Dynamic 3D computer-assisted reconstruction of a metallic retrobulbar foreign body for diagnostic and surgical purposes. [Case report of orbital injury with ethmoid bone involvement

The main goal of our dynamic 3D computer-assisted reconstruction of a metallic retrobulbar foreign body following orbital injury with ethmoid bone involvement was to use 3D-information obtained from standard computed tomography (CT) data to explore and evaluate the nasal cavity, ethmoidal sinuses, retrobulbar region, and the foreign body itself by simulated dynamic computed visualization of the human head. A foreign body, 10 x 30 mm in size, partially protruded into the posterior ethmoidal cells and partially into the orbit, causing dislocation and compression of the medial rectus muscle and inferior rectus muscle. The other muscles and the optic nerve were intact. Various steps were taken to further the ultimate diagnosis and surgery. Thin CT sections of the nasal cavity, orbit and paranasal sinuses were made on a conventional CT device at a regional medical center, CT scans were transmitted via a computer network to different locations, and special views very similar to those seen on standard endoscopy were created. Special software for 3D modeling, specially designed and modified for 3D C-FESS purposes, was used, as well as a 3D-digitizer connected to the computer and multimedia navigation through the computer during 3D C-FESS. Our approach achieves the visualization of very delicate anatomical structures within the orbit in unconventional (non-standard) sections and angles of viewing, which cannot be obtained by standard endoscopy or 2D CT scanning. Finally, virtual endoscopy (VE) or a 'computed journey' through the anatomical spaces of the paranasal sinuses and orbit substantially improves the 3D C-FESS procedure by simulating the surgical procedure prior to real surgery.     

Cavernous hemangioma involving the lacrimal outflow system

A 22-year-old woman, 26 weeks pregnant, presented with a right nasolacrimal duct obstruction, nasal congestion with intermittent epistaxis, right globe displacement, and choroidal folds in the right eye. Noncontrast head CT revealed a mass involving the right nasolacrimal duct, nasal cavity, ethmoid sinuses, and orbit. Transnasal endoscopic resection was performed. Histopathology revealed a cavernous hemangioma involving the nasolacrimal duct and nasal cavity. Cavernous hemangiomas may occur rarely in the nasal cavity, paranasal sinuses, and/or the nasolacrimal duct.     

Adult Rhabdomyosarcoma of the Maxillary Sinus with Orbital Extension

Abstract

A 40-year-old male presented with 2 weeks of left facial pain, nasal congestion, dysphonia, and epistaxis along with left-sided epiphora. CT showed a large infiltrative mass centered in the left maxillary sinus with extension into the left orbit, bilateral paranasal sinuses, nasal cavity, and bilateral enlarged cervical lymph nodes. Biopsy results confirmed adult alveolar rhabdomyosarcoma (RMS). Systemic workup confirmed bilateral cervical lymph node metastasis. Currently the patient is undergoing chemotherapy. We describe a rare case of adult paranasal sinus RMS with orbital invasion.     

Inverted papilloma presenting as unilateral proptosis: A case report with review of literature

Inverted papilloma is an interesting benign tumour arising from lining epithelium of paranasal sinuses which most commonly involves nasal cavity and paranasal sinuses. However, involvement of orbit and intracranial extension without malignant transformation is very rare. We report a case of extensive inverted papilloma of frontal sinus which primarily presented with proptosis, an uncommon presentation. Ophthalmologic symptoms are rare manifestations of paranasal sinus inverted papilloma without malignant transformation and signify extensive disease with possible intracranial extension.     

Orbital chondrosarcoma arising from paranasal sinuses

Orbital chondrosarcoma arising from paranasal sinuses or from the nasal cavity with orbital extension is highly unusual. The aim of this report is to describe our multidisciplinary experience in the treatment of three patients with extensive sino-orbital chondrosarcomas. The patients were aged 43, 75 and 63 years, and the tumors originated from the maxillary, sphenoidal, and ethmoidal sinuses, respectively. Magnetic resonance imaging studies showed homogeneously hypointense lesions on T1-weighted scans, which were hyperintense on T2-weighted images. Intranasal endoscopic surgery alone or in combination with other conventional surgical approaches was the main therapeutic choice. Two patients had recurrences treated with wider surgical removal. Fractionated stereotactic radiotherapy was used in two cases. Two patients had histopathological grade I tumor and one had grade III chondrosarcoma. No patient had regional spread or distant metastasis. All patients were disease-free at 4, 2, and 3 years, respectively, following their last therapeutic interventions. Endoscopic surgery results in lesser morbidity for chondrosarcomas arising from paranasal sinuses and extending into posterior parts of the orbit. However, because control of surgical margins may not be complete, recurrences may occur justifying more radical approaches.     

Subperiosteal abscesses of the orbit due to sinusitis in childhood

This paper reports 16 cases of subperiosteal abscesses of the orbit due to acute sinusitis in childhood. They comprise 12.4% of 129 patients presenting with an ‘acute orbit’. Acute ethmoidal sinusitis was the predominant cause. The typical clinical features, as well as CT scanning of the paranasal sinuses, orbit and brain, should assist in early diagnosis. If possible, the subperiosteal abscess and sinuses should be drained before loss of visual acuity or intracranial complications occur. Streptococcus milleri was the pathogen most commonly cultured. One patient in this series had intracranial complications, but no other patients had major complications and there were no deaths.     

Subperiosteal abscesses of the orbit due to sinusitis in childhood

This paper reports 16 cases of subperiosteal abscesses of the orbit due to acute sinusitis in childhood. They comprise 12.4% of 129 patients presenting with an 'acute orbit'. Acute ethmoidal sinusitis was the predominant cause. The typical clinical features, as well as CT scanning of the paranasal sinuses, orbit and brain, should assist in early diagnosis. If possible, the subperiosteal abscess and sinuses should be drained before loss of visual acuity or intracranial complications occur. Streptococcus milleri was the pathogen most commonly cultured. One patient in this series had intracranial complications, but no other patients had major complications and there were no deaths.     

A case of retained wooden foreign body in orbit

A 41-year-old man visited our clinic complaining of esodeviation of the right eye. He had been operated on for corneal laceration 3 years before. One month later, exodeviation of the right eye had developed. The result of computed tomography (CT) was reported as orbital abscess and cellulitis. Although antibiotic treatment was administered for 2 weeks, the exodeviation didn't improve. On ocular examinations performed in our hospital in November-2001, his right eye was esotropic and had a relative afferent pupillary defect. Vision of the right eye was decreased to 0.02. Fundus examination showed optic atrophy. A new CT scan disclosed a foreign body introduced into the right medial orbital wall, nasal cavity and ethmoidal sinus. Although foreign body was surgically removed, vision and eye movement were not improved. In the case of a patient who has undergone orbital trauma, complete history taking and physical examinations must be performed. On suspicion of a foreign body, imaging study such as CT or MRI must be performed. However, because CT findings can be variable, careful follow-up is needed.     

Failure of preenucleation radiation to decrease uveal melanoma mortality. The Collaborative Ocular melanoma Study Steering Committee

Four patients had malignant melanoma involving the conjunctiva, nasal cavity, and paranasal sinuses. In each patient, the conjunctival melanoma preceded recognition of the lesion in the nasal cavity by months or years. Each patient had one or more conjunctival biopsy specimens that documented melanoma, and in each patient the melanomas evolved in primary acquired melanosis of the conjunctiva. Histologic examination of the epithelium adjacent to the tumor in the nasal cavity failed to show either atypia or diffuse melanosis. We believe that these melanomas in the nasal cavity and paranasal sinuses are most likely to evolve as regional metastases, although it is possible that they arise de novo or as related foci in accordance with the multicentric characteristics of conjunctival melanoma. If a patient with a conjunctival melanoma has symptoms referable to the nasal cavity or paranasal sinuses, ophthalmologists should refer the patient to an otolaryngologist.     

Compressive Optic Neuropathy Caused by a Cholesterol Granuloma of the Sphenoidal Sinus

Cholesterol granuloma is a foreign body giant cell reaction to cholesterol deposits. The pathology is rarely seen in the paranasal sinuses. In this report we describe a case of compressive optic neuropathy caused by cholesterol granuloma arising from the sphenoidal sinus. A 46-year-old lady presented with painless progressive decrease in vision in her left eye over the past 7 years. Magnetic resonance imaging of the brain and orbit with gadolinium enhancement showed a homogenous T1 and T2 hyperintense lesion causing expansion of the sphenoidal sinus compressing the ethmoidal sinus and also the left optic nerve. An endoscopic marsupialisation of the lesion was performed. Histopathological examination showed multiple characteristic cholesterol clefts surrounded by numerous multinucleated giant cells, histiocytes, lymphocytes, haemosiderin-laden macrophages, and plasma cells. This case emphasises the importance of appropriate neuro-imaging in cases of progressive optic neuropathy: cholesterol granuloma of the paranasal sinuses is a rare cause of optic nerve compression.     

Orbito-sinal foreign body

Perforating injuries of the orbit involving the paranasal sinuses are uncommon. We report a case in which a large wooden foreign body lodged in the posterior orbit and maxillary sinus was surgically removed by a combined approach by ophthalmologists and ear, nose and throat surgeons.     

Total orbitoplasty

In injuries, removal of tumours and infections of the orbit the exenteration of the orbit may become necessary, sometimes even with sacrificing the eyelids. After healing of the orbital disorder the task of the orbitoplasty consists in rebuilding an orbit fit for a prosthesis; when the eyelids have to be reconstructed too, we speak of a total orbitoplasty. Further difficulties arise for the plastic surgeon, when the disorders or/and their treatment are followed by an open communication with the nasal hole and its paranasal sinuses. Mennig has called this complicated form of orbital reconstruction as total orbitoplasty of rhinosurgical type; its additional task is to close the open communications of the nasal hole and its paranasal sinuses with the orbit. Two selected clinical examples of total orbitoplasty demonstrate the procedure in such cases. The first case shows a total orbitoplasty with reconstruction of the eyelids after an injury to the right half of the face caused by high-tension current. The second case illustrates the rhinosurgical type of total orbitoplasty (Mennig), with closure of the fistulas between the orbit and the nasal cavity and paranasal sinuses as an additional reconstruction task.     

CT localization of foreign intra-ocular bodies

In the course of three years from the total number of 124 CT examinations indicated by the Ophthalmological Department of the Regional Hospital in Ustí nad Labem ten examinations of the orbit with an intraocular foreign body were made. Based on a group of 10 eyes the authors present a report of their hitherto assembled experience with the use of computed tomography in the diagnosis of intraocular foreign bodies. They draw attention to the advantages but also certain limitations of the location of foreign bodies by CT. In two of 10 cases the foreign body was located incorrectly by CT in the bulbar wall--although it was retrobulbar. In the remaining eight cases the CT examination was a great asset and contributed greatly to successful operation. 50% of the patients have after operation a vision of 6/6.     

Orbital floor implant migration across the ethmoidal sinuses and nasal septum

PURPOSE: To report an unusual case of orbital floor implant migration across the ethmoidal sinuses and nasal septum.METHOD: Case report. A 61-year-old woman with a history of right orbital floor fracture repair 25 years earlier is described.RESULTS: The patient presented with sinus congestion and difficulty breathing through the right nostril. Computed tomographic scan disclosed medial migration of the right orbital floor implant across the ethmoidal sinuses and nasal septum. The patient underwent transorbital and transnasal endoscopic surgery with removal of the implant.CONCLUSIONS: When an alloplastic orbital floor implant is required, size and fixation of the implant are important. Late paranasal sinus or nasal airway problems may be sequelae, and the possibility of implant migration should be considered.     

鼻内镜下鼻泪管阻塞激光疏通术的远期疗效观察

目的探讨鼻内镜下鼻泪管阻塞的有效治疗方法。方法用带针芯的泪道套管针按常规泪道插管术,自上泪点插至鼻泪管阻塞处,拔出针芯,输入磷酸钛氧钾激光导光纤维,发射激光,气化疏通泪道。鼻内镜直视下,同期处理引起鼻泪管阻塞的鼻腔、鼻窦原发病变。结果各种原因所致的鼻泪管阻塞139例(158只眼),其中单纯泪管阻塞96例(107只眼)、慢性泪囊炎33例(39只眼)、泪道置管术后再阻塞10例(12只眼)。一次性手术成功137只眼,治愈率86.7%。结论鼻内镜下激光泪道疏通术治疗鼻泪管阻塞,可同期处理引起鼻泪管阻塞的鼻腔、鼻窦原发疾病。对提高远期疗效有独特优点,方法简便,适应证广,组织损伤小,面部无瘢痕,有推广运用价值。     

鼻源性眼球突出的MRI及CT表现分析

通过对５６例鼻源性眼球突出的ＣＴ及ＭＲＩ检查表现分析，认为ＣＴ在揭示钙化及骨皮质上优于ＭＲＩ，但对密度差别不大者如炎症与肿瘤，复发性病变与疤痕组织等不易区分。ＭＲＩ从多方位显示病变，并可良好揭示软组织特点成分，对炎症，血管瘤，粘液性囊肿，纤维疤痕等可有效较异表现，ＣＴ对揭示骨结构明显优于磁共振，确定诊断必须结合临床表现，必要时两者联合应用，提高诊断正确率。     

Compressive optic neuropathy secondary to chronic sinusitis

The paranasal sinuses surround the orbit on three sides. The thin bony walls of the sinuses are an ineffective barrier to the spread of infection to either the orbit or the intracranial cavity. In this report a case of compressive optic neuropathy secondary to chronic sinusitis is presented. The anatomical and physiologic relation between the sinuses and the orbit are reviewed and sinusitis is discussed.     

Inverted papilloma invading the orbit

Inverted papilloma is an unusual entity for many ophthalmologists. We report a case of inverted papilloma of the nasal cavity and sinuses, invading the orbit in a 33-year-old man. The patient presented with a right medial canthal mass, proptosis, diminution of vision, epiphora and nasal obstruction. In the past, he underwent multiple procedures for surgical removal of the tumor with frequent recurrences. A computed tomographic scan revealed a mass filling both the nasal cavities and sinuses, destroying adjacent bones and invading the medial aspect of the orbit, leading to proptosis. Excision of the tumor was performed by a lateral rhinotomy approach. The tumor proved to be an inverted papilloma with focal transformation to transitional cell carcinoma. Post-operative CT scan revealed residual tumor, which responded to radiotherapy, with no recurrence over six months. Histopathologically, these tumors are benign, but locally invasive. The tumors that invade the orbit are usually locally aggressive, highly malignant and recur frequently. Radical excision of the tumor is technically difficult and often incomplete, so radiotherapy should be considered as an adjunct to surgery.     

Inverted papilloma invading the orbit

Inverted papilloma is an unusual entity for many ophthalmologists. We report a case of inverted papilloma of the nasal cavity and sinuses, invading the orbit in a 33-year-old man. The patient presented with a right medial canthal mass, proptosis, diminution of vision, epiphora and nasal obstruction. In the past, he underwent multiple procedures for surgical removal of the tumor with frequent recurrences. A computed tomographic scan revealed a mass filling both the nasal cavities and sinuses, destroying adjacent bones and invading the medial aspect of the orbit, leading to proptosis. Excision of the tumor was performed by a lateral rhinotomy approach. The tumor proved to be an inverted papilloma with focal transformation to transitional cell carcinoma. Post-operative CT scan revealed residual tumor, which responded to radiotherapy, with no recurrence over six months. Histopathologically, these tumors are benign, but locally invasive. The tumors that invade the orbit are usually locally aggressive, highly malignant and recur frequently. Radical excision of the tumor is technically difficult and often incomplete, so radiotherapy should be considered as an adjunct to surgery.     

Nasal and orbital recurrence of conjunctival melanoma 21 years after exenteration.

In our experience 5% of invasive malignant melanomas of the conjunctiva arising from areas of primary acquired melanosis with atypia spread to the ipsilateral nasal cavity and paranasal sinuses. Twenty one years after orbital exenteration for multicentric conjunctival melanoma an 82-year-old man was seen with an orbital recurrence, which had extended to the nasal cavity and paranasal sinuses through the nasolacrimal duct without invading the mucosa. This previously undescribed way of spread after the longest symptom-free interval following exenteration ever reported is illustrated.