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Clinical Challenge
June 2017

A Young Man With Proptosis Causing Decreased Visual Acuity

Author Affiliations
  • 1Department of General Surgery, American University of Beirut Medical Center, Beirut, Lebanon
  • 2Diagnostic Imaging & Radiology, Children's National Health System, Washington, DC
  • 3Division of Otolaryngology, Children's National Health System, Washington, DC
JAMA Otolaryngol Head Neck Surg. 2017;143(6):623-624. doi:10.1001/jamaoto.2016.3691

A teenage boy was referred with a progressive 2-week history of blurred vision in his right eye and right ear pain, which had worsened in the past 7 days. This change prompted a visit to an optometrist, who found a mild decrease in visual acuity and minor cataract in the right eye. His primary care physician diagnosed his ear pain as acute otitis media and prescribed a course of amoxicillin-clavulanate; however, the young man’s vision continued to deteriorate and became associated with the onset of right eye swelling and forehead tenderness. A repeat eye examination by an ophthalmologist was performed and showed normal peripheral visual acuity with a decrease in central vision and confirmed proptosis. The patient had not experienced nasal congestion, epistaxis, weight loss, fevers, or chills. Physical examination included right eye proptosis and restricted eye movement. A computed tomographic (CT) scan with contrast of the face showed a small relatively homogenous mass in the right anterior nasal cavity invading the right orbit, and a magnetic resonance image (MRI) with contrast showed a right superior nasal cavity mass, with invasion of the right orbit and right ethmoidal sinus with extension to the overlying soft-tissue scalp (Figure). A 30° endoscope was used to visualize the superior nasal cavity and revealed a fleshy red soft-tissue mass. Several biopsy specimens were taken and sent for frozen pathologic evaluation.

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