Acute Diplopia Following Rhinoplasty: Clearing the Air.

Diplopia after rhinoplasty is a rare complication that requires immediate medical attention. Workup should include a complete history and physical examination, appropriate imaging, and consultation with ophthalmology. Diagnosis may be challenging due to the wide differential ranging from dry eyes to orbital emphysema to an acute stroke. Patient evaluation should be expedient, though thorough to facilitate time-sensitive therapeutic interventions. Here, we present a case of transient binocular diplopia presenting 2 days after closed septorhinoplasty. The visual symptoms were attributed to either intra-orbital emphysema or a decompensated exophoria. This is the second documented case of orbital emphysema after rhinoplasty presenting with diplopia. It is the only case with a delayed presentation as well as the only case that resolved after positional maneuvers.

La diplopie après la rhinoplastie est une complication rare qui exige des soins médicaux. Le bilan inclut une histoire complète et un examen physique, une imagerie appropriée et une consultation en ophtalmologie. Le diagnostic peut être difficile à poser en raison du vaste diagnostic différentiel, qui va de la sécheresse oculaire à l'emphysème orbitaire, en passant par l'accident vasculaire cérébral aigu. L'évaluation des patients doit être rapide, mais approfondie, pour favoriser des interventions opportunes. Les auteurs présentent un cas de diplopie binoculaire transitoire s'étant manifestée deux jours après une septorhinoplastie fermée. Les symptômes visuels étaient attribués à un emphysème intraorbitaire ou une exophorie décompensée. Il s'agit du deuxième cas répertorié d'emphysème orbitaire après une rhinoplastie démontrée par une diplopie. C'est le seul cas aux manifestations tardives, de même que le seul à s'être résorbé après des manœuvres positionnelles.

Silent sinus syndrome presenting as enophthalmos long after orbital trauma.

Late enophthalmos is a well-known consequence of large orbital floor fractures. In rare cases, late enophthalmos can occur after direct trauma to the maxillary ostiomeatal complex and present as silent sinus syndrome (SSS). We report two cases of SSS manifesting as enophthalmos years after facial trauma. The first patient developed SSS 4 years after a minimally displaced orbital floor fracture. The second patient had progressive enophthalmos as a result of atelectasis of the maxillary sinus years after facial trauma and surgical repair of nasal fractures. There have been two prior reports of SSS presenting after orbital trauma. Our patients differ from these prior reports in that the enophthalmos was discovered years after the initial facial trauma. In the first patient, surgery addressing the blockage of the ostiomeatal complex arrested the enophthalmos; in the second patient, it reversed the enophthalmos.

Low complication rates of cranial and craniofacial approaches to midline anterior skull base lesions.

OBJECTIVE: Surgery is a cornerstone of treatment for a wide variety of neoplastic, congenital, traumatic, and inflammatory lesions involving the midline anterior skull base and may result in a significant anterior skull base defect requiring reconstruction. This study is a retrospective analysis of the reconstruction techniques and complications seen in a series of 58 consecutive patients with midline anterior skull base pathology treated with craniotomy or a craniofacial approach. The complication rates in this series are compared with other retrospective series and specific techniques that may reduce complications are then discussed. DESIGN: This is a retrospective analysis of 58 consecutive patients who had surgery for a midline anterior skull base lesion between January 1994 and July 2003. Data were collected regarding pathology, surgical approach, reconstruction technique, and complications. RESULTS: Twenty-nine patients underwent surgery for a meningioma (50%). The remainder had frontoethmoidal cancer, mucoceles/invasive nasal polyps, encephalocele, esthesioneuroblastoma, anterior falx dermoid cyst with a nasal sinus tract, or invasive pituitary adenoma. In most patients, a low and narrow two-piece biorbitofrontal craniotomy was used. When possible, the dura was repaired before entering the nasal cavity. Thirteen patients experienced a complication (22%). There was one case of postoperative cerebrospinal fluid (CSF) leak (2%), one case of meningitis (2%), two cases of bone flap infection (3%), and two cases of symptomatic pneumocephalus (3%). There were no deaths, no reoperations for CSF leak, and no patient had a new permanent neurologic deficit other than anosmia. CONCLUSIONS: Transcranial approaches for midline anterior skull base lesions can be performed safely with a low incidence of postoperative CSF leak, meningitis, bone flap infection, and symptomatic pneumocephalus. Our results, particularly with regard to CSF leakage, compare favorably with other retrospective series.

Bacterial infection after endoscopic sinus surgery: a controlled prospective study.

OBJECTIVES/HYPOTHESIS: The objective was to determine whether infections occurring after endoscopic sinus surgery represent overgrowth of sinonasal flora versus de novo bacterial infection. STUDY DESIGN: Prospective controlled cohort study. METHODS: A cohort of adult patients was prospectively followed after endoscopic sinus surgery. Baseline postoperative control cultures of the ethmoid sinus were obtained. Patients with acute infectious exacerbations of chronic rhinosinusitis had endoscopic culture, and these results were compared with baseline culture data. RESULTS: One hundred thirteen patients were followed for a mean period of 14.5 months after endoscopic sinus surgery. Baseline postoperative culture data revealed that the ethmoid labyrinth was sterile in 23% of cases, carried oral flora in 18% of cases, and was colonized in 60% of cases. Gram-positive cocci, particularly staphylococcal species, were the most common colonizing organisms (41% of cases). Twenty acute exacerbations were cultured in 17 patients during the follow-up period. All infectious cultures recovered bacteria; one culture recovered only oral flora. Gram-positive cocci predominated (56% of isolates) with Staphylococcus aureus being the most common isolate (28%). Of the 36 isolates, only 9 isolates (25%) corresponded to bacteria identified at the time of baseline culture. CONCLUSION: Although the postoperative sinonasal cavity may be colonized by bacteria after endoscopic sinus surgery, infections arising postoperatively most commonly represent de novo infections by bacteria other than colonizing bacteria. Empirical therapy based on baseline data may be misleading; acute exacerbations of chronic rhinosinusitis after endoscopic sinus surgery should be cultured to guide optimal antibiotic therapy.

Microbiology of the ethmoid sinus following endoscopic sinus surgery.

We prospectively studied the native microbiology of the ethmoid sinus following endoscopic sinus surgery in 113 patients (mean age: 41.3 yr). After each patient had regained complete mucosalization (minimum follow-up: 6 wk), we obtained a bacterial swab of the ethmoid sinus and submitted it for culture and sensitivity analysis. We then compiled data on sensitivity patterns and the number and type of bacteria isolated. Of the 113 patients, 67 (59.3%) had positive cultures, 26 (23.0%) had sterile cultures, and 20 (17.7%) had normal flora. Multiple bacteria were isolated in 31 of the 113 patients (27.4%). The most common isolates were gram-positive cocci, and the most common bacteria were staphylococcal species. A significant degree (42.9%) of beta-lactamase resistance was exhibited. We conclude that the ethmoid sinus is not microbiologically sterile following endoscopic sinus surgery.