Silent sinus syndrome:

Silent sinus syndrome: potentially misleading features that should be recognized

OBJECTIVE

Silent 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.

METHODS

A 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.

RESULTS

Ten 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.

CONCLUSION

SSS 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.

Cone-beam computed tomographic imaging of silent sinus syndrome: A case series and a literature review

While silent sinus syndrome (SSS) is familiar to otolaryngologists and ophthalmologists, it is a rare clinical entity in dentistry and is likely to be underdiagnosed due to dentists' lack of awareness of this condition. SSS presents a diagnostic challenge to dentists, as patients typically have no history of trauma or sinusitis. The characteristic feature of SSS is a gradual retreat of the maxillary sinus walls, resulting in enophthalmos and hypoglobus. Multidetector (multislice) computed tomography is the imaging modality of choice for SSS and other paranasal sinus diseases. Cone-beam computed tomography promises to be an alternative low-dose imaging modality. This report describes 3 cases of SSS in adults, who had no identified clinical symptoms except diminutive and opacified maxillary sinuses, as well as the inward bowing of the sinus walls as noted on cone-beam computed tomographic imaging.

Silent sinus syndrome in children

INTRODUCTION

Silent sinus syndrome (SSS) is defined as a progressive enophthalmos and hypoglobus associated with maxillary sinus atelectasis. There is extremely limited literature describing SSS in children. The goals of this study are to characterize SSS in children through an IRB approval retrospective chart review of cases identified through a large health system-wide imaging database and to compare the presentation and outcomes of patients who underwent surgery versus those who were observed.

METHODS

A radiology database of over 26 million reports from 2003 to 2017 was searched to identify children aged 1-18 years diagnosed with maxillary sinus hypoplasia or SSS on CT scan. Chart review was performed on the identified children including clinical presentation, eye symptoms, surgical treatment, and outcome.

RESULTS

Eighty-three children were identified to have maxillary sinus hypoplasia. Eighty-one patients had maxillary sinus opacification and 57 patients had hypoglobus or enophthalmos characteristic of SSS. Thirty-two patients (47%) were seen by a specialist and 19 had surgery. The majority of patients (55%) had headache as their presenting symptom. There were no statistically significant differences in the clinical presentation between those who received surgery and those who were observed clinically.

CONCLUSIONS

Silent sinus syndrome can present at any age. The majority of cases of maxillary sinus hypoplasia will have the orbital floor changes characteristic of SSS. Headaches are a common presenting symptom. Close follow up of pediatric patients is advised and early intervention may be favorable to prevent long term orbital changes and complications.

Case Report: A Rare Case of Silent Sinus Syndrome and Vertical Diplopia

SIGNIFICANCE

Silent sinus syndrome is classically a maxillary sinus disease characterized by transient and variable vertical diplopia, hypoglobus, and enophthalmos. Uncommon presentations may exist, and although rare, it should be considered when diagnostic testing is inconsistent with more common etiologies of diplopia.

PURPOSE

This study aimed to report an unusual presentation of silent sinus syndrome and review the thought process in diagnosing and managing this condition.

CASE REPORT

A 65-year-old white man presented to the eye clinic with left upper eyelid ptosis and intermittent vertical diplopia of 2-month onset. Clinical testing was variable, and initial differential diagnoses included a partial left pupil-sparing third nerve palsy involving the superior division, myasthenia gravis, and orbital disease. After extensive workup and review of his computed tomography images, the patient was diagnosed with severe chronic pansinusitis with an underlying condition known as silent sinus syndrome. He was referred to otorhinolaryngology for sinus decompression and oculoplastics for orbital reconstruction. While awaiting orbital reconstruction after decompression of multiple sinuses, he returned reporting a significant reduction in his diplopia.

CONCLUSIONS

Vertical diplopia is a common complaint in primary care optometry. It is important to delve into more rare etiologies when clinical, laboratory, and radiological studies do not support the more common diagnoses.

Indications and Outcomes for Patients With Limited Symptoms Undergoing Endoscopic Sinus Surgery

BACKGROUND

Previous research have suggested that chronic rhinosinusitis (CRS) patients with lower symptomatic scores, demonstrated by a 22-item Sinonasal Outcome Test (SNOT-22) score <20, may not achieve meaningful quality of life improvement following endoscopic sinus surgery (ESS). However, indications for ESS are continuing to be defined and many low SNOT-22 scoring patients still undergo elective surgery for CRS and other benign sinonasal pathologies. The outcomes for these patients have not been previously studied.

OBJECTIVES

We sought to evaluate surgical indications and outcomes for those patients with limited symptoms undergoing ESS.

METHODS

We screened 2829 ESS procedures from 2010-2018 to identify patients with a preoperative SNOT-22 score <20. We reviewed disease characteristics, preoperative Lund-Mackay (LM) scores, and pre- and postoperative SNOT-22 scores in patients with at least 3 months' follow-up.

RESULTS

Of all surgical ESS patients screened, 114 had low preoperative SNOT-22 scores (4.0%). Indications for these surgeries included CRS (50.0%), odontogenic sinus disease (11.4%), mucocele (10.5%), recurrent acute sinusitis (7.0%), fungal ball (5.3%), and silent sinus syndrome (4.4%). Specifically, among CRS patients, 45.6% had pulmonary comorbidities and/or systemic immunodeficiencies. Moreover, 100% of CRS patients with nasal polyps and 73.1% of CRS without polyps had LM scores >5. Patients with preoperative SNOT-22 scores between 15 and 19 achieved an average 6.5 point reduction (P < .001) postoperatively, whereas those with scores between 10 and 14 had a 5.4 point reduction (P < .001), and preoperative scores <9 resulted in no significant decrease in postoperative symptom scores (P = .98). Overall, there was a 3.3 point SNOT-22 reduction among all patients at 3 months postoperatively (P < .001).

CONCLUSION

Patients with limited sinonasal symptoms may benefit from surgical treatment despite asymptomatic clinical presentations. A case-by-case analysis of comorbidities or unique clinical features should inform surgical decision-making for patients with lower SNOT-22 scores.

Atypical Presentation of Silent Sinus Syndrome: A Case Report and Literature Review

Introduction

Silent sinus syndrome (SSS) is a condition characterized by ophthalmologic features, such as spontaneous enophthalmos and hypoglobus with ipsilateral maxillary sinus atelectasis and an otherwise asymptomatic presentation. SSS has been documented secondary to a number of external causes, including trauma or surgery, but has less commonly been described in the setting of a potential mass in the deep masticator space.

Case Presentation

A 56-year-old woman with a history of chronic headaches with normal prior sinonasal imaging presented with increasing right-sided facial pain and headaches that radiated to her occiput, subjective visual changes, sharp ear pain, and long-standing subjective diminished sense of smell. Physical examination was normal, while nasal endoscopy demonstrated lateral bowing of the medial maxillary wall on the right. Magnetic resonance imaging demonstrated a homogenous 2 × 2 × 2.4 cm T1- and T2-weighted, hyperintense mass lesion in the deep masticator space splaying the right medial and lateral pterygoid muscles concerning for a possible lipomatous lesion. Computed tomography revealed an atelectatic and opacified maxillary sinus with inward bowing of the posterior maxillary wall and increased orbital volume on that side. Endoscopic maxillary antrostomy was performed with biopsy of the retromaxillary space lesion and with near immediate resolution of the patient’s symptoms. Histologic examination of the mass demonstrated mature adipose tissue with few aggregates of benign small vessels.

Discussion

This is an unusual presentation of SSS, with an accompanying enlargement of the retromaxillary fat pad. We herein review our clinical experience with SSS and provide a literature review of the presentation, management, and perioperative considerations for SSS.

Laughter-Induced Transient Vision Loss in a Patient With Silent Sinus Syndrome

BACKGROUND

To report a patient with silent sinus syndrome (SSS) who experienced transient ipsilateral monocular vision loss during intense laughter.

METHODS

Case report.

RESULTS

Our patient's transient vision loss completely resolved after maxillary sinus decompression and during 7 months of follow-up.

CONCLUSIONS

Although the precise mechanism of our patient's vision loss remains undetermined, we suspect that the vascular supply to the eye and/or the optic nerve was compromised as the result of the combination of laughter (causing Valsalva maneuver and increased intrathoracic pressure) and SSS.

Silent Sinus Syndrome: Interesting Clinical and Radiologic Findings

Silent sinus syndrome (SSS) describes enophthalmos and hypoglobus in association with disease of the maxillary sinus. This syndrome has rarely been presented in the dental literature. Many dentists are not familiar with the syndrome and its associated clinical and radiologic features. A 57-year-old female patient presented to the Oral and Maxillofacial Surgery Outpatient Clinic at The Brooklyn Hospital Center for a routine dental examination. During this examination, she indicated that she felt her right eye had been sinking. Routine dental panoramic radiography showed opacification on the right maxillary sinus. Maxillofacial computed tomography showed a small maxillary sinus with retraction of the sinus walls. The floor of the orbit was thinned, causing hypoglobus. Obstruction of the right ostiomeatal complex was noted, with complete opacification of the right maxillary sinus. A diagnosis of SSS was made. SSS usually occurs in individuals in the third to fifth decade of life. It presents with enopthalmos and hypoglobus. On imaging, a small and opacified maxillary sinus is visualized with retraction of the orbital floor and a blocked ostiomeatal complex. Management includes functional endoscopic sinus surgery. The orbital floor can be reconstructed during the same operation, at a later date, or not at all. Knowledge about SSS can lead to prompt diagnosis and treatment recommendations while avoiding unnecessary diagnostic tests.

Silent sinus syndrome: an unusual case of facial numbness

A 49-year-old man presented with a 1-week history of right facial paraesthesia with blurred vision and diplopia. Examination was normal apart from reduced facial sensation. Following appropriate neuroimaging, we considered a diagnosis of silent sinus syndrome. He underwent a middle meatal antrostomy with complete resolution of symptoms. Silent sinus syndrome results from occlusion of the osteomeatal complex, preventing normal aeration of the maxillary sinus. Maxillary sinus hypoventilation typically causes inferior displacement of the globe in the orbit (unilateral hypoglobus). Neurologists will only infrequently see people with silent sinus syndrome but it can have devastating consequences if left untreated and so must be considered in the appropriate clinical context.

Rapid remodeling of the maxillary sinus in silent sinus syndrome

Silent sinus syndrome (SSS) is a rare disorder involving bony remodeling of the maxillary sinuses, including collapse of the orbital floor. It is typically unilateral and seen in the setting of chronic maxillary sinusitis. Patients present with enophthalmos and hypoglobus occasionally accompanied by diplopia. The condition is generally diagnosed with CT imaging and treated surgically. While SSS is most often reported as very slowly progressive, we report a patient with evidence of significant remodeling of the maxillary sinus over a period of 5.5 months.

Successful Treatment of Silent Sinus Syndrome With Combined Endoscopic Sinus Surgery and Blepharoplasty Without Orbital Floor Reconstruction

Silent sinus syndrome (SSS) is a rare clinical syndrome associated with characteristic spontaneous and gradual downward bowing of the orbital floor caused by impaired sinus ventilation. The author experienced a rare case of SSS in a 35-year-old woman patient. She was referred for evaluation of a spontaneous orbital asymmetry with right enophthalmos and hypoglobus. She underwent functional endoscopic sinus surgery to open obstructed maxillary sinus ostium and aesthetic eyelid surgery to enhance the appearance of her orbital asymmetry. These surgical treatments brought about the effect of making her eyes look more symmetric, refreshed, and alert. Here, the author reports a good treatment result of SSS without orbital floor reconstruction along with review of literatures.

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.

A case of concurrent silent sinus syndrome, thyroid eye disease, idiopathic orbital inflammatory syndrome, and dacryoadenitis

This is a retrospective case description of a single female patient found to have concomitant bilateral silent sinus syndrome, bilateral thyroid eye disease, unilateral dacryoadenitis, and idiopathic orbital inflammation that presented as progressive unilateral right-sided proptosis. The spectrum of inflammatory orbital diseases can make discerning between different entities challenging, but more unique in this case was the simultaneous presentation with bilateral silent sinus syndrome, a rare entity in its own right. Identifying each of these concurrent disease processes is important to establishing a multidisciplinary treatment approach to address all the patient's orbital and peri-orbital pathology. We hope to highlight the clinical and radiographic findings unique to each of these entities and share our approach to treatment in this complex case.