Intraorbital Region Research Articles

Case Series on Imaging Features of Trilateral and Quadrilateral Retinoblastoma: What Radiologists Need to Know

Objective: To identify the differences between trilateral and quadrilateral retinoblastoma based on radiologic imaging.Case: We found three cases of retinoblastoma at Sanglah General Hospital. The retinoblastoma patients we found were boys under the age of 5. The first patient presented with swelling, pain, and impaired vision in the right eye. The second and third patients presented with eye protrusion and leukocoria. Computed tomography (CT) imaging revealed a calcified mass in the intraorbital region that extended to the cerebral hemispheres. It may be accompanied by hair-on-end periosteal reaction. In the first patient, the mass extended to the pineal gland. In the second and third patients, the mass extended to the suprasellar and pineal regions. Trilateral retinoblastoma consists of a primordial midline neuroectodermal tumor that originates in the pineal or suprasellar region. It is an uncommon combination of unilateral or bilateral retinoblastomas. Quadrilateral retinoblastoma, on the other hand, presents with bilateral retinoblastoma and tumors in both the suprasellar and pineal regions. The histopathology of trilateral and quadrilateral retinoblastoma shows a different pattern from retinoblastoma.Conclusion: Retinoblastoma poses one of the most challenging problems due to its distinct patterns of growth, extension, and recurrence. Intracranial metastasis of trilateral and quadrilateral retinoblastoma exhibits a different pattern. The prognosis and diagnosis of retinoblastoma are significantly influenced by clinical examination, radiologic imaging, and histopathology.

Clinical characteristics depending on magnetic resonance imaging patterns in idiopathic isolated optic neuritis

To investigate differences in clinical features based on magnetic resonance imaging (MRI) in idiopathic isolated optic neuritis patients. We retrospectively analyzed 68 eyes of 59 patients diagnosed with optic neuritis and showed inflammatory findings indicative of optic neuritis on MRI. We investigated clinical features, such as the presence of accompanying pain, visual acuity, and optic disc swelling. Optic disc swelling was classified as normal, mild, or severe. The MRI results were divided into intraorbital, intracanalicular, and whole optic nerve according to the lesion, and these were compared and analyzed with clinical features. The study included 29 men and 30 women, with a mean age of 42.6 ± 16.6 years. Among 59 patients, 48 (81.4%) complained of pain. Optic disc swelling was not observed in 48.5% of patients (33 eyes). Inflammatory changes were the most common in the intraorbital region (33 eyes), intracanalicular region (20 eyes), and the entire optic nerve (15 eyes). There was no statistical difference in the pain pattern according to the location of the lesion (p = .677), but when inflammation was present in the entire optic nerve, optic disc swelling was severe (p = .023). The initial and final visual acuity did not significantly correlate with the MRI pattern, presence of pain, or optic disc swelling (p = .156, p = .714, and p = .436). The MRI contrast enhancement pattern was associated with optic disc swelling but was not associated with pain or initial visual acuity. It should be noted that it is insufficient to judge the clinical features of optic neuritis based on MRI findings.

Extracranial Schwannomas of the Head and Neck: A Literature Review and Audit of Diagnosed Cases Over a Period of Eight Years.

Schwannoma is a benign, slow growing, usually solitary and encapsulated tumor derived from Schwann cells of the nerve sheath. Schwannomas can be divided into central, or intraosseous, and peripheral lesions. The etiology is unknown, but it is postulated that lesions arise by the proliferation of Schwann cells at one point inside the perineurium. Schwannomas may mimic other diseases of the head and neck, such as infection, tumor ormetastasis. Extracranial schwannomas are rare; in this study we review a series of 22 cases of schwannomas originating in the head and neck region over a period of eight years. All tumors were benign and well-encapsulated. Tumor size ranged from 0.5 to 9cm.The age range of patients studied was 15-74years with a mean age of 35 yearsand a male predilection (M:F, 2.6:1)was noted. Four cases ofschwannomas occurred in thetongue (18.18%)and lower lip(18.18%), three in the nasal cavity(13.64%), twoeach (9.09%)in thebuccal mucosa, parapharyngeal space(9.09%), and eyebrow(9.09%), and one eachin the upper lip(4.55%), lateral canthus of the eye(4.55%), intraorbital region(4.55%), submandibular gland(4.55%), and ear(4.55%). Schwannomas can present in a wide variety of sites within the head and neck. The tumor is benign and tend to be asymptomatic for long periods of time. Histopathology is the gold standard for diagnosis.Our study describes the clinicopathologic features of extracranial head and neck schwannomas, highlights the histopathologic features, and discusses pertinent findings with correlation to the present literature. It is important that both clinicians and pathologists be familiar with theuncommon sites of occurrenceand the potential pitfalls associated with the diagnosis and management of these tumors.

Tension Pneumocephalus Unexpected Complication Following Lumbar Disc Surgery

Pneumocephalus (PNC) is termed as an abnormal air presence in the cranium. PNC is a well-known complication of epidural and spinal anesthesia but it develops rarely after spinal surgery for lumbar disc herniation. A 67-year-old female patient was presented to the emergency department (ED) with diffuse non-localized headache and change in mental status. Non-contrast brain-computed tomography scans revealed massive PNC in the frontotemporal fossa and intraorbital region. The patient was transferred to the neurosurgery intensive care unit for clinical observation. Among patients admitted to the ED in the early period after spinal surgery; PNC should be considered in the differential diagnosis if there is persistent headache and confusion.

Optic glioma in children: Turkish experience.

e14042 Background: Optic gliomas are the most common tumors of the optic pathway, comprising about 1% of all intracranial tumours. Here we present the clinical characteristics and the outcome of patients with optic glioma at our institution. Methods: Seventy two patients diagnosed and followed up at a pediatric cancer center in Ankara, Turkey between January 1, 2008 and December 31, 2020 were included in this analysis. The clinical features and outcome of patients were recorded from patient files and hospital information system retrospectively. Results: The median age at the time of diagnosis was 3.5 years (4-157 months), the female/male ratio was 1.3. Fourteen children (19%) were asymptomatic and tumors were detected with routine surveillance, and 58 (81%) had symptoms (the most common being proptosis in 16 patients (22%)). The most common site of optic glioma was the intraorbital region (31%). Fourty patients (55%) had neurofibromatosis type 1 (NF-1). Five patients had histopathological diagnoses; 3 pilomyxoid astrocytoma, 2 pilocytic astrocytoma. Children were treated if they had tumor progression on MRI and/or worsening visual acuity. Twenty seven (38%) children were observed without any therapy, 6 patients (8%) received radiation and chemotherapy, 4 patients (5%) received radiation only, and 35 patients (49%) received chemotherapy only. Treatment regimens for the 41 children who received chemotherapy included carboplatin/etoposide (17), cisplatin/etoposide (18), carboplatin/vincristine (5), and temozolomide (1). The 5-year progression-free survival (PFS) and overall survival (OS) were 64% and 90%, respectively with a 31 month median follow-up. The 5 year PFS was significantly lower in patients with optic tract-hypothalamic-chiasmatic involvement (34%) than orbital involvement (83%) (p=0.013). Five year PFS was significantly higher in patients with NF-1 (80%) than patients without NF-1(46%) (p=0.027) and significantly lower in patients diagnosed at <3 years old (37%) (p=0.05). Five patients died of disease, and one died of infection after chemotherapy. Two patients treated with platin (1 carboplatin, 1 cisplatin) developed ototoxicity. One patient with NF-1 developed Moya-Moya disease. Two patients developed multiple pituitary hormone deficiencies and one patient developed precocious puberty during follow-up. No secondary malignancy was observed. Conclusions: The management of optic glioma remains challenging. Although the overall survival for children with this disease is excellent, progression of disease is frequent, particularly in those children without NF-1, younger children and non-orbital tumors. This study from Turkey showed comparable results with high-income countries. Further studies with longer follow-up periods are needed to find appropriate treatment strategies.

Removal of Orbital Metallic Foreign Bodies With Image-Guided Surgical Navigation.

To describe the use of an image-guided 3-dimensional surgical navigation system for the removal of metallic foreign bodies from the human intraorbital region. Between January 2016 and June 2019, 30 patients with metallic foreign bodies in the orbital area underwent image-guided 3-dimensional surgical navigational removal at the authors' center, and their data were retrospectively analyzed. Patients' age, gender, complaints, cause of initial injury, location, interval between injury, and surgery were recorded. Preoperative CT scans of the orbits were obtained and used for preoperative planning. The 3-dimensional navigation system was used for intraoperative navigation. In all 30 patients, the foreign bodies were removed by minimally invasive access without any severe complications. The intraoperative average depth of foreign bodies was 19.98 ± 11.47 mm which was consistent with the depth measured in preoperative planning. The mean length, width, and height of foreign bodies determined in preoperative planning were confirmed by postoperative measurements. There was no significant difference between preoperative and postoperative mean logarithm of Mininal Angle Resolution (logMAR) best-corrected visual acuity. According to the postoperative CT scan, all 30 patients' metallic foreign bodies were successfully removed by surgeries using the surgical navigation system. Most patients who presented with diplopia, eye movement pain, and paresthesia were improved after surgery. This study demonstrated that computer-assisted image-guided 3-dimensional surgical navigation had the advantages of accurate real-time localization of foreign bodies, minimizing collateral damage, determining the appropriate surgical path, and increasing the successful rate of foreign body retrieval.

Hydatidosis of infratemporal fossa with proptosis \u2013 an unusual presentation: a case report\xa0and review of the literature

BackgroundHydatid disease is one of the common zoonotic diseases caused by the larval stage of Echinococcus granulosus. It is endemic in sheep-raising and cattle-raising areas worldwide and humans are an accidental intermediate host following the ingestion of the larvae. Head and neck involvement of echinococcosis is a rare entity and involvement of the infratemporal region is extremely rare even in endemic areas. Only a few cases of hydatid cysts located in the infratemporal fossa have been reported in the literature. Moreover, extension of the hydatid cyst into the intraorbital region and infiltrating into the surrounding orbital bone is even rarer.Case presentationWe present a case of a 65-year-old Gurung Nepalese woman with painless proptosis of her left eyeball of 2 months’ duration with recent progressive diminution of vision for 15 days. Radiological findings showed a cystic mass in the left infratemporal fossa extending into the left orbit and involving the surrounding orbital bone. Surgical removal was carried out. On histopathological evaluation, it was reported as hydatid cyst infiltrating into the bone. She was prescribed albendazole and discharged after surgery. However, she was lost to follow up and returned after 15 months with recurrence and proptosis of the same eye. Repeat excision of the lesion was carried out and postoperatively she was administered tablet albendazole. She was found to be disease free after 6 months of follow up.ConclusionsClinical and radiological findings are important but may not be sufficient in the preoperative diagnosis of hydatid disease especially if rare sites are involved. Proptosis may be seen in several conditions and orbital or infratemporal hydatidosis, although rare, should be considered a differential diagnosis.

Transcranial Supraorbital Approach for Tumor Removal of Spheno-Orbital Meningioma with Favorable Clinical Outcomes

Background: To describe and evaluate the surgery results regarding resectability and clinical outcomes oftranscranial supraorbital approach for tumor removal of spheno-orbital meningiomaCase Illustration: A 58-year-old woman presented with proptosis of the right eye since 9 years prior.At initial examination, visual acuity was 6/15 with significant nasal visual field defect. There wereprominent proptosis and inferior globe displacement of the right eye with no palpable mass. A frontoparietalbone deformity was also observed. CT scan examination revealed hyperostosis of sphenoid,frontal, and temporal bone with extensive intraorbital mass with contrast enhancement suggestive ofmeningioma. Incisional biopsy was the performed and confirmed the histopathological diagnosis ofmeningothelial meningioma (WHO grade 1). Transcranial supraorbital in conjunction with lateralorbitotomy was performed in this patient as the definitive treatment for tumor removal of sphenoorbitalmeningioma. Craniotomy and opening of orbital roof were carried out by neurosurgeon toexpose intraorbital region. Total tumor removal was than completed.Conclusion: Transcranial supraorbital approach is an effective surgery for spheno-orbital meningiomaremoval as it offers excellent exposure. A radical resection through transcranial approach can be achievedwith low morbidity, providing a significantly improved clinical outcome in long term period. In thiscase, the spheno-orbital meningioma was grossly resected totally with excellent visual outcome andacceptable cosmetic appearance.Keywords: spheno-orbital meningioma, transcranial approach, tumor resection

Periorbital and Intraorbital Studies of the Terminal Branches of the Ophthalmic Artery for Periorbital and Glabellar Filler Placements.

Filler injections for sunken upper eyelid correction and glabellar augmentation at the orbitoglabellar region need to be performed correctly. Precise knowledge of the emerging sites of all terminal branches of the ophthalmic artery is essential for these procedures to be conducted safely. The terminal branches of the ophthalmic artery were studied in both periorbital and intraorbital dissections. The aim of this study was to verify the critical positions of the emerging sites at the orbital septum that may act as potential retrograde channels for filler emboli. In the 40 eyes examined, the branches of the ophthalmic artery were found to emerge from four different sites. Two substantial emerging sites were situated on both sides of the trochlea of the superior oblique muscle. These sites were located at the superior part of the medial orbital rim (SMOR) and are alternatively named as the epitrochlear and the subtrochlear emerging sites. The other two sites can be regarded as accessory emerging sites due to the comparably smaller artery. Dissection of the intraorbital region revealed small periosteal branches of the infraorbital artery which coursed anteriorly on the orbital floor to form anastomoses with the lacrimal artery. In other areas of the orbital floor, no branches extended from the infraorbital artery. In front of the lacrimal gland, very minute branches descended and coursed along both margins of the superior tarsus but did not course outside the lateral orbital rim. A danger zone was located at the SMOR, where the ophthalmic branches emerge to form anastomotic channels. Compression at the trochlea guarantees safe injection of filler, reducing the risk of complication. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Association of a Subperiosteal Hematoma With Minor Injury.

An intraorbitalsubperiosteal hematoma is a rare clinical entity that is usually caused by head trauma. The authors experienced a patient involving an intraorbital hemorrhage that was associated with minor injury in the forehead and that required surgical decompression. The authors describe this rare case involving an intraorbitalsubperiosteal hematoma that occurred in a conscious young boy who had no remarkable head injury and who had sudden onset of proptosis. Three-dimensional computed tomography, which was conducted with a volume-rendering method, was very useful, and the transorbital approach that was used to remove the hematoma was very effective. The patient showed good recovery. The pathogenesis of the intraorbitalsubperiosteal hemorrhage could not be fully explained, and, thus, the authors suggest that a possible pathogenesis involved the migration of the hemorrhage from the forehead into the intraorbital region.

Primary, definitive treatment of the nasoethmoidorbital-midface-frontobasal injuries in the maxillofacial practice

Nasoethmoid-orbital (NEO) fractures are typically resulted by a drastic, forceful blow to the central aspect of the head and nose, associated injuries to adjacent structures occur and involve the midface, anterior cranial fossa and the eye. Dislocated bony parts of the nose may be impacted into the intraorbital region and lead to severe complications: cerebrospinal fluid leak, optic nerve lesion, anosmy, telecanthus and diplopy. In the complex management of the craniofacial lesions, a cooperative team-work of maxillofacial surgeon, neurosurgeon, otolaryngologist and ophthalmologist is required. The key of the surgery treatment is the actual status of the NEO structure. Stabilized nasoethmoidal fragments, midface and the watertight dura closure or plasty are basically important conditions for the ceasing of nasal liquorrhoea. Repositioning of fractured fragments, stabilization with titanium miniplates and reconstruction of bony defect using autologous bone are commonly used techniques at our practice. Between years 1995-2000, altogether 50 cases of injuries due to NEO fracture have been treated at our department of maxillofacial surgery. We report the possible combinations of traumatism, our operative methods, our supply tactics and experiences. Multiple and defect fractures of the craniofacial bones may cause irreversible deformities, chewing and nutritional disturbances. We preferred the early, primary, definitive supply, with the respect of aesthetic viewpoints with the application of streamlined operative methods like bone fixation and bone replacement. Our fundamental aim is the reduction of the patients' operative load, their nursing time and the enhancement of our operative results.

Intracranial extension of meibomian gland carcinoma with pagetoid changes

A 41-year-old man presented with exophthalmos and loss of visual acuity. Neuroradiological studies showed a large mass extending from the intraorbital region to the frontal lobe. In addition, it also involved the middle cranial and infratemporal fossae with accompanying skull destruction. The tumor was almost totally removed. The histological diagnosis was sebaceous carcinoma with pagetoid changes. Despite surgery and local irradiation, intracranial metastases were recognized one year later, and the patient underwent total tumor removal and whole-brain irradiation. Although multiple lung metastases were detected one year after the second operation, three years post-surgery he remains free of intracranial tumor recurrence. Sebaceous carcinoma of meibomian gland origin with pagetoid changes is a distinct, highly aggressive clinical entity. Early diagnosis and appropriate treatment are essential to improve the prognosis of patients with meibomian gland carcinoma with intracranial extension.

覚醒剤濫用歴を有する顎顔面部蜂窩織炎の１例

Stimulant abuse is a social problem in recent years. We describe a patient with a history of stimulant abuse who had flashback phenomena during hospitalization for the treatment of a maxillofacial phlegmon caused by intraoral self mutilation.The patient was a man in his forties who continued to take stimulants and served a sentence in prison since 1 year before admission to our hospital.He had pain in the left cheek for 1 month before admission to our hospital and was referred to a certain hospital. He was given a diagnosis of maxillofacial phlegmon with intracranial abscess on computed tomography. The patient was referred to the Department of Emergency and Critical Care Medicine in our hospital for further examination and treatments.Because the maxillofacial phlegmon was apparently caused by intraoral infection, he was referred to our department. With the patient under general anaesthesia, we performed drainage of the left fossa infratemporalis, intraorbital region, fossa pterygopalatine, and the submandibular space on the day of admission to our hospital. Incomprehensible speech and self mutilation occurred after the drainage. Amphetamine psychosis with flashback phenomenon was diagnosed by a psychiatrist in our hospital. Antipsychotic drugs and a tranquilizer were prescribed, and his symptoms improved.His prognosis was good. He returned to his original hospital 20 days after surgery.In conclusion, it is very important to recognize the clinical condition of amphetamine psychosis. The treatment of such patients requires close cooperation with a psychiatrist.

MINIMAL INVASIVE EXCISION OF INTRAORBITAL DERMOID CYST

Orbital dermoid cyst is a rare tumor for which the pathogenesis remains unclear. It is usually located in the lateral side of the orbita, and may also rarely be observed in the intraorbital region. In this cases, aggressive treatment is necessary for the success because recurrence rate is high. But it should work delicately because of the risk of the eye damage. We report three cases with intraorbital dermoid cysts who were successfuly treated by using a minimally invasive surgery. Eye movements and visual functions were normal in all patients. No recurrences or complications appeared postoperatively. We think that it is possible to excise dermoid cysts totally using a classical surgical technique, including an anterior approach, by careful dissection under loupe magnification.

Schwannoma of the oculomotor nerve

A 63-year-old woman presented with an extremely rare oculomotor schwannoma not associated with neurofibromatosis, manifesting as a transient diplopia and ptosis. Magnetic resonance images showed a well-enhanced mass extending from the cavernous sinus to the intraorbital region. Surgical exposure confirmed the tumor originating from the oculomotor nerve in the cavernous sinus. The intraorbital cystic part of the tumor was partially resected to preserve the oculomotor function. This is the first case of oculomotor schwannoma in the cavernous sinus with intraorbital component.

Retroauricular flap: its clinical application and safety

We report the application and safety of the retroauricular flap in 38 cases. The flap was used on the anterior auricular surface in 21 cases, in the peri-auricular region in five cases, in the region of the preauricular sideburn area in two cases, in the malar region in six cases, in the eyelid in three cases and in the intraorbital region in one case. When this flap was used in the auricular or periauricular region, the blood circulation was safe and the appearance was aesthetically good in flaps pedicled by the postauricular vessels or by the superficial temporal vessels. However, when the defect was more remote from the auricle, the blood circulation of the flaps pedicled by superficial temporal vessels, whether subcutaneous pedicle flaps or free flaps, was unstable. In some cases there was extensive or partial necrosis of the distal area of the flap. On the other hand, the free flaps pedicled by the postauricular vessels had satisfactory blood circulation, but the vessels were sometimes short, narrow and difficult to find, especially the veins. In these cases, we were obliged to use the superficial temporal vessels. A further problem is that some of the patients, especially younger women, were dissatisfied when the retroauricular flap was used in the malar region because of the reddish colour of the flap.

The trans-supraorbital approach.

The trans-supraorbital approach represents the advantage of combining the keyhole principle and skull base surgery. In cadaveric work the author shows the anatomic fields visualized with this procedure, advantages and potential surgical applications. The experimental surgical procedure was performed on 8 adult skulls and on 3 cadavers with intact cerebral structures. First, a 2 cm supraorbital approach for endoscopic exploration was used. The basic anatomic landmarks and corresponding dimensions of the microsurgical field were recorded and then compared with those from the trans-supraorbital approach, after removing the orbital arch and other parts of the orbital ceiling. This technique offers a 0.5 cm average increase in surgical field from the craniotomy. The surgical distance that results is shorter (about 2 cm), as well as the length of the surgical instruments required. A better microscope illumination in the deep fields, and the possibility of access to the intraorbital region, the superior orbital fissure, the optic foramen, and the cavernous sinus through the clinoid space are also obtained, with minimal cerebral retraction and similar advantages as through the pterional trans-sylvian approach. The author concludes that by extending the craniotomy and decreasing the surgical distance, the microsurgical field is more convenient for microscope-assisted surgery without totally relying on the endoscope, and with minimal brain retraction. It also provides multiple options to approach vascular and tumor lesions found in these microsurgical corridors, combining principles of minimal invasion and skull-base surgery.

Posttraumatic Meningioma: Explanation of an Epidemiologic Dichotomy

A 23-year-old soldier sustained a penetrating gunshot wound to the right frontoparietal region of the head in 1971 while serving in Vietnam. In 1984, he developed headaches and seizures, and a meningioma was found at the cranioplasty site. Recurrent meningiomas, requiring resection, developed at this site in 1988 and 1990. In 1994, he developed right proptosis. An extensive mass involving the right intraorbital region and the anterior and middle cranial fossa was found. Pathological examination of this tumor demonstrated malignant meningioma. Although antecedent head trauma has been implicated as a risk factor for meningioma, epidemiological studies of this association have yielded divergent conclusions. An explanation for this epidemiologic dichotomy is suggested.

Neovascularization occurs in response to crush lesions of adult frog optic nerves

The capacity of the adult frog optic nerve to regenerate following a crush lesion is well established and is in contrast to the lack of regeneration of mammalian optic nerves after similar lesions. One factor which may contribute to the enhanced regenerative capacity of amphibian optic nerves is the rapid removal of cellular debris from the nerve after injury. In this study the morphology of normal and crushed frog optic nerves has been compared. Although the intraorbital region of the normal adult frog optic nerve is avascular, new intraparenchymal blood vessels appear central to the crush site 24 h after the nerve lesion. The appearance of these blood vessels is coincident with the appearance of granulocytes and macrophages in the nerve. Successful regeneration of the adult frog optic nerve may depend on this neovascularization to facilitate the rapid removal of cellular debris and to supply regenerating axons with trophic substances.