Bicoronal Incision and Frontal-Basal Approach for Removal of Sinonasal Fibrous Dysplasia Complicated by Orbital Subperiosteal Abscess

Orbital Abscess Developed Apart From Paranasal Sinusitis and Dacryocystitis in Fibrous Dysplasia

A 48-year-old man visited the emergency department of our hospital with swelling of the left upper and lower eyelids from the day before. On the first examination, he had severe swelling of the left upper and lower eyelids, proptosis, and chemosis. Left intraocular pressure was 33 mmHg. Computed tomographic images showed an orbital abscess in the anterosuperolateral orbital space, maxillary and ethmoidal sinusitis, and dacryocystitis. The orbital abscess was not contiguous to maxillary and ethmoidal sinusitis and dacryocystitis. Ground-glass appearance was seen in the frontal, maxillary, and ethmoid bones, and most of the space of the frontal sinus was obliterated due to the expansion of the frontal bone. Emergent drainage of orbital abscess, dacryocystorhinostomy, and endoscopic sinus surgery were performed under general anesthesia. Intravenous tazobactam/piperacillin was administered. A culture test of the sinus pus and orbital abscess showed growth of Streptococcus intermedius (2+). At one month postoperatively, there was no recurrence of orbital abscess, paranasal sinusitis, and dacryocystitis.

Periorbital inflammation associated with craniofacial fibrous dysplasia: Report of three cases and review of the literature

Fibrous dysplasia (FD) is a mosaic skeletal disorder in which the craniofacial bones are commonly affected. Normal structures are replaced by expansile, highly vascular, fibro-osseous tissue. The typical clinical course is a gradual, asymptomatic expansion of the osseous structures. However, in the periorbital region, even minor structural changes may cause functional impairment, such as diplopia and hyposmia. Furthermore, rapidly evolving secondary lesions, such as fluid-filled cysts, can sometimes develop. In the midface and periorbital regions, such acute change may be associated with severe pain, vision loss, and, signs of inflammation. Here we describe three patients with craniofacial FD who presented with recurrent episodes of periorbital inflammation mimicking orbital cellulitis. All presented with pain, edema, erythema, and warmth, with varying degrees of functional impairment. On imaging, all had cystic changes in the FD lesion, including two with aneurysmal bone cysts (ABCs). Two were initially diagnosed with periorbital cellulitis and treated with antibiotics; in two, the radiographic findings were misdiagnosed as osteomyelitis. Recurrent episodes were recognized as not infectious and effectively managed with corticosteroids. Given the vascular nature of FD and the association of ABCs, it is likely the findings in these patients represent inflammation associated with vascular leak in the relatively confined space of the tissues overlying the periorbital bones. Recognition of this entity can lead to more rapid and appropriate treatment.