Maxillary sinus atelectasis with enophthalmos

Volumetric Analysis of the Sinus and Orbit in Silent Sinus Syndrome After Endoscopic Sinus Surgery

OBJECTIVE

The term "silent sinus syndrome" (SSS) describes spontaneous enophthalmos secondary to subclinical maxillary sinus atelectasis. Debate remains on whether treatment with endoscopic maxillary antrostomy alone is adequate in reversing atelectasis and globe displacement. This study aims to determine the degree of volume change of the diseased sinus and orbit as well as the change in orbital height in patients treated with endoscopic antrostomy without orbital floor augmentation.

STUDY DESIGN

Retrospective review with image analysis.

SETTING

Single tertiary care institution.

METHODS

Three-dimensional (3D) analysis of computed tomographic imaging data was performed using 3D Slicer. 3D models of the maxillary sinus and orbit of the diseased and normal sides were created, and volume measurements were calculated using the segmentation program.

RESULTS

Thirteen patients with SSS who underwent endoscopic sinus surgery (ESS) and had follow-up computed tomographic imaging were analyzed. After endoscopic antrostomy, the mean volume of the diseased maxillary sinus significantly increased by 9.82%, from 6.37 to 7.00 cm³ (p = .0302). There was no significant change in mean orbital volume; however, the mean orbital height decreased by 5.67%, from 38.09 to 35.93 mm from pretreatment to posttreatment samples (p = .0101). All patients had resolution of clinical or radiographic enophthalmos and orbital displacement with ESS alone.

CONCLUSION

Endoscopic maxillary antrostomy alone in the treatment of SSS significantly increased maxillary sinus volume and decreased diseased orbital height. These changes were associated with clinical and radiographic improvement in globe displacement. These findings support performing ESS alone, reserving orbital augmentation for patients who do not exhibit adequate clinical improvement.

A Rare Complication of Functional Endoscopic Sinus Surgery: Maxillary Atelectasis-Induced Spontaneous Enophthalmos

Background

The first case report of spontaneous enophthalmos due to maxillary atelectasis as a late complication of FESS is presented.

Methods

Chart review of a 24-year-old male who developed a left progressive enophthalmos within three months post bilateral functional endoscopic sinus surgery.

Results

The preoperative computed tomography showed a normal left maxillary sinus. The postoperative computed tomography revealed a left maxillary atelectasis with a descending orbital floor. The subject received revised endoscopic sinus surgery and his enophthalmos was stable without further progression after the operation.

Conclusions

This may have been caused by an ostium occlusion with retention of secretions inducing sinus inflammation, osteolytic activity, and osseous remodeling of the sinus walls. A negative pressure may develop. When the pressure gradient exceeds the sinus wall tension, maxillary atelectasis and enophthalmos occur. Prevention of this complication of FESS should include making a patent naso-antral window, minimizing mucosal trauma, and careful postoperative sinoscopic treatment. A “functional” sinus is the goal.

Chronic maxillary atelectasis and silent sinus syndrome: two faces of the same clinical entity

Chronic maxillary atelectasis (CMA) and silent sinus syndrome (SSS) are rare clinical entities characterized by an implosion of the maxillary sinus that may or may not be associated with sinonasal symptoms, and are complicated by ipsilateral enophthalmos. The objective of this article is to discuss the definitions, physiopathology, clinical and radiographic characteristics, and surgical management of these entities. We retrospectively reviewed 18 patients (7 women, 11 men, aged 12-70 years) diagnosed and treated in the ear, nose, and throat departments of four Belgian teaching hospitals between 2000 and 2015. Nine patients had a history of sinus disease. In all cases, a computed tomography scan showed downward displacement of the orbital floor, increased orbital volume, and maxillary sinus contraction. Five patients met the criteria for grade II CMA and 13 for grade III CMA. Four patients met the criteria for SSS. All patients underwent wide endoscopic middle maxillary antrostomy. There were no orbital complications and all patients experienced resolution or a dramatic reduction of their symptomatology. Only one patient asked for an orbital floor reconstruction to correct a persisting cosmetic deformity. Although CMA and SSS are usually regarded as different entities in the literature, we believe that they lie on the same clinical spectrum. Treatment for both conditions is similar, i.e., middle meatal antrostomy to halt or even reverse the pathological evolution and reconstruction of the orbital floor in the event of persistent cosmetic deformity.

Isolated unilateral upper alveolar numbness in silent sinus syndrome

We present a case of a 59-year-old man with left upper alveolar numbness of 2 years’ duration in the absence of sinonasal symptoms. On physical examination, he demonstrated mild left facial asymmetry and diminished sensation of his left upper alveolus from the left second upper incisor to first canine. CT imaging revealed chronic sinusitis changes of the left maxillary sinus, with reduced volume and depressed anterior wall. The patient underwent functional endoscopic sinus surgery to re-establish maxillary sinus ventilation. He was noted to have some improvement of his upper alveolar paraesthesia postoperatively. Silent sinus syndrome is part of the spectrum of chronic maxillary atelectasis. In the presented case, chronic osteitic bony sclerosis, as opposed to osteopenic change of the maxillary sinus, was seen. We postulate that bony encasement of the anterior superior alveolar nerve resulted in chronic nerve compression and the patient’s unusual symptom of upper alveolar paraesthesia.

Repetitive Sinus-Related Symptoms May Accelerate the Progression of Chronic Maxillary Atelectasis

Chronic maxillary atelectasis (CMA) is characterized by a progressive decrease in maxillary sinus volume. The factors that promote the stage progression of CMA remain poorly understood. Here, we describe the time course of anatomical changes in a 40-year-old woman with stage II CMA that progressed to stage III disease. She did not show stage progression until she started to develop repetitive sinus-related symptoms. The stage progression was characterized by ocular symptoms. The repetitive inflammatory episodes may have increased the negative pressure in the affected sinus and weakened the bone walls, thereby promoting stage progression. Thus, a history of repetitive sinus-related symptoms may be a risk factor for stage progression in CMA.

[The silent sinus syndrome in the patients presenting with the uncinate process apposed to the orbital wall]

The objective of the present study was to analyze the frequency of the silent sinus syndrome (SSS) based on the results of computed tomography of the paranasal sinuses (PNS) in the patients presenting with the uncinate process (UP) apposed to the orbital wall. The study included 35 patients with the uncinate process apposed to the orbital wall who had been operated in the Clinic of ENT Diseases of I.M. Sechenov First Moscow State Medical University. The examination of the nasal cavity with the use of computed tomography and PNS endoscopy revealed the silent sinus syndrome in 14 patients. Ten of them had endoscopically confirmed type 2 hypoplasia of maxillary sinuses (MS). This finding suggests the necessity of computed tomography of paranasal sinuses in the patients with this condition in order to exclude the diagnosis of silent sinus syndrome even in the absence of exophthalmos. All the patients included in the present study underwent endoscopic surgery on maxillary sinuses that resulted in the adequate widening of the ostium and comprehensive sanation of the sinuses.

Posttraumatic Delayed Enophthalmos: Analogies with Silent Sinus Syndrome? Case Report and Literature Review

Acute posttraumatic enophthalmos is a well-known symptom occurring in orbital blowout fractures. Its late onset in the absence of radiologic evidence of displaced fractures is rare and traditionally attributed to ischemic liponecrosis or fibrotic scarring of endo-orbital soft tissues. In this article, we describe a case of facial trauma, diagnosed and treated at the Maxillo-Facial Surgical Department of Hospital Ca' Granda Niguarda of Milan, in which delayed monolateral enophthalmos is associated with CT evidence of remodeling of orbital walls attributed to atelectasis of the maxillary sinus, as occurs spontaneously in patients suffering from silent sinus syndrome (SSS). Despite that classic criteria exclude traumatic etiology of SSS, recent literature suggests the possibility to include it. Our case is the first reported in literature supported by complete clinical and radiological documentation obtained before and after the condition established itself. The analogy with cases of spontaneous obstacle of aeration allows us to choose "two-step" surgical treatment with endoscopic uncinectomy and antrostomy and a delayed surgical correction of orbital volume to improve aesthetic results. The case described in this article and the review of the literature may focus physicians' attention on evaluating the possible traumatic changes in the physiologic sinus drainage system.

Imaging for headache: what the otolaryngologist looks for

Diagnosing a rhinogenic cause of headache or facial pain outside of the classic definitions of chronic, acute, and subacute sinusitis can be challenging for the practicing otolaryngologist. Contact-point headaches have been clinically characterized as causing facial pain secondary to abutting mucosal contact from the lateral nasal wall to the septum. Imaging landmarks may help identify these potential contact points radiographically through revealing anatomic variants such as septal spurs and abnormally large lateral nasal structures. However, other potential rhinologic sources, such as barosinusitis, recurrent barotrauma, or recurrent acute sinusitis occurring between active episodes, are challenging to identify through hallmark imaging findings.

The silent sinus syndrome

The silent sinus syndrome (SSS) involves painless facial asymmetry and enophthalmos, which is the result of chronic maxillary sinus atelectasis. In most cases, it is diagnosed clinically, however, using the characteristic imaging features including maxillary sinus outlet obstruction, sinus opacification, and sinus volume loss caused by inward retraction of the sinus walls. Obstruction of the maxillary ostium appears to play a critical role in the development of SSS. Treatment involves functional endoscopic surgery.

Enophthalmos due to atelectasis of the maxillary sinus: silent sinus syndrome

Silent sinus syndrome is a clinical entity with the constellation of progressive enophthalmos and hypoglobus due to gradual collapse of the orbital floor with opacification of the maxillary sinus, in the presence of subclinical maxillary sinusitis. It occurs secondary to maxillary sinus hypoventilation due to obstruction of the ostiomeatal unit. In this paper, a 35-year-old woman with a complaint of asymmetry in her left eye and denting of upper eyelid was reported. In the left eye, upper sulcus was deepened and there was 3-mm hypoglobus. There was no diplopia or restriction of eye movements in any gaze positions. Hertel exophthalmometry revealed a 4-mm enophthalmos on the left eye. Computed tomographic scan of the orbita and paranasal sinuses showed left maxillary sinusitis, air-fluid level, and collapse of left maxillary sinus walls. In addition, inferior bulging in the left orbital floor was also reported. The treatment was a 2-stage operation. In the first stage, she underwent endoscopic septoplasty plus left maxillary antrostomy, and in the second stage, she underwent a subciliary orbital floor repair of the iliac bone resulting in the improvement of the enophthalmos and her cosmetic appearance. Regarding this case, the literature is also reviewed in detail.

Radiology and endoscopic findings of silent maxillary sinus atelectasis and enophthalmos

OBJECTIVES

The objective of this study is to discuss the presentation and surgical management of patients presenting with silent maxillary sinus atelectasis with enophthalmos (SMSAE).

STUDY DESIGN AND METHODS

We performed an analysis of prospectively collected data on patients with maxillary sinus opacification and associated enophthalmos from 1999 to 2003. Patients were evaluated based on physical examination, nasal endoscopy, and computed tomographic findings.

RESULTS

Sixty-four patients were identified with unilateral maxillary sinus opacification. Of these, 7had radiographic evidence of maxillary sinus volume reduction. Of these 7 patients, 5 had maxillary sinus atelectasis with enophthalmos, the components constituting SMSAE. The mean age of the patients was 42 years (range, 22-65). None of the patients had any history of nasal trauma or developmental defects before presentation. All 5 patients with SMSAE had uncinate retraction on nasal endoscopy. Uncinate retraction was not seen in the 2 patients without enophthalmos (chi(2) = 7, P= .008). All 7 patients with maxillary opacification were treated with endoscopic sinus surgery, with resolution of their maxillary sinus obstruction at 2 years' follow-up. Only 1 of 5 patients with SMSAE requested orbital floor reconstruction after sinus surgery performed by the oculoplastic service with resolution of enophthalmos.

CONCLUSION

All patients with SMSAE had evidence of uncinate process retraction on nasal endoscopy, whereas patients without enophthalmos did not, and the difference was statistically significant. Surgical treatment is the mainstay of therapy for this condition, with resolution of maxillary opacification at 2 years' follow-up.

The silent sinus syndrome is a form of chronic maxillary atelectasis: a systematic review of all reported cases

BACKGROUND

The terms chronic maxillary atelectasis (CMA) and silent sinus syndrome (SSS) have been used to describe spontaneous enophthalmos in association with a contracted ipsilateral maxillary sinus. Despite the use of differing taxonomy, it appears that these two terms describe the same clinical entity. Nevertheless, many reports still discuss CMA and SSS in isolation or as distinct conditions.

METHODS

A systematic review of all reported cases of CMA and SSS was performed (1964-2006). Case reports were excluded if they involved facial trauma, diagnosis of mucocele, or previous surgery. Eligible cases were reviewed and entered into a database. Data were evaluated based on literature of publication, reported diagnosis, demographics, ophthalmologic examination, results of imaging, and operative findings. Only complete data sets were included in an additional analysis whereby the diagnostic criteria for CMA and SSS were applied and the data sets were compared.

RESULTS

Of the 105 cases reviewed, 55 contained complete data sets. Twenty-seven of these cases met the diagnostic criteria for SSS, and 48 could be diagnosed as CMA, with 23 meeting the criteria for both conditions. Comparing the cases across diagnoses, the only difference observed was that of the presence of sinus-related symptoms, which by definition distinguishes CMA III from SSS.

CONCLUSION

The entity termed SSS fits within the staging classification of CMA. We propose abandoning the term SSS and recommend universal adoption of the CMA staging system, which uses nomenclature that more accurately portrays the pathophysiology and natural history of this condition.

Silent sinus syndrome

PURPOSE OF REVIEW

Silent sinus syndrome is a clinical entity with the constellation of progressive enophthalmos and hypoglobus due to gradual collapse of the orbital floor with opacification of the maxillary sinus, in the presence of subclinical maxillary sinusitis.

RECENT FINDINGS

It occurs secondary to maxillary sinus hypoventilation due to obstruction of the ostiomeatal unit. Correction of the problem is surgical. Surgery is endoscopic with reestablishment of maxillary aeration and drainage. The orbital repair can be staged. The endoscopic surgeon must be careful of the prolapsed orbital contents in to the maxillary sinus.

SUMMARY

Silent sinus syndrome is rare and multiple findings are needed for the diagnosis. These include enophthalmos or hypoglobus in the absence of clinically evident sinonasal inflammatory disease. Treatment consists of correction of the maxillary sinus atelectasis and the orbital defects. There is evidence that a two-stage repair may eliminate the need to perform the orbital repair. Due to the lateral position of the uncinate, endoscopic maxillotomy needs to be done with care to avoid injury to the orbital contents.

Diagnosis and management of enophthalmos

Enophthalmos is a relatively frequent and misdiagnosed clinical sign in orbital diseases. The knowledge of the different etiologies of enophthalmos and its adequate management are important, because in some cases, it could be the first sign revealing a life-threatening disease. This article provides a comprehensive review of the pathophysiology, evaluation, and management of enophthalmos. The main etiologies, such as trauma, chronic maxillary atelectasis (silent sinus syndrome), breast cancer metastasis, and orbital varix, will be discussed. Its objective is to enable the reader to recognize, assess, and treat the spectrum of disorders causing enophthalmos.

Microsurgical enophthalmos correction after silent sinus syndrome

A 66-year-old man with silent sinus syndrome, resulting in progressive enophthalmos and subclinical chronic maxillary sinusitis, presented after several failed attempts at reconstruction with conventional methods. A free fibula osteoseptocutaneous flap was used to recreate the orbital floor, obliterate the maxillary sinus, and augment the periorbital contour deformity in a single stage. This is a novel approach for the treatment of Silent Sinus Syndrome in a single stage.

The silent sinus syndrome

Silent sinus syndrome is a rare clinical entity typically characterized by spontaneous and progressive enophthalmos and hypoglobus caused by an alteration of the normal orbital architecture and function from maxillary collapse in the setting of the chronic maxillary sinus hypoventilation. The authors report an unusual case revealed by mild dental pain, present the imaging (before, during and after the development of the disease), discuss the different theories related to pathogenesis and comment the treatment.

Silent sinus syndrome: a case presentation and comprehensive review of all 84 reported cases

OBJECTIVES

The term silent sinus syndrome has been used to describe the constellation of progressive enophthalmos and hypoglobus due to gradual collapse of the orbital floor with opacification of the maxillary sinus, in the presence of subclinical chronic maxillary sinusitis. Currently, it is believed to occur as a result of the sequence of events following maxillary sinus hypoventilation due to the obstruction of the ostiomeatal complex.

METHODS

In this study, we present a case of true silent sinus syndrome. In addition, we highlight the previously published cases of silent sinus syndrome, as well as provide a review of the etiology, pathophysiology, radiologic diagnosis, surgical treatment, and pitfalls to avoid in the management of patients with silent sinus syndrome.

RESULTS

Eighty-three previously published cases of silent sinus syndrome were reported in the literature and are summarized in this review.

CONCLUSIONS

A well-defined set of criteria is needed to classify a patient under the diagnosis of silent sinus syndrome, which include enophthalmos and/or hypoglobus in the absence of clinically evident sinonasal inflammatory disease.

The silent sinus syndrome: maxillary sinus atelectasis with enophthalmos and hypoglobus

PURPOSE OF REVIEW

The silent sinus syndrome is a rare clinical entity of spontaneous enophthalmos and hypoglobus caused by an alteration of the normal orbital architecture and function from maxillary sinus collapse in the setting of chronic sinusitis.

RECENT FINDINGS

The maxillary sinus collapse appears to result from the development of negative sinus pressure from an acquired obstruction of the maxillary sinus outflow. Patients most often present with symptoms relating to enophthalmos, although few report any symptoms of sinus disease.

SUMMARY

Characteristic radiographic features of the maxillary sinus including opacification and collapse of the antral walls with inward bowing of the orbital floor are necessary for diagnosis.

Clinical and radiologic characteristics of the imploding antrum, or "silent sinus," syndrome

OBJECTIVES

To present the clinical and radiologic details of a series of patients with the imploding antrum, or silent sinus, syndrome, together with examples of the surgical findings and management.

DESIGN

Retrospective, noncomparative case series.

PARTICIPANTS

Fourteen patients assessed in the Orbital Service at Moorfields Eye Hospital.

MAIN OUTCOME MEASURES

Changes of clinical signs, symptoms, and radiologic signs.

RESULTS

Seven men and seven women, between the ages of 25 and 78 years (mean, 41.3 years), had unilateral enophthalmos, their having noted the anomaly for an average of 8 months (range, 1-36 months). All patients were nonsmokers. There was no evidence of progression of the condition in eight cases followed up for up to 63 months. On the affected side, there was 1 to 4 mm enophthalmos and up to 4 mm hypoglobus, with secondary narrowing of the vertical palpebral aperture in some cases, but no effect on visual function, and there was significant disturbance of ocular motility in only one case. The condition is characterized radiologically by a smooth inward bowing of the walls of the maxillary antrum on the affected side, with secondary enophthalmos and hypoglobus. In all 14 cases, the maxillary roof (orbital floor) was drawn downwards, and the medial and posterolateral walls of the maxilla were concave in 13 cases where it could be assessed. In one patient, there was associated inward collapse of the ipsilateral ethmoid complex. There was a patchy loss of mineral from the maxillary roof in 9 of 13 cases and, where the posterolateral maxillary wall was affected, there was a concomitant increase in the radiolucency (fat) of the pterygopalatine fossa. Some soft-tissue changes were present in the affected antrum in all 14 patients, and there was an air-fluid level in three patients. In 12 patients where septal deviation was present, this was to the affected side in 10 (83%), and an abnormally directed middle turbinate was also frequently observed (10 of 14 cases).

CONCLUSIONS

The silent sinus syndrome mainly presents as unilateral enophthalmos in younger people and has very characteristic clinical and radiologic signs with, in many cases, abnormal intranasal anatomic characteristics on the affected side. The condition may be exclusive to nonsmokers. The acute onset and long-term stability of the condition suggests that, although chronic and largely asymptomatic sinus disease may be the underlying cause, an acute event precipitates collapse of the orbital floor or (in fact) a widespread "implosion" of all antral walls resulting from maxillary atelectasis. Therefore, we prefer the term imploding antrum syndrome-describing the relatively acute, symptomatic, event-rather than the name silent sinus syndrome, which relates to a putative underlying mechanism.

The silent sinus syndrome: clinical and radiographic findings

OBJECTIVE. The purpose of this article is to acquaint the reader with the clinical and imaging features of the silent sinus syndrome, which is relatively unknown. Discussion of the presentation, treatment, and theory regarding pathogenesis of the syndrome follows. CONCLUSION. The silent sinus syndrome consists of painless facial asymmetry and enophthalmos caused by chronic maxillary sinus atelectasis. Although the diagnosis is usually suspected clinically, it is confirmed radiologically by characteristic imaging features that include maxillary sinus outlet obstruction, sinus opacification, and sinus volume loss caused by inward retraction of the sinus walls.

The silent sinus syndrome: a case series and literature review

PURPOSE

The purpose of this study is to describe the clinical and pathologic features of a form of chronic maxillary atelectasis referred to as the silent sinus syndrome, which is characterized by progressive enophthalmos secondary to maxillary collapse resulting from maxillary sinus hypoventilation.

METHODS

A retrospective medical record analysis was carried out to identify patients with enophthalmos secondary to maxillary collapse. Clinical records, including ophthalmology and otolaryngology evaluations as well as computed tomography scans and operative reports, were carefully examined. A complete literature review for relevant studies was performed to examine possible pathophysiology and similar cases.

RESULTS

Four patients with enophthalmos and asymptomatic maxillary sinus disease were identified. On computed tomography, all four of the patients had opacified, partially collapsed maxillary sinuses with osteopenia of the sinus walls and orbital floor displacement resulting in enophthalmos. All four underwent successful functional endoscopic sinus surgery and transconjunctival orbital floor repair.

CONCLUSION

In some instances, chronic maxillary atelectasis can present with enophthalmos secondary to collapse of the maxillary sinus. For reasons that are unclear, the sinus component of the disease remains asymptomatic and is discovered only after thorough evaluation of the enophthalmos.

Sinusitis-induced Enophthalmos: The Silent Sinus Syndrome

Enophthalmos caused by inadequate maxillary sinus function was first reported in 1964. Since this initial report, scattered case reports and, more recently, reviews have appeared in the literature detailing the pathophysiology, clinical findings, and management of this process. We present a classic case of the asymptomatic development of enophthalmos caused by maxillary sinus hypoventilation: the silent sinus syndrome. In addition, this case included findings in the ethmoid sinuses that suggested their contribution to this disorder, which by our review of the literature has not been well described.

Unilateral lid retraction during pregnancy

A 32-year-old woman noted left lid retraction during pregnancy. Examination revealed unilateral enophthalmos without symptoms of diplopia or sinus disease. Orbital imaging showed characteristic features of the silent sinus syndrome, which were confirmed intraoperatively. The clinical and imaging attributes of this syndrome are discussed, including possible mechanisms of disease development. Management strategies are summarized. A brief discussion of the differential diagnosis of enophthalmos is also included.