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Patient of The Month

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

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  1. Patient of The Month Bakhshaee M, MD Rhinologist Azar 1388

  2. Presentation • 45 man complain from diplopia and headache

  3. 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

  4. 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

  5. Paraclinic Lab Imaging • CBC: Ok • FBS: Ok • Biochemistry : Ok • Conventional • CT Scan • MRI

  6. CT Scan

  7. MRI

  8. Next Step?

  9. What is the Best? • Diagnostic Endoscopy • Angiograghy • Theraputic Endoscopy

  10. Diagnostic Endoscopy

  11. Diagnosis • Chordoma

  12. Management • Surgery • Radiotherapy • Chemotherapy

  13. Isolated Sphenoid Sinus Disease

  14. 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.

  15. Classification • Isolated sphenoid sinus disease can be broadly divided • Inflammatory • Neoplastic • Miscellaneous categories

  16. Inflammatory lesions • Sinusitis • Acute • Chronic • Fungal infections • Invasive: Mucormycoses, disseminated Aspergillosis • Noninvasive: Mycetoma, Aspergilloma • Mucoceles • Pyoceles

  17. Neoplastic lesions 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

  18. Miscellaneous • Cerebrospinal leaks • Traumatic • Spontaneous • Encephaloceles

  19. Clinical signs and symptoms • 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

  20. Evaluation • CT Scan: • Air-fluid level • Acute & Chronic sinusitis • Polyp • Aneurism • Thining & Expansion • Mucocel • tumor • Sclerosis • Fungal • Fibroossous • Bone erosion • Malignant Tumor

  21. Chordomas • 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

  22. Symptoms • 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

  23. Evaluation • 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

  24. Management • Current and historical management of skull base chordomas has involved : • Surgical excision • Radiation therapy • Both

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