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Clinical Challenge
January 2019

A Destructive Sinonasal Process Leading to Sudden Blindness

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
JAMA Otolaryngol Head Neck Surg. 2019;145(1):83-84. doi:10.1001/jamaoto.2018.2580

A woman in her 70s with a history of pulmonary embolism presented to the emergency department with acute right eye vision loss. She described a 2-week medical history of diplopia and blurry vision as well as 4 months of nasal congestion and progressive headaches despite multiple antibiotic courses. She denied a medical history of sinonasal issues, immunodeficiency, autoimmune disease, malignant disease, or diabetes.

On examination, she was afebrile with stable vital signs. Ophthalmologic evaluation revealed a right afferent pupillary defect and cranial sixth-nerve palsy. Computed tomographic and magnetic resonance imaging of the sinuses revealed abnormal soft tissue throughout her sinuses with destruction of the sinus walls and skull base as well as extension of abnormal appearing tissue into the right orbital apex and posterior nasal septum. Laboratory evaluation demonstrated a normal white blood cell count and an elevated erythrocyte sedimentation rate and C-reactive protein level. Nasal endoscopy showed bloody mucus and crusting around the right middle turbinate and sphenoethmoidal recess.