Clinical manifestations, management, and outcomes of primary silent sinus syndrome: a systematic review.

INTRODUCTION: Silent sinus syndrome (SSS) is a rare disorder of the maxillary sinus, which may present with orbital symptoms. Most reports of silent sinus syndrome are limited to small series or case reports. This systematic review comprehensively characterizes the various clinical presentations, management, treatment, and outcomes in patients with SSS. METHODS: A systematic literature search of the PubMed, Cochrane, Web of Science, and Scopus databases. Inclusion criteria were studies describing the presentation, management, or treatment of SSS or chronic maxillary atelectasis. RESULTS: One hundred fifty-three articles were included in the final review (n=558 patients). Mean age at diagnosis was 38.8 +- 14.1 years, with a relatively even distribution among sexes. Enophthalmos and/or hypoglobus were the most frequent symptoms, along with diplopia, headache, or facial pressure/pain. Most patients (87%) underwent functional endoscopic sinus surgery (FESS), and 23.5% received orbital floor reconstruction. Post-treatment, patients had significant reductions in enophthalmos (2.67 +- 1.39 vs. 0.33 +- 0.75 mm) and hypoglobus (2.22 +- 1.43 vs. 0.23 +- 0.62 mm). Most patients (83.2%) achieved partial or total resolution of clinical symptoms. CONCLUSIONS: SSS has a variable clinical presentation, with enophthalmos and hypoglobus being most common. FESS with or without orbital reconstruction are effective treatments to address the underlying pathology and structural deficits.

Deep Orbital Hyaluronic Acid Gel Filler for Volume Augmentation in Orbital Dysplasia.

PURPOSE: Orbital dysplasia is caused by congenital microphthalmos, anophthalmos, or eye atrophy. Orbital volume growth is known to parallel ocular growth and the absence of an eye results in noticeable hemifacial deformity that affects patients' lives. The aim of this study was to observe the effects of injections of hyaluronic acid gel into the orbit combined with ocular prosthesis to treat orbital dysplasia. METHODS: Three patients with orbital dysplasia who were 3 to 7 years old treated in our department. Each year, the hyaluronic acid gel was injected into each patient intraconal and extraconal posterior orbit and each wore an ocular prosthesis. The length of the palpebral fissure and orbital volume were measured before and after the injections. RESULTS: A total of 9 injections were performed on 3 patients ages 7, 5, and 4 years old, respectively. The follow-up periods were 5, 5, and 2 years. The authors observed significant improvements in patient appearance. The length of the palpebral fissure and the volume of the orbit increased linearly with the increasing age, and there were no complications, such as intraorbital hemorrhage or local hyperplastic stimulation. CONCLUSIONS: Orbital hyaluronic acid gel injection and combined with an ocular prosthesis is a safe, convenient, and effective treatment for orbital dysplasia.

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.

[Computer technologies in diagnostics and treatment of worsening post-enucleation socket syndrome]. / Komp'iuternye tekhnologii v diagnostike i lechenii progressiruiushchego anoftal'micheskogo sindroma.

Enucleation with primary orbital implantation and the use of ocular prosthesis does not exclude the risk of post-enucleation socket syndrome (PESS). Correction of such conditions requires modern visualization methods and software for calculation, modelling and control of the surgery. PURPOSE: To demonstrate the capabilities of modern computer technologies in diagnostics and treatment of patients with worsening post-enucleation enophthalmos. MATERIAL AND METHODS: The retrospective study included 6 patients (4 male and 2 female) aged 29-68 years who exhibited signs of PESS in 2017-2018. To define the orbital condition, patients underwent multispiral computed tomography (MSCT) and magnetic resonance imaging (MRI) followed by image analysis with computed exophthalmometry and step-by-step computed exophthalmometry. Results of these examinations helped construct 3D-models of patients' orbits, which were then used to calculate the parameters of the silicone implants. Patient-specific silicone implants were implanted into their orbits during surgery under general anesthesia. RESULTS: Implantation of the patient-specific silicone implant resulted in increase of the volume behind orbital prosthesis and correction of post-enucleation enophthalmos in all patients allowing them to use thinner, more mobile ocular prosthesis, and restore normal eyelid position. The patients also noted better appearance of the eye and personal comfort. CONCLUSION: Modern visualization methods along with computer analysis and modelling, as well as technologies to produce medical products enable creation of the best suitable patient-specific orbital implants. This allows achieving better clinical results and better quality of life for patients with monolateral anophthalmos.

Autologous Fat Injection for the Correction of Facial Depression Resulting From Silent Sinus Syndrome.

The case of a 59-year-old woman who underwent endoscopic sinus surgery for right maxillary sinusitis 5 years before visiting our otorhinolaryngologic department complaining of right-sided facial depression was described in this study. Computed tomography (CT) scans revealed right facial depression and retraction of the orbital floor due to a hypoplastic right maxillary sinus. Symptoms and CT findings corresponded with silent sinus syndrome. Facial depression is a rare symptom in silent sinus syndrome and is well corrected by autologous fat transfer.

[Hyaluronic acid gel implants for correction of pathological conditions of the orbit and eyelids]. / Primenenie in''ektsionnykh implantatov na osnove gelia gialuronovoi kisloty pri patologii vek i orbity.

PURPOSE: To evaluate the effectiveness of injectable implants made of hyaluronic acid gel (HAG) in ophthalmoplastics. MATERIAL AND METHODS: The study included 57 patients (37 patients with lagophthalmos related to acute or chronic facial nerve palsy, endocrine ophthalmopathy; 20 patients with enophthalmos, anophthalmic syndrome). Depending on filler particle size, the patients received either intrapalpebral or intraorbital HAG injection. The biometric measures of palpebral fissure, the position of the eye/implant, and the condition of the cornea were evaluated during the follow-up period (12 months for eyelid and 18 for orbital injection). RESULTS: In the course of the follow-up, all patients showed reliable reduction of lagophthalmos; additionally, improvement of the condition of the cornea was observed in patients after intrapalpebral injection; patients after intraorbital injection exhibited reduction in enophthalmos, upper orbital palpebral fold retraction and upper eyelid excursion. No serious complications have occurred after the injection. CONCLUSION: As minimally invasive method of treating various pathologies of the orbit and eyelids, HAG fillers showed good clinical effectiveness and safety.

Orbital volume augmentation using expandable hydrogel implants in acquired anophthalmia and phthisis bulbi.

The purpose of this study is to describe our experience using expandable spherical hydrogel implants and injectable hydrogel pellets for orbital volume augmentation in cases of post-enucleation socket syndrome after acquired anophthalmia or phthisis bulbi. We retrospectively reviewed the clinical records of all adult patients who received an expandable hydrogel implant for orbital volume loss following enucleation or phthisis bulbi at the Emory Eye Center between 2004 and January 2007 and the Yale Eye Center between 2009 and 2011. The study included 9 women and 5 men with a mean age of 51.2 years old (range 35-76 years old). Follow-up spanned 6 to 71 months (median of 18.5 months). Four patients received spherical hydrogel implants and 10 patients received hydrogel pellet injections. On average, nine pellets (range 5-16) were placed in each patient over an average of 1.7 injections (range 1-3). Most commonly, five pellets were injected per session, as was the case for 13 of the 17 treatment sessions. Post-operative complications included 2 cases of pellet migration, one subcutaneously and one anteriorly due to insufficiently posterior implant placement, and 1 hospital admission for pain after injection of 10 pellets in one visit. All patients experienced an overall subjective improvement in cosmesis. Self-expandable hydrogel implants appear to offer several advantages over other existing options for orbital volume augmentation, as they are easy to place, generally well-tolerated, volume-titratable, and to the extent that our follow-up shows, may be a safe and durable means of treating orbital volume loss in patients with acquired anophthalmia and phthisis bulbi.

Hyaluronic Acid Gel Re-Injection for Enophthalmos Correction in Silent Sinus Syndrome.

A 43-year-old female with residual enophthalmos following functional endoscopic surgery (FESS) due to silent sinus syndrome (SSS) was initially successfully treated with a 2-ml intraorbital injection of hyaluronic acid gel (HAG). The enophthalmos partially recurred 22 months after the injection. HAG was re-injected with good functional and cosmetic results. Functional (kinetic) computed tomography was performed to visualize HAG distribution in the orbit.

[Reconstruction of the orbital fracture with enophthalmos using customized titanium mesh combined with Medpor].

OBJECTIVE: This study aims to evaluate the effect of customized titanium mesh, which was designed by mirror imaging and rapid prototyping technique, with Medpor applied for orbital fracture with enophthalmos. METHODS: Orbital axial, coronal, and sagittal CT scan, and three-dimension CT examination were performed routinely in. 18 cases of orbital fracture with enophthalmos preoperatively. Based on the CT data, prosthesis model was designed by reverse engineering and rapid prototyping technique. The customized titanium mesh and Medpor were applied for orbital reconstruction and enophthalmos correction. Orbital reduction and globe projection were evaluated by postoperative CT scan and clinical follow-up visits. RESULTS: CT scans revealed that the customized titanium mesh with Medpor had great accuracy to reconstruct the orbital fracture and correct the enophthalmos in all patients without serious complications. The eye and facial appearance and function recovered significantly. No serious complication occurred in the operation and after operation. CONCLUSION: The customized titanium mesh, based on mirror imaging and rapid prototyping technique, can accurately reconstruct the orbital fractures with enophthalmos. The application of Medpor can effectively correct enophthalmos and eyeball mobility malformation.

[Combined middle meatus and expand prelacrimal recess-maxillary ainus approach for orbital fracture treatment].

OBJECTIVE: To study surgical techniques and clinical applications of the intranasal endoscopic combined middle meatus and expand prelacrimal recess-maxillary ainus approach for orbital fracture treatment. METHOD: A retrospective clinical analysis of 3 patients whose admitted for orbital floor fractures or medial wall fractures operated by the intranasal endoscopic middle meatus with expand prelacrimal recess-maxillary ainus approach surgical treatment was studied, and the treatment effects and the postoperative complications were analyzed. RESULT: All patients had been followed up for 6 to 12 months. All cases of diplopia symptom were disappeared, enophthalmos were totally corrected, no cases of complication were found. CONCLUSION: Endonasal endoscopic combined middle meatus and expand prelacrimal recess-maxillary ainus approach for orbital fracture treatment have great and clear view. This approach with less tissue damage and high therapeutic effect makes the cost lower than other methods and complications will be decreased as well, it has a great advantage in the orbital fracture treatment.

Anophthalmic syndrome: a review of management.

PURPOSE: To review and summarize current management of anophthalmic syndrome-enophthalmos, superior sulcus syndrome, lower eyelid laxity, and upper eyelid ptosis. METHODS: The authors performed a PubMed search of all articles published in English on the management of anophthalmic socket syndrome. RESULTS: A review of 37 articles demonstrated that anophthalmic syndrome occurs in a significant proportion of this patient population. Primary prevention through careful selection of primary orbital implant is ideal. Residual mild deficits can then be corrected through prosthesis modification. When modification of the prosthesis is no longer sufficient, specifically targeted procedures become necessary. CONCLUSIONS: Ocularists and oculoplastic surgeons should work together closely to treat anophthalmic syndrome. Future studies should establish uniform measurement criteria as the next step in validating the benefit and limitation of each technique.

The coming age of enophthalmos.

PURPOSE OF REVIEW: Many factors are known to affect the health of the ocular surface. Enophthalmos is an often-overlooked component of ocular surface disease, and its prevalence is likely on the rise. This review outlines the many causes of enophthalmos, summarizes recent literature describing its relation to the health of the conjunctiva and cornea, and reviews new ways to treat it in clinical practice. RECENT FINDINGS: The terms giant fornix syndrome, senile sunken upper lids, and prostaglandin-associated periorbitopathy have recently been coined to describe newly recognized syndromes associated with enophthalmos. Many of these syndromes can lead to ocular surface disease and are becoming more prevalent as the population ages. SUMMARY: With an understanding of the causes of enophthalmos and its relation to the health of the ocular surface, an accurate diagnosis and treatment plan can be made for patients presenting with periorbital and ocular surface disease.

Medial orbital wall reconstruction with flexible Ethisorb patches.

OBJECTIVES: The aim of this study was to analyse the long-term result after reconstruction of the medial orbital wall with a flexible, biodegradable material (Ethisorb). MATERIALS AND METHODS: During a period of almost 8 years, 31 patients with a medial orbital wall fracture were analysed retrospectively. Inclusion criteria were patients with a maximum size fracture of the orbital medial wall measuring 1.5-2 cm(2). Exophthalmos, enophthalmos, bulbus motility, diplopia and skin sensation were investigated over a period of 6 months. In all patients, the medial orbital wall was reconstructed with Ethisorb patches. RESULTS: No significant intraoperative complications were detected. No postoperative infection, abscess or seroma was found in any of the patients receiving an Ethisorb patch. CONCLUSIONS: The advantage of the semiflexibility of the Ethisorb patch is that it supplies an anatomically correct fit to the orbital medial wall but does not require fixation by screws or the use of sutures. CLINICAL RELEVANCE: The low rate of reported bulbus motility disturbance, diplopia, exophthalmos and enophthalmos demonstrates acceptable results after medial orbital wall reconstruction using the Ethisorb patch.

Anterior filler displacement following injection of calcium hydroxylapatite gel (Radiesse) for anophthalmic orbital volume augmentation.

OBJECTIVE: To describe the complication of anterior filler displacement following injection of calcium hydroxylapatite gel (Radiesse) for anophthalmic enophthalmos correction. METHODS: Retrospective case series of patients who experienced anterior filler displacement following orbital injection of calcium hydroxylapatite. Data includes patient demographics, indication for injection, route and volume of injection, description of postinjection complications, and final outcome. RESULTS: Four cases of anterior filler displacement and expansion following injection of calcium hydroxylapatite were identified. The patients' ages ranged from 33 to 64 years old. All 4 patients underwent multiple prior orbital surgeries and suffered from anophthalmic enophthalmos. Injectable calcium hydroxylapatite was delivered transcutaneously, to the deep extraconal orbital space, via 27-gauge, 1.25-inch retrobulbar needles. Each patient received an initial 1.3 ml of filler, with 1 patient receiving an additional 0.8 ml. Within 1 week, all patients experienced prominent, edematous lower eyelids. A CT scan of 1 patient radiographically documented anterior migration of the filler material. Two patients required transconjunctival excision of the filler and infiltrated orbital fat. Histopathologic examination of 1 specimen revealed chronic foreign body granulomatous inflammation. Two patients were treated medically, with resolution of clinical findings over 6 to 9 months. CONCLUSIONS: Anterior filler displacement is a potential complication of orbital volume augmentation with injectable calcium hydroxylapatite. Patients should be counseled regarding this possibility when considering options for the treatment of anophthalmic enophthalmos. A history of multiple prior orbital surgeries, with associated tissue disruption and scarring, may be a risk factor for filler displacement.

Sarcoidosis presenting as imploding antrum syndrome.

We present a case of a male patient who presented with facial asymmetry and epiphora. A diagnosis of imploding antrum syndrome secondary to sarcoidosis was made on the basis of characteristic computerised tomography features, elevated serum ACE and histopathological findings. We suggest that chronic inflammation within the sinus cavities, due to sarcoid, had caused osteolysis of the sinus walls, subsequently leading to the typical presentation of imploding antrum syndrome.

Comparison of conchal cartilage graft with nasal septal cartilage graft for reconstruction of orbital floor blowout fractures.

Our aim was to compare autogenous nasal septal cartilage and conchal cartilage as grafts for reconstruction of orbital blowout fractures. Twenty-two patients with blowout fractures were randomly assigned to two groups for treatment with a graft of nasal septal cartilage or conchal cartilage. Patients were evaluated for the presence of enophthalmos, diplopia, dysfunction of the infraorbital nerve, and restriction of the ocular muscles. Patients with enophthalmos of more than 2 mm were included in the study, and were followed up postoperatively at 10 days, 1 month, and 3-6 months. The patients treated with a nasal septal cartilage graft had significantly better correction of enophthalmos than those treated with conchal cartilage (p=0.02) after 10 days (p=0.02), 1 month (p=0.004), and 3-6 months (p=0.001). There was significantly less residual enophthalmos in the nasal septal graft group after 1 month (0.91 compared with 1.72 mm, p=0.02), and after 3-6 months (1.0 compared with 2.54 mm, p=0.008). Correction of enophthalmos was considerably better in patients who were operated on within 4 weeks of injury. We think that nasal septal cartilage is a better graft than conchal cartilage for reconstruction of blowout fractures. The time to intervention (the earlier the better) is a critical point in the correction of enophthalmos.

[Volume overload from hydrogel expander after treatment for enophthalmos]. / Volumenüberschuss durch Hydrogelexpander nach Enophthalmuskorrektur.

In the subject of this case report, a self-inflating hydrogel expander was implanted as a treatment for posttraumatic enophthalmos in a fully sighted eye. The intervention caused hypertropia with diplopia, restriction of eye movements, visual field defects, and colour desaturation as a result of excessive swelling of the expander. Once the expander volume was adjusted, clinical signs regressed, and the aesthetic results were excellent. Following the implantation of self-inflating orbit expanders, it is advisable to carry out immediate follow-up during the expander's swelling period, and long-term follow-up is also advised to rule out late sequelae, as a position-dependent secondary glaucoma could occur.

Correlation between changes of medial rectus muscle section and enophthalmos in patients with medial orbital wall fracture.

BACKGROUND: Enophthalmos is the most distressing and common complication of the blow-out fracture. In spite of well-established indications for early operative repair of orbital fracture, 7-10% of patients treated non-operatively develop enophthalmos. There have been reports on the correlation between changes of orbital bone and enophthalmos; however, there is no report on muscle changes in computed tomography (CT) in medial blow-out fracture. The present authors have documented the correlation between change of medial rectus muscle and enophthalmos using CT scan in medial blow-out fracture patients. METHODS: In this study (from January 2001 to December 2006) of 340 patients diagnosed with medial blow-out fracture, 24 patients were treated non-operatively. Nine patients (Group 1) have over 2-mm enophthalmos and 15 patients (Group 2) have enophthalmos less than 2mm. The height-to-width (H-W) ratios of medial rectus muscle were measured in coronal views, and the size of defects were measured in coronal and axial views in CT. Hertel's exophthalmometry was measured on both eyes for all patients. RESULTS: The H-W ratios measured in the affected orbits were statistically significant between the two groups (p<0.0001). However, the size of defect is not related with enophthalmos in two groups statistically (P=0.421). CONCLUSION: These results mean that the H-W ratio of medial rectus muscle in coronal views of CT is a useful parameter to predict enophthalmos, and whether H-W ratios of medial rectus muscle over 0.7 need surgical correction.

Intraorbital polyacrylamide gel injection for the treatment of anophthalmic enophthalmos.

PURPOSE: To evaluate the use of orbital polyacrylamide gel injection for the correction of anophthalmic enophthalmos. METHODS: Noncontrolled clinical trial of 21 patients (14 with ocular implants, 5 with phthisis bulbi, and 2 with dermis-fat graft). Orbital CT was performed to estimate the volume of polyacrylamide gel needed to restore orbital volume. Polyacrylamide gel was injected using a 22-gauge (30 x 0.7 mm) needle transcutaneously inserted in the lateral third of the lower eyelid, directed to the orbital muscle cone. A second injection was administered 15 days later, if necessary. CT was repeated 30 days after the last procedure. Exophthalmometry was performed before and 90 days after the procedure. RESULTS: The mean total volume injected per orbit was 2.4 +/- 0.7 ml (range, 1-3.5 ml). The volume of the enophthalmic orbit increased from 26.9 +/- 5.0 ml to 29.3 +/- 4.9 ml (p < 0.001). The mean difference in exophthalmometry readings was 3.3 +/- 1.6 mm (range, 1.5-8.0 mm) before the procedure and 1.0 +/- 0.9 mm (range, 0.0-3.0 mm) after 3 months (p < 0.001). Adjustment of the ocular prosthesis or fabrication of a new one was necessary in 11 patients (52.4%), and the mean volume of the ocular prosthesis was reduced from 2.0 +/- 0.6 ml to 1.6 +/- 0.6 ml (p = 0.003). All patients were satisfied with the aesthetic results. No serious adverse events were observed. The initial results were maintained 1 year after the procedure. CONCLUSIONS: Polyacrylamide gel injection in the orbital space effectively reduces enophthalmos in ocular prosthesis wearers.