• headache
• ENT
• surgery

A 58-year-old immunocompetent woman gave a 2-week history of headache, facial pain and fever, without photophobia, nausea or vomiting. Initially, the pain was left-sided retrobulbar and radiated to the vertex. It was dull and intermittent without postural variation but progressively intensified, becoming more constant with nocturnal interference. The pain gradually extended bilaterally to the cheeks, maxillae and frontoparietal regions while remaining predominantly left-sided. Two days before assessment, she had developed horizontal diplopia on left lateral gaze. On examination, her temperature was 38.5°C, and there was limited left eye abduction consistent with left sixth nerve palsy. Her other cranial and peripheral nerve function, ears, nose and throat were normal with no signs of meningeal irritation. Blood tests (including blood cultures) were negative. CT scan of the head identified left sphenoid sinus opacification (figure 1A,B; black arrows) with …