Benign orbital tumors with bone destruction in children

Blood within the bone: orbital intraosseous venous malformation

PURPOSE

Description of clinical features, radiological characteristics, and management strategies in primary orbital intraosseous venous malformation (OIVM) with pertinent literature review.

METHODS

A retrospective analysis including clinical, radiologic, operative, and histopathological data of six cases of histopathologically proven OIVM was done. A comprehensive literature review was conducted using online databases and augmented with manual search to identify reported cases of OIVM.

RESULTS

Study data showed five females and one male in young to middle-age group, with an average age of 30 years (range: 20-48 years). Proptosis was noted in five cases (83.33%), and the duration of symptoms ranged from 6 months to 10 years. Frontal and zygomatic bones were most frequently affected and expansile bony lesion was the most common CT scan finding. Three patients underwent pre-operative embolization of feeders followed by en bloc excision of mass and surgical reconstruction (50%); one patient was managed with partial excision (16.66%) while two were regularly followed-up after incision biopsy (33.33%). Histopathology revealed vascular spaces with endothelial lining, separated by bony trabeculae in all patients. Follow-up periods ranged from 6 to 48 months and no recurrence or progression were noted.

CONCLUSIONS

OIVM is an exceptionally rare disorder with a gradually progressive benign course. Ophthalmologists need to be mindful of this entity during patient evaluation as it has propensity for large volume blood loss intra-operatively, owing to its vascular nature. Complete excision with reconstruction of resultant defect is the preferred treatment strategy and without known recurrence.

Posterior pedicle screw fixation combined with local steroid injections for treating axial eosinophilic granulomas and atlantoaxial dislocation: A case report

BACKGROUND

Eosinophilic granuloma (EG) is a proliferative condition that affects the cells of bone tissue. There are no specific clinical signs or imaging manifestations in the early stages of the disease, making it simple to overlook and misdiagnose. Because of the disease's rarity, there is presently no standardized treatment principle. There are few accounts of such occurrences affecting the axis among children. We discovered a case of a child whose EG resulted in atlantoaxial joint dislocation and destruction of the axial bone.

CASE SUMMARY

After having pharyngeal discomfort for more than six months without a clear explanation, a 6-year-old boy was brought to our hospital. Following a careful evaluation, the pathology indicated a strong likelihood of an axial EG. Ultimately, we decided to treat the boy with posterior pedicle screw fixation and local steroid injections.

CONCLUSION

EGs of the upper cervical spine are quite uncommon in children, and they are exceedingly easy to overlook or misdiagnose. Posterior pedicle screw fixation and local steroid injections are effective treatments for patients with axial EGs affecting the atlantoaxial junction.

Orbital Langerhans Cell Histiocytosis: A Case Report

An eight-year-old boy presented with a one-month history of left eyelid swelling. The patient was diagnosed with periorbital cellulitis at another clinic and was treated with oral antibiotics. However, the swelling did not subside. On initial consultation, the patient had left upper eyelid swelling with erythema. His extraocular muscle motility was normal, and the results of blood tests were unremarkable. A computed tomographic scan demonstrated a mass in the superior orbit with destructive changes in the left frontal bone. Histopathological examinations revealed a dense infiltrate of histiocytic cells. Immunohistochemical staining of the tumors for CD1a and Langerin was positive. A pathological diagnosis of Langerhans cell histiocytosis was made. Since orbital Langerhans cell histiocytosis has a high risk for central nervous system involvement, chemotherapy was the treatment of choice for any residual lesion to prevent sequelae to the central nervous system. At the six-month follow-up, the lesion did not recur, and the patient did not experience any central nervous system sequela.

Langerhans Cell Histiocytosis of the Orbit Presenting as Periorbital Cellulitis

Langerhans cell histiocytosis (LCH) is a rare disease of the reticuloendothelial system. It is characterized by misguided differentiation of myeloid dendritic cell precursors. LCH most commonly presents in childhood and the clinical presentation is dependent on the site and extent of organ involvement. We report a case of orbital Langerhans cell histiocytosis in a 12-year-old boy who presented with left periorbital cellulitis with subsequent proptosis. He later underwent a successful left orbital-frontal-temporal craniotomy and is currently undergoing postoperative chemotherapy.

The Management of Orbital Roof Fractures and Defects: A Review

PURPOSE

To explore the anatomy, etiopathogenesis, diagnosis and classification, current evidence on intervention and the surgical management of orbital roof fractures and defects (ORFD) for oculoplastic surgeons presented with such cases.

METHODS

A review of the current literature through the MEDLINE database using the following search terms: "orbital roof fracture (+treatment/management)," "orbital roof defect (+treatment/management)," "orbital roof erosion (+treatment/management)," "orbital roof repair," "orbital roof," "orbital fracture," "pediatric orbital roof (defect/fracture/erosion)," "orbital anatomy," and "orbital roof anatomy" was conducted. As relatively little has been published on this topic, inclusion criteria were broad and peer-reviewed articles judged to be of clinical importance, relevant to the aims of this review, were included. Non-English abstracts were also included if relevant. Year of publication was not a strict exclusion criterion, and older articles were judged for their suitability based on clinical importance and relevance to current practice. Additional references were obtained from citations in key articles and recommendations from the coauthors based on their areas of expertise.

RESULTS

The etiopathogenesis of ORFD varies. Classification systems have been formulated to guide management decisions and can range from conservative management to complex neurosurgery. Eyelid approaches have also been described. This review provides a summary of the evidence for each and a management framework oculoplastic surgeons can use when presented with ORFD.

CONCLUSION

Oculoplastic surgeons can be involved, either alone or as part of a multidisciplinary team, in the management of ORFD, and for some, conduct orbital approach reconstructive surgery.

Infantile orbital abscess: clinical presentation, microbiological profile, and management outcomes

Purpose: Orbital abscesses in children are not uncommon. Unless managed in a timely fashion, they can potentially lead to vision-threatening as well as life-threatening complications. The objective of this study is to report the clinical and microbiological profile and management outcomes in infants presenting with orbital abscesses.Materials and Methods: A retrospective review of electronic medical records of children younger than 1 year with a diagnosis of an orbital abscess was done. The data was collected from a time period of 12 years (2007-2019). The data collected included mode of presentation, radiological, microbiological and histopathological features, and the final outcome.Results: A total of nine patients met the inclusion criteria. The mean age at presentation was 19 weeks. Three patients had upper respiratory tract infection, one had a congenital nasolacrimal duct obstruction, two had sinusitis, and one patient had neonatal sepsis. All patients underwent imaging following which abscess drainage was performed. Methicillin-sensitive Staphylococcus aureus was the most common organism, which was isolated in five patients, Methicillin-resistant S. aureus was isolated in three, while one patient had Entomophthorales fungal infection. The median follow-up period was 10 months (range 5 days to 89 months). There was no recurrence in the cohort. At least one patient had visual impairment at the last follow up.Conclusion: Orbital abscesses in infants are rare. Imaging and prompt drainage of the abscess supplemented by appropriate antimicrobial regimen leads to a successful outcome.

Cribra orbitalia is a vascular phenomenon unrelated to marrow hyperplasia or anemia: Paradigm shift for cribra orbitalia

The orbital phenomenon, cribra orbitalia, has long been a source of controversy, especially with regard to its nature, derivation, and relationship to anemia. Therefore, the external surfaces of orbital roofs were systematically examined microscopically in human skulls from historical collections. Superior orbital surfaces of 278 individual crania within the Hamann-Todd collection were assessed at various magnifications using epi-illumination microscopy to identify the presence of cribra orbitalia and characterize its nature. Also, 12 additional individuals with diagnosed anemia in the Hamann-Todd collection were evaluated. Orbital roof alterations, present in one-third of examined crania, had two discrete appearances: Vascular grooves (45%) and application of new bone in a vascular branching pattern on the orbit surface (55%). Porosity of the orbit was not observed. Evaluation of the orbits of 12 individuals with diagnosed anemia revealed one with a single deep defect, suggesting a space-occupying phenomenon, but no evidence of bone accretion, vascular grooves, or porosity. Cribra orbitalia has often been lumped indiscriminately as an indicator of organismal stress, rather than identified as a indicating a specific etiology. Neither that perspective nor porosity are supported by high resolution examination of orbital roof changes. Recognition of the blood vessel imprint pattern falsifies previous speculations and provides a new paradigm. The actual character of cribra orbitalia is documented and new hypotheses generated. While population prevalence of cribra orbitalia seems excessive for explanation on the basis of these hypotheses, the imprints are clearly vascular in origin.

Orbital Paraganglioma

BACKGROUND

Paragangliomas are groups of neuroendocrine neoplasms originating from neural crest cells throughout the body, but are rarely observed within the orbit.

CASE REPORT

Two patients, a 4-year-old male and 27-year-old female, presented with a slow-growing proptosis. Well-defined masses were located in the superomedial (male) and temporal (female) portion of the right orbit and involved the entire bodies of either the superior (male) or lateral (female) rectus muscles. B-mode ultrasound scan revealed a homogeneous, well-defined, hypoechoic mass, with rich blood flow signals inside the mass on CDI. CT scans indicated a well-defined, homogeneous mass with moderate enhancement, while MRI showed a well-defined mass with a salt and pepper appearance due to the prominence of blood vessels in the form of flow-void areas. Anterior orbitotomy and total tumor excision were performed on both patients. Subsequent histological and immunohistochemistry assays confirmed the diagnosis of orbital paraganglioma. The male patient is currently at 14 years of follow-up without recurrence or metastasis. The female patient developed recurrence at 3 months post-surgery. After a second surgery and local radiotherapy, there were no signs of the recurrence as assessed at 13 years of follow-up in this female patient.

CONCLUSION

Orbital paraganglioma is an extremely rare benign tumor. The salt-and-pepper appearance as observed with MRI scan represents a relatively salient characteristic of this condition. Total excision of the lesion by orbitotomy is the treatment of choice and the possibility of tumor recurrence warrants diligent consideration. Radiotherapy is useful in patients with tumor recurrence or subtotal surgical excision.

A simple method to estimate the linear length of the orbital floor in complex orbital surgery

BACKGROUND

The orbital floor (OrF) and infraorbital rim (IOR) repair in cases of complete destruction is challenging mainly due to the fact that the defect length cannot be measured. The aim of the current study is to develop a method of calculating the Orf length by using the gender and the lengths of the medial, superior and lateral orbital walls (OrW) of the same orbit.

MATERIAL AND METHODS

Ninety-seven (59 male and 38 female) European adult dry skulls were classified according to age: 20-39, 40-59 and 60 years and above. The length of each OrW was measured by using the direct distance between the optic foramen and a landmark in each orbital rim.

RESULTS

A side asymmetry was detected for the lengths of the inferior, superior and medial OrW. Although a gender dimorphism was detected, no correlation with the age was found. Using the Stepwise multiple regression analysis two formulas were developed, one for the right and one for the left OrF with coefficient of determination R² 0.43 and 0.57, respectively.

CONCLUSIONS

The proposed formulas represent a simple, applicable and individualized method to calculate the OrF linear length in cases of complete destruction of the IOR and OrF, with accuracy and without the use of expertise material. Such data may improve the surgery planning of orbital floor fractures and complex orbital reconstructions.

Optic Disc Deformation and Orbital Bone Erosion Secondary to a Huge Neglected Orbital Cavernous Hemangioma

Cavernous hemangioma (CH) is the most common benign tumor of the orbit which can expand the bony orbit by gradual growth of a large tumor. In this article, the authors report a 28-year-old man presented with a longstanding unilateral proptosis secondary to a huge orbital CH which also caused optic disc deformation and bone erosions in the adjacent orbital walls. The optic disc deformities resolved after the tumor removal.

Atlantoaxial instability secondary to eosinophilic granuloma of the axis in adults: long-term follow-up in six cases

BACKGROUND CONTEXT

Eosinophilic granuloma (EG) involving the spine is uncommon in adults. Atlantoaxial instability (AAI) secondary to EG of the axis in adults is an extremely rare clinical condition that can give rise to severe neurologic morbidity or mortality if not treated appropriately. There have been no previous reports on the condition in adults.

PURPOSE

To present the outcome and clinical experience for the management of AAI secondary to EG of the axis in adults.

STUDY DESIGN

A retrospective review study.

PATIENT SAMPLE

All adult patients with AAI secondary to EG of the axis who were admitted to the spine service at the study institution between January 1999 and April 2012.

OUTCOME MEASURES

Clinical symptoms, neurologic status, radiologic manifestations, treatment, outcome, and/or complications were recorded and analyzed.

METHODS

Six consecutive adults who presented clinical and radiographic manifestations of AAI secondary to EG of axis were treated and monitored. All patients were treated surgically with anterior tumor resection and posterior reconstruction of spinal stability. Oral steroid therapy was administered after surgery as adjuvant therapy.

RESULTS

The mean duration of follow-up was 77 months (range, 37-140 months). The most common radiographic feature was osteolytic destruction of the vertebral body of the axis. All patients had favorable recoveries, with osseous fusion. There were no surgery-related postoperative complications, and neither recurrence nor spinal deformity had occurred by the final follow-up examination.

CONCLUSIONS

Surgical intervention via anterior tumor resection and posterior reconstruction was found to be safe and effective for treating AAI secondary to EG in adults, in terms of recovering neurologic function, improving symptom relief, and reducing the risks resulting from osteolytic destruction. Surgical treatment plus oral steroid therapy can produce beneficial results and definitive local control during the follow-up period.

A clinical, radiologic, and immunopathologic study of five periorbital intraosseous cavernous vascular malformations

PURPOSE

To correlate the clinical, radiographic, histopathologic, and immunohistochemical features of 5 primary periorbital intraosseous cavernous vascular malformations.

DESIGN

Retrospective interventional case series.

METHODS

Clinical and operative records and radiographic images were reviewed. Histopathologic slides were evaluated with hematoxylin-eosin, trichrome, and elastin stains. Immunohistochemical studies were performed with a spectrum of monoclonal antibodies directed at antigens of vascular cells.

RESULTS

Three men and 2 women ranged in age from 36 to 64 years. Vision was unaffected and there was no proptosis or globe displacement. The slow-growing lesions measured 13-25 mm in greatest diameter (mean 16.4 mm). Computed tomographic studies revealed that 2 lesions were situated in the maxillary bone, 2 in the frontal, and 1 in the zygoma, all anteriorly and with circumscribed, lucent, honeycombed, or sunburst characteristics. Histopathologically the lesions were composed of cavernous or telangiectatic channels; 1 showed advanced fibrotic vascular involution. Immunohistochemistry demonstrated CD31/34 positivity for vascular endothelium and D2-40 negativity for lymphatic endothelium. A typically thin mural myofibroblastic cuff was smooth muscle actin positive, weakly calponin positive, and desmin negative. Glucose transporter-1 and Ki-67 were negative in the endothelium.

CONCLUSIONS

Intraosseous vascular lesions resemble orbital cavernous venous malformations (not true hemangiomas), except that their vascular walls are thinner owing to the constraints imposed by neighboring bone spicules, which limit the amount of interstitium from which mural myofibroblasts can be recruited. The bony trabeculae conferred the honeycomb or sunburst appearances observed radiographically. En bloc excision of these lesions was successful and avoided complications (mean follow-up, 46 months).

[Orbital leiomyoma. Case report and review of the literature]

Leiomyoma are slowly growing lesions arising from smooth muscle. Orbital location has been reported in 25 cases. Histological findings and no recurrence after total resection support their benign behaviour. We report an intraconal orbital haemangioleiomyoma in a 55-year-old female treated by total resection through fronto-orbital craniotomy, with no recurrence after 15 months of follow-up. Radiological and pathological features are discussed, emphasising the prognostic role of the surgery.