A 63-year-old has deep retro-orbital headache, rapidly falling visual acuity and a relative afferent pupillary defect. CT/MRI shows an isolated opacified sphenoid sinus with inflammatory tissue abutting the optic canal and no intracranial mass. What is the best next step?
Visual loss transforms isolated sphenoid opacification from an incidental radiological finding into an emergency requiring drainage, diagnosis and targeted medical therapy.
A. Treat as idiopathic optic neuritis with steroids alone: Steroid without source control may worsen occult infection and delays decompression.
B. Routine outpatient repeat imaging in six weeks: Rapid objective visual decline is time-critical.
C. Urgent endoscopic sphenoidotomy for drainage and tissue sampling with ophthalmology input and antimicrobial treatment: Optic neuropathy adjacent to isolated sphenoid disease requires prompt decompression/source control and histology/microbiology to distinguish infection, fungus and tumour.
D. Optic-nerve sheath fenestration: This treats selected raised intracranial pressure, not a sphenoid source abutting the optic canal.
E. Transcranial biopsy before nasal drainage: An endonasal route directly accesses the diseased sinus with less morbidity.
If vision were normal and imaging showed a small non-expansile retention cyst without bone change, interval observation could be appropriate.
Independent Clinora educational preparation material; not official JCIE content, an accredited programme, or a substitute for local policy and specialist clinical judgement.
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