Management of Unilateral Continuous Headache with Diplopia in a 17-Year-Old with Bilateral Sinusitis
The next best step in management is to complete the planned MRI of the brain with orbit while continuing methylprednisolone treatment, as this combination has already shown clinical improvement and will help rule out serious neurological complications.
Assessment of Current Presentation
The 17-year-old patient presents with:
- Unilateral continuous headache for 21 days
- Diplopia (double vision)
- Photophobia
- No abnormal CNS signs
- CT showing bilateral sinusitis
- X-ray PNS showing less severe findings than symptoms would suggest
- Improvement after just one dose of methylprednisolone
- Normal fundus examination
- MRI brain with orbit already planned
Diagnostic Considerations
Possible Etiologies
- Inflammatory sinusitis with orbital complications
- Orbital inflammatory syndrome secondary to sinusitis
- Intracranial extension of sinusitis
- Idiopathic intracranial hypertension
- Other neurological conditions (meningitis, encephalitis)
Importance of MRI
MRI of the brain with orbit is the optimal imaging modality for this presentation as it provides:
- Superior soft tissue characterization compared to CT 1
- Ability to detect inflammatory changes in the orbit and optic nerve
- Assessment of potential intracranial complications
- Evaluation of the cavernous sinus and other orbital structures
Management Plan
1. Continue Methylprednisolone
- Continue methylprednisolone as started, since clinical improvement has already been observed
- Methylprednisolone is effective for inflammatory conditions affecting the orbit and sinuses 2
- For severe inflammatory conditions, high-dose glucocorticoids (methylprednisolone) are recommended 1
2. Complete the Planned MRI
- Proceed with the planned MRI brain with orbit as soon as possible
- MRI is preferred over CT for evaluating diplopia with suspected orbital or intracranial pathology 3
- Include contrast enhancement to better visualize inflammatory changes
3. ENT Evaluation
- Refer to an ENT specialist for comprehensive evaluation of sinusitis
- Consider functional endoscopic sinus surgery (FESS) if medical management fails 4
- The American Academy of Otolaryngology recommends FESS for patients with chronic rhinosinusitis who have failed appropriate medical management 4
4. Ophthalmology Consultation
- Arrange ophthalmology consultation for detailed assessment of diplopia
- Complete eye movement examination to determine specific pattern of diplopia
- Assess for other ocular manifestations that may require specific treatment 1
Treatment Considerations
Corticosteroid Therapy
- Continue methylprednisolone as it has shown clinical improvement
- For severe inflammatory conditions, a typical regimen includes:
- Initial high-dose methylprednisolone (1 mg/kg/day)
- Gradual taper over 2-3 weeks based on clinical response 2
- Monitor for steroid-related side effects, especially in an adolescent
Antibiotic Therapy
- Consider broad-spectrum antibiotics if bacterial sinusitis is suspected
- First-line treatment for bacterial sinusitis includes amoxicillin-clavulanate or high-dose amoxicillin 4
- Add intranasal corticosteroids and saline irrigations as adjunctive therapy
Follow-up Plan
- Reassess after MRI results are available
- Monitor for improvement in headache, diplopia, and photophobia
- If symptoms persist despite treatment, consider additional investigations:
Potential Complications to Monitor
- Orbital complications (cellulitis, abscess)
- Intracranial complications (meningitis, abscess)
- Cavernous sinus thrombosis
- Optic nerve involvement
Key Points
- The combination of unilateral headache, diplopia, and photophobia with sinusitis requires thorough evaluation
- MRI is essential to rule out serious neurological complications
- Continuing methylprednisolone is appropriate given the positive initial response
- A multidisciplinary approach involving ENT and ophthalmology is important for comprehensive management