Posttraumatic Delayed Enophthalmos: Analogies with Silent Sinus Syndrome? Case Report and Literature Review

Delayed onset enophthalmos and hypoglobus mimicking silent sinus syndrome following midface trauma

Craniomaxillofacial trauma is primarily diagnosed and managed by oral and maxillofacial surgeons. Among the cases encountered, midface fractures involving orbital walls are highly prevalent. In these fractures, involvement of the orbital walls, particularly floor of the orbit, can lead to considerable aesthetic and functional limitations. From a maxillofacial perspective, indications for surgical repair of orbital floor encompass marked decrease in ocular motility, fracture affecting more than 50% of surface area, an increase in orbital volume exceeding 18% and enophthalmos greater than 2 mm. In the absence of these discernible signs, surgical intervention is not generally indicated. However, in this case, an early adolescent with a history of midface trauma and minimal orbital floor fracture 8 months earlier presented with progressively delayed onset enophthalmos and hypoglobus closely resembling features of silent sinus syndrome. The enophthalmos and hypoglobus were corrected by placing custom-made non-resorbable high-density polyethylene implant in the orbital floor. Postoperative follow-up demonstrated aesthetically and functionally satisfactory outcomes.

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 10 years 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 37 years 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.

Silent Sinus Syndrome Post Trauma: A Case Report and Literature Review

Silent sinus syndrome (SSS) is a relatively rare clinical condition occurring in the maxillary sinus exhibiting progressive enophthalmos and hypoglobus. The communication between the orbit and maxillary antrum due to trauma further leads to changes in the maxillary sinus. This could lead to the development of negative pressure within the maxillary sinus, collapse of antrum walls, and sucking in of orbital contents. Here, we present a case of a delayed orbital trauma, which was not treated initially. The patient's complaint was a constant feeling of a sunken right eye along with restriction in eye movements. On examination, the clinical and radiographic features were consistent with SSS. Orbital floor reconstruction was performed with the help of a titanium mesh for the correction of hypoglobus and enophthalmos. During follow-up, the patient showed no recurrence of the presenting functional and esthetic complaints. This clinical entity needs prompt diagnosis and early intervention so as to prevent further complications.

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 missed entity?

Silent sinus syndrome is a rare anomaly caused due to hypoventilation in the maxillary sinus. This is mostly unilateral and asymptomatic in majority of patients. Some patients develop complications due to this such as hypoglobus and enophthalmos. The usual age of occurrence is after 30 years. We report this unique case as our patient was very young to develop this.

Secondary Correction of Posttraumatic Enophthalmos

Posttraumatic enophthalmos (PE) arises when the ocular globe is displaced posteriorly and inferiorly in the orbital cavity due to a mismatch in orbital volume and orbital content. This most commonly happens after orbital fractures. The resulting disruptions to aesthetic form and ocular functions often necessitate surgical correction for reconstruction and restoration. The purpose of surgical management of PE is to reconstruct orbital shape and volume as well as to restore any herniated orbital content. This can be particularly challenging in cases involving large defects that require complex orbital reconstruction. Recent advancements in computer-aided surgery have introduced innovative and important tools to assist surgeons with these difficult cases. The ability to create customized, patient-specific implants can facilitate reconstruction involving complicated anatomy. Additionally, intraoperative imaging and intraoperative navigation can serve as useful guides for surgeons to more accurately place implants, especially in cases with limited visualization, in order to achieve optimal outcomes.

Etiology, Early Diagnosis and Proper Treatment of Silent Sinus Syndrome Based on Review of the Literature and Own Experience

PURPOSE

The authors' aim was to review the literature in terms of the etiology of the syndrome, the frequency of Silent Sinus Syndrome (SSS) and surgical procedure, as well as to present their own experience.

METHODS

The authors used PubMed, Medline, and Science Direct websites to find and review the most significant papers related to SSS. The case reports of SSS published between 2010 and 2020 were reviewed. A retrospective case review of 8 patients with SSS treated at the authors' departments was done.

RESULTS

The silent sinus syndrome has been reported in both children and adults. It is relatively rare and should be differentiated from congenital sinus hypoplasia or atelectasis. It most often affects the maxillary sinus. SSS is usually diagnosed when facial asymmetry or vision problems occur. Late diagnosis requires endoscopic sinus surgery, involving orbital wall reconstruction. The etiology of the syndrome, including the role of bacterial flora found in the sinuses, is unclear.

CONCLUSION

Early diagnosis of SSS enables avoiding orbital complications and limits surgical intervention to endoscopic surgery. Further research into bacteriology may help to understand the pathophysiology of the silent sinus syndrome.

Surgical Advances in the Management of the Silent Sinus Syndrome: Our Experience and Review of the Literature

Silent sinus syndrome is a rare disorder characterized by ipsilateral enophthalmos and hypoglobus caused by collapse of the orbital floor in the presence of asymptomatic long-term maxillary sinusitis. The basic principles in the management are to address the diseased sinus and reconstruct the orbit concurrently or separately. Failure to accurately restore the orbit volume can have significant consequences on the patient. In this article, we provide an update on current practices and highlight our experience of using computer-assisted planning and patient-specific implant in managing this syndrome.

Combined Single-Step Procedure for Correction of Silent Sinus Syndrome

Silent sinus syndrome (SSS) is a rare condition characterized by enophthalmos and hypoglobus that is generally not related to trauma or surgery. We present a 30-year-old man who noticed facial asymmetry during the previous month and was referred to our oculoplastic clinic. His examination revealed right hypoglobus and a 2-mm right enophthalmos. The diagnosis of right SSS was confirmed by orbital and paranasal computed tomography scan. The patient had no otolaryngological symptoms and visual acuity was normal bilaterally. He was treated surgically in a combined approach by a team of oculoplastic and otorhinolaryngology surgeons. Functional endoscopic sinus surgery included uncinectomy, maxillary antrostomy, and orbitotomy, with insertion of an orbital implant. This case demonstrates that a single-step surgery for correction of enophthalmos secondary to SSS is a viable option, leading to quick rehabilitation and excellent aesthetic results.

Clinical Features and Outcomes of Post-Traumatic Silent Sinus Syndrome

PURPOSE

To identify demographic features and clinical outcomes associated with post-traumatic silent sinus syndrome.

METHODS

A retrospective review was carried out at 3 academic medical centers to identify all cases of post-traumatic silent sinus syndrome. Clinical features and management strategies were recorded. Postoperative outcomes were assessed, and statistical analyses were performed via a dedicated computerized software package.

RESULTS

Twenty cases were identified (14 men and 6 women, mean age = 44.2 years). Seven patients underwent sinus surgery as the sole means of treatment, and the mean pre- and postoperative enophthalmos measurements were 2.86 and 1.93 mm. Alternatively, 13 patients underwent combined orbital reconstruction and sinus surgery, respectively; the mean pre- and postoperative enophthalmos measurements were 3.42 and 0.39 mm, respectively. The change in enophthalmos was statistically significantly greater in patients who underwent sinus surgery and orbital reconstruction (p = 0.00028). Among patients who underwent sinus surgery alone, one patients (14.2%) experienced complete resolution of enophthalmos, as compared with 10 patients (76.9%) who underwent combined procedures.

CONCLUSIONS

This study represents the largest published cohort of patients with post-traumatic silent sinus syndrome. Combined orbital reconstruction and sinus surgery results in greater reductions of enophthalmos and a markedly improved chance of postoperative symmetry of globe position.

Ethmoid Silent Sinus Syndrome Following Orbital Trauma

A 55-year-old man presented with progressive "enophthalmos" of his ocular prosthesis, 12 years after secondary orbital implant placement following evisceration of a severe traumatic globe rupture. The medial orbital wall was found to be displaced inwards, associated with ethmoid sinus opacification, and consistent with post traumatic silent sinus syndrome affecting the ethmoid paranasal sinuses. The authors present the clinical and radiological findings, review the literature on silent sinus syndrome of nonmaxillary sinuses, and discuss the possible mechanisms for his presentation.

Silent sinus syndrome after facial trauma: A case report and literature review

OBJECTIVE

The accepted definition of silent sinus syndrome (SSS) excludes posttraumatic cases. To challenge current exclusion criteria of antecedent facial trauma, we have identified all published cases of posttraumatic SSS in English literature, including a new representative case from our institution.

DATA SOURCES

MEDLINE, EMBASE, and Scopus databases.

REVIEW METHODS

All case reports and case series published in English literature from 1964 through August 2016 were sequentially identified. Authors of cases with missing information were contacted for completion.

RESULTS

Thirteen documented cases of posttraumatic SSS were identified through the literature review. An additional case from our institution was presented, bringing the total reported case count to 14. Time from initial trauma to presentation ranged from 2 months to 32 years, with a median duration of 6 months. Endoscopic sinus surgery (ESS) with either concurrent or staged orbital floor implant repair was used to treat posttraumatic SSS in 64% of reported cases. Three patients had ESS alone, with one case showing postoperative improvement in enophthalmos.

CONCLUSION

Recent emergence of case reports of SSS postorbital and facial trauma challenge the current exclusion criteria of precedent facial trauma. Posttraumatic SSS is rare, but the availability of cross-sectional imaging pre- and postdevelopment of SSS makes a strong case for a causal relationship. Laryngoscope, 127:1520-1524, 2017.