Volumetric analysis of chronic maxillary atelectasis

Post-traumatic Sinus Syndrome, Proposal for a New Clinical Entity (CDR Syndrome) as Variant of the Silent Sinus Syndrome: Systematic Review and Case Series

The diagnostic criteria for silent sinus syndrome (SSS) are still controversial, especially for the post-traumatic/surgery cases that are, nowadays, excluded from the diagnosis of SSS because lacking of spontaneously. We present a systematic review of the last 10 years and our case series of SSS associated to previous trauma/surgery, proposing a new interpretation of SSS. In this work, following the PRISMA guide lines for systematic reviews, we collected 86 articles published on PubMed, Cochrane Library and Medline Plus since 2013 to 2023 about SSS. We divided them in six groups forming the structure of the review: (1) epidemiology, (2) clinical presentation, (3) imaging, (4) etiopathogenesis, (5) sss and craniofacial trauma and (6) treatment. We reported two explicative clinical cases: two men of 34 and 37 years old, involved in motorcycle accident in 2020 and 2014, respectively, and underwent surgery. They came back in 2023 referring diplopia documented by Hess-Lancaster test. CT-scan reported two clear cases of SSS. Basing on what is reported in literature, and basing on our experience, the post-traumatic/surgery SSS are more frequent than the idiopathic ones. Our proposal is to considered them as two individual entities. We propose to adopt the name of Post-traumatic sinus syndrome, or CDR syndrome (Catalfamo-De Rinaldis), for all cases that respect four specific diagnostic criteria reported into the text.

Silent sinus syndrome with interfrontal sinus retraction: A 3-case series using CARE methodology

INTRODUCTION

Silent sinus syndrome (SSS) is a rare entity, almost exclusively involving the maxillary sinus, frontal location being very rarely reported. The aim of the present study was to describe clinical and radiological characteristics and surgical treatment using the CARE methodology.

RESULTS

One woman and 2 men were referred for chronic unilateral frontal pain with imagery showing silent sinus syndrome. All showed partial or complete liquid opacification of the affected sinus associated with a thin interfrontal sinus (IFS) retracted toward the affected sinus. Functional endoscopic sinus surgery was performed in all cases, with good functional results.

DISCUSSION

We describe 3 cases of SSS with IFS involvement. The frontal sinus wall seemed most vulnerable, probably most liable to be weakened by atelectasis. The study suggests that frontal SSS can be an etiology in chronic frontal sinusitis. Preoperative findings of IFS retraction are useful for surgical restoration of frontal sinus ventilation, relieving chronic pain and preventing complications.

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.

Silent sinus syndrome: systematic review and proposal of definition, diagnosis and management

Silent sinus syndrome (SSS) is a rare disease consisting of a collapse of maxillary sinus walls with concomitant orbital floor descent. Due to its rareness, the literature highlights some confusion on its definition, diagnosis and management. A PRISMA-compliant systematic review was performed on SSS with focus on definition, diagnosis and therapeutic management. Twenty-eight studies were selected, with 276 patients evaluated. The analysis revealed that the leading definition of SSS includes evidence of both enophtalmos and maxillary atelectasia. Although the definition of SSS accepts only spontaneous sinus collapse, the presence of sinonasal diseases and history of facial trauma are starting to be included in the criteria. Most studies (n = 21) considered CT scans satisfactory for diagnosis of SSS, while 7 also performed MR. The majority of SSS were successfully treated with isolated functional endoscopic sinus surgery (n = 17), sparing orbital reconstruction as a rescue procedure in case of non-satisfactory long-term resolution of signs. Although the literature is starting to coordinate on diagnosis of SSS, our review revealed the necessity of consensus on its definition and management.

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.

Chronic maxillary atelectasis (including silent sinus syndrome) can present bilaterally

OBJECTIVE

Chronic maxillary atelectasis is a rare and underdiagnosed condition in which there is a persistent and progressive decrease in maxillary sinus volume secondary to inward bowing of the antral walls. Chronic maxillary atelectasis is typically unilateral. Simultaneous bilateral chronic maxillary atelectasis is extremely uncommon.

METHODS

A retrospective review was performed of patient data collected by the senior clinician over a three-year period (2015-2018). A comprehensive literature search was conducted to locate all documented cases of chronic maxillary atelectasis in English-language literature. Abstracts and full-text articles were reviewed.

RESULTS

Three patients presented with sinonasal symptoms. Imaging findings were consistent with bilateral chronic maxillary atelectasis. The literature review revealed at least nine other cases of bilateral chronic maxillary atelectasis. Management is typically via endoscopic middle meatus antrostomy.

CONCLUSION

Chronic maxillary atelectasis was initially defined as a unilateral disorder, but this description has been challenged by reports of bilateral cases. Further investigation is required to determine the aetiology and pathophysiology of the disease.

Salivary biomarkers and proteomics: future diagnostic and clinical utilities

Saliva testing is a non-invasive and inexpensive test that can serve as a source of information useful for diagnosis of disease. As we enter the era of genomic technologies and -omic research, collection of saliva has increased. Recent proteomic platforms have analysed the human salivary proteome and characterised about 3000 differentially expressed proteins and peptides: in saliva, more than 90% of proteins in weight are derived from the secretion of three couples of "major" glands; all the other components are derived from minor glands, gingival crevicular fluid, mucosal exudates and oral microflora. The most common aim of proteomic analysis is to discriminate between physiological and pathological conditions. A proteomic protocol to analyze the whole saliva proteome is not currently available. It is possible distinguish two type of proteomic platforms: top-down proteomics investigates intact naturally-occurring structure of a protein under examination; bottom-up proteomics analyses peptide fragments after pre-digestion (typically with trypsin). Because of this heterogeneity, many different biomarkers may be proposed for the same pathology. The salivary proteome has been characterised in several diseases: oral squamous cell carcinoma and oral leukoplakia, chronic graft-versus-host disease Sjögren's syndrome and other autoimmune disorders such as SAPHO, schizophrenia and bipolar disorder, and genetic diseases like Down's Syndrome and Wilson disease. The results of research reported herein suggest that in the near future human saliva will be a relevant diagnostic fluid for clinical diagnosis and prognosis.

Silent sinus syndrome without opacification of ipsilateral maxillary sinus

Silent sinus syndrome (SSS) is a rare disease characterized by spontaneous enophthalmos and hypoglobus secondary to collapse of the orbital floor in patients with asymptomatic maxillary sinusitis. Radiographic findings include ipsilateral maxillary sinus opacification, lateralization of the uncinate and middle turbinate, and infundibular occlusion. We present a case series of three patients with clinical and radiographic evidence of SSS but without maxillary sinus opacification. Although uncommon, an aerated maxillary sinus in patients with unexplained enophthalmos, hypoglobus, and maxillary atelectasis should not exclude the diagnosis of SSS. Laryngoscope, 128:2004-2007, 2018.

Silent sinus syndrome and maxillary sinus atelectasis in children

OBJECTIVE

Silent sinus syndrome (SSS) and chronic maxillary atelectasis (CMA) are unusual conditions having subtle symptoms with a possible progressive evolution. They are particularly infrequent in the pediatric population. Our objective was to review our experience with pediatric patients having SSS or CMA, and to review all cases involving patients under 14 years of age reported in the literature.

METHODS

A retrospective review of 6 patients diagnosed with SSS or CMA surgically treated from 2001 to 2014 was carried out. All cases reported in literature were reviewed.

RESULTS

All patients underwent functional endoscopic sinus surgery with an improvement in symptoms after surgery. Diplopia disappeared in two patients who presented with it and enophthalmos improved in all five patients presenting with it. Only one patient out of four presenting with headache had a persistence of the symptoms which were, however, milder than they had been preoperatively. Endoscopic examination demonstrated a reventilated maxillary sinus in all cases. A radiological examination at follow-up was performed in 5 cases and demonstrated a reexpansion of the maxillary sinus as compared to the contralateral side in all patients except one. None of the patients required an orbital floor reconstruction. Eleven similar cases reported in the literature were analyzed and compared.

CONCLUSION

Endoscopic uncinectomy and middle meatal antrostomy should be the treatment of choice for these conditions in patients presenting with enophthalmos and/or hypoglobus and symptoms related to it. Orbital floor reconstruction should be performed as a delayed procedure only in selected cases. Chronic maxillary atelectasis or SSS should be considered as a possible cause of persistent headache of unknown origin in pediatric patients.

Bilateral silent sinus syndrome: A rare case and review of literature

Objective:

In this report, we presented a rare case of bilateral silent sinus syndrome (SSS) in an otherwise healthy 57-year-old man treated with functional endoscopic sinus surgery (FESS). A systematic review of the literature regarding bilateral SSS was performed.

Case Report:

A 57-year-old man with well-controlled allergic rhinitis in the absence of previous surgery or trauma presented with bilateral SSS, which was successfully managed with bilateral FESS.

Methods:

A medical literature data base search of the terms “silent sinus syndrome” “maxillary atelectasis,” “imploding antrum syndrome,” and “bilateral silent sinus syndrome” was performed. The results were then narrowed to include only relevant articles.

Results:

Relevant articles included three case reports and two articles that describe or mention bilateral SSS. Of the three case reports found, two patients presented with bilateral SSS, whereas the third patient presented metachronously, with the contralateral SSS manifesting 4 months after presentation of the initial ipsilateral SSS.

Conclusion:

The present literature regarding bilateral SSS is likely incomplete, and further investigation is required to provide greater insight into the prevalence of this disease. In this report, bilateral FESS was successful in resolving symptoms and preventing disease progression.

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.

Bilateral stage I chronic maxillary atelectasis: A case report

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A rare case of bilateral chronic maxillary atelectasis is described.

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There is a poor correlate between symptoms and severity of chronic maxillary atelectasis.

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As seen in this case, the term ‘chronic’ maxillary atelectasis can be misleading, and rapid disease progression may occur.

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Re-ventilation of the affected sinuses alleviates symptoms, halts disease progression and facilitates antral re-expansion.

Introduction

Chronic maxillary atelectasis (CMA) is a rare acquired condition of persistent and progressive reduction in maxillary sinus volume and antral wall collapse secondary to ostiomeatal obstruction and development of negative intra-sinus pressure gradients.

Case presentation

A 32-year old male was referred with a 6 week history of persistent and worsening sinonasal symptoms, following a significant upper respiratory tract infection. Imaging confirmed bilateral stage I CMA and successful treatment entailed bilateral endoscopic uncinectomy and maxillary antrostomy.

Discussion

Review of the literature has demonstrated CMA to describe an all-encompassing disease process of ostiomeatal obstruction and atelectatic maxillary sinus remodelling that overcomes early variations in taxonomy (‘silent sinus syndrome’, ‘imploding antrum syndrome’, ‘acquired maxillary sinus hypoplasia’) and inconsistencies in reporting. Unilateral CMA is well documented, however a systematic search of the literature reveals only six bilateral cases. To the best of our knowledge, this is the first individual report of bilateral stage I CMA in which the inciting event is established and a uniquely rapid progress of disease followed.

Conclusion

The present literature regarding CMA is incomplete and further investigation is required to provide greater insight into its aetiology and pathogenesis. Minimally invasive endoscopic approaches can be employed to re-establish aeration to the affected maxillary sinus for symptomatic relief, to halt disease progression and facilitate antral remodelling and sinus re-expansion.

Is there a correlation between the clinical findings and the radiological findings in chronic maxillary sinus atelectasis?

OBJECTIVE

Silent sinus syndrome (SSS) is a clinical syndrome that occurs as a result of chronic maxillary sinus atelectasis (CMA) and is seen with progressive enophthalmos and hypoglobus. The aim of this study was to investigate the correlation between radiological findings and clinical findings in patients with radiologically asymmetrical reduced maxillary sinus volume.

MATERIAL AND METHOD

A comparison was made of patients with CMA through evaluation of paranasal sinus computed tomography, magnetic resonance imaging examination of maxillary sinus volume of the CMA side and the contralateral side, thickness of the retroantral fat tissue, infraorbital bone curve, uncinate process lateralisation measurement, middle concha diameter, and calculation of the change in location of the inferior rectus muscle.

RESULTS

The study included 16 patients. Although a statistically significant difference was determined between the healthy and the pathological sides in respect to maxillary sinus volume, thickness of the retroantral fat tissue, infraorbital bone curve, uncinate process lateralisation measurement, and middle concha diameter (p = 0.00, p = 0.002, p = 0.020, p = 0.020, p = 0.007), no significant difference was determined in respect to the change in location of the inferior rectus muscle (p = 0.154). A positive correlation was determined between the increase in sulcus depth and maxillary sinus volume and inferior orbital bone curve (p < 0.05).

CONCLUSION

In CMA patients suspected of having SSS, radiological maxillary sinus volume analysis, determination of retroantral fat thickness, measurement of the infraorbital bone curve, and measurement of the uncinate process lateralisation can be used as objective tests. However, it should be kept in mind that radiological findings may not always be compatible with the ophthalmological examination findings.