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Objective: Infected mucocele of the paranasal sinuses can induce orbital infection, including orbital subperiosteal abscess, which may lead to life-threatening intracranial complications. Effective diagnosis is important, and treatment should be aggressive. This paper presents our experiences in endoscopic surgical management of orbital complications secondary to infected paranasal sinus mucoceles., Methods: From our retrospective review of the medical charts for 82 patients with 92 sides diagnosed with paranasal sinus mucoceles, we present 7 sides in 7 adult patients with orbital complications secondary to infected mucoceles. The collected data include the suggested etiology, side of sinus involvement, localization of abscess in the orbit, orbital wall bone defects caused by mucocele compression, ophthalmic symptoms, duration between symptom onset and initial visit, operation date, type of surgery performed, and follow-up., Results: The mucocele was located in the ethmoid-frontal region in 9.8% of the sides (9/92), in the frontal sinus in 7.6% (7/92), in the ethmoidal sinus in 9.8% (9/92), in the maxillary sinus in 67.4% (62/92), in the maxillary-ethmoidal sinus in 3.3% (3/92), and in the sphenoid sinus in 2.2% (2/92). The patients with ethmoid-frontal mucoceles had a significantly higher incidence of orbital complications (6/9) as compared with the other sub-types of mucoceles (frontal, 0/7; ethmoidal, 0/9; maxillary, 1/62; maxillary-ethmoidal, 0/3; sphenoid, 0/2). Chandler's classification showed Type I in one, Type II in three, and Type III in three. Sinus involvement was observed at the ethmoid-frontal sinuses in six cases and the maxillary sinus in one case. All seven cases had a partial defect of the orbital wall bone (lamina papyracea, or inferior orbital wall bone) by mucocele compression, and the patients underwent endoscopic marsupialization. For the cases with subperiosteal abscess, the lamina papyracea was also removed partially for draining the abscess. In all cases, symptoms were resolved without any recurrence of the mucocele., Conclusions: Infected ethmoid-frontal mucoceles with a defect of the lamina papyracea tend to induce orbital infection, so prompt surgery for the infected mucoceles should be considered early even with Types I and II, before visual acuity is impaired, because surgery is the only curative treatment for the mucoceles., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest., (Copyright © 2020. Published by Elsevier B.V.)

The authors present their experience about clinical evidences that include patients with an untreated diabetes who developed rhino-orbito-cerebral mucormycosis (ROCM). They were treated with endoscopic sinus surgery and medical treatment with intravenous, intradural therapy, and sinus washes with amphotericin B. The ROCM is a disease with a rapid evolution and an increase in mortality rate, especially if the fungus enters the cranial cavity. Therefore, it would be necessary in all diabetic patients with sinus symptoms, headaches, visual changes, suspect a mucormycosis, and perform a careful radiology assessment and a nasal endoscopy. Often, despite an early diagnosis and rapid treatment for ROCM, it is not possible to stem the disease, which ends with the patient's death.

Background: Sino-orbital fistulas (SOF) are a well-reported complication of orbitalexenteration and sinonasal carcinoma resection. Despite repair, however, complete fistula closure may be difficult., Case: A 79 -years-old man had undergone total exenteration of right orbit for spreading sqamous cell carcinoma of conjunctiva. Subsequently he developed two large sinoorbitalfistulae medially to the ethmoid sinus wall of the orbit. Post- operatively good socket hygiene was maintained but the fistulae increased in size. At 3 month follow-up, closure of the fistulae using glabellar rotation advancement flap was done. The defects have remained closed at follow-up with excellent cosmetic results. There is no recurrence of fistula or malignancy till date. Patient was cosmetically rehabilitated with spectacle prosthesis., Conclusion: Glabellar rotation flap for closure of medially situated sino- orbital fistulae is a good option with excellent cosmetic result., (© NEPjOPH.)

Orbital surgeons are quite familiar with the diagnosis and management of paranasal sinus mucoceles due their frequent involvement of the orbit. These benign masses form and expand following sinus outflow obstruction secondary to various causes including trauma, inflammation and malignancy, amongst others. The authors present two cases of isolated orbital mucoceles without associated sinus outflow obstruction. There were notably no connections between the paranasal sinuses and the lesions. The mucoceles were diagnosed following orbitotomies and excisional biopsies with confirmatory histopathology. These rare orbital lesions should be considered when evaluating cystic orbital lesions, and the orbital surgeon should be familiar with the proposed pathophysiology and treatment recommendations.

Background: Cholesterol granuloma (CG) is a foreign body reaction to crystallized cholesterol. Orbitofrontal CG is a rare entity with few cases reported in literature. It is usually seen in young to middle-aged males with a history of trauma. Computed tomography features include hypodense lesion-causing bone erosion. CG has typical histopathological features with cholesterol clefts, multinucleated giant cells, histiocytes, foamy macrophages, and altered blood pigments. Management is by total excision of the lesion with curettage of the underlying bone to prevent recurrence., Material & Method: We present an interventional case series of five patients of orbitofrontal CG, two of them females., Result: None of the patients gave a history of trauma. Management was by excision of the lesion and curettage confirmed with a 30° rigid endoscope., Conclusion: Cholesterol granulomas can present as superior orbital mass lesions in the absence of trauma.

Objective: Invasive sino-orbital fungal infections are life-threatening complications of immunonosupression that are difficult to treat. Currently there are no standard treatment guidelines. The most widely accepted therapy includes parenteral anti-fungal therapy and surgical debridement of sinuses with orbital exenteration, a procedure that is not only disfiguring, but may increase morbidity. Injection of retrobulbar Liposomal Amphotericin B (L-AMB) is an alternative approach that provides local administration to infected tissues. The adjunct use of anti-fungal retrobulbar injections not been extensively reviewed in treating sino-orbital infection. We are reporting the multimodal approach of using L-AMB retrobulbar injections in combination with sinus debridement, intravenous (IV) anti-fungal therapy, and hyperbaric oxygen (HBO) for the management of sino-orbital infection., Method & Results: Review of literature of 12 cases and retrospective evaluation of one patient with sino-orbital Aspergillus flavus infection on chemotherapy for T-cell acute lymphocytic leukemia treated with retrobulbar Amphotericin B, IV anti-fungal agents, and hyperbaric oxygen therapy. Clinical characteristics, radiographic features, management techniques, and clinical outcomes are described., Conclusion: Retrobulbar Amphotericin B injection may be an effective adjunct to hyperbaric oxygen and parenteral anti-fungals in the control of sino-orbital fungal infections.

Objective: The aim of the study was to review the use and outcomes of image-guided sinus surgery (IGSS) in sinonasal pathologies with skull base/orbital erosion without intracranial or intraorbital extension., Method: A retrospective charts and medical records review was performed for 474 consecutive sinonasal surgeries performed by a single surgeon at tertiary, academic center from August 2010 to December 2013., Result: Fourteen subjects (mean age 27 years; 8 men and 6 women) were identified. Mucocele and tumor were the most common pathological indication for IGSS use in this case series. Orbital wall erosion was detected in 57%, skull base in 29%, and both sites in 14%. The average blood loss was 80  mL, the average operative time was 190 minutes, and the average hospital stay was 3 days. There was no major intra- or postoperative complications. Two patients required revision endoscopic sinus surgery. The mean follow-up was 14 months (range 8-36 months)., Conclusion: Image-guided sinus surgery alone is safe and effective procedure for a variety of sinonasal pathologies with orbital and skull base erosion.

Introduction: The silent sinus syndrome (SSS) is a rare clinical entity in both ENT and ophthalmology. It is characterized by enophthalmos and ptosis associated with a reduction in pressure in the maxillary sinus caused by chronic hypoventilation. The objective of this study was to demonstrate the importance of maxillary hypoplasia whether congenital or acquired in this disease, and the use of Medpor implant for reconstruction of the orbital floor., Material and Methods: We report 3 cases of silent sinus syndrome proved clinically and radiologically. The first is a 45 year old male patient complaining of enophthalmos which occurred gradually, without any medical history; the second case is that of a woman of 39 years with a gradual onset enophthalmos, with a history of sinusitis; the third case, a man of 25 years who had a history of nasal trauma and consults for enophthalmos and diplopia., Results: Endoscopic surgery is performed quickly allowing a disappearance of enophthalmos and diplopia. All patients underwent a reconstruction of the orbital floor with a Medpor implant fixed by miniplates without complications.

Purpose: To highlight a rare case of hidradenitis suppurativa affecting the periorbital skin in which chronic nodules resulted in a sinus tract connecting the lacrimal sac and ethmoidal sinus., Methods: A single interventional case note review with clinical history, examination, results of investigations and details of medical and surgical management., Results: The patient showed no response to antibiotics and steroids. One attempt at local drainage was unsuccessful. MRI showed a defined ring enhancing lesion anterior to the orbital septum overlying the medial canthus. Surgical exploration revealed a cutaneous fistula which tracked through the left orbicularis oculi into the medial canthal tendon and into the left lacrimal sac. A further fistula connected the lacrimal sac to adjacent structures and the lacrimal bone was found to be eroded., Conclusions: Hidradenitis suppurativa is a chronic skin disease which can involve the face. Inflammation, scarring and sinus tract formation are common findings. Periorbital lesions can spread to involve surrounding adnexal structures.

Silent SINUS SYNDROME is a clinical syndrome defined by unilateral maxillary sinus opacification with atelectasis of the uncinate process. Clinically, this disorder is characterized by enophthalmos and hypoglobus. The current case report illustrates dramatic bony remodeling of the maxillary sinus following maxillary antrostomy. Although the remodeling is noted in the posterior wall of the maxillary sinus, this demonstrates the dynamic nature of bone remodeling in silent sinus syndrome, which may obviate the need for surgical correction of enophthalmos and hypoglobus. Following maxillary antrostomy, observation with staged orbital surgery, if required, is recommended., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Fibrous dysplasia (FD) involving the mid-face may be associated with cystic and other secondary changes that make diagnosis more difficult. We present a case of FD associated with a remote history of blunt facial trauma and extensive cystic changes involving the medial orbit and sinuses. An endoscopic exploration revealed "stalagmites" along the floor of the cystic cavity that were consistent with dystrophic calcification. This case was unusual given the degree of dystrophic calcification and the presence of sino-orbital stalagmites within the cystic cavity. Radiologic and pathologic features of the stalagmites are characterized.

Paranasal sinus mucoceles (PSMs) can involve the orbit because the topographic anatomies of the paranasal sinuses and orbit are interrelated. We encountered 27 patients with PSMs involving the orbit that caused orbital symptoms. In this study, we evaluated the frequent symptoms and signs of PSMs involving the orbit, and report postoperative changes of orbital symptoms including the effects on visual acuity. A retrospective chart review, radiologic evaluation, and interviews were conducted after Institutional Review Board approval was obtained. Over the past 11 years, we encountered 27 patients with PSMs involving the orbit. We classified the patients according to orbital symptoms and PSM origin, and evaluated the surgical outcomes. A total of 27 patients (17 males and 10 females) with PSMs involving the orbit were included in the present study. The mean patient age was 51.0 ± 9.7 years (range 32-90) and the mean follow-up period was 20.5 months (range 2-84). Proptosis (15/27, 56%) was the most common symptom. Other common symptoms included orbital pain (9/27, 33%), decreased visual acuity or vision loss (9/27, 33%), and diplopia (7/27, 26%). All symptoms except for vision loss were improved by endoscopic marsupialization regardless of the disease period. Four out of five patients with decreased visual acuity experienced complete recovery. The remaining patient showed partial improvement after surgery. Four patients who were blind when they initially visited the hospital did not show any improvement after surgery. For PSM patients with decreased visual acuity, we can predict that vision will improve after surgery regardless of the disease duration. However, blindness will probably not resolve after endoscopic marsupialization. Even if the orbital symptoms (except for blindness) have persisted for a long time, surgery could still produce positive outcomes.

Background: Immunoglobulin G4 (IgG4)-related sclerosing disease is a systemic disease characterized by extensive IgG4-positive plasma cells and T-lymphocyte infiltration of various organs. We present a case of a 69-year-old man with maxillary sinus IgG4 sclerosing disease, with orbital invasion treated with rituximab and dexamethasone pulse therapy. Surgery was used as well to debulk the disease and to obtain tissue for diagnosis., Methods: A PubMed search using the key phrase "IgG4-related Sclerosing Disease" was performed. There were 304 different articles regarding the disease for a multitude of different organ sites. Of the 304 articles, there were 3 articles that reported this disease in the paranasal sinuses., Conclusions: IgG4-related sclerosing disease is a rare entity in the head and neck. There are documented reports of steroid therapy for this disease, but the patient presented here demonstrated clinical progression of disease with steroids alone. The use of combination therapy of surgery, dexamethasone, and rituximab provided clinical improvement and stable disease determined by radiographic means., (Copyright © 2013 Wiley Periodicals, Inc.)

Maxillary sinus mucocele, known as a rare condition, can cause major therapeutic difficulties, especially when it invades the orbit leading to exophthalmia. Treatment is very difficult because the eye globe has to be repositioned, and the facial symmetry needs to be reconstructed as a result of malar bone invasion. This article reports the case of a 54-year-old patient with unilateral exophthalmia caused by the evolution of a maxillary mucocele that extended toward the orbit after destroying the malar bone and the orbital floor. The treatment consisted of a 1-step restoration of both the orbit floor and the malar bone using a temporomandibular flap composed of 2 bone fragments. Lipostructure and a titanium mesh to reconstruct the calvarial defect were necessary to restore facial aesthetics after placing back the eye globe in its initial site. After surgery, the patient followed a complex rehabilitation program including massage kinesiotherapy and psychological consultation and support. These had an essential contribution to the successful final outcome in terms of psychological impact, functionality, and aesthetics.

The objective of this article is to describe our surgical technique for accessing orbital and supraorbital ethmoid sinus mucoceles and the novel application of a biliary T-tube to stent and redirect mucociliary flow into the frontal recess. We describe in technical terms our surgical approach and the use of an 8-Fr pediatric biliary T-tube as a paranasal sinus stent with demonstrative case reports. Four patients have been successfully managed employing the endoscopic trans(naso)orbital approach to access and marsupialize supraorbital and superiorly located orbital mucoceles without egress to the frontal recess. Patency of drainage was maintained by utilizing a flexible, pediatric, biliary T-tube that is inserted via an above (trephination) and below (endoscopic) approach in three patients, and without the need for stenting in one patient (median follow-up, 14.5 months). The presented surgical strategy is safe and effective in accessing and maintaining long-term patency of problematic supraorbital and superiorly located intraorbital mucoceles without communication to the frontal recess., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Introduction: Paranasal sinuses mucoceles are extremely rare in children and adolescents. The objective of this study was to assess their clinical presentations and the contribution of endoscopic surgery in their management., Material and Methods: we retrospectively reviewed 11 children with paranasal sinus mucoceles who were managed during a period of 15 years (1995-2009)., Results: The mean age was 11.8 years with a sex ratio of 2.66. One patient had a history of nasal polyposis surgery. The symptomatology was dominated by ophthalmological complains. The ethmoïd sinus was the main localization. Orbital extension was found in eight cases, pyomucocele in one case. The surgical management was endoscopic (nine cases), and by an external approach (two cases). Two cases of recurrence were assessed. The mean follow-up was 22.3 months., Discussion: Paranasal sinuses mucocele is exceptional in children. Cystic fibrosis is the main etiologic factor. The symptoms depend on the location and size of the mucocele. The treatment is surgical and most authors prefer the endoscopic approach., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Background: Rhinocerebral mucormycosis (RCM) is a rare, fulminating opportunistic fungal infection caused by a fungus of order Mucorales. These fungi are ubiquitus, subsisting on decaying vegetation and diverse organic material. Although fungi and spores of Mucorales show minimal intrinsic pathogenicity towards normal person, they can initiate aggressive and fulminating infection in immunocompromised host. Since RCM occurs infrequently, it may pose a diagnostic and therapeutic dilemma for those who are not familiar with its clinical presentation., Case Report: We present a patient with classical presentation of RCM involving paranasal sinuses, orbit, and cranial base who was treated by combination of aggressive surgical and medical therapy., Discussion: The purpose of this paper is to draw attention to the clinical presentation and pathogenesis of RCM and to emphasize need for high index of suspicion in diagnosis and treatment.

The purpose of this case series is to characterize the CT and MRI features of pathology-proven inflammatory pseudotumors in the head and neck. Our search identified three orbital, one maxillary sinus, and one skull base inflammatory pseudotumor. All of the lesions demonstrated some degree of infiltrative features on imaging. On CT, all of the orbital inflammatory pseudotumors were of homogeneous soft tissue density. One of the orbital inflammatory pseudotumors demonstrated bone erosion and two others demonstrated stranding of the orbital fat. The maxillary sinus lesion initially appeared aggressive with bone erosion and orbital invasion. Calcifications were identified in the dural inflammatory pseudotumor. Among the lesions that were given contrast during CT or MRI. All exhibited some degree of enhancement. The two pseudotumors that underwent MRI were isointense on T1 and T2, with scattered areas of low signal. The orbital inflammatory pseudotumors underwent orbitotomy. However, the maxillary sinus and skull base lesions regressed with steroid therapy. Inflammatory pseudotumors of the head and neck regions typically manifest as enhancing soft tissue masses associated with infiltrative changes. Despite their sometimes-aggressive appearance, these lesions may respond well to steroid treatment. Imaging plays an important role in diagnosing and following inflammatory pseudotumors., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Introduction: Silent sinus syndrome (SSS) is a rare idiopathic collapse of the maxillary sinus and orbital floor. We present the second largest series of sixteen patients with SSS and describe their management., Methods: A cohort of 16 patients with spontaneous SSS between 1999 and 2009 were reviewed at the Royal National Throat Nose and Ear Hospital. All patients were initially referred from a postgraduate ophthalmic hospital, Moorfields Hospital., Results: Fourteen patients required endoscopic sinus surgery to re-establish maxillary sinus drainage and the remaining two settled with intranasal medical therapy consisting of steroids and decongestions. Follow- up ranged from 6 months to 4 years with a mean of 2.6 years. An improvement in enophthalmos and was seen in all surgically treated patients with a mean improvement of 2.2mm and range 0.5-4mm., Discussion: SSS arises from congestion of the ostiomeatal complex resulting in negative pressure within the maxillary sinus and a gradual implosion of the antral cavity. Endoscopic sinus surgery successfully re-establishes maxillary aeration in our series and leads to clinical and aesthetic improvement in the degree of enophthalmos and has avoided the need for orbital floor repair in all but two cases.

Background and Purpose: Mucocoele of the paranasal sinuses falls within the scope of interest for neurosurgery when erosion of the sinus wall and the osseous structures of the skull base develops and the lesion extends towards the cranial cavity, the orbit, the cavernous sinus or the sella turcica. The pa-per aims to present the method of treatment of extensive mucocoele which is used in our clinic., Material and Methods: We treated 7 patients (2 women and 5 men; age range: 27-68 years). Mucopyocoele was diagnosed in two cases, and mucocoele in the other five. In 5 cases, extension of the mucocoele to the cranial cavity and the orbit or to the ethmoid sinus and the orbit was observed. In the remaining 2 cases, mucopyocoele extended to the ethmoid sinus, the sphenoid and maxillary sinuses, cranial cavity and the orbit. The purpose of surgery was to remove the mucocoele or the mucopyocoele and to prevent recurrence., Results: The postoperative course in all 7 patients was uneventful. All symptoms gradually receded. No relapse was observed in any patient during a follow-up period that varied from 10 months to 8 years; nor did incidents of inflammation of collateral sinuses occur., Conclusions: The treatment of mucocoele or mucopyocoele of the frontal sinus penetrating to the cranial cavity and the orbit consists of the following stages: cranialization of the frontal sinus, complete resection of the mucosa, tight closing of the frontal-nasal duct, and separating the air space of the opened collateral nasal sinuses from the cranial cavity with a large pedicled periosteal flap.

The authors report the case of a 75-year-old man presenting with an exceptionally large giant posttraumatic mucocele of the frontal sinus years after a gunshot blast to the head. The lesion had grown so extensively that the right eye had shrunk and calcified, resulting in total monocular blindness, a complication that has been reported only once. To the best of our knowledge, it is the first time that a giant mucocele of such a large size is reported. We describe how the patient underwent surgical removal of this massive lesion, cranial base reconstruction, and a cosmetic oculoplastic procedure. The etiology, clinical presentation, and possible complications are reviewed, as well as the importance of a regular clinical follow-up and early surgical cure. Although the diagnosis and management of mucoceles are nowadays considered quite standard, the exceptional size of the lesion illustrated here emphasizes the destructive potential of such seemingly indolent lesions. Despite the benign histology of mucoceles, one should never underestimate their morbid potential or be lulled in delaying surgical cure. Large mucoceles should be removed as quickly as possible to prevent such unacceptable complications as permanent visual loss.

Sino-orbital cutaneous fistulas are a well-documented complication of orbital exenteration and sinonasal carcinoma resection. Challenges to successful closure of this common complication include complex anatomy, communication with sinonasal mucosa, persistent mucopurulent drainage, compromised wound healing due to previous irradiation, and wound infection. We describe a novel approach for closure of sino-orbital cutaneous fistulas in two patients using a galeopericranial flap. The galeopericranial flap is ideal due to its thin, pliable nature and predictable, abundant vascularity. Additionally, it obviates the need for a more cosmetically disfiguring closure. Although used successfully in a variety of skull base and ophthalmologic surgeries, the galeopericranial flap has not been previously described for closure of sino-orbital cutaneous fistulas. Both patients' defects have remained closed at follow-up with excellent cosmetic results., (Copyright © 2011 The American Laryngological, Rhinological, and Otological Society, Inc., Rhinological, and Otological Society, Inc.)

Objectives: Access to the medial orbit traditionally has been gained transcutaneously, with potential for associated soft tissue and lacrimal disruption. Endoscopic transnasal approaches to the medial orbit may be limited in certain scenarios by tumor presence or patient-specific factors. The medial transconjunctival approach, or transcaruncular approach, has been recently described for access to the medial orbit in orbital decompression and repair of medial blowout fractures. The aim of this study is to determine the utility of this minimally invasive external approach in the endoscopic management of advanced sino-orbital disease., Methods: This is a cadaver study with additional clinical correlations. The transcaruncular approach was combined with a transnasal endoscopic approach in cadaver dissections performed on eight sides. Five cases are described in which the transcaruncular approach was used as an adjunctive technique in advanced endoscopic sinus surgery., Results: In cadaver dissection, the transcaruncular approach is a simple, reliable method to ligate the ethmoid arteries and place bony cuts along the medial orbital wall. In certain anatomic configurations, supraorbital dissection into the frontal sinus or anterior fossa may be achieved. In the cases examined, exposure of the medial orbital subperiosteal plane allowed for ligation of ethmoid arteries, assessment of periorbital invasion of disease, assistance in tumor dissection, and placement of a malleable retractor for protection of orbital contents., Conclusions: The transcaruncular approach to the medial orbit has certain advantages over the traditional open approach. Ligation of the ethmoid arteries, assessment of the lacrimal sac and periorbita for tumor invasion, protection of orbital contents, and en bloc resection of the periorbita and lamina papyrecea are possible through this route.

Type III frontal recess air cell as a cause of frontal sinus pneumocele has not been previously reported in literature. A 31-year-old woman with chronic history of sinusitis presented with pressure in the left eye on blowing the nose. Computed tomography examination of the orbits and paranasal sinuses with coronal and sagittal reformatted images showed abnormal collection of gas in the soft tissues at the superior aspect of the left orbit contiguous with the overlying left frontal sinus through a large defect in the orbital roof and a type III frontal recess air cell narrowing the left frontal recess., (Published by Elsevier Inc.)

Rhinocerebral mucormycosis is a rare angioinvasive fungal infection that has a strong predilection for patients with poorly controlled diabetes and immunosuppression. Initial presenting symptoms are nonspecific and frequently are attributed to more mundane sinonasal and orbital pathologies. Early diagnosis and treatment are essential for survival and minimizing neurologic sequelae. CT and MR imaging are often used in the diagnostic work-up; however, CT findings are nonspecific.

Purpose: The aim of the study was to report the clinical characteristics, management, and outcome of patients with extensive paranasal sinus mucoceles., Materials and Methods: In a retrospective study, 82 patients with intracranial or intraorbital extension due to paranasal sinus mucoceles who were surgically treated between 1993 and 2007 were studied. In addition, clinical data, presenting symptoms, clinical features, management, and outcome were analyzed., Results: The study population included 42 males and 40 females, with a mean age of 52.7 years (range, 15-87 years). The most common presenting symptoms were ptosis (27/82, 32.9%) and periorbital swelling (24/82, 29.3%). The main radiologic finding on computed tomography scan was bony defect of lamina papyracea and/or medial superior orbital rim. Sixty-six patients underwent endoscopic sinus surgery; among them, 3 patients had recurrence (3/77, 3.9%) during follow-up periods., Conclusion: In our study, a majority of patients with extensive paranasal sinus mucoceles exhibited ophthalmologic symptoms before treatment (81/82, 98.8%). Computed tomography scanning was a feasible tool for preoperative assessment. A satisfactory outcome can be achieved after surgical treatment of endoscopic sinus surgery.

Background: Solitary bone cyst is rarely situated in facial bones., Aim: We discuss clinical view, results of radiological examinations and differential histopathological diagnostics of cases., Results: We present 3 cases of patients: 51 year old man with cyst in frontal sinus; 29 year old man and 46 year old woman--both with changes in bones of the orbit. In all the cases results of histopathological examinations were similar. Cystic-shape pieces of vascularizated connective tissue were observed. Multiple cracks filled with cholesterol, macrophages with hemosiderin and occasionally multinuclear cells were noticed., Conclusions: Solitary bone cyst may be located in the periorbital bone, especially frontal. Excellent laryngological, optic and cosmetic results are results of the surgery. Suspicious of the solitary bone cyst is possible due to MR or CT imaging, but final diagnosis must be confirm by histological examination.

This is a case of an 11-year-old male with an ethmoid sinus mucocele who presented to our emergency department with an orbital mass. This mucocele was most likely related to an ipsilateral orbital subperiosteal abscess that required endoscopic drainage 9 years ago. Mucoceles are mucus-filled, epithelial-lined sacs that slowly develop in the paranasal sinuses when sinus drainage is obstructed by inflammatory processes, trauma, or prior surgery. They are rare in children and should be suspected in patients with progressive headache or orbital complaints.

The silent sinus syndrome consists of painless facial asymmetry characterized by unilateral enophthalmos. Reabsorbed bone with displacement of the orbital floor is a constant finding. It is secondary to chronic maxillary sinus atelectasis. The onset of symptoms is usually slightly progressive but can be brisk due to sudden collapse of the orbital thin bony floor. The diagnosis is suggested by clinical findings including endonasal endoscopic examination and confirmed on the basis of computed tomography and magnetic resonance imaging. The restitution treatment of the silent sinus syndrome involves functional endoscopic sinus surgery and plastic reconstruction of the floor of the orbit via transconjunctival approach; an additional vestibular incision may be necessary to treat the malar region. Four cases of this rare and therefore relatively unknown disease are fully discussed.

Objectives: We report two unusual and contrasting cases of Wegener's granulomatosis involving the orbit, requiring urgent endoscopic orbital decompression surgery., Case Series: Both patients presented with an acute deterioration in visual function which failed to improve with medical management. Case one presented with systemic features of the condition, in contrast with case two, who presented with a more localised form of the disease. Whereas case one exhibited primary orbital disease with maxillary sinus extension (i.e. focal disease), case two illustrates orbital involvement secondary to sinus disease extension (i.e. contiguous disease). Prompt diagnosis, assisted by the presence of systemic features, led to a good visual outcome in case one. In case two, in which diagnosis was difficult and surgery delayed, the outcome was poor., Conclusions: These cases of orbital Wegener's granulomatosis illustrate the diagnostic challenge, the requirement for early intervention following acute visual deterioration and the importance of heightened awareness of the rarer ENT manifestations of this disease.

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.

Purpose: To report the clinico-radiological findings, clinical course, and treatment outcomes in five patients with orbital and adnexal Rosai-Dorfman (R-D) disease., Methods: Analysis of case records of patients with Rosai-Dorfman disease seen at four orbital units between January 2000 and December 2006., Results: Five patients (3 Caucasian males, 1 Hispanic female, and 1 African female), mean age 41.1 years, (range 18 months to 75 years) with orbital or adnexal Rosai-Dorfman disease were seen during the study period. Four of the patients had orbital involvement and one had eyelid involvement. Presenting features were proptosis (4 patients), diplopia (1 patient), epiphora (1 patient), and eyelid thickening (1 patient). Three of the patients with orbital involvement also had adjacent paranasal sinus involvement, and the nasolacrimal duct was involved in one patient. The patient with eyelid involvement had evidence of cutaneous R-D disease elsewhere in the body. The follow-up period (since initial diagnosis of R-D disease) ranged from 1 month to 15 years, and 2 of the patients had a history of recurrent growth despite treatment. Surgical debulking was employed in 2 patients with good results., Conclusions: Orbital and adnexal Rosai-Dorfman disease is a condition with protean manifestations that may show indolent but unremitting growth despite treatment. The disease may remain extranodal and localized for many years. Adjacent paranasal sinus involvement is commonly seen in conjunction with orbital disease, simulating midline destructive lesions. Surgical debulking gives good results in patients with functional or significant cosmetic problems.

Purpose: Sinus mucoceles with orbital extension are often managed primarily by an otolaryngologist to relieve the sinus obstruction. In this study, a series of patients was examined to determine whether or not reconstruction of the orbit was necessary at the time of the initial sinus surgery from the perspective of an orbital surgeon often involved in the comanagement of orbital complications of sinus mucoceles., Methods: A retrospective interventional case series of 5 patients with frontoethmoidal mucoceles comanaged by otolaryngology and oculoplastics. We reviewed symptoms, clinical findings, course, and treatment of our patients and reviewed the literature regarding management options for frontoethmoidal mucoceles., Results: In extended follow-up, clinical resolution of presenting orbital symptoms and radiographic evidence of reformation of the bony orbit was noted without the need for orbital reconstruction at the time of the initial sinus surgery for a sinus mucocele with orbital extension., Conclusions: A specific subset of sinus mucoceles with orbital extension may resolve by primary sinus surgery alone. A decision on the relative merits of orbital surgery at the time of primary sinus surgery should be made on a case-by-case basis.

Wegener's granulomatosis is an idiopathic, granulomatous disease with the potential for multiple head and neck manifestations (80 % of the patients). Sinonasal symptoms are observed in more than 60 % of the patients. Due to these facts the otorhinolaryngologist plays an essential role in the multidisciplinary team involved in establishing the diagnosis early, initiating immunosuppressive therapy and providing ongoing care. The treatment is based on medical therapy consisting of corticosteroids and immunosuppressive agents, whereas surgery is reserved for selected head and neck manifestations. By means of 3 patients presenting with distinct visual loss in consequence of orbital complications with sinonasal origin the course of disease and theoretical background are reviewed. In our patients Wegener's granulomatosis was diagnosed by histopathological examination and serological detection of ANCA, cANCA. The progression of the granulomatous process and an additional purulent inflammation in 2 cases led to a temporary amaurosis and in another case to a visual loss of 50 %. Immediate orbital decompression in combination with sufficient systemic immunosuppressive treatment relieved the compression of the optical nerve and preserved vision. We conclude that early orbital decompression either by external or endonasal approach and concomitant immunosuppression is necessary to determine or improve rapidly decreasing vision subsequent to high intraorbital pressure produced by a granulomatous process and inflammation.

Purpose: To report the incidence, characteristics, and management of sino-orbital fistulas, a complication of orbital exenteration., Design: Retrospective interventional case series., Participants: One hundred ten patients who underwent orbital exenteration at 2 orbital units., Methods: Retrospective chart review of all cases of orbital exenteration between 1993 and 2005 at one orbital unit and between 1999 and 2005 at a second orbital unit., Main Outcome Measures: Incidence of sino-orbital fistulas., Results: Seventy-three and 37 orbital exenterations were performed at the first and second orbital units, respectively. Five patients developed sino-orbital fistulas, 1 of whom developed 2 fistulas at separate sites. In the first unit, 4 fistulas developed in 3 of 73 (4.1%) patients who underwent orbital exenteration. In the second unit, 2 fistulas developed in 2 of 37 (5.4%) exenterated orbits. The majority (5/6) of fistulas occurred medially to the ethmoid sinus, whereas 1 occurred superiorly to the frontal sinus. Risk factors that may have contributed to fistula formation include radiotherapy (3/6), sinus disease (3/6), intraoperative penetration into a sinus (3/6), and immunocompromise (1/6). Management was tailored to the individual case and ranged from conservative socket hygiene to surgical repair with grafts or flaps. Four of the 6 fistulas recurred after repair. Three of these subsequently were closed successfully. Only 1 fistula persisted until the patient died from malignant disease., Conclusions: Sino-orbital fistulas are uncommon but not rare complications of orbital exenteration that may be predicted by several risk factors. Bothersome symptoms may necessitate treatment, which can range from conservative management to surgical repair with various grafts or flaps. Despite repair, fistulas may be difficult to eradicate.

Frontal sinus obliteration is accomplished with many materials such as fat, bone, muscle and alloplasts. Fat obliteration is very common but not devoid of morbidity. An alternative method of treatment with PRP platelet rich plasma and human bank bone or autogenous cortical shavings is presented for obliteration and craniofacial repair. A patient with severe symptomatic fronto-orbital fibrous dysplasia underwent reconstruction with PRP. After an uneventful recovery there was complete remission of the symptoms and early bone formation; 18 months after surgery the patient remains asymptomatic and free from sequels. PRP associated to an allograft or to cortical bone shavings seems to be a safe and simple treatment with the advantage of the absence of donor site surgery and morbidity.

Silent sinus syndrome (SSS) is a rare disease exhibiting unilateral enophthalmos and hypoglobus. A 26-year-old white female presented with right side enophthalmos and hypoglobus. There was no history of previous trauma or maxillary sinus diseases. A CT scan showed an opacified right maxillary antrum with decreased volume and downward bowing of the right orbital floor. From clinical and radiological findings the diagnosis SSS was made. Biopsies were collected from the maxillary sinus for the exclusion of malignancy. Two months later orbital floor reconstruction was carried out. Before antrostomy of the affected maxillary sinus, a relative enophthalmos of 4mm was determined. Five days after antrostomy the value reduced to 2.3mm. During the following 2 months the enophthalmos remained constant. At the end of the operation for orbital floor reconstruction it was 0.1mm. Five days after surgery the relative enophthalmos increased to 0.8mm. The value remained constant during the following 3 months. Initial antrostomy of the affected maxillary sinus may lead to a relevant, spontaneous reduction of enophthalmos. After a minimum period of 2 months a re-evaluation should be made, if a reconstruction of the orbital floor is still necessary for the correction of the globe position.

Glial heterotopia or the occurrence of isolated non-teratomatous extracranial glial tissue is rare. Most of the reported cases of this entity arise in the nose. Herein a rare case of heterotopic glial tissue in the orbit and extranasal region without bony defect is described.

Objective: Studying the method to treat the sinus mucoceles invaded in orbit with marsupialization under nasal endoscope, and determing the long-term efficacy of the endoscopic surgical treatment., Method: Twenty-four patients underwent endoscopic wide marsupialization of the mucocele cavity. The postoperative cleaning were carried out according to ESS routine, the focus on preventing obstruction of sinus ostia and middle meatal adhesions., Result: Follow-up ranged from 1 to 5 years. There is no case of recurrence and orbital complications., Conclusion: Endoscopic approach with marsupialization to the treatment of sinus mucoceles invaded in orbit is associated with no rate of recurrence and no complication, and it is a reliable therapeutic measures. The aim of postoperative cleaning is at preventing obstruction of sinus ostia and middle meatal adhesions. Long time follow-up is needed.

Frontal sinus mucoceles are rare benign neoplasms that can result in bony erosion extending from the borders of the sinus into the orbital cavity. The authors report the fronto-orbital mucoceles they have observed in the last 8 years. The authors used an "open surgery" approach in 12 fronto-orbital mucoceles, characterized by an osteoplastic frontal flap, through a coronal incision or Lynch incision. In this way, they were able to expose the frontal sinus and to remove completely the mucocele from the periorbita. Only one recurrence is reported 2 years after surgery. Excellent aesthetic results have been reached in all cases. In the literature, many different positions are reported for the treatment of mucoceles. The endoscopic surgery of the paranasal sinuses has become the procedure of choice for mucoceles of maxillary, ethmoidal, and sphenoidal sinuses. However, few authors have recommended the endoscopic approach for frontal mucoceles. The indications and limitations of endoscopic and "open" surgery are critically discussed in the light of the authors' personal experience and current literature.

Purpose: To evaluate the results of endoscopic sinus surgery (ESS) for paranasal sinus mucocoele with orbital involvement and assess the frequency with which a direct orbital approach is required in these cases., Methods: Retrospective, consecutive series of sinus mucocoeles with orbital involvement treated by ESS by a single surgeon over a 4-year period (1998-2002)., Results: A total of 24 mucocoeles of 15 patients, including 10 frontal, eight frontoethomoidal, two ethmoidal, and four maxillary. All cases demonstrated radiological orbital extension. Globe displacement was seen in 73%. At a median follow-up of 15.5 months, the mean cumulative clinical score improved from 4.2 +/- 1.5 (range 1-7) to 0.4+/-0.7 (range 0-2). Ophthalmic symptoms and signs resolved in all patients but one who had complex sinus anatomy following neurosurgery. Minor, self-limiting complications including epistaxis and intranasal adhesions occurred in three cases. Additional endoscopic sinus surgery was required in four patients for revision of narrowed frontal sinus ostium (two), mucocoele recurrence (two), and sinus toileting (one). No cases required external sinus surgery and the average hospital in-patient stay was 2.5 +/- 1.6 days. At final follow-up, sinus ostia were patent in all excluding one case that required a stent due to disrupted anatomy., Conclusion: ESS is effective in improving ophthalmic symptoms and signs due to paranasal sinus mucocoele. ESS may be a viable treatment for paranasal sinus mucocoele with orbital extension, and a direct orbital approach is rarely necessary.