Paciente com proptose ocular associado a mucocele etmoidal: apresentação clínica e tratamento / Patient with ocular properties associated with ethmoidal mucocele: clinical presentation and treatment

Resumo Relato de um caso clínico de proptose ocular relacionado com mucocele etmoidal, o caso é raro e seu acometimento ocular não é comumente relacionado na literatura. Ressaltamos ainda sua apresentação clínica e o tratamento instituído. W.L.S, Paciente do sexo masculino, 27 anos procedente de Fortaleza-CE. Comparece ao ambulatório HUWC com queixa de baixa da acuidade visual percebida há 10 dias em olho direito (OD). Ao exame oftalmológico melhor acuidade visual corrigida de 20/200 OD e 20/20 olho esquerdo (OE), ausência de abdução e elevação do OD com ptose leve (distância margem reflexo 1-2 mm) e diplopia ao olhar para direita. Proptose OD de aspecto axial de grau moderado (24mm). Biomicroscopia lâmpada de fenda sem alterações. Pressão intraocular: 18mmHg OD 12 mmHg OE. Fundo de olho: OD aspecto palidez discreta de disco, sem outras alterações e OE dentro da normalidade. Solicitada tomografia de crânio (TC) que demonstrou presença de lesão arredondada em área do seio etmoidal penetrando parede óssea da órbita do OD sugestiva de mucocele etmoidal. Encaminhado para serviço de otorrinolaringologia do HUWC, sendo submetido a procedimento cirúrgico endoscópico etmoidectomia. Um mês após o procedimento cirúrgico a acuidade visual OD 20/25, movimentos oculares presentes e simétricos, ausência de diplopia e persistência de leve palidez em OD. Expansão da mucocele pode ocorrer ao longo de muitos anos ou rapidamente. Acometimento ocular com baixa da acuidade visual é incomum como primeiro sintoma, quando ocorre merece tratamento imediato. O tratamento cirúrgico é geralmente indicado no caso e deve ser instituído assim que possível para adequada recuperação visual.

Abstract Report of a clinical case of ocular proptosis related to ethmoidal mucocele, the case is rare and ocular involvement is not commonly related in the literature. We also emphasize its clinical presentation and the treatment instituted. W.L.S., male, 27 years old from Fortaleza-CE. He presents to the HUWC outpatient clinic complaining of low visual acuity perceived for 10 days in the right eye (OD). The ophthalmologic exam showed a best corrected visual acuity of 20/200 OD and 20/20 left eye (OS), absence of abduction and elevation of OD with light ptosis (distance margin 1 - 2 mm) and diplopia when looking to the right. Proptose OD of moderate aspect axial aspect (24mm). Biomicroscopy slit lamp without changes. Intraocular pressure: 18mmHg OD 12 mmHg OS. Background of eye: OD discrete pallor disk appearance, no other changes and OS within normality. A CT scan was performed that showed presence of a rounded lesion in the ethmoidal sinus area penetrating the bone wall of the OD orbit suggestive of ethmoidal mucocele. Forwarded to the otorhinolaryngology service of the HUWC, being submitted to endoscopic surgical procedure etmoidectomy. One month after the surgical procedure visual acuity of OD 20/25, present and symmetrical ocular movements, absence of diplopia and persistence of mild pallor in OD. Expansion of mucocele may occur over many years or rapidly. Ocular involvement with low visual acuity is uncommon as the first symptom, when it occurs it deserves immediate treatment. Surgical treatment is generally indicated in the case and should be instituted as soon as possible for adequate visual recovery.

Unusual ocular manifestations of silent sinus syndrome / Manifestações oculares incomuns na síndrome do seio silencioso

Silent sinus syndrome is an acquired condition in which there is a gradual collapse of the orbital floor and inward retraction of the maxillary sinus (atelectasis of the maxillary sinus). This in turn may cause associated ocular occurrences of enophthalmos and hypotropia. This is a report of an 8 year-old boy with silent sinus syndrome and associated ocular motility disorders. The association between silent sinus syndrome and ocular motility disturbance has been recently described in the literature. However, this is an infrequent association, mainly in childhood.

A síndrome do seio silencioso é uma afecção adquirida em que há colapso gradual do assoalho orbital e do seio maxilar (atelectasia do seio maxilar), o que pode acarretar alterações orbitárias e oculares associadas, como enoftalmia e hipotropia. Relatamos o caso de um paciente de 8 anos de idade com síndrome do seio silencioso e distúrbios da motilidade ocular. A associação entre a síndrome do seio silencioso e alterações da motilidade ocular extrínseca tem sido descrita na literatura. No entanto, esta é uma associação pouco frequente, principalmente na infância.

Aspergilosis nasosinusal con extensión intracraneal en una paciente inmunocompetente: una entidad infrecuente con características radiológicas típicas / Sinonasal aspergillosis with intracranial extension in an immunocompetent patient: a rare disease with typical imaging features

El aspergilo es un hongo ubicuo. Las localizaciones de infección primaria más comunes son el tracto respiratorio y los senos paranasales. La afectación intracraneal es rara y conlleva una alta mortalidad. Ocurre mayoritariamente por extensión hematógena desde el pulmón, pero en pacientes inmunocompetentes, la extensión directa desde los senos paranasales es más común. Describimos el caso de una mujer de 25 años originaria de India que se presentó en el servicio de urgencia de nuestro centro hospitalario con cefalea frontal crónica y progresiva. Los hallazgos en los estudios de imágenes sugirieron el diagnóstico de sinusitis fúngica con extensión intracraneal, siendo el patógeno más frecuente el aspergilo. El diagnóstico fue confirmado anátomo-patológicamente. Revisamos los hallazgos radiológicos típicos que deben ayudar al diagnóstico precoz de esta entidad, rara, pero potencialmente mortal.

Aspergillus is a ubiquitous fungus. The most common primary sites of infection are the respiratory tract and sinuses. Intracranial infection is rare and implies a high mortality. It occurs mainly by hematogenous extension from the lung, but in immunocompetent patients, direct extension from the sinuses is more common. We describe the case of a 25 year old woman from India who consulted in the emergency room of our hospital with chronic and progressive frontal headache. The findings in imaging studies suggested the diagnosis of fungal sinusitis with intracranial extension, being the most common pathogen of Aspergillus. The diagnosis was anatomically-pathologically confirmed. We review the typical radiological findings which should help in the early diagnosis of this rare but potentially fatal disease.

Ethmoidal Sinus Mucocele as a Cause of Acquired Brown Syndrome

No abstract available.

Frontoethmoidal Mucocele Presenting as Progressive Enophthalmos

In this case report we describe a 27-year-old man who presented with progressive enophthalmos for 5 months without any other associated ocular symptoms such as pain, diplopia, or visual disturbance. Computed tomography showed that his progressive enophthalmos originated from a frontoethmoidal mucocele and this caused destruction of the lamina papyracea and shrinkage of the ethmoidal air cell. Finally the enlarged orbital space caused an inward deviation of the eyeball. Endoscopic marsupialization was successfully performed by an otolaryngologist and did not result in any ophthalmologic sequelae. Although frontoethmoidal sinus mucoceles mostly frequently originates from orbital mucoceles, enophthalmic manifestations are very rare. Enophthalmic conditions are not as responsive to surgical interventions as exophthalmic conditions.

Paranasal sinuses and nasal cavity; the notorious neighbours of orbit

To describe the clinical and neuro-radiological patterns of orbital invasion by the sino-nasal diseases. Descriptive, Retrospective study. 2004 to 2009. We retrospectively reviewed fifty four cases of nasal and paranasal sinus diseases invading the orbit. The medical charts were analyzed. The data considered for the study was age, sex, ocular presentation and associated systemic problems of the patients. The neuro-radiological results were correlated with the clinical picture. The age range was from 6 to 85 years [mean 45.5]. Male to female ratio was 3.5: 1. The initial clinical presentation was Proptosis [66.66%], disturbance of vision [25.9%], ophthalmoplegia [11.11%], diplopia [9.26%] and ptosis [9.26%]. 79.63% patients had inflammatory etiology and 20.4% had neoplastic lesions in the nasal and paranasal sinuses extending into the orbit

Adult Chronic Rhinosinusitis:Spectrum of Clinical Features and Management in aTertiary Health Institution and Literature Review

Background:Rhinosinusitis is defined as inflammation of the nasal and paranasal sinus mucosa.Chronic rhinosinusitis occurs when this inflammation and the symptoms persist for more than 3 months.The objective of this study was to evaluate the clinical features and management of adult chronic rhinosinusitis in a tertiary health institution and to review the literature for its current modalities of management.Methods:This is a 5-year retrospective study of all adult patients managed for clinically and radiologically diagnosed chronic rhinosinusitis at the study center.Their medical records were reviewed for essential data which included demographic data; clinical presentations; skin sensitivity test; radiologic reports and treatment offered.The data were collated and analyzed using simple descriptive statistics.Results: There were 228 patients; 97(42.54) males and 131(57.46) females with a male:female ratio of 1:1.35; age ranged between 18 - 67 years (mean =35.2).The five major presenting symptoms were nasal discharge 228(100.00); nasal obstruction 224 (98.25); equent throat hawking 189 (82.89); itching of eye; ear; nose or throat 138 (60.53) and excessive sneezing 136(59.65).About 6of the patients developed complications.Allergy accounted for the cause in 93 (40.79)patients. Maxillary antral mucosal thickening and engorged inferior turbinates were the commonest radiological features. About 51of the patients were treated with intranasal inferior meatal antrostomy with or thout inferior turbinectomy.There was recurrence of symptoms in about 18of these patients from 3 to 8months after surgery.Conclusions: Both subjective and objective measures should be employed in the diagnosis of chronic rhinosinusitis and intranasal inferior meatal antrostomy may rarely produce satisfactory clinical improvement

A rare cause of nasolacrimal duct obstruction: Dentigerous cyst in the maxillary sinus.

The most common abnormality of the lacrimal drainage system is congenital or acquired nasolacrimal duct obstruction. The causes of acquired nasolacrimal duct obstruction may be primary or secondary. The secondary acquired obstructions may result from infection, inflammation, neoplasm, trauma or mechanical causes. The maxillary sinus cysts usually obstruct the nasolacrimal duct mechanically. Dentigerous cysts are one of the main types of maxillary cysts. These cysts are benign odontogenic cysts which are associated with the crowns of unerupted teeth. The clinical documentations of mechanical nasolacrimal duct obstructions due to a dentigerous cyst in the maxillary sinus are very rare in literature. In this case report, we describe a dentigerous cyst with a supernumerary tooth in the maxillary sinus in an 11-year-old male child causing an obstruction to the nasolacrimal duct. The case was successfully managed surgically by Caldwell Luc approach.

Liver cirrhosis and rhino-orbital mucormycosis, a possible but rare association: description of a clinical case and literature review

Only few cases of rhino-orbital mucormycosis in patients with liver cirrhosis are described in the literature and most of these patients showed an associated diabetes mellitus. We describe a case of rhino-orbital mucormycosis in a patient with liver cirrhosis without other risk factors.

Diferencias en la sensibilización a aeroalergenos en pacientes con poliposis nasosinusal / Different patterns of sensitization to airborne allergens in patients with nasal polyposis

Introducción: La poliposis nasosinusal (PN) es una enfermedad inflamatoria crónica de la mucosa. Apoyado en los hallazgos clínicos, histológicos e inmunológicos, se postula a la alergia como un factor etiopatogénico, lo cual no ha sido plenamente demostrado. Objetivo: Evaluar la presencia de hipersensibilidad a aeroalergenos en pacientes con PN y compararla con pacientes normales. Material y método: Se realizó prick test a aeroalergenos a todos los pacientes utilizando 30 alérgenos frecuentes en el área metropolitana de Santiago, incluyendo pólenes de árboles, malezas y pastos, ácaros, epitelio de animales y hongos habituales. Este test se amplió con el uso de tres hongos habitualmente no evaluados (Stemphyllium, Pullularia, Helminthosporium). Se utilizó la prueba de Chi cuadrado con una significancia de 0,05. Resultados: El 71 por ciento de los pacientes con PN (n =73) y el 66 por ciento del grupo control (n =44) presentaban un test cutáneo positivo, sin diferencia estadística significativa. El patrón de sensibilización a aeroalergenos fue similar, salvo para los alérgenos fúngicos: los pacientes con PN estaban sensibilizados en 40 por ciento a Pullularia, 30 por ciento a Stemphyllium, y 10 por ciento a Helminthosporium. En tanto que los controles no presentaron sensibilización a estos hongos no habituales. Discusión y conclusiones: Existe una alta tasa de sensibilización a aeroalergenos en pacientes normales y con PN, lo que sugiere un probable rol de la alergia en la patogénesis de la poliposis nasal. Destaca un patrón diferente de sensibilización a alérgenos fúngicos, cuya relevancia clínica debe ser evaluada a futuro.

Introduction: Nasal polyposis (NP) is a chronic inflammatory disease that leads to tissue oedema and eventually polyps. The pathogenesis of NP has not been fully understood yet, but there are clinical, histological, and immunological findings that suggest that allergy plays a role. Aim: The aim of this study was to find out the prevalence of airborne allergen hypersensitivity in patients with nasal polyposis. Material and method: Skin prick test (SPT) was performed to patients with NP and to a control group (CRS). Thirty frequent airborne allergens of the Santiago de Chile metropolitan area, including tree, grass and weed pollens, house dust mites, animal dander and common fungal allergens were tested. This SPT was extended by using three fungal allergens that usually are not evaluated (Stemphyllium, Pullularia, Helminthosporium). Chi square test was used to compare both groups of patients. Results: 71 percent of NP patients (n=73) versus 66 percent of the controls (n=44) had a positive SPT, although there was no statistical significance. The only difference in sensitization was for fungal allergens. In NP patients, sensitization to Pullularia was about 40 percent>, 30 percent> to Stemphyllium, and 10 percent to Helminthosporium. CRS patients were not sensitized to uncommon fungal allergens. Conclusions: We found a high frequency of sensitization to airborne allergen in CRS and NP patients that suggest a probable role of allergic inflammation in the pathogenesis of nasal polyposis. Stands out a different pattern of sensitization to fungal allergens in the NP group; the clinical relevance of this finding awaits future evaluation.

Sphenoid sinus mucocele with blindness: a rare presentation.

Isolated sphenoid sinus mucocele is a rare entity. Here we report a case of isolated sphenoid sinus mucocele in a 9 years old girl presenting with unilateral blindness and without any sinonasal complaints. C.T. scan revealed an isolated sphenoid sinus mucocele which was managed endoscopically. A brief review of literature is also included.

Bilateral Ophthalmic Artery Occlusion in Rhino-Orbito-Cerebral Mucormycosis

PURPOSE: To report a case of bilateral ophthalmic artery occlusion in rhino-orbito-cerebral mucormycosis. METHODS: Reviewed clinical charts, photographs, and fluorescein angiography RESULTS: An 89-year-old man with poorly controlled diabetes developed sudden bilateral ptosis, complete ophthalmoplegia of the right eye, and superior rectus palsy of the left eye. Brain and orbit magnetic resonance imaging showed midbrain infarction and mild diffuse sinusitis. On the 2nd day of hospitalization, sudden visual loss and light reflex loss developed. There were retinal whitening, absence of retinal arterial filling, and a total lack of choroidal perfusion on fluorescein angiography of the right eye. The left eye showed a cherry red spot in the retina and the absence of retinal arterial filling and partial choroidal perfusion on fluorescein angiography. On rhinologic examination, mucormyosis was noticed. Despite treatment, visual acuity and light reflex did not recover and he died 4 days after admission. CONCLUSIONS: Bilateral ophthalmic artery occlusion can occur in rhino-orbital-cerebral mucormycosis.

Bilateral Ophthalmic Artery Occlusion in Rhino-Orbito-Cerebral Mucormycosis

PURPOSE: To report a case of bilateral ophthalmic artery occlusion in rhino-orbito-cerebral mucormycosis. METHODS: Reviewed clinical charts, photographs, and fluorescein angiography RESULTS: An 89-year-old man with poorly controlled diabetes developed sudden bilateral ptosis, complete ophthalmoplegia of the right eye, and superior rectus palsy of the left eye. Brain and orbit magnetic resonance imaging showed midbrain infarction and mild diffuse sinusitis. On the 2nd day of hospitalization, sudden visual loss and light reflex loss developed. There were retinal whitening, absence of retinal arterial filling, and a total lack of choroidal perfusion on fluorescein angiography of the right eye. The left eye showed a cherry red spot in the retina and the absence of retinal arterial filling and partial choroidal perfusion on fluorescein angiography. On rhinologic examination, mucormyosis was noticed. Despite treatment, visual acuity and light reflex did not recover and he died 4 days after admission. CONCLUSIONS: Bilateral ophthalmic artery occlusion can occur in rhino-orbital-cerebral mucormycosis.

Association of Cholesterol Granuloma and Aspergillosis in the Sphenoid Sinus

Cholesterol granuloma (CG) is usually associated with chronic middle ear disease, and is not common in the paranasal sinuses. Additionally, it is very rare for cases of CG to be associated with a fungal infection. However, in this paper, we report a case of sphenoid sinus CG that is associated with aspergilloma in a 78-year-old male patient who presented with right hemifacial pain, headache and toothache. CT revealed the presence of an expansile cystic mass lesion in the sphenoid sinus that showed a high signal intensity on both the T1 and T2 weighted images. This mass was later determined to be CG. The suspected etiologic mechanisms of both CG and aspergilloma of the paranasal sinuses are similar, and impaired drainage and obstruction of the ventilation of the paranasal sinuses are considered to be the causative mechanism of both diseases. Overall, the results of this study indicate that the use of MRI findings could be helpful for differentiating CG from other paranasal sinus mass lesions.

Síndrome do seio silencioso: relato de caso e revisão da literatura / Silent sinus syndrome: case report and literature review

O objetivo deste trabalho é relatar um caso de síndrome do seio silencioso e revisar os aspectos mais importantes para o diagnóstico e tratamento. A síndrome do seio silencioso é uma entidade clínica rara caracterizada por enoftalmia espontânea e por hipoglobus associados a atelectasia do seio maxilar, que requer tratamento cirúrgico. O diagnóstico é usualmente acidental durante a investigação radiológica de pacientes com enoftalmia. A endoscopia nasal pode apresentar um padrão característico com colapso lateral da concha média e apófise unciforme. Usualmente observa-se uma retração importante da fontanela posterior do seio maxilar comprometido. O tratamento é cirúrgico, objetivando a aeração do seio maxilar comprometido para o meato médio por meio de antrostomia. O óstio natural de drenagem do seio comprometido deve ser incluído na antrostomia, para evitar o fenômeno de recirculação de muco. O mesmo apresentou evolução favorável pós-cirúrgica com follow-up de 1 ano sem progressão da enoftalmia. Conclui-se que a síndrome do seio silencioso é uma patologia rara, que deve ser incluída no diagnóstico diferencial de enoftalmia. Os achados de imagem com envolvimento da órbita e do seio maxilar confirmam o diagnóstico, e o tratamento exige a aeração cirúrgica do seio comprometido

This paper aims to report a case of silent sinus syndrome and to review importantaspects related to the diagnosis and the treatment of this condition. The silent sinus syndrome is a rare disorder characterized by spontaneous enopthtalmos and hypoglobus associated to maxillary sinus atelectasis that requires surgical treatment. The diagnosis might be suspected during the investigation of enophtalmos. Nasal endoscopy might present a classical pattern with lateral collapse of the middle turbinate and the uncinate process. A severe retraction of the posterior fontanelle might also be noted. Treatment is surgical and aims to ventilate the maxillary sinus through the middle meatus antrostomy. The antrostomy must include the natural ostium in order to prevent mucus re-circulation phenomenon. The patient reported in this study showed 1 year post-surgery a excellent result with no progression of the enophtalmos. We conclude that the silent sinus syndromeis a rare entity that must be included in the differential diagnosis of nophtalmos. Image findings with orbital and maxillary sinus involvement confirms the diagnosis and that the treatment requires surgical ventilation of the compromised sinus

Mucocele frontal lateral, tratamiento combinado endoscópico y externo: caso clínico / Frontal lateral mucocele, combined endoscopic and external treatment: clinical case

El mucocele frontal es la ubicación más frecuente de los mucoceles de senos paranasales, sin embargo aún no hay consenso respecto a la técnica quirúrgica adecuada para su tratamiento. El presente trabajo muestra un caso clínico de un mucocele frontal lateralizado, que desplaza el globo ocular y lóbulo cerebral frontal. Se muestra la técnica quirúrgica empleada (vía externa combinada con vía endoscópica). Se exponen las distintas técnicas de imagenología diagnóstica y técnicas computacionales que ayudan en el procedimiento quirúrgico.

Mucopiocele de concha média: relato de caso

A mucopiocele de concha média é uma doença incomum. A maioria das mucoceles se situa nos seios paranasais, principalmente nos seios etmoidal e frontal. Neste trabalho descreveremos um caso de mucopiocele de concha média associada com uma pansinusopatia.