Is fungal infestation of paranasal sinuses more aggressive in pediatric population?

OBJECTIVE

Comparison of characteristic features, radiology, management and recurrence pattern of fungal sinusitis between children and adults.

METHODS

A prospective study conducted in the department of Otorhinolaryngology, Head and Neck Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh in which all the cases presenting with the features of allergic fungal sinusitis (AFS) between January 2000 and January 2005 were enrolled. These cases were divided into two groups, group 1 comprised of cases with age less than 15 years and group 2 with age more than 15 years. Detailed history, physical examination and nasal endoscopic examination and computed tomography (CT) scan of the paranasal sinuses was done in all the cases. The cases with prior history of sinonasal surgery were excluded from the study. All patients refractory to medical management were subjected to endoscopic sinus surgery. All the cases were followed up for a period ranging from 6 to 39 months to see for the recurrence. The data of both the groups was analysed statistically using chi square test.

RESULTS

The study population comprised of 200 cases, with 68 cases in group 1 and 132 cases in group 2. The most common symptom in both the groups was presence of nasal obstruction. The children had higher incidence of having unilateral disease (46 out of 68) compared with adults, where it was 38 out of 132. The bony erosion was seen more often in group 1. Surgery was done endoscopically in all the cases. The intra orbital or intra cranial extension was seen in 58 cases of group 1 and 47 cases of group 2 (p<0.001). Recurrence was seen in 18 (15 with intraorbital and 3 with intracranial extension) cases in group 1 and 13 cases (11 with intraorbital and 2 with intracranial extension) in group 2 (p<0.005).

CONCLUSION

In our study, we found a higher incidence of facial deformities, proptosis, intraorbital/intracranial extension and a higher rate of recurrence in group 1, therefore, suggesting a more aggressive nature of AFS in children than adults mandating an early diagnosis, proper management and regular follow up in these cases.

Mechanical properties and functional importance of pulley bands or 'faisseaux tendineux'

INTRODUCTION

Connective tissue bands connect the horizontal rectus muscles at the level of the posterior pole to the orbital wall. These bands, referred to as pulley bands or faisseaux tendineux, purportedly act like springs to keep the rectus muscle bellies in place during eye movement out of the plane of the muscle. We examined the mechanical properties of these bands in human specimens obtained during surgery. In addition, we examined eye motility and stability of rectus muscles in a patient who had no functional pulley bands.

METHODS

Exenterations were carried out on two patients with sebaceous gland carcinoma. Pulley bands were identified and force-elongation behavior was examined with a forceps and a force gauge. Stability of rectus muscles was examined in a patient with severe Crouzon's syndrome by orbital CT scans and during surgery under local, eye drop, anesthesia.

RESULTS

The pulley bands showed leash-like mechanical behavior: they were slack over approximately 10mm and became taut when stretched further. In the patient with Crouzon's syndrome, both CT and observation of the muscle during surgery showed little sideways displacement of the muscle bellies in eye movement out of the plane of the muscle, despite the lack of functional pulley bands.

DISCUSSION

The leash-like mechanical behavior of the pulley bands seems unsuited for stabilization of the muscle bellies. The patient with Crouzon's syndrome had relatively good eye motility and stable rectus muscle paths despite the lack of functional pulley bands.

Orbital hydatid cyst manifested as expanding exophthalmos following blunt orbital trauma

A 14-year-old boy suffered right blunt orbital trauma. X-ray revealed a compressed fracture of the right ethmoidal sinuses. Three months after the trauma, progressive, painless right proptosis developed. Ocular examination revealed a severe proptosis and pronounced down displacement of the right globe without signs of orbital inflammation. A well-demarcated, extraconal right orbital cystic mass was seen on computerized tomography scan. The cyst contents were aspirated and found to contain echinococcal scolices and "hydatid sand." Hypertonic saline was injected and the cyst was excised. Progressive proptosis after blunt orbital trauma in patients from endemic areas should be suspected of being an orbital hydatid cyst.

Unilateral Exophthalmos Associated with Severe Fibrous Dysplasia

Fibrous dysplasia is a benign developmental anomaly of bone, often affecting craniofacial bones. We report on a 9-year-old boy, who presented for routine checkup. Clinical examination revealed unilateral exophthalmos of his left eye without decrease of visual acuity or double vision. Radiologic studies showed characteristic extensive changes of fibrous dysplasia involving the left frontal bone, left orbital bones, maxillary and sphenoid bones. The patient was started on conservative therapy and the condition of the affected eye remained stable. As fibrous dysplasia of the orbital bones can be a cause of significant dysfunction and a treatable cause of blindness, early diagnosis is very important. These patients are most likely to present with complaints of facial asymmetry, including axial, vertical, or horizontal displacement of the globe, or visual loss. Therefore the ophthalmologist plays an important role in the early diagnosis of fibrous dysplasia.

Orbital volumetric analysis of allergic fungal sinusitis patients with proptosis before and after endoscopic sinus surgery

BACKGROUND

The aim of this study was to examine the changes of orbital volumes in allergic fungal sinusitis (AFS) patients with proptosis who undergo endoscopic sinus surgery.

METHODS

A retrospective study of operative patients with proptosis due to AFS was performed. Normative data were obtained using patients with chronic sinusitis without orbital involvement. Orbital volume measurements were obtained using digitized images and computer software to calculate volumes (cm3) of outlined regions on 1.3-mm axial computed tomography images. Orbital volumes were measured as total volumes and volumes within the bony orbit. Bony orbits were defined using two techniques: (1) the region posterior to a line from ipsilateral zygoma to contralateral zygoma and (2) the region posterior to a line from zygoma to ipsilateral lacrimal bone. Four affected orbits in three AFS patients with proptosis were evaluated. Twenty-eight unaffected orbits in 14 patients were used as normal comparisons.

RESULTS

Orbital involvement by AFS resulting in proptosis decreased orbital volumes within the bony orbit to a mean of 70% of normal. After successful endoscopic sinus surgery, bony orbital volumes normalize or approach normal ranges to a mean 90% of normal with resolution of clinically apparent proptosis. Total volumes remained stable before and after surgery.

CONCLUSION

Massive AFS may affect the orbit resulting in proptosis. Spontaneous orbital remodeling with clinical resolution of proptosis and normalization of bony orbital volumes can be seen in AFS patients several months after sinus surgery and aggressive medical treatment. Surgical orbital reconstruction typically is not needed once the sinus disease is adequately addressed.

Unusual Progression of Pleomorphic Adenoma of the Lacrimal Gland-Case Report-

A 72-year-old female complained of acute pain on left eye movement followed by progressive exophthalmos. Neuroimaging revealed a large well-demarcated lesion consisting of solid and cystic parts, as well as bone destruction and hemorrhage, within the left orbital cavity. The preoperative diagnosis was pleomorphic adenoma with or without malignant transformation, or cavernous angioma. En bloc excision including adjacent tissues was planned to resolve the progressive symptoms and to obtain a histological diagnosis. The transcranial route was chosen since tumor invasion to the cranial base was possible. The histological diagnosis was pleomorphic adenoma. Pathological and preoperative radiological examinations indicated that repeated intratumoral hemorrhage had caused the orbital bone destruction and acute orbital pain. Neoplasms should be differentiated from a wide spectrum of other possible pathologies. Accurate clinical diagnosis of neoplasm in the orbital cavity is important for correct therapeutic management. Malignancy is generally suspected if painful and progressive signs and symptoms are associated with an orbital mass lesion. The present case suggests that pleomorphic adenoma should also be considered in the differential diagnosis. The therapeutic strategy for lacrimal gland tumors remains controversial, so a flexible management approach is required.

Kappa III immunoglobulin light chain origin of localized orbital amyloidosis

Isolated orbital amyloidosis is a rare condition in which intra-muscular deposits result in proptosis and restriction of eye movement. Previous reports have suggested an immunoglobulin origin of the amyloid fibrils, but this has not been proven biochemically. A case is presented in which initial unilateral orbital amyloidosis progressed to bilateral disease. Biochemical analysis of resected ocular muscle determined that the amyloid fibrils were derived from a kappa III immunoglobulin light chain. Questions of pathogenesis and tissue tropism are considered.

Acute myeloid leukemia presenting as bilateral proptosis from diffuse extraocular muscle infiltration

PURPOSE

To report a case of acute myeloid leukemia with bilateral proptosis as the sole presenting sign.

DESIGN

Observational case report.

METHODS

A patient with bilateral proptosis was seen in consultation by pediatric ophthalmology.

RESULTS

Complete blood count, computerized tomography, and bone marrow biopsy confirmed the diagnosis of acute myeloid leukemia, with the proptosis due to diffuse infiltration of all extraocular muscles.

CONCLUSION

In a child with the sudden onset of proptosis without any other systemic findings, the diagnosis of acute leukemia must be considered.

Targeted compartmental embolization of cavernous sinus dural arteriovenous fistulae using transfemoral medial and lateral facial vein approaches

There are multiple transvenous approaches for treatment of cavernous dural arteriovenous fistulae (DAVF). The choice of a specific route depends on the compartment of the cavernous sinus involved in the fistula and its venous drainage. We used two different facial vein approaches to treat patients with cavernous DAVF draining directly into the anterior compartment of the cavernous sinus and thence to the superior ophthalmic vein. Other transvenous routes to the sinus were not apparent. Embolization was targeted to the involved compartment with preservation of those not embolized. No major post-procedure ophthalmic venous engorgement occurred. We believe that ideal treatment of cavernous DAVF is targeted transvenous coil deposition, which necessitates detailed knowledge of the anatomy of the facial veins and cavernous sinus compartments.

Use of Bioglass for Orbital Volume Augmentation in Enophthalmos

PURPOSE

To investigate the clinical and histologic response of Novabone-C/M as an osteoproductive alloplastic implant for volume augmentation in the orbit in the treatment of enophthalmos and to compare its outcome alone versus its use in combination with autogenous bone or Medpor granules.

METHODS

Novabone-C/M, a bioactive silicone glass material, was implanted in the subperiosteal space of the left orbit of 12 New Zealand White rabbits. The animals were divided into 3 groups, each with 4 animals, based on the material implanted in the orbit: group 1, Novabone alone; group 2, Novabone plus Medpor granules; and group 3, Novabone plus autogenous bone fragments. All rabbits were studied clinically, radiographically, and histologically at 1-, 3-, and 6-month intervals. Animals underwent preoperative and postoperative computed tomography (CT) with 3-dimensional reconstruction, proptosis measurements, and volumetric analysis. Orbit specimens were studied histologically with mineralized bone stain (MIBS) to look for bone formation, reactivity, infection, implant resorption, and migration.

RESULTS

There were no signs of significant inflammation or infection. Subcutaneous migration of the implant was seen radiographically but not clinically in groups 1 and 3. Induced proptosis averaged 2.5 mm (at 1 month) and showed regression in all groups over a 6-month period but was not statistically significant. Implant volume was markedly reduced in all groups, averaging 69% in group 1, 37% in group 2, and 59% in group 3 at 6 months. New bone formation and bone remodeling was present in all 3 groups at 3 months and only in group 2 at 6 months. The rate and amount of implant remodeling and bone formation was greatest in the Novabone/Medpor group (group 2).

CONCLUSIONS

Bioglass particulate is biocompatible, easy to use in the orbit, and stimulates bone growth. Bioglass is associated with volume loss and migration over 6 months and may not provide adequate volume augmentation in the orbit when used alone for the treatment of enophthalmos. The duration and amount of bone formation may be enhanced when Novabone is used in conjunction with Medpor.

[Retrorbital metastasis an initial manifestation of prostatic cancer]

Orbital metastasis is an unusual localization within tumoral dissemination of prostatic cancer. Similarly, it is rare that orbital metastasis might be responsible for the clinic manifestations that determine the initial diagnosis of neoplasia. We illustrate the case of a patient suffering from prostatic adernocarcinoma that displayed alterations of facial sensitivity and right eye exophthalmos. We describe how the final diagnosis was reached and the patient's response to the suppressive hormonal treatment. The patient's rate of survival has proved to be longer than the rest of cases documented, with over 30-month follow-up.

[Post-traumatic exophthalmos caused by a subperiosteal hematoma of the orbit]

We report a case of a 27-year-old man who developed major exophthalmos associated with ophthalmoplegia occurring 48 hours after head trauma. CT scan showed an orbital roof fracture and a subperiosteal hematoma. Surgical evacuation of the hematoma and reconstruction of the orbital roof was performed via a frontal craniotomy. Two months later, the ophthalmologic examination was normal. We stress the importance of early diagnosis and prompt surgical treatment in such an unusual complication of head trauma.

[A rare cause of exophthalmos, hydatid cyst of the orbit]

INTRODUCTION

The orbital hydatid cyst is a rare (1 to 2%) localization of the Echinococcus granulosus parasite.

OBSERVATIONS

An intra-orbital localization of hydatidosis was revealed in two patients by the occurrence of unilateral exophthalmia. After tumoral resection the diagnosis was confirmed by histological examination.

COMMENTS

The principle clinical sign of an orbital hydatid cyst is exophthalmia. Imaging is essential for pre-operative diagnosis. Serology is insufficient and treatment is surgical.

Exophthalmos and orbital floor thickening related to maxillary sinusitis

A 59-year-old woman presented with periocular pain and 1.5 mm of relative proptosis. A computed tomography scan demonstrated thickening of the orbital floor, and an endoscopic sinusectomy revealed chronic sinusitis. Although cases of maxillary sinus disease with orbital floor thickening have been reported, these findings are in contrast to cases of silent sinus syndrome, in which maxillary sinus disease induces thinning and inferior displacement of the orbital floor with secondary enophthalmos and hypoglobus. Thus, while chronic maxillary sinus disease may create negative antral pressure and inferior displacement of the orbital floor, whether orbital floor thinning or thickening occurs varies with each case. The present case represents a combination of maxillary sinusitis with orbital floor thickening and exophthalmos, a less common manifestation of maxillary sinus-related orbitopathy.

Proptosis after retrobulbar corticosteroid injections

PURPOSE

This report describes the clinical, radiographic, and histopathologic findings in patients with proptosis secondary to lipomatosis after retrobulbar corticosteroid injection.

DESIGN

Retrospective, noncomparative, interventional case series and review of the literature.

METHODS

Five patients who developed symptomatic unilateral proptosis after steroid injection were studied and the literature was reviewed.

RESULTS

No previous description was found in the literature. All five cases were studied with computed tomography, and two cases were confirmed with histopathology. No fibrosis or granulomatous inflammation was identified.

CONCLUSIONS

Orbital lipomatosis is a potential complication of retrobulbar steroid injections. Symptomatic relief can be provided by a transconjunctival approach to the lower lid fat compartment.

Treatment of prominent eyes with orbital rim onlay implants: four-year experience

PURPOSE

Different approaches have been proposed to address the aesthetic or reconstructive challenge associated with relatively prominent eyes. Operations that address the soft tissues alone are prone to failure if the underlying orbital bony relationships are not addressed. Orbital rim advancement can serve as a supplement to orbital decompression in this setting or as an alternative for patients who may not maximally benefit from decompression surgery.

METHODS

We report our 4-year experience with porous polyethylene orbital rim onlay grafts used to address relative proptosis in 24 patients.

RESULTS

All patients had some degree of subjective and objective improvement. Proptosis decreased an average of 4.65 mm, with a range of 3 to 9 mm, based on single-observer Hertel exophthalmometry measurements (5.2 mm in those with concomitant decompression). Lagophthalmos was also improved in all patients with preoperative inadequacy in eyelid closure. Interpalpebral fissure size was reduced 1.3 mm on average, with a range of 0.5 to 6 mm (2 mm in those with concomitant decompression). Average follow-up was 41 months, with a range of 7 to 70 months. In 3 cases, we noted postoperative lower eyelid retraction with eyelid adhesion to the implant; possible risk factors for this complication included reoperative cases and simultaneous eyelid reconstruction with hard palate grafts.

CONCLUSIONS

The porous polyethylene orbital rim onlay implant offers a relatively simple and effective surgical technique for the treatment of symptomatic relative proptosis. It can be used alone or in combination with other techniques including midface lift, lower eyelid retractor recession, and orbital decompression. To be effective, the implant should be placed so that it is flush with or overlapping the orbital rim; lateral displacement negates the effect of the implant in improving the eyelid/globe relationship. Postoperative eyelid retraction with tethering to the implant is a potential risk of the onlay implant, and although it may not be possible to avoid this in all cases, surgeries should be designed to minimize postoperative eyelid retraction.

Taenia serialis causing exophthalmos in a pet rabbit

A 16-month-old, male, neuter Dwarf Lop rabbit presented with exophthalmos of the right eye of 3 weeks duration. Under sedation an ultrasound of the right eye was performed and showed an orbital hypo-echoic area posterior and ventrolateral to the right globe, which was presumed to be a cyst. Fine needle aspirate removed 5.5 mLs of straw-colored fluid from the cyst, which allowed the globe to return to its normal position. Two months later the rabbit re-presented with exophthalmos of the right eye. Exploratory surgery was performed and a large cystic structure was removed from the ventro-lateral conjunctival fornix. Histology confirmed the cyst to be a coenurus of Taenia serialis.

[Ocular myopathies - cause of exophthalmia]

It presents the "thickenings" of the extraocular muscles that can cause exophthalmos. It makes the difference between myositis limited to the orbit and the systemic myopathies and endocrine myopathies.