An Interesting Case of Bilateral Abducens Nerve Palsy Secondary to Large Sphenoid Mucocele

To report a rare case of bilateral large sphenoid mucocele presenting with cranial neuropathies. A 77 year old female presented to ophthalmology OPD with chief complaints of headache since 4 months, double vision and restricted movements in the right eye since 4 months, on examination the patient was diagnosed to have bilateral lateral rectus palsy and underwent CECT PNS which showed the sphenoid sinus to be expanded and completely filled with non enhancing low attenuation material suggestive of mucocele and was impinging on bilateral optic canal with posterior displacement of pituitary gland. The patient was then referred to Oto-rhino-laryngology department for further management. Diagnostic nasal endoscopy did not reveal any positive findings. Ophthalmology examination revealed bilateral lateral rectus palsy and restriction of extraocular movements on abduction. The patient underwent FESS under GA and intra-operatively there was a bulge seen in the sphenoethmoidal recess on the left anterior wall of the sinus which was debrided, gush of purulent material was seen. The sinus was cleared. Similarly opposite side sphenoid sinus was opened and cleared. Wide sphenoidotomy and posterior septectomy was done. Dehiscent pituitary gland and lateral wall seen. Post operatively patient got relieved of headache, diplopia and showed improvement in lateral rectus paresis. Mucoceles of the sphenoid sinus are a very rare with variable clinical presentation. Imaging play a crucial role in diagnosis and early surgical intervention is vital to avoid complications. Endonasal endoscopic approach is the preferred line of management.