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Table of Contents    
LETTER TO EDITOR
Year : 2016  |  Volume : 64  |  Issue : 6  |  Page : 1316-1318

Hypoglossal palsy in a case of cavernous sinus thrombosis


1 Department of Cardiology, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Medicine, PGIMER and Dr. RML Hospital, New Delhi, India

Date of Web Publication11-Nov-2016

Correspondence Address:
Gopal C Ghosh
Department of Cardiology, Christian Medical College, Vellore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.193802

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How to cite this article:
Ghosh GC, Sharma B. Hypoglossal palsy in a case of cavernous sinus thrombosis. Neurol India 2016;64:1316-8

How to cite this URL:
Ghosh GC, Sharma B. Hypoglossal palsy in a case of cavernous sinus thrombosis. Neurol India [serial online] 2016 [cited 2019 Sep 20];64:1316-8. Available from: http://www.neurologyindia.com/text.asp?2016/64/6/1316/193802


Sir,

Cavernous sinus thrombosis is a rare though potentially fatal condition. Sometimes it may occur as a serious complication secondary to an invasive fungal disease. It requires an early initiation of treatment and a high index of suspicion for diagnosis. Patients may present with fever, headache, nausea and vomiting, proptosis, chemosis, ophthalmoplegia, papilledema, diplopia, and mental status changes. However, cranial nerve involvement other than 3rd, 4th, 5th, and 6th is rare in literature. Thus, we report a case of cavernous sinus thrombosis caused by invasive aspergillosis presented with an atypical involvement of cranial nerves 7th and 12th.

A 16-year-old girl presented with complaints of fever for 5 days and headache for 5 days, which was radiating from the occipital to the frontal region and not resolving with analgesics. She also had redness and swelling of both the periorbital regions with diplopia in bilateral horizontal gaze. She was not a known case of diabetes mellitus. On examination, the patient was irritable, her blood pressure was 116/78 mmHg, the pulse was 104/min, and she had raised oral temperature (102°F). Ophthalmological examination revealed redness and swelling around both the periorbital regions, with near complete restriction of movements of both the eyeballs. She, however, had normal acuity of vision with a normal pupillary function. Other cranial nerve examinations were within normal limits. A provisional diagnosis of cavernous sinus thrombosis was considered and she was immediately started on intravenous antibiotics and subcutaneous low molecular weight heparin. The initial blood investigations revealed a hemoglobin of 11.6 gm%, total leucocyte count of 30,000/cumm with a shift towards the left and a platelet count of 1.9 lakh/cumm. Liver function tests, kidney function tests, and serum electrolytes were within normal limits. A computed tomography (CT) scan revealed features suggestive of cavernous sinus thrombosis with bilateral maxillary sinusitis. After the initial 48 hours of treatment, the patient's symptoms did not improve significantly, and a repeat clinical examination revealed a left-sided facial nerve palsy [Figure 1] with a right-sided hypoglossal nerve palsy [Figure 2]. The blood culture revealed growth of Aspergillus flavus. Scraping from bilateral maxillary sinuses also revealed growth of  A.flavus Scientific Name Search  sensitive to amphotericin B. Magnetic resonance imaging (MRI) of the brain with MR venography revealed thrombosis of bilateral cavernous sinus [Figure 3], with thrombosis of the left transverse sinus [Figure 4] with bilateral preseptal and postseptal orbital cellulitis. However, MRI of the brain did not reveal any meningeal enhancement, and the brain parenchyma and the brain stem were within normal limits. She clinically responded to injection Amphotericin B.
Figure 1: Photograph of the patient showing loss of left nasolabial fold with deviationof angle of mouth towards the to right side suggestive of left facial nerve palsy

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Figure 2: Photograph of the patient showing deviation of the tongue to the right side suggestive of right hypoglossal nerve palsy

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Figure 3: Magnetic resonance imaging of the brain showing bilateral internal carotid arteries (red arrow) and filling defects (blue arrow) in bilateral cavernous sinuses suggestive of cavernous sinus thrombosis

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Figure 4: Magnetic resonance venography showing narrowing of the left transverse sinus (red arrow) suggestive of transverse sinus thrombosis

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Cavernous sinus thrombosis usually involves 3rd, 4th, 6th, and branches of 5th cranial nerves.[1] Facial nerve palsy [2] has also been reported in literature with cavernous sinus thrombosis. However, our patient was unique in the following aspects; first, she had both facial and hypoglossal nerve palsy, which has still not been reported in the literature. Second, she was immunocompetent but still had disseminated fungal central nervous system infection. Third, although the infection was caused by fungus, the presentation was acute, thus mimicking a pyogenic pathology.

Cavernous sinus is a narrow compartment bounded by a rigid dural envelope. With increasing pressure, venous drainage from the nerves is impeded, with precipitation of nerve paresis.[3] With increasing pressure, the arterial supply to the nerves is interrupted with consequent development of complete nerve deficit. Carotid artery stenosis has also been described in relation to cavernous sinus thrombosis because of involvement of the cavernous carotid artery by the inflammatory process within the cavernous sinus.[4] This can lead to a stroke and consequently, hemiparesis. Our patient had thrombosis of bilateral cavernous sinus and left transverse sinus, which was causing venous stasis of the draining veins, thus leading to 7th and 12th cranial nerve palsy.

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  References Top

1.
The Cavernus Sinus. A Comprehensive Test. In: Eisenberg MB, Al-Metty O. Philadelphia: Lippincott Williams & Wilkins; 2000. p. 339-53.  Back to cited text no. 1
    
2.
Ramanand Y, Sidhu TS, Jaswinder K, Sharma N. An atypical presentation of cavernous sinus thrombosis. Indian J Otolaryngol Head Neck Surg2007;59:163-5.  Back to cited text no. 2
    
3.
Kuehnen J, Schwartz A, Neff W, Hennerici M. Cranial nerve syndrome in thrombosis of the transverse/sigmoid sinuses. Brain 1998;121:381-8.  Back to cited text no. 3
    
4.
Jones TH, Bergvall V, Bradshaw JP. Carotid artery stenoses and thrombosis secondary to cavernous sinus thromboses in Fusobacterium necrophorum meningitis. Postgrad Med J 1990;66:747-50.  Back to cited text no. 4
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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