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Diplopia, Ptosis, and Drooling in an 80-Year-Old Woman

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

An 80-year-old woman presented to the emergency department with sudden-onset bilateral horizontal diplopia accompanied by left-sided upper eyelid ptosis. On further questioning, she reported a 1-week history of drooling when eating. She had no other associated neurological or constitutional symptoms. No anhidrosis was noted. Her medical history was significant for a 2-year history of constant, dull, left-sided facial pain diagnosed as trigeminal neuralgia by her treating neurologist and moderately improved with gabapentin and nortriptyline. Recent computed tomography (CT) of the brain, conducted as part of her headache workup, had been reported as normal.

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Trigeminal schwannoma involving left cavernous sinus and the Meckel cave

C. Obtain magnetic resonance imaging of the brain with contrast

This patient’s abnormalities comprise left sixth nerve palsy with ipsilateral Horner syndrome and trigeminal nerve palsy. This process localizes to the left cavernous sinus where the sixth nerve, trigeminal nerve, and sympathetic fibers travel in proximity: third-order sympathetic fibers from the hypothalamus exit the internal carotid artery adventitia and pass alongside the sixth nerve as it courses through the cavernous sinus. The trigeminal ganglion is located in the Meckel cave, a dura-lined cavity lateral to the cavernous sinus, where the peripheral trigeminal divisions originate. Divisions V1 and V2 are pure sensory nerves, whereas V3 also carries motor nerves involved in mastication, explaining impaired chewing and drooling in this patient. All 3 divisions enter the cavernous sinus after exiting the Meckel cave. While brainstem lesions can cause multiple cranial neuropathies, slow progression of symptoms without accompanying neurological deficits make this unlikely in this case.

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Article Information

Corresponding Author: Edward Margolin, MD, 800 Eglinton Ave W, Ste 301, Toronto, ON M5N 1G1, Canada (edward.margolin@uhn.ca).

Published Online: October 7, 2021. doi:10.1001/jamaophthalmol.2021.0691

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

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