Orbital Symptoms Research Articles

Paranasal sinus cholesterol granuloma: systematic review of diagnostic and management aspects

Cholesterol granuloma (CG) is an expansile, cystic lesion most commonly observed in the temporal bone. CG is rarely encountered in the paranasal sinuses. Given its paucity in this region, the diagnostic and management aspects remain to be elucidated. Systematic review of the literature yielded 66 cases reported as individual data in 37 articles; an additional 69 cases were reported as aggregate data in 5 case series. The mean age of the 135 patients was 43.8 years, with a male:female ratio of 5.6:1. The most common presenting symptoms were orbital (66%), followed by headaches (19.3%). The most common location for CG was the frontal sinus (60%), followed by maxillary (34.1%) and ethmoid (3.7%) sinuses. Computed tomography (CT) imaging was used in 84 patients (63.3%), with bone erosion being noted in 80% of cases. Magnetic resonance imaging (MRI) was reported in only 9 cases (6.7%); high signal on T1- and T2-weighted images was evident in 77.8% and 66.7%, of cases respectively. Surgical data was available on 65 cases; drainage was achieved by open and endoscopic techniques in 52 (80%) and 13 (20%) cases, respectively. Primary symptom improvement and CG cavity patency was achieved in 92% of cases at a mean follow-up of 34.5 months. Paranasal sinus CG is most commonly observed in middle-aged males, arises in the frontal sinus, and typically presents with orbital symptoms. Both open and endoscopic techniques can be used with high success rate. The present study represents the first attempt in the literature to construct a clinical profile of this rare entity.

Atypical Traumatic Subperiosteal Orbital Hematoma Treated by Surgical Evacuation

Subperiosteal orbital hematoma occurs rarely after blunt trauma. However, this is of importance, as this condition may cause ocular symptoms. The major characteristics of subperiosteal orbital hematomas are painful proptosis, downward displacement of the globe, absence of lid ecchymosis, chemosis without subconjunctival hemorrhage, and motility impairment. Visual impairment is known as a rarely presenting symptom. A 22-year-old male patient presented with right periorbital ecchymosis, swelling, and diplopia with upper lateral gaze limitation. Besides, the patient complained of lower visual field disturbance. Radiologic evaluation revealed traumatic subperiosteal orbital hematoma. The hematoma was evacuated through a lacerated wound on the right lateral eyebrow with additional incision. After the hematoma evacuation, the orbital symptoms are restored. Postoperative computed tomographic scans showed normally restored orbital space without any evidence of remnant hematoma or rebleeding. In case of subperiosteal hematoma, early detection and complete surgical evacuation is crucial for preventing possible complications and sequelae.

Association of Clinical Response and Long-term Outcome Among Patients With Biopsied Orbital Pseudotumor Receiving Modern Radiation Therapy

To retrospectively evaluate institutional outcomes for patients treated with modern radiation therapy (RT) for biopsied orbital pseudotumor (OP). Twenty patients (26 affected orbits) with OP were treated with RT between January 2002 and December 2011. All patients underwent biopsy with histopathologic exclusion of other disease processes. Sixteen patients (80%) were treated with intensity modulated RT, 3 (15%) with opposed lateral beams, and 1 (5%) with electrons. Median RT dose was 27 Gy (range 25.2-30.6 Gy). Response to RT was evaluated at 4 months post-RT. Partial response (PR) was defined as improvement in orbital symptoms without an increase in steroid dose. Complete response (CR) 1 and CR 2 were defined as complete resolution of orbital symptoms with reduction in steroid dose (CR 1) or complete tapering of steroids (CR 2). The median follow-up period was 18.6 months (range 4-81.6 months). Seventeen patients (85%) demonstrated response to RT, with 7 (35%), 1 (5%), and 9 (45%) achieving a PR, CR 1, and CR 2, respectively. Of the 17 patients who had ≥ PR at 4 months post-RT, 6 (35%) experienced recurrence of symptoms. Age (>46 years vs ≤ 46 years, P=.04) and clinical response to RT (CR 2 vs CR 1/PR, P=.05) were significantly associated with pseudotumor recurrence. Long-term complications were seen in 7 patients (35%), including 4 with cataract formation, 1 with chronic dry eye, 1 with enophthalmos, and 1 with keratopathy. RT is an effective treatment for improving symptoms and tapering steroids in patients with a biopsy supported diagnosis of OP. Older age and complete response to RT were associated with a significantly reduced probability of symptom recurrence. The observed late complications may be related to RT, chronic use of steroids/immunosuppressants, medical comorbidities, or combination of factors.

Idiopathic Inflammation of the Orbit and Contiguous Structures

Idiopathic orbital inflammation is a common cause of acute orbital signs and symptoms. It is typically confined to the bony orbit; however, it can rarely involve contiguous structures with or without lytic change raising clinical suspicion for malignancy. Three cases of idiopathic inflammation of the orbit that affected adjacent structures are reported here; 2 cases had maxillary sinus involvement, while a third had extension in the temporal fossa.

Prevalence of Diplopia and Extraocular Movement Limitation according to the Location of Isolated Pure Blowout Fractures

BackgroundIsolated pure blowout fractures are clinically important because they are the main cause of serious complications such as diplopia and limitation of extraocular movement. Many reports have described the incidence of blowout fractures associated with diplopia and limitation of extraocular movement; however, no studies have statistically analyzed this relationship. The purpose of this study was to demonstrate the correlation between the location of isolated pure blowout fractures and orbital symptoms such as diplopia and limitation of extraocular movement.MethodsWe enrolled a total of 354 patients who had been diagnosed with isolated pure blowout fractures, based on computed tomography, from June 2008 to November 2011. Medical records were reviewed, and the prevalence of extraocular movement limitations and diplopia were determined.ResultsThere were 14 patients with extraocular movement limitation and 58 patients complained of diplopia. Extraocular movement limitation was associated with the following findings, in decreasing order of frequency: floor fracture (7.1%), extended fracture (3.6%), and medial wall (1.7%). However, there was no significant difference among the types of fractures (P=0.60). Diplopia was more commonly associated with floor fractures (21.4%) and extended type fractures (23.6%) than medial wall fractures (10.4%). The difference was statistically significant (Bonferroni-corrected chi-squared test P<0.016).ConclusionsData indicate that extended type fractures and orbital floor fractures tend to cause diplopia more commonly than medial wall fractures. However, extraocular movement limitation was not found to be dependent on the location of the orbital wall fracture.

Complications of Bacterial Rhinosinusitis in Children and their Management

Sinus infection can spread through anastomosing veins or by direct extension to close by structures. Orbital complications of rhinosinusitis were categorized by Chandler et al. [2] into five stages according to their severity. Contiguous spread to the oribital area can cause periorbital cellulitis, subperiosteal abscess, orbital cellulitis, and abscess. Orbital cellulitis can complicate acute ethmoiditis if thrombophlebitis of the anterior and posterior ethmoidal veins spreads to the lateral or orbital side of the ethmoid labyrinth. Sinusitis can also spread intracranially, where it can cause cavernous sinus thrombosis, retrograde meningitis, and epidural, subdural, and brain abscesses [2-5]. Orbital symptoms often precede intracranial extension of the infection [5]. Other complications include sinobronchitis, maxillary osteomyelitis, and frontal bone osteomyelitis [6-10]. Frontal bone osteomyelitis often originates from an extending thrombophlebitis. Frontal sinus periostitis can cause outer membrane osteitis and periostitis, which produces a tender, puffy swelling of the forehead. The most common pathogens causing these complications are those seen in acute and chronic rhinosinusitis, depending on the length and etiology of the primary rhinosinusitis. These include Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcos aureus (including methicillin resistant), anaerobic bacteria (Prevotella, Porphyromonas, Fusobacterium and Peptostreptococcus spp.) and Microaerophilic streptococci [5]. Anaerobic bacteria are mostly found in chronic rhinosinusitis and those associated with dental etiology [11]. Early diagnosis of a complication is of prime importance. Diagnosis is assisted by computed tomography (CT) and nuclear isotope scanning. Prevention of these complications is of great importance. This can be accomplished by administering appropriate empiric antimicrobial therapy, obtaining sinus cultures from those who fail to respond to treatment after 2-4 days and those with severe symptoms who do not respond within 48 hours, and the immunocompromised. These cultures

Paradoxical Worsening of Ocular Symptoms after Spontaneous Closure of a Carotid Cavernous Fistula: Case Report

We report an interesting case of a spontaneous occlusion of a carotid cavernous fistula (CCF) causing a paradoxical worsening of orbital symptoms. A 59-year-old woman presented to our institution with conjunctival injection, raised intraocular pressures (IOP) and mild exophthalmos of her left eye. A digital subtraction angiography (DSA) demonstrated a Type-D CCF draining into the left superior ophthalmic vein (SOV). The patient declined endovascular treatment. She presented 15 months later with acute exacerbation of her orbital signs and symptoms. A DSA showed no evidence of arteriovenous fistula, and a brain MRI was consistent with spontaneous thrombosis of the SOV. At her 2-week clinical assessment, the patient showed clinical improvement and her IOP were within normal limits. Spontaneous thrombosis of the SOV can trigger the obliteration of a CCF with possible paradoxical worsening of orbital symptoms. DSA is the gold standard of diagnosis and management is directed toward decreasing IOP.

The diagnosis of sinonasal lymphoma: a challenge for rhinologists

The presenting symptoms of sinonasal lymphoma are usually similar to those of benign inflammatory diseases. Adequate amount of biopsy tissue is required for a definitive diagnosis because tumor coexisting with necrosis or inflammation is not uncommon. Therefore, the diagnosis of sinonasal lymphoma is a challenge for rhinologists. Thirty-two patients diagnosed as having sinonasal lymphoma from 1990 to 2010 in our hospital were included in this study. The presenting symptoms of these patients included nasal obstruction, rhinorrhea, bloody discharge/epistaxis, post nasal drip, facial swelling, neck mass, orbital symptoms, fever, and body weight loss. The average period between patients' awareness of their symptoms and their decision to seek medical help was 8.9 months. When they were referred to our hospital, the first impression of 20 patients (62.5%) was benign or malignant nasal neoplasm, and that of the other 12 patients (37.5%) was rhinitis or rhinosinusitis. These patients then received image studies and biopsy or surgical intervention. Most patients needed repeated biopsies, endoscopic sinus surgery, turbinectomy, or Caldwell-Luc operation for a definitive diagnosis. Their histopathologic classification included NK/T cell lymphoma (n = 13, 40.6%), peripheral T cell lymphoma (n = 12, 37.5%), and diffuse large B cell lymphoma (n = 7, 21.9%). Peripheral T cell lymphoma and NK/T cell lymphoma mostly occurred in the nasal cavity, whereas sinus involvement without nasal disease is common in B-cell lymphoma Our results reveal that patients with sinonasal NHL tend to ignore their symptoms until they become serious, and a definitive diagnosis usually requires repeat and deep biopsy.

Ustékinumab

Non-specific orbital inflammation (NSOI) is a noninfectious inflammatory condition of the orbit. Although it is generally considered the most common diagnosis derived from an orbital biopsy, it is a diagnosis of exclusion, meaning that the diagnosis requires exclusion of a systemic process or another identifiable etiology of orbital inflammation. The clinical diagnosis of NSOI is ill-defined, but it is typically characterized by acute orbital signs and symptoms, including pain, proptosis, periorbital edema, chemosis, diplopia, and less commonly visual disturbance. NSOI poses a diagnostic and therapeutic challenge: The clinical presentations and histological findings are heterogeneous, and there are no specific diagnostic criteria or treatment guidelines. The etiology and pathogenesis of NSOI are poorly understood. Here we recapitulate our current clinical understanding of NSOI, with an emphasis on the most recent findings on clinical characteristics, imaging findings, and treatment outcomes. Furthermore, gene expression profiling of NSOI and its implications are presented and discussed.

Haematic cyst formation after orthognathic surgery

A 34-year-old man suffered from discomfort originating from a mass located in his right zygomatic area. He developed orbital symptoms, such as diplopia, which lasted for 5 months. He also suffered from Crouzon's syndrome and had undergone a Lefort III osteotomy 9 years prior for correction of midfacial hypoplasia. The size of the mass slowly increased and his orbital symptoms developed further, eventually leading to surgical exploration. During the operation, a mass was found near titanium plates which had been used to fix bone segments during a previous surgery. The total mass, including the capsule, was excised. The pathologic report was a chronic haematic cyst with a non-neoplastic collection of blood or blood products that exerted a mass effect in the orbit and adjacent tissues. The causes of haematic cysts are diverse, with trauma being the most common. Although haematic cysts resulting from trauma have been widely reported, there have been few reports on haematic cysts associated with orthognathic surgeries, such as Lefort III osteotomies. This case demonstrates that haematic cysts may be delayed complications of major bone surgery and that surgeons and patients should be aware of this possibility.

Intraorbital Arteriovenous Malformation Treated by Transarterial Embolization: Technical Case Report

Intraorbital arteriovenous malformations (AVMs) are rare, and their clinical management is controversial. A case of orbital AVM successfully treated by transarterial embolization with diluted glue is reported. A 53-year-old man developed a left pulsating exophthalmos, chemosis, and ocular pain, revealing the presence of a left intraorbital AVM. A microcatheter was selectively placed into the feeders arising from the left ophthalmic artery. Diluted glue was injected toward the nidus through the microcatheter, with monitoring by digital subtraction angiogram. These procedures were performed for 2 individual proper feeders. Superselective angiography for the central retinal artery was also performed instead of a retinal Wada test. His orbital symptoms improved immediately after the procedure without further visual disturbance. Follow-up digital subtraction angiogram revealed the disappearance of the AVM. Transarterial embolization can be considered one of the radical treatments for orbital AVMs.

Intercavernous Sinus Dural Arteriovenous Fistula Successfully Treated with Transvenous Embolization

The venous sinuses commonly found in the margins of the diaphragm and sella are venous interconnections between the bilateral cavernous dural sinuses and are termed intercavernous communications or intercavernous sinuses. They form a venous ring, a single "circular sinus" that extends throughout the skull base. We report the first case to our knowledge of an intercavernous sinus fistula. We emphasize the importance of thorough knowledge of lesion characteristics before considering any interventional procedure.An 84-year-old woman presented with alarming progressive orbital symptoms for one month affecting her left eye. A cerebral angiogram showed an intercavernous sinus fistula supplied by internal and external carotid arterial branches.Transvenous embolization through retrograde catheterization of the right inferior petrosal sinus allowed complete coil occlusion of the lesion. Cerebral angiography confirmed the absence of residual blood flow through the fistula.This report represents the first case of an intercavernous sinus dural arteriovenous fistula successfully treated with transvenous embolization. A detailed awareness of the regional anatomy is essential for treatment approach and favorable outcomes.

Clinical Study of Paranasal Sinus Cyst with Orbital Manifestations

Paranasal sinus cyst may cause orbital manifestations such as visual disturbance, diplopia, and oculomotor disturbance. We treated 15 cases—11 men and 4 women—of paranasal cyst with orbital symptoms from January 2005 to December 2009. We assessed the chief orbital complaint, lesion site, case history, history of sinus surgery, first diagnostic visit, and prognosis. Four of the 15 with visual disturbance were analyzed further. Subjects were 31 to 71 years old (mean; 61.3 years). Of the 15, 11 (73.3%) had postoperative cysts and 4 (26.7%) had idiopathic cyst. Among paranasal sinus cysts, 4 were maxillary, 3 each anterior ethmoid and frontoethmoid, 2 sphenoethmoid, 1 each posterior ethmoid, frontal, and sphenoid sinuses. Of the 15, 12 had first seen ophthalmologists and 2 an internist. Time from orbital symptom onset to the first diagnostic visit averaged 5.9 (0 to 44) days. Chief complaints were visual disturbance in 4, diplopia in 7, and oculomotor disturbance in 4. All underwent endoscopic sinus surgery, after which orbital symptoms disappeared in most. Visual acuity returned to expected levels after surgery in the 4 with visual disturbance. Of orbital manifestations, visual disturbance was considered the most serious clinical feature because vision loss may become permanent without immediate surgical exploration. We consider specifically treating the involved sinuses soon after diagnosis to be of primary concern.

Occlusion of the Internal Carotid Artery due to Intracranial Fungal Infection

In recent years the immunocompromised population has increased rapidly to include people with acquired immune deficiency syndrome (AIDS), drug abusers, and transplant patients. Accordingly, the incidence of intracranial fungal infection has increased. Our institution experienced 2 cases of internal carotid artery (ICA) occlusion due to invasion of the cavernous sinus by an intracranial fungal infection. The first case was a 60-year-old man who presented with headache, eye pain, conjunctival injection, right-sided diplopia, and blurred vision. Infected tissues within the frontal and ethmoid sinuses were removed via bifrontal craniotomy and endoscopic sinus surgery through the Caldwell Luc approach. The second case was a 63-year-old woman who developed right-sided facial pain after a tooth extraction. The infection was not controlled despite continuous use of antifungal agents, resulting in death from sepsis. We believe that when intracranial fungal infection is suspected in a patient with orbital symptoms and a focal neurologic deficit, immediate angiographic investigation of possible ICA occlusion is warranted. Aggressive treatment with antifungal agents is the only way to improve prognosis.

Atypical Presentation of Orbital Pseudotumor with Visual Loss as an Initial Manifestation

BackgroundAn orbital pseudotumor typically presents with periorbital pain, cranial nerve palsies and proptosis. Although visual deterioration is not unexpected in this pathology, its presentation solely with visual loss is unusual.Case ReportIn this short report, we summarize a case of orbital pseudotumor which presented solely with a decrease in visual acuity, and discuss the clinical and radiological findings.ConclusionsThis atypical presentation likely resulted from the orbital pseudotumor originating in the optic foramen, leaving the neurovascular structures of the superior orbital fissure untouched initially. In the early clinical period, an orbital pseudotumor may manifest itself solely by visual loss. It should therefore be included in the differential diagnosis of visual pathologies-even in the absence of orbital pain and symptoms related to ocular movements.

Clinical Study in 10 Surgical Cases of Paranasal Sinus Disease with Visual Prognosis

Orbital complications in sinus infections occur due to the anatomical proximity of the paranasal sinuses and orbit. Delayed diagnosis and treatment may involve unfavorable morbidity and mortality. We report 10 cases—7 men and 3 women—of acute rhinosinusitis and acute exacerbation of chronic sinusitis complicating orbital symptoms in the last 5 years. Mean age at consultation was 64.6 years (54-75). Seven had undergone previous sinus surgery. The posterior ethmoid and sphenoid sinus were mainly affected. Mean preoperative visual acuity of 0.07 became 0.53 postoperatively. Restricted eye movement occurred in 1 case of good recovery. Of antibiotics, second- or third-generation cephem was used in 8 cases and carbapenem in 2. Corticosteroids were administered by pulse therapy in 5 and by tapering schedule in 4. Visual recovery occurred in 7. Unrecovered cases were likely to receive delayed surgery. We recommend initial 3-day steroid pulse therapy in subject with decreased vision, discontinued on vision recoveries. Pulse therapy should be continued in case of incomplete or poor recovery.

Pediatric acute sinusitis: Predictors of increased resource utilization

To determine variations in resource utilization in the management of pediatric acute sinusitis. Retrospective analysis of a publicly available national dataset. The Kids' Inpatient Database 2006 was analyzed using ICD-9 codes for acute sinusitis. A total of 8,381 patients (55% male, mean age 8.5 years [SE = 0.2]) were admitted with acute sinusitis. Mean total charges was $20,062 (SE = 1,159.1). Mean length of stay was 4.2 days (SE = 0.12), with 4.8 diagnoses (SE = 0.06) and 0.85 procedures (SE = 0.06). Thirty-six percent had concomitant respiratory diseases, 11% otitis media, and 8% orbital symptoms. A total of 703 patients underwent operations on the upper aerodigestive tract (534 were nasal sinusectomies); 582 patients underwent lumbar puncture and 162 underwent orbital surgery. The primary payer was private insurance in 50% and Medicaid in 41%. Predictors of increased total charges were male gender (P =.028), being a teaching hospital (P < .0001), metropolitan patient location (P < .0001), hospitals in the western region (P < .0001), admission source from another hospital (P < .0001), and discharge status to another inpatient hospital or home healthcare (P < .0001). There is a large geographic variation in resource utilization (range = $5,837 [Arkansas] to $48,327 [California]). Race, primary payer, admission type, and urgency were not significant predictors of increased resource utilization. Despite being a common diagnosis, there exists a large national variation in management of acute pediatric sinusitis. Predictors of increased resource utilization included male gender, teaching hospital status, metropolitan patient location, western hospital region, admission source, and discharge status. Knowledge of these variables may allow interventions and potentially facilitate benchmarking to reduce the economic burden of this entity while ensuring optimal outcomes.

Orbital swelling as a first symptom in breast carcinoma diagnosis: a case report

IntroductionThe frequency of intra-orbital metastasis in systemic cancer is a controversial topic. Of all metastatic tumors to the orbit of the eye, breast carcinoma is considered to be the most prevalent. Orbital findings typically present themselves after the diagnosis of the primary tumor, with an average delay of three to six years. In spite of that, this study reports a case in which orbital manifestation was the initial symptom in breast carcinoma diagnosis.Case presentationA 66-year-old Italian Caucasian woman presented with a swelling located on the lower orbit of her right eye.ConclusionsPrevious cases report orbital manifestations discovered secondary to breast cancer. This case demonstrates that orbital symptoms may be the primary presentation of the disease. Orbital metastasis originating from breast cancer predicts widespread metastatic disease in other organs. In the presence of an ambiguous infiltrative orbital process, diagnostic examination of the breast is recommended.

Management of Orbital Subperiosteal Abscess

To discuss the role of surgical intervention in subperiosteal orbital abscess (SPOA) using a retrospective medical chart review. A retrospective medical chart review of subjects who were diagnosed and surgically treated for SPOA between 2002 and 2009. Ten patients were identified (8 males and 2 females). All SPOAs were unilateral. Of 10 SPOAs, 7 were on the left and 3 were on the right. Six of these were medially located abscesses, whereas 4 were superior abscesses. Of the 6 medially located abscesses, 4 were treated with transnasal endoscopy (TNE). External (E) drainage was needed in 2 of the medially located abscesses. In one of these abscesses, the surgeon was forced to drain the abscess with TNE and turned to E drainage. In the other, TNE was performed first. Despite medical therapy and TNE, patients' orbital symptoms did not resolve. A second operation was performed with E drainage. Four of the superiorly based SPOAs were treated with combined E-TNE approach. External drainage of the SPOA is needed on 6 (60%) of the patients in this study. Superiorly located abscesses were initially treated with E drainage, and then functional endoscopic sinus surgery was performed to treat the affected sinuses. Transnasal endoscopic management failed in 2 patients, hence E drainage was needed. The characteristics of the patients are presented and discussed in view of a surgical approach.

Clinical Study of Paranasal Sinus Cysts with Orbital Symptoms

Clinical Study of Paranasal Sinus Cysts with Orbital Symptoms