Abstract
Objectives
We describe the clinical presentation and management of a patient with a remote history of orbital trauma who presented with spontaneous right enophthalmos and radiographic findings consistent with silent sinus syndrome over 30 years after her initial orbital injury.
Methods
The patient chart and imaging results were reviewed. A literature review of silent sinus syndrome and traumatic enophthalmos was performed.
Results
Our patient had both clinical and radiographic findings consistent with silent sinus syndrome. Only 2 other cases of silent sinus syndrome after orbital trauma have been reported in the literature. The underlying anatomic pathology common to all cases is obstruction of the ostiomeatal complex with subsequent maxillary sinus hypoventilation and sinus collapse. Our patient underwent single stage repair with endoscopic maxillary antrostomy and had resolution of the mucosal disease at 6-month follow-up.
Conclusions
Posttraumatic cases of silent sinus syndrome are much less common than spontaneous cases but share similar pathophysiology and can be effectively treated using endoscopic techniques.
1
Introduction
Posttraumatic enophthalmos results from expansion of the orbital cavity and is most frequently caused by orbital floor or medial wall fractures . Enophthalmos is typically most apparent within 1 to 2 weeks after injury, after resolution of edema and/or hemorrhage. However, it may also present immediately after significant orbital trauma or may present late, weeks or months after injury . In addition to traumatic etiologies, spontaneous enophthalmos is often a presenting sign in silent sinus syndrome, a relatively rare clinical entity characterized by progressive enophthalmos and hypoglobus associated with asymptomatic maxillary sinus disease and bone thinning . Although silent sinus syndrome has been well described in the ophthalmology and otolaryngology literature, these reports have traditionally excluded patients with a prior history of orbital trauma. In this report, we describe a patient with a remote history of a right orbital floor fracture who presented with spontaneous right enophthalmos and radiographic findings consistent with silent sinus syndrome over 30 years after her initial orbital injury.
2
Case reports
A 50-year-old African American woman presented to an ophthalmologist in October 2007 with complaints of progressive left eye proptosis over the prior few months. She denied pain, blurry vision in the left eye, diplopia, pulsations, or headaches. She had been previously seen by an ophthalmologist for a 6-month history of blurry vision in the right eye that was attributed to cataracts. Her medical history was significant for diabetes, proliferative diabetic retinopathy, cataracts, chronic renal failure requiring hemodialysis, hypertension, hypercholesterolemia, sleep apnea, and congestive heart failure. Of note, she reported a remote history of a right orbital blow-out fracture sustained in a motor vehicle crash in 1975 that had been repaired with an orbital floor prosthesis.
On ophthalmologic examination, her uncorrected visual acuity was 20/30 in both eyes and she had full extraocular movements. Although she reported subjective left eye proptosis, she was actually found to have 3 mm of relative right enophthalmos. There was also right greater than left upper lid ptosis with margin reflex distance superiorly measuring 1.5 mm on the right and 2 mm on the left.
Computed tomography (CT) scan of the orbits demonstrated expansion of the right orbital volume secondary to deformity of the right orbital floor with bowing down into the right maxillary sinus and a healed fracture of the right lamina papyracea ( Fig. 1 ). There was complete opacification of the right maxillary sinus with occlusion of the infundibulum and surrounding reactive osteitis, suggestive of a chronic inflammatory process. These CT findings were consistent with silent sinus syndrome.
She was subsequently referred to our otolaryngology clinic for evaluation and underwent right maxillary antrostomy to ventilate her maxillary sinus. Intraoperative findings demonstrated thick mucopurulence. She has since done well, and at her 6-month follow-up visit, had complete resolution of her mucosal disease ( Fig. 2 ).
2
Case reports
A 50-year-old African American woman presented to an ophthalmologist in October 2007 with complaints of progressive left eye proptosis over the prior few months. She denied pain, blurry vision in the left eye, diplopia, pulsations, or headaches. She had been previously seen by an ophthalmologist for a 6-month history of blurry vision in the right eye that was attributed to cataracts. Her medical history was significant for diabetes, proliferative diabetic retinopathy, cataracts, chronic renal failure requiring hemodialysis, hypertension, hypercholesterolemia, sleep apnea, and congestive heart failure. Of note, she reported a remote history of a right orbital blow-out fracture sustained in a motor vehicle crash in 1975 that had been repaired with an orbital floor prosthesis.
On ophthalmologic examination, her uncorrected visual acuity was 20/30 in both eyes and she had full extraocular movements. Although she reported subjective left eye proptosis, she was actually found to have 3 mm of relative right enophthalmos. There was also right greater than left upper lid ptosis with margin reflex distance superiorly measuring 1.5 mm on the right and 2 mm on the left.
Computed tomography (CT) scan of the orbits demonstrated expansion of the right orbital volume secondary to deformity of the right orbital floor with bowing down into the right maxillary sinus and a healed fracture of the right lamina papyracea ( Fig. 1 ). There was complete opacification of the right maxillary sinus with occlusion of the infundibulum and surrounding reactive osteitis, suggestive of a chronic inflammatory process. These CT findings were consistent with silent sinus syndrome.
