Acute cavernous sinus syndrome due to metastatic infiltration of the cavernous sinus and clivus: Unknown primary

Abstract

A 75-year-old Caucasian man presented with a three month history of headaches around the left eye. The pain had now become severe and was associated with diplopia and ptosis of the left eyelid. On examination the patient had left sided 3rd, 4th, 5th and 6th cranial nerve palsies. He then developed severe hearing loss on the left side in a few days. He also had conjunctival oedema and severe left sided facial pain. Interestingly, the patient had presented on two separate occasions over the previous 2 months with frontal headaches, and on each occasion a non-contrast CT head did not show any evidence of a space occupying lesion. Magnetic resonance imaging (MRI) of the orbits and head showed multiple cavernous sinus metastases with clival involvement (Fig. 1). Histology of the lesions showed an undifferentiated carcinoma with differential diagnosis including a primary poorly differentiated sino-nasal carcinoma or metastases from a distant site, including colon, rectum, and prostate etc. Subsequent computerised tomography (CT) scan of thorax, abdomen and pelvis, and whole body bone scan showed multiple pulmonary and sclerotic bony metastases (Fig. 2) with moderately enlarged prostate. His prostate specific antigen (PSA) levels were 12. Following multispecialty team discussions involving oncologists,