Orbital Roof Research Articles

前頭洞血瘤腫例

The blood boil is a benign hemorrhagic pseudotumor that usually arises in the sinonasal tract, particularly the maxillary sinus and blood boils in the frontal sinus are very rare. We experienced a rare case of a blood boil in the frontal sinus. A 55-year-old female visited our hospital because of a swelling in her forehead and lateral deviation of the left eye. CT and MRI showed a large mass extending from the left frontal sinus to the orbital roof with bone erosion. Because of poor improvement with conservative medical treatment, we performed a frontal sinus operation via the transcranial approach and removed the tumor. Histopathologically, the tumor was composed of necrotic tissue with hemosiderin deposition and no malignant tissue, and it was diagnosed as a blood boil in the frontal sinus. No recurrence has been seen for about 1 year after the operation.

Asymmetry of the anterior skull base at the level of frontal ostium, a radioanatomical study

Radioanatomical studies have shown that the ethmoid roof is asymmetric in 10 to 40% of individuals. The right ethmoid roof has been found on average to be lower compared to the left. The aim of this study was to extend existing results by assessing asymmetry between the right and left anterior skull base at the level of the frontal ostium. Curved multiplanar reconstruction was used to analyse 247 consecutive paranasal sinus CT scans. The corresponding left and right parasagittal profiles of the skull base marked from the anterior ethmoidal artery to the level of the orbital roof were superimposed and compared. Asymmetry greater than 1 mm was found in 87% of patients, greater than 2 mm in 40.5% of patients, and greater than 3 mm in 8% of patients. The prevalence of the patients with lower skull base on the right side was greater than those with lower skull base on the left side at a ratio of more than 2:1. Skull base asymmetry in the region of the frontal ostium is observed in a large percentage of the population and may be a potential source of complications during endoscopic sinus surgery.

Expanding contralateral epidural hematoma causing acute intraoperative brain swelling

Expanding contralateral epidural hematoma causing acute intraoperative brain swelling

An intraorbital metallic foreign body.

A 30-year-old male presented with diplopia for 20 days post occupational accident involving left side of his nose, while he was working with a nail gun. He was fully conscious and did not have any neurological deficits. Patient narrated the mechanism of injury and was sure that the nail fell down after hitting the left side of his nose. He had normal vision, but extra ocular movements were restricted and painful. Computed tomography (CT) scan revealed a curved metal object lodged in the posterior aspect of the left orbit extending diagonally from medial wall to the anterior-superior aspect of the orbital roof. The object was removed via a small surgical approach, inflicting least possible surgical trauma. Post surgery, the patient recovered with complete resolution of diplopia. The original aspects of this case are the lack of signs of a foreign body entry and its relative harmlessness in spite of its large size.

Orbital roof leptomeningeal cyst presenting as proptosis

Orbital roof leptomeningeal cyst presenting as proptosis

Traumatic Aneurysm of the Callosomarginal Artery-Cortical Artery Junction from Penetrating Injury by Scissors

Traumatic intracranial aneurysms (TICAs) are rare and are associated with high rates of morbidity and mortality. TICAs usually result from head injuries caused by traffic accidents, industrial accidents, or gunshots. We report a traumatic aneurysm of the callosomarginal artery-cortical artery junction arising from a penetrating injury by scissors. A 51-year-old woman was admitted to our hospital after suffering a penetrating injury caused by scissors. Computed tomography (CT) and CT-angiography demonstrated a right orbital roof fracture, subarachnoid hemorrhage, frontal lobe hemorrhage, intraventricular hemorrhage, and a traumatic aneurysm of the right callosomarginal artery-cortical artery junction. We trapped the traumatic aneurysm and repositioned a galeal flap. Postoperative CT showed a small infarction in the left frontal lobe. Follow-up angiography two months later showed no residual aneurysm. We suggest that an aggressive surgical intervention be performed whenever TICA is diagnosed.

Anterior clinoidectomy

The optic nerve within the optic canal, the parophthalmic segment of the carotid artery, and the oculomotor nerve in the superior orbital fissure all lay against the anterior clinoid process. Bone resection uncovers these structures. For extradural resection of the anterior clinoid process and surrounding bone, two key steps are recommended: bony opening of the superior orbital fissure, and transection of the orbitotemporal periosteal fold. Anterior clinoidectomy is technically challenging. Following a sequence of surgical steps to expose clearly-defined surgical landmarks helps to make this procedure simple and safe. • Pterional craniotomy • Complete extradural anterior clinoidectomy • Slit dura (3 mm) to drain cerebrospinal fluid • Peel dura from orbital roof and lateral wall • Bony opening of superior orbital fissure to use it as surgical corridor • Drilling of optic canal • Transection of orbitotemporal periosteal fold • Hollow anterior clinoid process and piece-meal resection • Transection of falciforme ligament to free optic nerve • Replace falciforme ligament by extradural free pericranial flap.

Teaching Video Neuro Images : Pulsatile proptosis

A 44-year-old man with neurofibromatosis type 1 had been aware that his right eye pulsated. His visual acuity was 20/15 in both eyes and his intraocular pressures were normal. He had 4 mm of right exophthalmos and there was pulse-synchronous pulsation of the right eye (video on the Neurology® Web site at www.neurology.org). No bruit was heard. Lisch nodules were present on both irides. CT showed a large osseous defect of the greater wing of the right sphenoid bone. The differential diagnosis of pulsatile proptosis includes absence of the sphenoid wing in patients with neurofibromatosis 1,(1) carotid-cavernous fistula, orbital roof fractures, and arteriovenous malformations.(2.)

Bone porosity and longevity in early medieval Southern Croatia

Porosity of the skull and skeletal remains, especially of the orbital roof, are one of the most frequent pathological findings on ancient human skeletal remains. There are several presumed causes of this condition and anthropologists consider skull porosities as a marker of physical and nutritional stress. A total of 115 graves were discovered at the early-medieval graveyard near Zadar (Croatia) that contained 128 partially preserved skeletons. Average estimated age at death was 37.2 ± 12.6 years for men, 31.9 ± 13.9 for women, and 5.3 ± 3.6 years for subadults. Pathological bone porosity was analysed. Cribra orbitalia was observed on 21 skulls (28.7%), signs of temporal porosity were noticed on six skulls and signs of subperiosteal bleeding on three skulls. Nineteen skulls had bone porosities in other areas. There was a significant difference (p = 0.039) in achieved age of adults with and without cribra orbitalia as those with cribra orbitalia lived on average 8.1 years longer. The bone porosity was probably caused by malnutrition that might have had a beneficial effect on longevity of adults, similar to effects of restricted food intake on extending lifespan through epigenetic signatures influencing gene expression.

Cone beam computed tomography for imaging orbital trauma—image quality and radiation dose compared with conventional multislice computed tomography

We compared the image quality and radiation dose to the lens of the eye in patients with suspected orbital fractures who were imaged using cone beam computed tomography (CBCT) or conventional multislice computed tomography (CT). Although CBCT has a lower radiation dose than conventional CT, it is not known whether the image quality is comparable for diagnostic purposes. We identified fractures of the orbit (floor or roof, or both) in 6/10 patients who were scanned using CBCT and in 5/10 patients who were scanned using multislice CT (orbital floor and medial wall). Impingement of the rectus muscle on fracture lines was identified with both techniques, but retro-orbital haemorrhage was detected only on multislice CT. The mean radiation dose to the lens of the eye was 42% lower (range 23–53, SD 10) for CBCT than for multislice CT (p<0.001), and the effective dose (a measure of the risk of developing a radiation-induced cancer) was also significantly lower. CBCT can therefore be used to diagnose orbital fractures, and is associated with a significantly lower radiation dose than multislice CT.

Porous polyethylene reconstruction of orbital floor and roof defects – clinical and radiological evaluation

Aim: The aim of this study was to evaluate clinically and radiologically the use of high porous polyethylene (Medpor) for reconstruction of post-traumatic orbital roof and floor defects. Patients: 37 patients had traumatic orbital wall defects were studied. Patients were classified into three groups. Group (A) included 22 patients had orbital floor defects. Group (B) included 10 patients had orbital roof defects. Group (C) included 5 patients had combined orbital roof and floor defects. All defects were reconstructed by medpor. Patients were followed by CT scan and by serial MRI. Results: Near all presentations improved in the immediate postoperative period and maintained in the postoperative follow-up period. Neither extrusion nor infection was recorded in any case. Enhancement was detected in the implants by MRI as early as one month post operative in 23 patients and 1.5 months postoperative in the remaining 14 patients. Conclusion: Porous polyethylene was found to be flexible, strong, porous and is highly biocompatible. Its porosity enables vascular and bony ingrowth leading to tissue adhesion and a reduced risk of infection. The current study is the first one described in humans to detect vascular ingrowth into medpor orbital sheets utilizing Gadolinium enhanced MRI. Porous polyethylene sheets was shown to have very favorable results in orbital wall reconstruction.

Acute traumatic orbital encephalocele: A case report with review of literature

Orbital roof fractures after a blunt injury are an uncommon complication of trauma. Traumatic encephaloceles in the orbital cavity are even rarer, with only 15 cases published till date. Raised intraorbital pressure leading to irreversible damage to the optic nerve can be prevented by early diagnosis and management. Orbital computed tomography (CT) with thin axial and coronal sections is helpful in trauma patients with a concurrent orbital trauma. Decompression of the orbital roof is the key step in surgical treatment and should be performed in every case. Repairing the orbital roof has to be performed to avoid transmission of variation in the intracranial pressure to the orbit. We present a case of traumatic orbital encephalocele who underwent surgical treatment via a frontobasal approach with evacuation of the contused herniated brain and reconstruction of the orbital roof using temporalis fascia which is readily available in contrast to costly materials like titanium mesh, screws, bone powder, fibrin glue, and so on, which are not easily available in every hospital. Rapid resolution of proptosis and visual symptoms along with excellent cosmetic outcome was seen at follow-ups after three and nine months. We emphasize the early diagnosis of this rare condition and also emergency treatment to prevent permanent visual loss as well as to achieve good cosmetic results.

Orbital roof isolated blow-in fracture: case report and review of biomechanics of the craniofacial skeleton

Introduction: Orbital roof blow-in fractures without involvement of the vertical portion of the frontal bone are a rare entity in the adult population. Mechanisms of this fracture pattern often remain unclear.

English

BACKGROUND: Requirement of the good specimens of human eye showing all its muscles from their origin to insertion, optic nerve and ciliary ganglion has been always felt during the teaching of anatomy of human eye. AIM: To make Museum specimens of human eye showing eye ball with its muscles, nerves, vessels, ciliary ganglion and optic nerve for teaching of surgical and gross anatomy. These specimens may help in formation of better eye prosthesis used in the field of ophthalmic plastic surgeries. MATERIAL AND METHOD: Five cadavers were marked for procurement of specimens during routine dissection in dissection hall by undergraduates. Cranial vault and brain were already removed. Roof of orbit were removed by superior approach with preservation of apex with cone of muscles and optic nerve. Removal of superciliary arch with frontal approach was followed to obtain complete eye ball and other structures. Fine dissection was performed to clean the area for demonstration. Specimens were mounted by Kaiserling's technique in glass jars. RESULT: By this method ten specimens of eye were mounted showing all muscles with their origin and insertion, their nerve supply, optic nerve, ophthalmic artery and its branch entering into optic nerve in different views of different specimens. CONCLUSION: Ten specimens were procured from five cadavers dissected routinely in dissection hall by undergraduates. These specimens are providing a very good 3- dimensional view of eye and related structures. An interactive method of teaching using prosected specimens is raising a good satisfactory level among students.

Orbital Dystopia Due to Orbital Roof Defect

We performed a retrospective review of patients who presented with delayed dystopia as a consequence of an orbital roof defect due to fractures and nontraumatic causes to search for a correlation between orbital roof defect size and surgical indications for the treatment thereof. Retrospective analyses were performed in 7 patients, all of whom presented with delayed dystopia due to orbital roof defects, between January 2001 and June 2011. The causes of orbital roof defects were displaced orbital roof fractures (5 cases), tumor (1 case), and congenital sphenoid dysplasia (1 case). All 7 patients had initially been treated conservatively and later presented with significant dystopia. The sizes of the defects were calculated on computed tomographic scans. Among the 7 patients, aspiration of cerebrospinal fluid, which caused ocular symptoms, in 1 patient with minimal displaced orbital roof and reconstruction with calvarial bone, titanium micromesh, or Medpor in 6 other patients were performed. The minimal size of the orbital roof in patients who underwent orbital roof reconstruction was 1.2 cm (defect height) x 1.0 cm (defect length), 0.94 cm(2). For all patients with orbital dystopia, displacement of the globe was corrected without any complications, regardless of whether the patient was evaluated grossly or by radiology. In this retrospective study, continuous monitoring of clinical signs and active surgical management should be considered for cases in which an orbital roof defect is detected, even if no definite symptoms are noted, to prevent delayed sequelae.

Endonasal Endoscopic Approach to the Orbit (EEAO)

Objectives: Describe the endoscopic anatomy of medial and inferior orbital walls and present 5 illustrative clinical cases. Methods: Two vessel-injected cadavers (4 sides) were dissected through endoscopic endonasal transethmoid-sphenoid-maxillary approach. Results: Total ethmoidectomy and maxillary antrostomy were performed. Maxillary sinus roof was removed until reaching the infraorbital canal laterally. Anterior and posterior ethmoidal arteries were identified. Lamina papyracea was removed. Transnasal and transethmoidal sphenoidotomies were made. Periorbita was incised along medial and inferior orbital walls. Cavernous carotid artery was exposed and medialized to show oculomotor (CNIII), trochlear (CNIV), ophthalmic (CNV1), maxillary (CNV2), and abducent (CNVI) nerves in cavernous sinus. In superolateral wall of sphenoid sinus, the optocarotid recess was visualized as well as the optic nerve (CNII) and ophthalmic artery (OphA) entering the orbit. Anteriorly, the annulus tendineus of Zinn (ATZ) was found and incised, showing the insertion of superior, medial, and inferior rectus muscles with CNIII and its branches. CNII, nasociliary branch of CNV1, CNVI, and OphA also enter ATZ. Superior and inferior oblique muscles were seen outside ATZ. The anterior limit of dissection was the eye globe. Five clinical cases of EEAO (lymphoma, aspergilloma, hematoma, abscess, Graves’ disease) will be presented. Conclusions: EEAO is ideal for inferior and medial lesions of the orbit. Contrary to craniotomies, EEAO exposes CNII without removing orbital roof and anterior clinoid. Contrary to orbitotomies, EEAO provides excellent visualization with angulated endoscopes. Limits are lesions of superior or lateral part of the orbit or lesions that need manipulation of CNII or a section of medial rectus muscle.

An unusual case of orbito-frontal rod fence stab injury with a good outcome

BackgroundHigh-energy non-missile penetrating injuries (stab injuries) account for a small percentage of penetrating head injuries and they present a series of special features.Case presentationA 35-year-old man suffered orbito-frontal? and trans-cranial injuries after falling five meters from a terrace onto a rod iron fence. The removal of the metal rod was performed outside the operating room. The orbital roof was exposed and repaired through a bifrontal craniotomy and the frontal sinuses were cranialised. The orbital floor and zygoma were plated with micro-screws.ConclusionThe patient recovered without significant complications, apart from a slight paresis of the right superior rectus; the ocular globe remained intact.The positive outcome obtained in this very challenging case is attributable to the competency of the Neurotrauma Unit and to the use of a synergistic approach which involved the contribution of neurosurgeons, maxillo-facial surgeons, radiologists and anaesthesiologists.

Presumed eosinophilic granuloma of the orbital roof in an adult man

AbstractPurpose To report on an unusual case of presumed adult‐onset eosinophilic granuloma of the orbital roof, which showed spontaneous resolution.Methods Descriptive review of the clinical records of one patient.Results A 42‐year‐old man presented with a 3‐month history of relapsing edema in his right upper eyelid. Visual acuity was 20/20 bilaterally. Apart from the detection of a group of dilated vessels in the right lower bulbar conjunctiva, both eyes were unremarkable. There was no proptosis and ocular motility was normal. CT and gadolinium‐enhanced MRI head scans disclosed a 15 mm solid mass in the right anterior cranial fossa, which had eroded the orbital roof, penetrated into the orbit, and caused mild displacement of the levator palpebrae and superior rectus muscles. An initial diagnosis of intradiploic meningioma of the orbital roof was made. Total resection of the lesion was planned and the patient was put in the waiting list for neurosurgery. One year later, preoperative MRI head scans disclosed a significant regression of the lesion; consequently, neurosurgery was postponed. Six months later, MRI scans showed complete disappearance of the solid mass and full reossification of the orbital roof. A presumptive, final diagnosis of solitary eosinophilic granuloma of the orbital roof was made. He was cancelled from the waiting list for neurosurgery and MRI at 6‐month intervals has been scheduled.Conclusion Persistent upper eyelid edema may be the presenting sign of an osteolytic intracranial mass eroding the orbital roof and extending into the orbit. Radiological differential diagnosis may be difficult; in this report, the detection of an osteolytic lesion and its subsequent spontaneous resolution are suggestive of an adult‐onset eosinophilic granuloma.

Evaluation of a Limited Three-Slice Head CT Protocol for Monitoring Patients With Ventriculoperitoneal Shunts

Patients with a ventriculoperitoneal shunt for the management of hydrocephalus often undergo multiple head CT examinations for assessment of shunt malfunction. The purpose of this study was to evaluate whether a limited three-slice CT protocol would consistently provide adequate information for the diagnosis of shunt malfunction with a decrease in effective dose. The study group included 231 unenhanced head CT examinations performed on 128 patients with shunts for hydrocephalus. The original contiguous CT images were reviewed retrospectively. A theoretic limited three-slice study was then created from the original complete CT study and separately reviewed. This limited three-slice study was created by using the lateral topographic image to select three axial locations as follows: midpoint between foramen magnum and vertex, top of the mastoid air cells, and orbital roof. The limited study was graded for parameters of image adequacy with the original full protocol study as the reference standard. Twenty-four of the 231 (10.4%) full studies had findings consistent with shunt failure; all 231 studies would have been correctly categorized with the limited three-slice protocol. The sensitivity of three-slice CT for identifying the ventricular system was 91.6% and for identifying the catheter tip, 93.5%. Limited-slice CT examination would have resulted in greater than 90% mean dose reduction in both adult and pediatric populations. Unenhanced head CT with a limited-slice protocol provides adequate diagnostic information for the diagnosis of shunt malfunction with a greater than 90% reduction in effective dose.

Freiburg Neuropathology Case Conference: A Contrast-Enhancing Orbital, Intra-Conal Lesion

a 61-year-old woman developed progressive exophthalmos of the left ocular bulb over a period of several weeks. she complained of conjunctival irritation, increased lacrimation, and associated gait disturbance. Ophthalmologic examination showed no visual field deficit and a visus of 0.8 versus 1.0 on her right eye. These findings remained stable at follow-up 4 weeks later. at clinical examination no neurological deficit was observed. Magnetic resonance imaging (MRI) revealed a left-sided orbital, intra-conal lesion. Lateral orbital decompression (according to Kronlein) was performed with resection of the lateral orbital wall and the orbital roof. Opening the periorbita, the capsulated tumour was situated in the intra-conal fat tissue. The tumour capsule was mostly of a white colour with some vascular injections and also adherent veins. after coagulation and opening of the capsule, the tumour was of a tough and adherent consistence, appearing white-greyish. intra-capsular tumour reduction without manipulation of the optic nerve could be achieved. The post-operative course was uneventful without visual impairment. Mild ptosis and diplopia resolved completely within several days. Imaging