Onodi sinusitis presenting with orbital apex syndrome

Orbital Decompression: Conceptual Approach for Orbital Volume Expansion

PURPOSE

To review the advances in the surgical techniques of orbital decompression.

METHODS

A literature review of orbital decompression surgery and experience-based consideration of bony areas for decompression.

RESULTS

In the 100-year-plus span of orbital decompression literature, multiple incisions and multiple bone and fat removal strategies have been described. In general, bone removal has been conceptualized as consisting of 4 walls of the orbit. However, the orbital bony anatomy is more subtle than a simple box, and considering 6 areas of potential bony removal allows a more nuanced paradigm for clinical decision-making and for understanding various technique descriptions. Historical and current techniques, and surgical planning and decision-making, are described from the perspective of a 6 area paradigm. Potential complications are reviewed.

CONCLUSION

A conceptual framework for orbital decompression focusing on 6 potential areas of bone removal provides a nuanced and flexible paradigm for understanding and describing surgical techniques, and for designing individualized surgery. Orbital decompression surgery should be customized to the patient's anatomy and symptoms.

CT analysis of predictors for visual acuity in optic neuropathy with mucocele

OBJECTIVE

To evaluate the causative and risk factors for optic neuropathy with mucocele via imaging studies.

METHODS

We included 21 patients with rhinogenous optic neuropathy with mucocele. We collected data on the sinus involved, age, sex, number of days from the onset of visual impairment to surgery, and computed tomography (CT) imaging findings (bone defects in the lamina papyracea, Onodi cell mucocele, exophthalmos, and optic nerve deviation). The results were compared between two groups, the one having nine patients with pre-operative visual acuity of <0.1 (the poor group) and the other having 12 patients with pre-operative visual acuity of ≥0.1 (the fair group). Whether or not there was a difference in pre-operative visual acuity between patients with and without Onodi cell mucocele was determined.

RESULTS

After surgery, visual acuity improved in 16/21 (76.2%) patients, and a correlation analysis showed a significant positive correlation between pre-operative and post-operative visual acuity. In imaging, the causative sinuses accounted for 85.7% of both posterior ethmoid and sphenoid sinuses. Bone defects of the lamina papyracea at the optic canal and the vertical downward deviation of the optic nerve at each location, especially in 6/9 patients with Onodi cell mucocele, were characteristic in the poor group. In these conditions, increasing the contact areas of the optic nerve and mucocele can leads to more chances of direct downward compression of the optic nerve and infection occurring, and it may lead to severe pre-operative visual impairment.

CONCLUSION

Imaging studies of optic neuropathy with mucocele help to determine the risk factors and perform early and precise diagnostic imaging and decision-making for surgery.

Optic neuropathy related to Onodi cell mucocele: a systematic review and meta-analysis of randomized controlled trials

<abstract><sec> <title>Background</title> <p>Onodi cells (OC) are important for rhinologists because they contain the optic canal, and are close to the optic nerve and internal carotid artery. Therefore, any pathologic processes within OCs, including infectious or inflammatory sinusitis, fungus ball, inverted papilloma, mucocele, or sino-nasal malignancy can cause devastating ophthalmologic complications. We aimed to define the different optic neuropathy conditions related to isolated OC mucoceles, determine the different symptoms of each condition and its risk factors, and explore the efficacy of the relevant diagnostic tools and treatment strategies.</p> </sec><sec> <title>Methodology</title> <p>A comprehensive electronic search with time and language restrictions was conducted. Several known databases were included: PubMed, The Cochrane Library, and Web of Science from 1990 to 2020. We combined the search terms and limited the study to the English language. We removed duplicates, and the articles were screened based on title, abstract, and full text according to the PRISMA checklist.</p> </sec><sec> <title>Results</title> <p>The electronic search strategy conducted in this review resulted in 409 hits. After removing duplicate studies and studies with inadequate information, 20 case studies were finally included in this analysis, 65% of which presented men (n = 13), and seven presented women (35%). The mean age reported in these studies was 54.75 with a standard deviation of 14.62 years. We found that visual disturbances that can lead to visual loss were present in most cases (75% of cases). Other symptoms included headache (35%) and eye pain (30%). The risk factors for developing optic neuropathy conditions related to OC mucoceles include being Asian and elderly with a history of either nasal or eye conditions. Our findings showed that the mean time between the onset of symptoms and intervention was 16.8 ± 21.8 days. Most patients underwent endoscopic sinus surgery to remove the OC mucocele (18/20; 90%) with a success rate of 77%. Pharmacologic intervention as a solo treatment (IV corticosteroids or /and antibiotic) was used in only six patients, with a success rate of only 33%. Computed tomography (CT) and magnetic resonance imaging (MRI) is the most commonly used diagnostic tools, with diagnostic success rates of 40% and 82.3%, respectively.</p> </sec><sec> <title>Conclusion</title> <p>Optic neuropathy conditions related to OC mucoceles are very rare. However, a higher incidence of these conditions was observed in elderly Asian patients with a history of nasal or optic conditions. Visual disturbances are the most common symptoms accompanying any type of eye condition. Endoscopic sinus surgery is considered an effective and safe intervention for these patients, and the period between the onset of symptoms and surgery does not affect the outcomes of the surgery. Furthermore, treatment with corticosteroids and/or antibiotics cannot replace surgery and it can also worsen the condition. Moreover, MRI is superior to CT scans for demonstrating this abnormality, and both are superior to other diagnostic tools. Finally, further investigations should be conducted to study the causes of the low incidence of these conditions in the eastern region.</p> </sec></abstract>

A 16-Year Study on Incidence and Progression of Diseased Sphenoethmoidal (Onodi) Cell

Traumatic operative injury of the optic nerve in an endoscopic sinus surgery may cause immediate or delayed blindness. It should be cautioned when operating in a sphenoethmoidal cell, or known as Onodi cell, with contact or bulge of the optic canal. It remains unclear how frequent progression to visual loss occurs and how long it progresses to visual loss because of a diseased sphenoethmoidal cell. Research to discuss these questions is expected to help decision making to treat diseased sphenoethmoidal cells. From July 2001 to June 2017, 216 patients received conservative endoscopic sinus surgery without opening a diseased sphenoethmoidal cell. We used their computed tomography images of paranasal sinuses to identify diseased sphenoethmoidal cells that could be associated with progression to visual loss. Among the 216 patients, 52.3% had at least one sphenoethmoidal cell, and 14.8% developed at least one diseased sphenoethmoidal cell. One patient developed acute visual loss 4412 days after the first computed tomography. Our results show that over half of the patients have a sphenoethmoidal cell but suggest a rare incidence of a diseased sphenoethmoidal cell progressing to visual loss during the follow-up period.

Onodi Cell Mucocele-Associated Optic Neuropathy: A Rare Case Report and Review of the Literature

Purpose

To present a rare case report of Onodi cell-associated optic neuropathy, conducting a review of the literature.

Methods

A 36-year-old male presented with an 18-h history of acute deterioration of vision in his left eye (LE). Ophthalmic examination and Magnetic Resonance Imaging (MRI) were consistent with an Onodi cell-associated compressive optic neuropathy.

Results

Despite immediate, successful surgical decompression, severe optic nerve atrophy and permanent visual loss occurred during early postoperative period. The reported case gives rise to different hypotheses regarding pathophysiology that may lead to irreversible blindness. A systematic review of the respective literature is provided attempting to compare different approaches in the management of Onodi cell-associated compressive optic neuropathy and assess their efficacy in the final visual outcome. Poor initial visual acuity (VA) may represent a bad prognostic factor. Moreover, age and gender do not seem to significantly influence the outcome.

Conclusion

This report and associated literature review highlight the importance of the radiologic characteristics and early diagnosis in the final visual outcome of the Onodi cell-associated optic neuropathy. High level of suspicion is crucial for early diagnosis of mucoceles, which must be treated promptly by surgical and medical means to enhance visual recovery.

Is there a relationship between Onodi cell and optic canal?

OBJECTIVES

We investigated the relationship between Onodi cells and optic canal by paranasal sinus computed tomography (PNSCT).

METHODS

In this retrospective study, 508 PNSCT (265 males and 243 females) was examined. Onodi cell presence, pneumatization types, optic canal types; and also sphenoid sinusitis and anterior clinoid process pneumatization were evaluated.

RESULTS

The prevalence of Onodi cells was 21.2% of the patients. Onodi cells were observed 40.7% on the right side and 25.9% on the left side. In 33.4% of the patients, bilateral Onodi cells were present. Male/Female ratio was 24.5%/17.6%. Onodi cell types were detected as Type I > Type II > Type III bilaterally. There was a positive correlation between the right and left Onodi cell types (p < 0.05). Optic canal types were detected as Type IV > Type I > Type II > Type III. bilaterally. There was a positive correlation between right and left optic canal types. Onodi cell presence and ACP pneumatization were found as statistically significant (p < 0.05). In 65.5% of the patients, Onodi cells and ACP pneumatization were absent. ACP pneumatization was present in 35.4% of the cases. In nine cases, bilateral Onodi cells and ACP pneumatization were detected. Sphenoid sinusitis was detected in 11.4% of Type I and 13.8% of the Type II Onodi cells on the right side. On the left side, it was detected in 12.9% of the Type I and 19.0% of Type II Onodi cells.

CONCLUSION

Identification of Onodi cell is very important clinically because of its proximity to optic nerve canal. We concluded that type IV Onodi-optic canal relationship was the most common finding in our study. Onodi cell presence and their patterns of pneumatization must be evaluated on PNSCT preoperatively to avoid optic canal damage.

Orbital decompression for thyroid eye disease

The literature regarding orbital decompression for thyroid eye disease is vast, spanning multiple specialty areas including neurosurgery, head and neck, maxillofacial, and ophthalmic plastic surgery. Although techniques have advanced considerably over the more than 100 years during which this procedure has been performed, the 4 major approaches remain: transorbital, transcranial, transantral, and transnasal. The explosion in literature related to orbital decompression has mostly involved minor technical variations on broader surgical themes. The purpose of this review is to organize the major approaches in terms of bony anatomy and to contextualize variation in transdisciplinary techniques within a common conceptualization.

The role of Onodi cells in sphenoiditis: results of multiplanar reconstruction of computed tomography scanning

Introduction

Onodi cells are the most posterior ethmoid air cells and extend superolateral to the sphenoid sinus. These cells are also intimately related with the sphenoid sinus, optic nerve, and carotid artery. Radiologic evaluation is mandatory to assess for anatomic variations before any treatment modalities related to the sphenoid sinus.

Objective

To evaluate the effect of Onodi cells on the frequency of sphenoiditis.

Methods

A retrospective analysis was performed in 618 adult patients who underwent high-resolution computed tomography between January 2013 and January 2015. The prevalence of Onodi cells and sphenoiditis was evaluated. Whether the presence of Onodi cells leads to an increase in the prevalence of sphenoiditis was investigated.

Results

Onodi cell positivity was observed in 326 of 618 patients and its prevalence was found to be 52.7%. In the study group, 60.3% (n = 73) were ipsilaterally (n = 21) or bilaterally (n = 52) Onodi-positive, whereas 39.7% (n = 48) were Onodi-negative (n = 35) or only contralaterally Onodi-positive (n = 13). Of the control group, 48.3% (n = 240) were Onodi-positive and 51.7% (n = 257) were Onodi negative. The co-existence of Onodi cells ipsilaterally was observed to increase the identification of sphenoiditis 1.5-fold, and this finding was statistically significant (p < 0.05).

Conclusion

The prevalence of sphenoiditis appears to be higher in patients with Onodi cells. However, it is not possible to state that Onodi cells are the single factor that causes this disease. Further studies are needed to investigate contributing factors related to sphenoiditis.

Visual loss in patients with sphenoethmoidal cells

BACKGROUND

A sphenoethmoidal cell is a posterior ethmoid cell that pneumatises superiorly and/or laterally to the sphenoid sinus. Disease within such a cell may cause visual symptoms because of the close relationship of the optic nerve.

CASE REPORTS

This paper reports four cases of chronic rhinosinusitis involving a sphenoethmoidal cell, two with visual loss. The management of such cases is discussed and the current literature is reviewed.

CONCLUSION

Pathology within a sphenoethmoidal cell must be considered in cases of optic neuropathy. The presence of these cells may be relevant even in cases of seemingly uncomplicated rhinosinusitis as they are associated with a higher rate of optic nerve protrusion and dehiscence.

Blinding Orbital Apex Syndrome due to Onodi Cell Mucocele

The onodi cell is a posterior ethmoidal cell that is pneumatized laterally or superiorly to the sphenoid sinus with close proximity to the optic nerve. A mucocele, a benign, expansile, cyst-like lesion of the paranasal sinuses, may uncommonly involve the onodi cell causing compression of the optic nerve and nearby structures. In this paper, we report a rare case of onodi cell mucocele causing orbital apex syndrome, with prompt recovery after endoscopic removal. However, optic neuropathy did not improve and the patient remained blind.

The central Onodi cell: A previously unreported anatomic variation

Preoperative recognition of the Onodi cell is necessary to avoid injury to closely associated structures, including the internal carotid artery and the optic nerve. This article describes the central Onodi cell, a variation in which a posterior ethmoid cell lies superior to the sphenoid sinus in a midline position with at least one optic canal bulge. To our knowledge, this anatomic variation has not been previously reported in the literature. Radiographic and endoscopic imaging of this unique variation is provided.

Optıc neuropathy secondary to inflammation of sphenoidal sinuses and Onodi cell polyps: a case report

An inflammation or injury to optic nerve anywhere its pathway by extrinsic lesions causes the optic neuropathy. These lesions are more effective in confined spaces like optic canal, orbital apex. We present a 61 year old woman with optic neuropathy due to lesion in an Onodi cell. In this case patient presented with progressive loss of vision in her right eye within a few days. Computed tomography (CT) revealed mucosal thickening and inflammatory signs in right sphenoid sinus and presence of Onodi cell in that side. Magnetic Resonance Imaging confirmed compression to the optic nevre. Systemic antibioterapy and endoscopic sinus surgery was performed. Postoperatively, the visual acuity and control CT views were better than initial findings. Histopathologic evaluation revealed polyps in Onodi cell. Ophthalmologists should be aware of the Onodi cell pathologies that caused compressive optic neuropathy.