|Year : 1971 | Volume
| Issue : 1 | Page : 18-23
Uncommon sinus lesions as a cause of proptosis
Hari Mohan, DK Sen
Department of Ophthalmology, Irwin Hospital, New Delhi, India
Department of Ophthalmology, Irwin Hospital, New Delhi
|How to cite this article:|
Mohan H, Sen D K. Uncommon sinus lesions as a cause of proptosis. Indian J Ophthalmol 1971;19:18-23
Two thirds of the wall of the orbit consists of thin bony plates of the paranasal sinuses. Any lesion in them is likely to affect the orbit and at times cause displacement of the globe by decreasing orbital volume. However, there is a tendency for the clinical importance of this fact to get lost sight of in recent years. The purpose of this paper is to reemphasis the importance of rhinological examination and sinus radiology as one of the preliminary investigations in all cases of proptosis so that proper diagnosis could be made early and effective treatment instituted in time.
The common sinus lesions to invade the orbit in this country are malignant neoplasms (Mohan, Sen and Gupta  ). The present report concerns our experiences in diagnosing and managing other sinus lesions seen over a period of six years. Management was undertaken in co-operation with rhinologists.
| Present Study|| |
Only those patients having a proptosis of 3 mm. or more as measured by Hertel's reflecting exophthalmometer were taken up for study. Diagnosis was based on complete clinical work-up, X-ray examination, surgical exploration when indicated and histopathological examination of the tissues removed.
Out of a total of 2,79,726 cases examined in the eye out-patient department over a period of six years, 138 cases were of proptosis. In 1/3 of them (46 cases constituting 33.3%) it was due to a lesion in the paranasal sinuses. The break-up of the uncommon lesions is given in [Table - 1]. Maximum number of cases were of mucocele and pyocele (5) followed by pseudo-tumours (3). A brief account of the lesions are given below with short comments along with.
| Mucocele and Pyocele|| |
There were 5 cases in this series. Of them only one was female. Their age ranged from 16-50 years. All of them were of long duration and limited to the fronto ethmoidal sinuses. Of the mucoceles, in one it grew so big as to cause marked displacement of the globe and complete pressure atrophy of the optic nerve head (Mohan and Sen  ). In two cases the globular swelling in the upper-inner quadrant of the orbital margin was felt soft and fluctuant with egg-shell crackling in the periphery. The pyocele case reported with all the features of an acute inflammation. There was oedema of upper lid, chemosis and proptosis. Rhinological examinations were normal in 3 cases; rest showed enlarged ethmoidal bullar cells pressed tightly against the middle turbinate. Radiograph of the paranasal sinuses showed marked general expansion of the affected sinus [Figure - 1] in all the cases.
The cases were referred to the E. N. T. Surgeon for management. Acute inflammation in the pyocele case was controlled with broad-spectrum antibiotics and after 6 weeks an external fronto-ethmoidal operation was done. Mucocele cases were directly treated by the same surgical procedure. The over all results were good in all the cases. However, in two cases the proptosis was not corrected fully.
| Pseudotumours|| |
In all the 3 cases the degree of proptosis ranged from 8-11 mm. Displacement of the globe was forwards in one and forwards and lateralwards in two cases. All of them were associated with chronic sinusitis with gross changes as revealed by skiagraphy. Detailed investigations revealed no other factor which could be linked up etiologically with the orbital pathology. Orbit was opened up in two cases by Kronlein's procedure. Histopathological examination of the tissue removed. revealed chronic inflammatory granuloma [Figure - 2]. It was decided to treat the chronic sinusitis surgically in all the cases and put them on heavy doses of tetracycline systemically. Two cases were cured and there was remarkable improvement in the third. A 2year-follow up revealed no recurrence.
Moro  suggested that there are two main types of orbital pseudotumours: One in which the granulomatous reaction dominates the histological picture and one in which there is a benign lymphocytic reaction. Two of our cases belong to the first group.
Chronic hypertrophic and/or hyperplastic changes in the ethmoid lead on to polypoid formation which may invade the orbit by causing pressure atrophy of the lamina papyracia. Such an occurrence is rather uncommon. There were only two cases. The eye was pushed forwards and outwards [Figure - 3]. Proptosis was between 6-8 mm. A firm mass beneath the supraorbital ridge on the medial side was felt. On rhinological examination there was evidence of chronic ethmoiditis with polypi formation in the middle meatus. Skiagraphy showed displacement of the uppermedial orbital wall. The sinuses were hazy. On exposure through an external curvilinear incision the bony structure of the ethmoid labyrinth was found to be grossly distorted; it had been replaced by cystic spaces and necrotic polypoid tissue. Exenteration of the diseased tissue was all that was required to yield a satisfactory result.
Though the lesion is not so infrequent it is not yet reported to be so expansive as to cause proptosis. Our case, a 60-year-old male, was in the nodular stage. He reported with the complaint of nasal block on the right side and forward protrusion of the right eye. Rhinological examination revealed bluish-red masses of rubbery consistency filling the nasal fossa which was so distended as to cause fulness at the naso-orbital angle and forward and lateral displacement of the globe, the former by 6 mm. There was a discharging sinus on the outer aspect of the nose [Figure - 4] which is again a very rare sequence. Diagnosis was confirmed by biopsy and the patient was referred to E. N. T. Surgeon for management, who on finding backward extension of the lesion to the nasopharynx and soft palate decided to put him first on radiotherapy and a full systemic course of tetracycline. He felt better and was discharged from the hospital with the advice to report after 6 weeks for surgery but he failed to turn up.
Xanthogranuloma of maxillary Sinus
Xanthogranulomas are so rare as to excite curiosity. The etiopathogenesis is not known but the underlying cause is believed to be an unknown infectious agent (Reese  ). In the present case, a forty-year-old female the lesion was primarily in the left maxillary sinus and the involvement of the left orbit was due to pressure atrophy of the roof of the sinus. The left eye ball was displaced upwards, outwards and forwards the latter by 8 mm. Skiagraphy revealed very hazy left maxillary antrum and the orbit was opened up by combined Caldwell-Luc and Kronlein's procedures. Major portion of the granuloma was removed. On histopathological examination the lesion was essentially granulomatous. Presence of numerous fat-laden histiocytes ("foam cells") was the dominant feature. Besides, there were diffuse as well as localised collections of chronic inflammatory cells and varying amount of fibrous tissue. There was no necrosis and the lesion was negative for acid-fast-bacillus and fungus. As the surgical_ removal was incomplete, the patient was put on radiotherapy. The end result of the combined therapy was very good. A 3-year-follow-up revealed no recurrence of the lesion.
Although the incidence of fungus infections of the eye is on the increase due to indiscriminate use of antibiotics and corticosteriods, fungal infections of the orbit continue to be rare. We came across only one case which was reported in detail earlier (Mohan Sen and Gupta  ). The lesion was primarily in the maxillary sinus and invaded the orbit through its roof.
Fracture of paransal air sinuses may be associated with development of surgical emphysema, particularly when the patient attempts at forcibly blowing the nose with the nostrils partially pinched with a view to clearing it. In our two cases due to fracture of ethmoid no special management was necessary excepting control of infection by systemic antibiotics and avoidance of blowing the nose. In the third case which was due to fracture of frontal bone involving the sinus there was displacement of the fractured segment as revealed by skiagraphy. Surgical exposure and reduction of the fractured segment was, therefore, carried out under general anaesthesia. Patient recovered completely with good realignment.
| Summary|| |
A brief account of 16 uncommon lesions of the paranasal air sinuses causing unilateral proptosis with their line of management is given. Maximum number of cases were of mucocele and pyocele of the sinuses (5) followed by pseudo-tumours of the orbit probably as a complication of chronic sinusitis (3). Diagnosis was based on complete clinical work-up, X-ray examinations, surgical exploration when indicated and histopathological examination of the tissues removed. The importance of rhinological examination and skiagraphy of the paranasal sinuses as one of the preliminary investigative procedures in all cases of proptosis is emphasised.
| References|| |
|1.||MOHAN H., SEN D. K. and GUPTA D. K.: Orbital affection in nasal and paranasal neoplasms. Acta. Ophthalmologica, 47, 289 (1969). |
|2.||MOHAN H., and SEN D. K.: Frontoethmoidal mucocele or pyocele. Orient. Arch. Ophthal, 8, 44 (1970). |
|3.||MORO F. (0phthalmologica (Basel), 151, 349 (1960). |
|4.||REESE A. B.: Tumours of the Eye, ed. 2 p. 544. Hoeber, New York, (1963). |
|5.||SEN D. K., MOHAN H. & GUPTA D. K.: Fungal granuloma of the orbit. Orient, Arch. Ophthal 7, 106 (1969). |
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
[Table - 1]