Pediatric tonsillectomy with adenoidectomy is one of the most common surgical procedures in the field of otolaryngology. The postoperative morbidity results largely from pain and hemorrhage.1,2 Neurological complications of this procedure are rare but likely underdiagnosed and include the glossopharyngeal, hypoglossal, and recurrent and additional nerve lesions followed by facial and lingual nerve lesions.1 Most of these were a transient and reversible nerve dysfunction.1 However, there has been no report of oculomotor nerve palsy, especially with pupil involvement. We describe a child who developed pupil-involving partial oculomotor palsy following adenotonsillectomy.
A 6-year-old boy was referred for sudden onset of abnormal eye movements and vertical diplopia that developed immediately after the surgery. He underwent tonsillectomy, adenoidectomy, and inferior turbinate reduction for recurrent tonsillitis, persistent allergic rhinitis, and obstructive sleep apnea. He also complained of left eye pain and periorbital numbness. He had mild ptosis in the left eye, but his preoperative photographs indicated that it was upper eyelid crease asymmetry.
On examination, his corrected visual acuity was 20/20 in each eye. His left eye did not elevate and depress in all directions. The prism and alternate cover test revealed a left hypotropia of 12 prism diopters (PD) in the primary position, increasing to 30 PD in up gaze, and left hypertropia of 35 PD in down gaze (Figure 1A). The left pupil was dilated and responded poorly to light and accommodative stimuli (Figure 1B). The fundus examination showed intorsion of the left eye, but the remaining results were normal (Figure 1C).
Initial presentation on the day of surgery. (A) Gaze photographs show the prominent limitation of supraduction and infraduction in the left eye. (B) Slit-lamp photographs show left mydriasis. (C) Fundus photographs show intorsion in the left eye.
There were no abnormal findings on the neurologic examination. Orbit and brain magnetic resonance imaging showed a diffuse increased T2 hyperintensity in the sphenoid and cavernous sinus expanding to the left orbit apex, suggesting a hemorrhagic mass effect and mild infraposition of the cerebellar tonsil that did not meet the criteria for Chiari malformation (Figure 2). He received one intravenous injection of 250 mg of methylpredniso-lone per day for 3 days, which was followed by tapering of oral prednisone during the next 3 weeks.
(A) Brain magnetic resonance imaging at presentation. (B) Axial T1-weighted images with gadolinium enhancement and fat suppression show isointense to hyperintense lesions in the sphenoid and cavernous sinus expanding to the left orbit apex, suggesting postoperative hematoma (arrows). (C) Axial T2-weighted image shows heterogeneous hyperintensity in the same lesion (arrow). (D) Sagittal T1-weighted image shows mild infraposition of cerebellar tonsil below the foramen magnum.
Six weeks after the initial presentation, the patient's ocular movement was restored completely but his left pupil remained moderately dilated. He also complained of blurring vision in the left eye when reading a book, which improved with hyperopic correction of +1.25 diopters and resolved 15 months after the initial presentation. He did not show any aberrant regeneration during 3 years of follow-up.
Oculomotor nerve palsy is rare in children.3,4 The most common cause of pediatric oculomotor nerve palsy is congenital.3 However, it can occur as a result of trauma, infection, inflammation, neoplasm, or neurosurgery.3,4 Acquired oculomotor palsy with pupil involvement often presents as a form of complete palsy secondary to trauma, after neurosurgery, or compression from neoplasm or aneurysm.5 However, in the current study, the patient presented with pupil-involving partial oculomotor palsy that did not affect the medial rectus or levator palpebrae superioris muscles. Inferior oblique involvement was presumed by intorsion in the fundus. Sparing the medial rectus muscle among those innervated by the inferior division of oculomotor nerve is difficult to explain topographically; however, based on the imaging findings, this partial oculomotor nerve palsy can be attributed to the lesions in the cavernous sinus and left orbital apex.
Adenoidtonsillectomy is one of the most frequently performed operations in children. Neurologic complications following this procedure are uncommon.1,6,7 In terms of ocular complications, 5 cases of vision loss and 14 cases of Horner's syndrome have been reported.1,6 In addition, nystagmus was reported as a part of medullary injury.7 However, isolated ocular motor problem has not been reported in the literature.
During adenoidectomy under general anesthesia, the patient's neck is extended in the “Rose” position to expose the adenoid.7 In an attempt to reduce bleeding and postoperative pain, an injection of vasoconstrictors and local anesthetics into the surgical site is often performed during the surgery.8 Hypoperfusion caused by the hyperextension of the neck, infiltration of local anesthesia, postoperative hematoma or abscess compressing the nerve, and direct injury to the nerve were postulated as the cause of neurological complications.1,6,7 In addition, a cadaver study showed the rich valveless anastomoses between the retropharyngeal and subarachnoid veins.9 Because local drugs were not used in our patient, the bleeding reflux into the sphenoid sinus and cavernous sinus through the opening of sphenoid sinus and retropharyngeal vein could explain this neurologic complication.
To our knowledge, this is the first reported case of pupil-involving oculomotor nerve palsy developing after adenotonsillectomy with turbinate reduction. The close anatomical relationship between the adenoid and the cavernous sinus puts the cranial nerve pathway in the cavernous sinus at risk during this surgery. This case report highlights a rare complication of a common surgery. Ophthalmologists should be aware of the possibility of oculomotor nerve palsy after adenotonsillectomy.
- Windfuhr JP, Schlöndorff G, Sesterhenn AM, Kremer B. From the expert's office: localized neural lesions following tonsillectomy. Eur Arch Otorhinolaryngol. 2009;266(10):1621–1640. doi:10.1007/s00405-009-0910-2 [CrossRef]19184078
- Yuen SN, Leung PP, Funamura J, et al. Complications of turbinate reduction surgery in combination with tonsillectomy in pediatric patients. Laryngoscope. 2017;127(8):1920–1923. doi:10.1002/lary.26421 [CrossRef]
- Schumacher-Feero LA, Yoo KW, Solari FM, Biglan AW. Third cranial nerve palsy in children. Am J Ophthalmol. 1999;128(2):216–221. doi:10.1016/S0002-9394(99)00128-2 [CrossRef]10458179
- Park KA, Oh SY, Min JH, Kim BJ, Kim Y. Acquired onset of third, fourth, and sixth cranial nerve palsies in children and adolescents. Eye (Lond). 2019;33(6):965–973. doi:10.1038/s41433-019-0353-y [CrossRef]
- Fang C, Leavitt JA, Hodge DO, et al. Incidence and etiologies of acquired third nerve palsy using a population-based method. JAMA Ophthalmol. 2017;135(1):23–28. doi:10.1001/jamaophthalmol.2016.4456 [CrossRef]
- Topcu-Yilmaz P, Kutluk S, Onder F. Horner syndrome as a rare complication of radiofrequency tonsil ablation. J Pediatr Ophthalmol Strabismus. 2018;55:e14–e15. doi:30074605
- Kang PB, Phuah HK, Zimmerman RA, et al. Medial medullary injury during adenoidectomy. J Pediatr. 2001;138(5):772–774. doi:10.1067/mpd.2001.111326 [CrossRef]11343061
- Park AH, Pappas AL, Fluder E, et al. Effect of perioperative administration of ropivacaine with epinephrine on postoperative pediatric adenotonsillectomy recovery. Arch Otolaryngol Head Neck Surg. 2004;130(4):459–464. doi:10.1001/archotol.130.4.459 [CrossRef]15096431
- Isaacson G, Parke WW. Meningitis after adenoidectomy: an anatomic explanation. Ann Otol Rhinol Laryngol. 1996;105(9):684–688. doi:10.1177/000348949610500903 [CrossRef]8800053