziness of the right maxillary antrum. opacity without a fluid level. All that can be said In May, 1945, the vision of the right eye became misty. is that sinusitis had been present in every patient There was slight papilleedema with reduction of visual at the time of the illness or earlier, and that it acuity to 6/36. The visual field showed a generalized appeared worse on the affected side. Exacerbation peripheral constriction with a central scotoma to 5/2000 of ophthalmoplegia followed dental extraction in white. The vision continued to deteriorate in this eye one patient. and during the next year was reduced to 6/60. The right evidence of infection as shown by an optic disc showed a secondary atrophy. In 1947 the Pathological patient's condition was unchanged. increased sedimentation rate, leucocytosis or changes in the cerebrospinal fluid, was infrequently present. At the time of onset of the right-sided facial pain The inflammatory nature of the lesion was the patient had radiological evidence of maxillary detected by radiological examination or at operation sinusitis which was seen later on the right side only. in four cases. In one patient (Case 7) diagnosis A year later he developed right proptosis and depended on relationship of symptoms to nasal papilloedema, a partial right third nerve paresis, a discharge, the presenice of a raised sedimentation sixth nerve palsy, and pyramidal signs in the left rate and the spontaneous recovery. In one (Case http://jnnp.bmj.com/ upper limb. The sixth nerve palsy may have resulted 10) diagnosis rested on the findings at operation in from dental extraction. At craniotomy the appear- conjunction with the clinical course of the disease ances were suggestive of thickening of the lateral observed over several years. wall of the right cavernous sinus. Right papill- Radiological changes consisted of erosion of bone cedema proceeded slowly to secondary optic atrophy. in the orbital roof (Case 5), destruction of the walls Persistent pain in the distribution of the right of the orbit (Case 6), and of the lesser wing of the trigeminal nerve was relieved by injection of the sphenoid and optic foramen (Case 8). Recovery gasserian ganglion. The dura was abnormally was associated with regeneration of bone, and in on September 28, 2021 by guest. resistant to the passage of the needle. one case with reduction in size of the optic foramen (Case 8). Discussion Craniotomy was performed on three patients. The course of the infection in all these patients In two (Cases 8, 9) pachymeningitis was found in was subacute or chronic. There appeared to be a the region of the sphenoidal ridge and middle high resistance to the infecting organisms, and as cranial fossa. When the infection was prolonged the inflammatory process subsided, complete or over years (Case 8) extension to the opposite side J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.13.3.225 on 1 August 1950. Downloaded from

OCULAR PALSIES WITH NASAL SINUSITIS 235

occurred. Distortion of the wall of the cavernous Whether any degree of sinus or venous thrombosis sinus and toughness of the dura mater at the was present in these patients requires consideration. foramen ovale suggested the presence of thickening The occurrence of multiple cranial nerve palsies in of the dura in a third patient (Case 10). the posterior fossa due to inferior petrosal sinus The diagnosis of a chronic infection in the region thrombophlebitis complicating otitis media has ofthe superior orbital fissure is not easy; air studies, been described by Symonds (l944l, though in an arteriography and exploration may be necessary to earlier discussion of these cases (1927) extradural exclude the presence of other lesions. The idio- inflammation *was postulated. Extensive post- pathic or " rheumatic" form of orbital periostitis mortem studies recorded by Byers and Hass (1933) as described by Collier (1922) was characterized by and Courville and Neilsen (1934, 1935, and 1937) the rapid onset of the ocular palsies, with pain and supported the hypothesis of a thrombophlebitis. proptosis. Recovery was usually complete in a few The multiple cranial nerve palsies in our patients months and intracranial complications did not occur. can be accounted for by the presence of local The production of proptosis and ophthalmo- inflammation in the superior orbital fissure, some- plegia by a non-fistulous carotid aneurysm in the times with osteitis and pachymeningitis. It appears anterior part of the cavernous sinus has been dis- that this fissure may act as a channel for the spread cussed by Jefferson (1938). Pain was sudden in of inflammation into the cranial cavity. In these onset. The ophthalmoplegia tended to be complete patients the nasal sinuses provided a possible site and there was dense anmsthesia of the first and for the origin of the infection. The development of second division of the trigeminal nerve. Godtfred- an external rectus palsy after dental extraction in a sen (1947) considered that and patient with a partial third nerve palsy may have ophthalmoplegia due to penetration of the orbit been due to an extension of the local inflammatory by a nasopharyngeal growth occurred late and was lesion or to a spreading thrombophlebitis from the associated with a poor general state. A meningioma tooth socket. Brain (1947) has described the arising from the medial third of the sphenoidal occurrence of ocular palsies with trigeminal involve- Protected by copyright. ridge may produce proptosis and ophthalmo- ment following extraction of a tooth from the upper plegia, but pressure on the optic nerve usually jaw. results in primary optic atrophy with a nasal The nature of the lesion causing contralateral hemianopia. Hyperostosis of the sphenoidal ridge pyramidal signs in the last four patients was not may be detected on radiological examination. clear. In Case 8 there was evidence at craniotomy Eosinophilic granuloma of bone is a rare lesion of the direct spread of infection in continuity to the occurring mainly in children and adolescents. It brain, but the sudden onset of hemiplegia suggested is considered to be related to Hand-Schuiller- a vascular lesion. Christian disease (lipogranulomatosis), " apparently In Case 9 the patient developed a hemiplegia with represents a peculiar inflammatory reaction to some fits as a post-operative complication. There was as yet unknown agent of infection" (Jaffe and some hemorrhagic swelling of the brain but the Lichtenstein, 1944), and may recover spontaneously. surface vessels appeared normal. In two patients In the calvarium the lesion presents radiologically (Cases 7 and 10) contralateral pyramidal signs as a translucent " punched-out " area. Hill (1949) were detected on clinical examination. In one states that periosteal new bone formation in this was in the lumbar patient (Case 7) blood present http://jnnp.bmj.com/ condition is usually slight and appears to be con- and ventricular cerebrospinal fluids due perhaps fined to the shafts of the long bones. This is in to the presence of vascular congestion from an contradistinction to the well-marked radiological insidious cerebral venous thrombosis. In all these appearances of periosteal new bone formation patients the pyramidal signs disappeared over a during the stage of recovery in two of our patients few months. (Cases 6, 8). Benign giant cell tumour, reviewed by Symonds (1937) described the occurrence of focal McNerney (1949) is another rare lesion which may epilepsy, and hemiplegia (with recovery, and as affect the base of the skull; with other without brain abscess formation) in cases of otitis on September 28, 2021 by guest. this is, untreated, a progressive condition, and the media, and brought clinical evidence for regarding radiological appearance is purely that of bone this as due to thrombophlebitis involving the super- destruction, with a clear-cut edge. In unilateral ficial cerebral veins. The last four cases described exophthalmic ophthalmoplegia and pseudo-tumour here may be comparable, though craniotomy in of the orbit pain is absent. Insidious thrombosis three of them failed to provide visible evidence of of the cavernous sinus is usually associated with venous thrombosis. congestion of the orbital and angular veins and No definite recommendations can be made on the signs of extension to the opposite sinus. treatment of chronic infections in the region of the J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.13.3.225 on 1 August 1950. Downloaded from

236 HELEN DIMSDALE AND D. G. PHILLIPS superior orbital fissure. Sulphonamides and anti- Case 5; to Dr. M. H. Jupe for his reports and review biotics may have an application in the earlier stages of the radiographs, to Dr. J. W. D. Bull for radiographs of Case 5 ; and to Mr. A. Bowen-Davies, Mr G. H. of the infection. Drainage or any other local Howells, and Mr. C. A. Keogh who performed operations treatment of the sinuses is indicated only if an active on the nasal sinuses, for their operative findings. infection persists there. Intracranial exploration may be necessary for diagnosis, but vascular REFERENCES complications may result. Decompression of the Brain, W. Russell (1947). "Diseases of the Nervous optic canal and freeing of meningeal adhesions of System ", 3rd ed. London. P. 156. Byers, R. K., and Hass, G. M. (1933) Amer. J. Dis. the optic nerve may be necessary to arrest the Child., 45, 1161. development of optic atrophy and visual failure. Cairns, H. (1938). Trans. Ophthal. Soc. U.K., 58, 464. Caliceti, P. (1927). Riv. Oto-neuro-oftaim., 4, 419. Summary Collier, J. (1922). In " A Textbook of the Practice of Medicine ", ed. by F. W. Price. 1st ed. London. Ten cases of ocular palsy associated with nasal P. 1284. sinusitis, which fall into two clinical groups, are Courville, C. B., and Nielsen, J. M. (1934). Arch. described. Otolaryng., Chicago, 19, 451. , (1935). Amer. J. Dis. Child., 49, 1. The first group is composed of four patients with Diamant, M. (1937). Acta oto-laryng., Stockh., 25, 550. palsies of one or two ocular nerves associated with Genet, L. (1929). Lyon mid., 143, 738. chronic sphenoiditis, and destruction of bone in the Godtfredsen, E. (1946-7). Proc. R. Soc. Med., 40,131. region of the sella turcica. Recovery and regenera- Hermann, K., and Hall, I. S. (1944). Trans. Ophthal. Soc. U.K., 64, 154. tion of bone followed drainage of the infected Hill, R. M. (1949). Brit. J. Surg., 37, 69. sinuses. Horgan, J. B. (1931). J. Laryng., 46, 542. The second group consists of six patients with Houser, K. M. (1933). Penn. med. J., 36, 411. ocular palsies and signs of a subacute or chronic Jaffe, H. L., and Lichtenstein, L. (1944). Arch. Path., inflammatory lesion in the region of the superior 37, 99. Jefferson, G. (1938). Brit. J. Surg., 26, 267. Protected by copyright. orbital fissure. All showed radiological evidence of (1946-7). Proc. R. Soc. Med., 40, 419. sinusitis on the affected side at some time during Kretzschmar, S., and Jacot, P. (1939). Schweiz. med. their illness. Destruction of bone in the region of Wschr., 20, 1103. McNerney, J. C. (1949). J. Neurosurg., 6, 169. the superior orbital fissure with later recovery of Nielsen, J. M., and Courville, C. B. (1937). Annt. Otol., bone density was demonstrated radiologically in etc., St. Louis, 46, 13. three cases. Involvement of the second and fifth Onodi, A. (1914). Z. Augenheilk., 31, 324. cranial nerves, meninges and cerebrum might occur Onodi, L. (1914). J. Laryng., 29, 304. Redslob, E., and Delbos, R. (1941). Ann. Oculist., in the course of the disease. Paris, 177, 371. Resistance ofthe tissues to the invading organisms Rollet, E. (1933). J. Med. Lyon, 14, 165. appeared high. No deaths occurred. All the Rollet, J., and Parthiot (1929). Lyon med., 143, 825. patients recovered wholly or in part with subsidence Sargnon, (1923). Arch. franco-belges Chir., 26, 944. --, and Parthiot, (1930). Arch. int. Laryng., N.S., 9, of activity over a long follow-up. 703. The diagnosis and treatment are discussed. Sluder, G. (1913). Arch. Laryng. Rhin., 27, 369. (1927). " Nasal , Headaches and Eye Our grateful thanks are due to Mr. D. W. C. Disorders." London. P. 318. Northfield for his helpful advice in the preparation of Stieren, E., and McKee, G. J. (1932). Penn. med. J., this paper, and for permission to publish the records of 36, 84. http://jnnp.bmj.com/ these patients, all of which with the exception of Case 5, Symonds, C. P. (1927). J. Laryng., 42, 656. were under his care. - (1937). Brain, 60, 531. We should also like to express our indebtedness to (1943-4). Proc. R. Soc. Med., 37, 386. Dr. Russell Brain for permission to record cases admitted Taylor, J. (1950). Ibid., 43, 129. to Chase Farm Hospital E.M.S. Neurological Unit, Trantas, A. (1893). Arch. Opthal., Paris, 13, 358. to Dr. S. P. Meadows for cases seen at the Royal London Yaskin, J. C. (1939). Arch. Opthal., Chicago, 21, Ophthalmic Hospital, to Mr. Wylie McKissock for 1010. on September 28, 2021 by guest.

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