Cavernous Sinus Mass Causing Right 3rd and 4th Nerve Palsies

𝗢𝗿𝗶𝗴𝗶𝗻𝗮𝗹 𝗗𝗲𝘀𝗰𝗿𝗶𝗽𝘁𝗶𝗼𝗻: 25-yo-man who complained of diplopia and was initially found to have right 4th and 6th nerve palsies in the setting of a right cavernous sinus mass (subsequently diagnosed as Ewing's sarcoma). When seen in follow-up (this video), there was a new right 3rd nerve palsy, still with a right 4th nerve palsy, and improved 6th nerve palsy. Video shows right 3rd and 4th nerve palsies (very mild 6th nerve palsy too) in the setting of a right cavernous sinus syndrome. In downgaze OD, there is no clear incyclotorsion of the eye, suggesting that the right 4th nerve is involved. 𝗡𝗲𝘂𝗿𝗼-𝗼𝗽𝗵𝘁𝗵𝗮𝗹𝗺𝗼𝗹𝗼𝗴𝘆 𝗮𝗻𝗱 𝗡𝗲𝘂𝗿𝗼-𝗼𝘁𝗼𝗹𝗼𝗴𝘆 𝗧𝗲𝘅𝘁𝗯𝗼𝗼𝗸 𝗟𝗲𝗴𝗲𝗻𝗱: This patient had a known right cavernous sinus mass due to Ewing's sarcoma, and presented with diplopia. He had a right 3rd NP, right 4th NP, and mild right 6th NP. This video demonstrates that in addition to the right 3rd (ptosis, mydriasis, impaired adduction, supra- and infraduction), in downgaze, there is no clear incycloduction of the right eye, suggesting that the right 4th nerve is also involved. This is a subtle sign, but should be sought since a 3rd NP + an ipsilateral 4th NP is suggestive of a cavernous sinus localization. https://collections.lib.utah.edu/ ark:/87278/s6186g5w