Silent Sinus Syndrome Research Articles

Silent Sinus Syndrome: A Paediatric Condition Diagnosed in the Orthodontic Department

Silent sinus syndrome (SSS) is defined as unilateral maxillary sinus hypoplasia and orbital floor resorption. This case report highlights a rare paediatric diagnosis of SSS during an orthodontic clinic. The diagnostic orthopantogram (OPG) and cone-beam computed tomography showed complete opacification of the left maxillary sinus. Following referral to the ear, nose and throat (ENT) department, a CT sinus confirmed SSS. Owing to the risk of facial asymmetry in a growing adolescent patient without surgical intervention, functional endoscopic sinus surgery will be used to manage this. This case highlights the importance of a thorough investigation of incidental findings. CPD/Clinical Relevance: The clinical relevance of early diagnosis of silent sinus syndrome and its implications on facial symmetry is discussed.

Варианты хирургического лечения хронического ателектаза верхнечелюстной пазухи (синдрома молчащего синуса)

Silent sinus syndrome is a fairly rare ENT pathology. It is still not possible to explain the exact cause of this syndrome. Modern equipment and accurate diagnostics provide the opportunity to make a diagnosis and choose the right treatment and rehabilitation tactics. The authors analyzed 36 patients from 2008 to 2024 who were admitted to the ENT department with symptoms of different nature and clinical manifestations, allowing making diagnosis silent sinus syndrome, to confirm which data on the course of the disease, radiological and endoscopic characteristics of the maxillary sinus were used. For surgical access, three options for opening the maxillary sinuses were used: through the middle and lower nasal passages as well as through the canine fossa. Access through the canine fossa (micro maxillary sinusotomy) with the formation of a persistent anastomosis in the middle and lower nasal meatus turned out to be the most optimal. The choice of location for opening the sinus was determined by the degree of prolapse of the orbital contents into the lumen of the sinus and the condition of the bone walls of the orbit. The article also presents a clinical case of complete opening of the maxillary sinus, with correctly formed bone walls and normal aeration of the sinus in a patient with this syndrome, after treatment.

Diplopia in Silent Sinus Syndrome – From Diagnosis to Minimal Surgical Intervention

Abstract Silent sinus syndrome (SSS) is a rare disease mostly affecting the maxillary sinus. It is described as a slowly progressive painless enophthalmos with hypoglobus secondary to atelectasis of the maxillary sinus in patients with an unremarkable history of preexisting sinonasal or ophthalmological pathologies. Diplopia is an unusual presentation of SSS and opting for orbital floor correction is a matter of debate. Limited reports in the literature show the efficacy of endoscopic maxillary antrostomy alone without orbital floor reconstruction in patients with diplopia. This study reports a case of an unusual presentation of SSS. The paper also reviews the diagnostic approach and focuses on the treatment by minimally invasive endoscopic antrostomy for aeration of the maxillary sinus without the need of orbital floor reconstruction for correction of diplopia and enophthalmos. This paper discusses a 41-year-old previously healthy male presenting with gradually progressive hypoglobus and enophthalmos associated with diplopia and mild facial asymmetry. There was no past medical history of sinonasal or ophthalmological diseases, surgeries, or trauma. The differential diagnoses initially were variable. Endoscopic evaluation in the outpatient clinic along with computed tomography and magnetic resonance imaging of the paranasal sinuses and orbit confirmed the diagnosis of SSS. Relieving the negative maxillary pressure with endoscopic wide middle meatal maxillary antrostomy without orbital floor reconstruction restored the normal extraocular muscle movement and improved the diplopia, hypoglobus, and enophthalmos. Our case report demonstrates the association between SSS and diplopia, and it reviews the diagnostic approach to the disease including comprehensive clinical assessment, endoscopic evaluation, and radiological studies. The case report also signifies the effectiveness of endoscopic maxillary antrostomy without orbital floor reconstruction in re-establishing the ventilation of the atelectatic maxillary sinus and allowing spontaneous resolution of diplopia, enophthalmos, and hypoglobus.

The CBCT Retrospective Study on Underwood Septa and Their Related Factors in Maxillary Sinuses-A Proposal of Classification.

Introduction. The presence of bone septum in the maxillary sinus is one of the most common anatomical findings. So-called Underwood septa (US) are an atypical bone formation in the maxillary sinuses. Mostly they are quite easily found in CBCT studies and have major importance in sinus lift procedures in dental surgery. Furthermore, the shape, location, and size of the bony septa are important in each maxillary sinus surgery. Material and methods. A retrospective study of 120CBCT scans from the authors' own database was conducted. Results. Approximately 37.5% of each CBCT was associated with the occurrence of US, while just 25% had a full septum, and a total of only 14 patients had a half septa. More females have US, while healthy pneumatized maxillary sinus is most commonly found (82.22%). There is no correlation between the occurrence of silent sinus syndrome (p = 0.174), mucosal thickening (p = 0.325), or retention cyst formation (p = 0.272). Most sinuses are without any opacification in CBCT evaluation (91.11%), while other syndromes are not statistically relevant. Conclusions. It seems that the occurrence of Underwood septa is not statistically related to any clinical, radiological, or pathological condition within the sinus (p > 0.05). Furthermore, a more full or partial appearance of US was found in female patients.

Post-traumatic Sinus Syndrome, Proposal for a New Clinical Entity (CDR Syndrome) as Variant of the Silent Sinus Syndrome: Systematic Review and Case Series.

The diagnostic criteria for silent sinus syndrome (SSS) are still controversial, especially for the post-traumatic/surgery cases that are, nowadays, excluded from the diagnosis of SSS because lacking of spontaneously. We present a systematic review of the last 10years and our case series of SSS associated to previous trauma/surgery, proposing a new interpretation of SSS. In this work, following the PRISMA guide lines for systematic reviews, we collected 86 articles published on PubMed, Cochrane Library and Medline Plus since 2013 to 2023 about SSS. We divided them in six groups forming the structure of the review: (1) epidemiology, (2) clinical presentation, (3) imaging, (4) etiopathogenesis, (5) sss and craniofacial trauma and (6) treatment. We reported two explicative clinical cases: two men of 34 and 37years old, involved in motorcycle accident in 2020 and 2014, respectively, and underwent surgery. They came back in 2023 referring diplopia documented by Hess-Lancaster test. CT-scan reported two clear cases of SSS. Basing on what is reported in literature, and basing on our experience, the post-traumatic/surgery SSS are more frequent than the idiopathic ones. Our proposal is to considered them as two individual entities. We propose to adopt the name of Post-traumatic sinus syndrome, or CDR syndrome (Catalfamo-De Rinaldis), for all cases that respect four specific diagnostic criteria reported into the text.

A Retrospective Study on Silent Sinus Syndrome in Cone Beam-Computed Tomography Images—Author Classification Proposal

Introduction. Facial asymmetry might have many etiological factors. Most known and recognized factors are related to hemimandibular hyperplasia, elongation, condyle-related pathologies hemifacial microsomia, laterogenia, and others. In some cases, however, facial asymmetry has a different origin within the maxillary sinus (MS) bones. This rare entity as a silent sinus syndrome (SSS) causes secondary midfacial and maxillary asymmetry because of the retraction of the sinus walls. The authors present their own proposal for SSS/CMA (chronic maxillary atelectasia) classification and possible maxillary sinus disease alterations related to the scope of changes in the maxillary sinus walls, asymmetry, opacification, and related features. Material and Methods. The study consisted of 131 CBCT images which were evaluated. The authors focus on fourteen retrospective cone beam-computed tomography studies (CBCT) performed to establish and evaluate sources of facial asymmetry. Results. Neither presented maxillary and facial asymmetry cases correspond to the typical SSS/CMA findings. Asymptomatic maxillary sinusitis co-existing in maxillary asymmetry cases in patients suffering from skeletal malocclusion remains atypical for SSS pure and in-pure cases. The osteomeatal complex (OMC) patency is more common for pure forms. Conclusions. Computed tomography quite easily can identify the source of the problems in the maxillary sinus and identify SSS. Coexistent chronic rhinosinusitis might correspond with another MS pathology, CMA—chronic maxillary atelectasia. The scope and the degree of MS cause midfacial asymmetry; however, the scope of sinus opacification, osteomeatal complex drainage, and occurrence of other symptoms might be more or less present. The OMC patency is more common for pure forms.

Silent sinus syndrome with interfrontal sinus retraction: A 3-case series using CARE methodology

IntroductionSilent sinus syndrome (SSS) is a rare entity, almost exclusively involving the maxillary sinus, frontal location being very rarely reported. The aim of the present study was to describe clinical and radiological characteristics and surgical treatment using the CARE methodology. ResultsOne woman and 2 men were referred for chronic unilateral frontal pain with imagery showing silent sinus syndrome. All showed partial or complete liquid opacification of the affected sinus associated with a thin interfrontal sinus (IFS) retracted toward the affected sinus. Functional endoscopic sinus surgery was performed in all cases, with good functional results. DiscussionWe describe 3 cases of SSS with IFS involvement. The frontal sinus wall seemed most vulnerable, probably most liable to be weakened by atelectasis. The study suggests that frontal SSS can be an etiology in chronic frontal sinusitis. Preoperative findings of IFS retraction are useful for surgical restoration of frontal sinus ventilation, relieving chronic pain and preventing complications.

Clinical manifestations, management, and outcomes of primary silent sinus syndrome: a systematic review.

Silent sinus syndrome (SSS) is a rare disorder of the maxillary sinus, which may present with orbital symptoms. Most reports of silent sinus syndrome are limited to small series or case reports. This systematic review comprehensively characterizes the various clinical presentations, management, treatment, and outcomes in patients with SSS. A systematic literature search of the PubMed, Cochrane, Web of Science, and Scopus databases. Inclusion criteria were studies describing the presentation, management, or treatment of SSS or chronic maxillary atelectasis. One hundred fifty-three articles were included in the final review (n=558 patients). Mean age at diagnosis was 38.8 ± 14.1 years, with a relatively even distribution among sexes. Enophthalmos and/or hypoglobus were the most frequent symptoms, along with diplopia, headache, or facial pressure/pain. Most patients (87%) underwent functional endoscopic sinus surgery (FESS), and 23.5% received orbital floor reconstruction. Post-treatment, patients had significant reductions in enophthalmos (2.67 ± 1.39 vs. 0.33 ± 0.75 mm) and hypoglobus (2.22 ± 1.43 vs. 0.23 ± 0.62 mm). Most patients (83.2%) achieved partial or total resolution of clinical symptoms. SSS has a variable clinical presentation, with enophthalmos and hypoglobus being most common. FESS with or without orbital reconstruction are effective treatments to address the underlying pathology and structural deficits.

Patient Specific Implants for Orbital Reconstruction in the Treatment of Silent Sinus Syndrome: Two Case Reports.

Silent sinus syndrome is a rare disorder characterized by ipsilateral enophthalmos and hypoglobus following a collapse of the orbital floor, in the presence of asymptomatic long-term maxillary sinusitis. It results in enophthalmos, hypoglobus and deepening of the superior palpebral sulcus. A standardized treatment protocol for this infrequent syndrome has not yet been established. The management includes restoration of maxillary sinus ventilation with functional endoscopic sinus surgery and orbital reconstruction, either concurrently or separately. In this paper, the authors presented two patients successfully treated with patient-specific implants, and intraoperative navigation. These cases highlight the benefit of computer-assisted planning and titanium patient-specific implants in the management of silent sinus syndrome. To the best of our knowledge, this is the first report that described the use of PSI with titanium spacers performed with the aid of intraoperative navigation for SSS treatment. Advantages, drawbacks of this technique and treatment alternatives currently available in the literature were also discussed.

Silent Sinus Syndrome: A Case of Orbital Reconstruction With Patient-specific Implant and Intraoperative Navigation System and Computed Tomography Scan

Objective By reporting a case of orbital restoration with a patient-specific implant (PSI), intraoperative navigation and computed tomography scan (CT) in a silent sinus syndrome patient, we aim to make reconstructive surgeons aware of the advantages these tools confer. Case Report We report a case of a 33-year-old woman affected by spontaneous enophthalmos and hypoglobus of her right eye. Anamnesis, physical exam and CT findings were compatible with a silent sinus syndrome. Caldwell-Luc technique and concurrent transconjunctival repair of the orbital floor using a PSI with intraoperative navigation and CT scan were performed successfully, achieving satisfactory repositioning of the globe and facial symmetry. Conclusion The silent sinus syndrome is an acquired uncommon condition which may require correction of secondary orbital deformities. In this scenario, patient-specific implants, CAD/CAM and intraoperative navigation have emerged as safe and effective tools.

Volumetric Analysis of the Sinus and Orbit in Silent Sinus Syndrome After Endoscopic Sinus Surgery.

The term "silent sinus syndrome" (SSS) describes spontaneous enophthalmos secondary to subclinical maxillary sinus atelectasis. Debate remains on whether treatment with endoscopic maxillary antrostomy alone is adequate in reversing atelectasis and globe displacement. This study aims to determine the degree of volume change of the diseased sinus and orbit as well as the change in orbital height in patients treated with endoscopic antrostomy without orbital floor augmentation. Retrospective review with image analysis. Single tertiary care institution. Three-dimensional (3D) analysis of computed tomographic imaging data was performed using 3D Slicer. 3D models of the maxillary sinus and orbit of the diseased and normal sides were created, and volume measurements were calculated using the segmentation program. Thirteen patients with SSS who underwent endoscopic sinus surgery (ESS) and had follow-up computed tomographic imaging were analyzed. After endoscopic antrostomy, the mean volume of the diseased maxillary sinus significantly increased by 9.82%, from 6.37to 7.00 cm3 (p = .0302). There was no significant change in mean orbital volume; however, the mean orbital height decreased by 5.67%, from 38.09 to 35.93 mm from pretreatment to posttreatment samples (p = .0101). All patients had resolution of clinical or radiographic enophthalmos and orbital displacement with ESS alone. Endoscopic maxillary antrostomy alone in the treatment of SSS significantly increased maxillary sinus volume and decreased diseased orbital height. These changes were associated with clinical and radiographic improvement in globe displacement. These findings support performing ESS alone, reserving orbital augmentation for patients who do not exhibit adequate clinical improvement.

Проблема синдрома «немого» синуса (СНС) в оториноларингологии детского возраста

In the structure of diseases of the ENT organs, the pathology of the maxillary sinus is the most common, including in children. Some diseases of this anatomical zone are quite rare, especially in children. This pathology includes chronic atelectasis of the maxillary sinus—the silent sinus syndrome (SSS). The disease itself has been known for about 60 years, but only in the last couple of decades the eyes of the world otorhinolaryngology have turned more closely toward the SSS. This is primarily due to both the wider introduction of modern diagnostic radiology and the widespread introduction of endoscopic methods for treating the pathology of the paranasal sinuses and the orbit as well as the improvement of surgeons in this direction. In turn, in children, this pathology began to be studied more carefully even later due to the more complex use of modern radiation diagnostic methods in children and the less common possibilities of surgical endoscopic treatment in pediatric otorhinolaryngology. In children, this pathology is no less relevant than in adults, and in case of incorrect management tactics and late diagnosis it leads to no less sad consequences than in adult patients.

Concurrent Mucocele and Silent Sinus Syndrome after Orbital Fracture Repair

A 59-year-old man sustained a left medial wall-floor fracture requiring repair (Fig A). Eight years later, the patient presented with left-sided proptosis and binocular diplopia. Visual acuity was normal with no afferent pupillary defect. Extraocular movements were limited in supraduction and abduction in the left eye. Orbital computed tomography demonstrated a large soft tissue density representing a mucocele encasing the implant (Fig B). There was also opacification of the left maxillary sinus and bowing of the orbital floor consistent with silent sinus syndrome.

Silent sinus syndrome: systematic review and proposal of definition, diagnosis and management.

SUMMARYSilent sinus syndrome (SSS) is a rare disease consisting of a collapse of maxillary sinus walls with concomitant orbital floor descent. Due to its rareness, the literature highlights some confusion on its definition, diagnosis and management. A PRISMA-compliant systematic review was performed on SSS with focus on definition, diagnosis and therapeutic management. Twenty-eight studies were selected, with 276 patients evaluated. The analysis revealed that the leading definition of SSS includes evidence of both enophtalmos and maxillary atelectasia. Although the definition of SSS accepts only spontaneous sinus collapse, the presence of sinonasal diseases and history of facial trauma are starting to be included in the criteria. Most studies (n = 21) considered CT scans satisfactory for diagnosis of SSS, while 7 also performed MR. The majority of SSS were successfully treated with isolated functional endoscopic sinus surgery (n = 17), sparing orbital reconstruction as a rescue procedure in case of non-satisfactory long-term resolution of signs. Although the literature is starting to coordinate on diagnosis of SSS, our review revealed the necessity of consensus on its definition and management.

Maxillary sinus volume changes after functional endoscopic sinus surgery in patients with chronic maxillary atelectasis and silent sinus syndrome.

Maxillary sinus volume changes after functional endoscopic sinus surgery in patients with chronic maxillary atelectasis and silent sinus syndrome.

Prevalence of chronic maxillary atelectasis: a radiological study.

Chronic maxillary atelectasis is an infrequent entity and data on its prevalence are lacking. This study investigated the prevalence of chronic maxillary atelectasis and aimed to determine the bilaterality of this entity. The data for 5835 patients who underwent paranasal sinus computed tomography from 2016 to 2020 were retrospectively analysed. Fifty-four patients were diagnosed with chronic maxillary atelectasis; its prevalence was 0.92 per cent. The mean age of these 54 patients was 42.98 ± 18.89 years (range, 18-85 years); 17 of the patients were female and 37 were male. Chronic maxillary atelectasis was unilateral in 42 patients and bilateral in 12 patients (22.2 per cent). Eight patients were found to have enophthalmos with apparent facial asymmetry. The prevalence of bilateral chronic maxillary atelectasis may be higher than previously reported and bilaterality may increase as the number of diagnosed cases increases. A unified classification is also proposed, which describes the silent sinus syndrome as chronic maxillary atelectasis IIIS.

Maxillary Sinus Barotrauma in a Silent Maxillary Sinus Syndrome Scenario: Case Report

Barosinusitis is defined as an entity where damage to a paranasal sinus occurs secondary to sudden changes in atmospheric pressure. These dysbarisms respond to Boyle's Law where -given constant temperature- the pressure of a gas is inversely proportional to its volume. On the other hand, silent sinus syndrome is a pathology with few case reports in which the paranasal sinus undergoes a remodeling of its bony walls generating, in the case of the maxillary sinus, a descent of the eyeball and a herniation of the fat of the pterygopalatine fossa. The symptoms in these patients are insidious, so the diagnosis is usually fortuitous. The authors report a case where a diagnosis of silent maxillary sinus syndrome was made after an episode of severe maxillary barosinusitis.

Ethmoidal silent sinus syndrome after nasal swab test.

This study reported the case of a healthy male in his 40s who presented with a 3-month history of frontal headache and post-nasal drip, which did not improve with oral antibiotics. One month prior to the onset of the symptoms, he underwent a nasopharyngeal swab testing for SARS-CoV-2 (which yielded a negative result) for a history of malaise and cough. The patient claimed that the swab insertion into the nasal cavity was particularly painful on the left side. Sinus computed tomography (CT) scan showed deformity of the left middle nasal turbinate with occlusion of the osteomeatal complex, resulting in ethmoid silent sinus syndrome. This study makes a significant contribution to the literature because nasopharyngeal, midturbinate and anterior nasal swabs have been recommended as initial diagnostic specimen collection methods by the US Centers for Disease Control and Prevention (CDC) for the coronavirus disease 2019. These methods require introducing an instrument into the nasal cavity, potentially leading to adverse effects due to the delicate and complex nasal anatomy. However, complications related to swab testing for respiratory pathogens have not yet been fully discussed in the literature.

Silent sinus syndrome: potentially misleading features that should be recognized

ObjectiveSilent sinus syndrome (SSS) usually manifests clinically as hypoglobus and enophthalmos. Patients may experience different symptoms and may present to an assortment of specialties and delay diagnosis and management. The objective of this article was to describe the different and sometimes misleading signs and symptoms of SSS to improve the level of suspicion and reduce time to diagnosis. MethodsA retrospective consecutive audit of the records of all patients diagnosed with SSS between 2015 and 2019 in the Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust. Demographic and clinical data including presentation, diagnosis, and symptoms were obtained from the patients’ medical files. ResultsTen patients were included; mean age was 42.5 ± 11.5 years (range, 16–56 years). Four patients were initially referred to an ophthalmologist with globe asymmetry, diplopia, eyelid asymmetry, or retraction. Three patients were initially referred to an ear, nose, and throat specialist with facial asymmetry or infraorbital paraesthesia. Two patients were referred from the maxillofacial department with an incidental finding, and the last patient was seen initially by the neurology team with headaches. ConclusionSSS has a variable presentation. Patients may have common or misleading signs. Patients may attend different clinics and subspecialties, and physicians should be aware of the broad range of presenting signs in this condition to prevent delay in diagnosis and further morbidity.

Patient specific implants in orbital reconstruction: A pilot study

PurposeSuccessful repair of the orbital skeleton restores function and cosmesis by normalizing globe position and allowing full motility of the extraocular muscles. Routine repairs are successful with standard implants. However, defects that are irregular or cause volume deficiency can be challenging to repair. The development of patient specific implants (PSI) offers an additional tool in complex cases. Herein, we report our experience using PSI for orbital reconstruction. MethodsAn IRB-approved review was conducted of consecutive patients who received PSI from 8/2016–9/2018. Demographic and examination findings were recorded. PSI was designed using high-density porous polyethylene or polyetheretherketone (PEEK) and implanted for repair. The postoperative course was reviewed for outcomes and complications. ResultsEight patients were identified. Two had silent sinus syndrome, 3 were complex facial fracture revisions, and 3 were post-oncologic reconstruction. Seven received porous polyethylene implants, and 1 had a PEEK implant. Mean follow up time was 10.2 months (3.3–28.3). All had an improved functional and aesthetic result. Diplopia and enophthalmos completely resolved in 60% of fracture and silent sinus patients. All fracture and silent sinus patients were orthotropic without diplopia in primary gaze at last follow up. Tumor patients had improvement in symmetry and functionality. There were no complications. Conclusion and importanceComplex orbital skeleton derangements can be difficult to repair and standard implants may incompletely resolve the anatomic problem. In challenging cases, PSI may better achieve an aesthetically and anatomically successful outcome and improve functionality.