An 86-year-old female with medical comorbidities including well-controlled type 2 diabetes (HbA1c 5.6 %) on oral therapy and glaucoma who presented with 2 weeks of right ear pain, right frontal headache and right facial pain just lateral to the nose. The patient also described painful extraocular movements (EOMs) on the right, decreased vision, and thick purulent drainage from the right nasal cavity. Vitals were normal with a blood pressure of 132/70, heart rate of 78, respiratory rate of 14, oxygen saturation of 97 % on room air, and temperature of 36.7 degrees Celsius. Examination was significant for hand motion vision, severely restricted right eye EOMs with ptosis, and excyclotorsion. Computerized tomography of the head and orbits demonstrated soft tissue thickening and indistinctness of fat in the region of the right optic canal and right orbital apex, possibly representing extension of paranasal inflammatory disease to an unusual bone defect in the right lateral wall of the right sphenoidal sinus (). Additionally, there was associated right anterior ethmoidal mucosal disease and complete opacification of the right maxillary antrum. Magnetic resonance imaging (MRI) of the brain without and with intravenous (IV) contrast showed right-sided paranasal sinus infection with transsphenoidal phlegmonous extension into the right orbital apex and cavernous sinus consistent with orbital apex syndrome (, ). Ophthalmology and otolaryngology (ENT) were consulted and performed a right endoscopy of the nasal cavities. This revealed purulence from the right middle meatus obstructing the view of the sphenoid. Nasal swab was sent for bacterial culture. Infectious disease was consulted who recommended IV vancomycin, cefepime, and metronidazole in addition to dexamethasone.\nThe patient underwent surgery on hospital day three. ENT completed a broad endoscopic sinus debridement including right total ethmoidectomy, frontal sinusotomy, sphenoidotomy, tissue biopsy, and washout of orbital apex with tissues sent for bacterial and fungal cultures. Tissue from the right naris and right ethmoid sinus grew methicillin-susceptible Staphylococcus aureus (MSSA). Initial pathology at frozen section examination revealed mixed acute and chronic inflammation at all biopsy sites. The patient’s antibiotics were narrowed to IV cefazolin on hospital day 5. On hospital day 6, one colony of Aspergillus fumigatus grew from a culture of the right orbital apex tissue. The pathology revealed fungal hyphae consistent with Aspergillus spp. and related molds, with tissue invasion in the orbital apex (, ). She was started on IV voriconazole. She was discharged to a skilled nursing facility after a 9-day hospital course with antimicrobials including oral cefdinir for a 4-week course and oral voriconazole with a planned treatment course of at least 12 weeks. At two-week follow-up with infectious disease, a repeat MRI brain showed worsening right ethmoid and sphenoid sinus fungal infection. Intravenous caspofungin was added to her regimen for a two-week course of therapy with clinical improvement. She underwent further debridement with rigid endoscopy at two, four, and six weeks after diagnosis with mostly crusted blood products and no evidence of necrotic tissue. Ophthalmologic exam ultimately demonstrated improvement in visual acuity to 20/50 with full EOMs.
A 64-year-old male had experienced a paroxysmal pain in the frontal region and left nose radiating to the occipital region for 7 months. The patient also reported progressive paresthesia on the left cheek and rapidly decreasing visual acuity in the left eye. Neurological examination revealed a left-sided ptosis as the only new finding. Interestingly, body temperature (axillary) fluctuated between 36.1 °C and 38.4 °C. The patient denied a history of other diseases. Physical examination showed no light perception or reflex was detected in the left eye. His pupils were 3 mm on the right and 4 mm on the left. CT showed an isodense lesion in the region of the left cavernous sinus, left orbital apex, left optic nerve canal, and sphenoid sinus. Bone destruction was seen in the left wall of the sphenoid sinus (Fig. a). MRI showed a 33 × 16 mm isointense lesion in both T1WI and T2WI of the left optic canal region and extending into the orbit. Enhanced-MRI showed ring enhancement of the lesion. Lesions with hyperintense T2-weighted signal were seen in paranasal sinuses (Fig. b–d). The patient was self-treated with anti-infectious medication but his headache increased in intensity, frequency, and duration. The patient underwent mass excision of the mass via pterional craniotomy. Cream-like liquid amidst a gray growth was observed in the left cavernous sinus. A biopsy was performed immediately, and histopathologic examination revealed an Aspergillus species (Fig. e). Post-operative images indicated the resection of mass (Fig. f). The patient received voriconazole after surgery. However, he was lost to follow-up.