Objective:

NA

Background:

Headaches account for approximately 3% of emergency room encounters in the US, with nearly half of patients getting a head CT as part of the initial workup. Isolated sphenoid sinusitis (ISS) is a rare but important diagnosis, making up about 1–3% of all sinus infections. ISS usually presents with headaches that are poorly localized and often resistant to typical headache treatments. This can lead to misdiagnosis as a primary headache disorder. Due to the close proximity of the sphenoid sinus to critical neurovascular structures, early recognition and imaging are important to prevent serious complications such as cranial neuropathies, cavernous sinus thrombosis, intracranial abscess, or meningitis.

Design/Methods:

NA

Results:

A 17-year-old male with a history of allergic rhinitis presented with acute right occipital headache and fever following minor head trauma. His neurological exam was normal, with no focal findings or meningeal signs. Initial evaluation revealed leukocytosis and CT showed ISS. CSF indices were consistent with meningitis and beta-2 transferrin from nasal drainage was elevated, suggestive of a CSF leak. MRI later identified a large clival/sellar mass. The patient’s symptoms improved with empiric broad-spectrum antibiotics, and multidisciplinary management including neurosurgery and endocrinology was initiated for further evaluation and treatment of the skull base lesion.

Conclusions:

In this case, standard 5-mm CT head slices missed the clival/sellar mass, but the incidental finding of ISS led to an MRI brain that later revealed a lactotroph adenoma. The patient’s long-standing “allergic rhinitis” was later recognized as CSF rhinorrhea that had been therapeutically relieving intracranial pressure for a year. Following minor trauma, the CSF drainage was abruptly blocked, leading to an acute severe headache prompting the hospitalization. This case highlights how subtle historical clues and incidental findings on, at times, low-yield imaging, can uncover serious secondary causes of headache that might otherwise be missed.