- Email: [email protected]
Maxillary sinus posterior wall remodeling following surgery for silent sinus syndrome
Maxillary sinus posterior wall remodeling following surgery for silent sinus syndrome Yoseph Aaron Kram BA, Steven D. Pletcher MD PII: DOI: Reference:
S0196-0709(14)00115-X doi: 10.1016/j.amjoto.2014.05.007 YAJOT 1396
To appear in:
American Journal of Otolaryngology–Head and Neck Medicine and Surgery
Received date: Accepted date:
29 April 2014 12 May 2014
Please cite this article as: Kram Yoseph Aaron, Pletcher Steven D., Maxillary sinus posterior wall remodeling following surgery for silent sinus syndrome, American Journal of Otolaryngology–Head and Neck Medicine and Surgery (2014), doi: 10.1016/j.amjoto.2014.05.007
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Maxillary Sinus Posterior Wall Remodeling Following Surgery for Silent Sinus
T
Syndrome
RI P
Authors: Yoseph Aaron Kram BA1, Steven D. Pletcher MD1 1
Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco
SC
Running Title: Silent Sinus Syndrome
NU
Corresponding author: Steven D. Pletcher, MD
MA
Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco 2233 Post Street 3rd Floor, Box 1225
Phone Number: 415 476-4952
PT
Email: [email protected]
ED
San Francisco, CA 94115
CE
Keywords: Silent Sinus Syndrome, bony remodeling, maxillary antrostomy, maxillary sinus, enophthalmos,
AC
hypoglobus, posterior wall, sinus atelectasis, orbital floor, endoscopic surgery
1
ACCEPTED MANUSCRIPT Abstract: 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
T
current case report illustrates dramatic bony remodeling of the maxillary sinus following maxillary antrostomy.
RI P
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
SC
hypoglobus. Following maxillary antrostomy, observation with staged orbital surgery, if required, is recommended.
NU
1. Introduction:
Silent Sinus Syndrome is a clinical syndrome defined as progressive enophthalmos and hypoglobus
MA
secondary to maxillary sinus collapse with chronic hypoventilation. It is believed that the syndrome’s pathophysiology involves chronic negative pressure resulting from obstruction of the maxillary sinus ostium. In turn, atelectasis of the maxillary sinus pulls the orbital floor inferiorly and can affect ocular motor function and aesthetics. Patients often
ED
present with symptoms of facial asymmetry and diplopia1. Physical exam often reveals orbital asymmetry, deepening of the superior sulcus, sinking or pulling sensation of the eye, lid lag or nasal shift toward the affected sinus.
PT
Diagnosis is confirmed with imaging that demonstrates a loss of maxillary sinus volume, typically best seen with computed tomography (CT)1. The critical finding is inward retraction of the sinus walls with downward retraction
CE
of the orbital floor. Sinus wall bone resorption is also frequently noted. The differential diagnosis includes chronic sinusitis, which does not produce the same contraction of the sinus2. It has previously been asserted that the diagnosis
AC
of Silent Sinus Syndrome requires exclusion of chronic sinusitis, otherwise the term Chronic Maxillary Atelectasis should be used3. However, this distinction has not clearly persisted. An increase in infratemporal fossa fat has also been noted in Silent Sinus Syndrome, likely secondary to remodeling of the posterior maxillary sinus wall. An increase in the nasal and orbital volumes is another common finding. Given the uncommon nature of Silent Sinus Syndrome, optimal surgical management has not been clearly established. Specifically, the necessity for and timing of orbital reconstruction remains an open clinical question. Overall enophthalmos resolution rates are also unclear and may depend on disease variation not yet measured.
2. Case Report: A 27-year-old attorney presented to Otolaryngology Clinic with symptoms consistent with acute on chronic sinusitis. Previously she had reported chronic congestion and exacerbations with bilateral facial pressure and increased postnasal drainage and congestion. During these episodes, she also experienced anosmia and sore throat. Her
2
ACCEPTED MANUSCRIPT exacerbations frequently followed upper respiratory infections. She had been previously treated with guaifenesin, Fexofenadine, as well as Fluticasone and Mometasone nasal sprays. She also received Azithromycin and Sulfamethoxazole/Trimethoprim for exacerbations of her symptoms. Her past medical history was significant for
RI P
superior sulcus of the orbit on the right-side and corresponding enophthalmos.
T
anemia, migraines and hypothyroidism, and she was a non-smoker. On physical exam, she had deepening of the
A CT scan (Figure 1A, 2A) demonstrated partial opacification of the left maxillary sinus with mucosal
SC
thickening ethmoid sinuses bilaterally. The right maxillary sinus was completely opacified and there was inferior displacement of the right orbital floor and subsequent expansion of the bony orbit. The uncinate process was also
NU
lateralized. Remodeling of the posterolateral aspect of the maxillary sinus as well as low-density soft tissue enlargement of the inferotemporal fossa in this region was noted. Based on her clinical and radiographic findings, the
MA
patient was diagnosed with atelectatic maxillary sinus.
On 2/8/08, she underwent bilateral endoscopic sinus surgery including bilateral maxillary antrostomies. The uncinate process on the right side was noted to be atelectatic, and the right orbital floor was inferiorly displaced with
ED
rarefaction of the bone. A backbiter was used to remove the inferior aspect of the atelectatic uncinate process. This allowed visualization of thick mucus extruding through the natural ostium of the maxillary sinus. The antrostomy was
PT
enlarged posteriorly and inferiorly with care not to injure the inferiorly displaced orbital floor. Palpation of the globe confirmed absence of bone along the inferomedial aspect of the orbit. Although the maxillary sinus was full of thick
CE
cloudy mucus; no pathologic bacteria were identified on culture. Following surgery, the patient noted persistent, mild right-sided enophthalmos. Because of these cosmetic
AC
concerns, she decided to undergo evaluation with an oculoplastic surgeon for consideration of placement of an orbital implant to improve her enophthalmos. Although her appearance improved while awaiting her appointment, she did follow through with a CT scan ordered as part of her evaluation. Her CT scan (Figure 1B, 2B) five months after her operation (7/8/2009) showed remarkable resolution of the anterior bowing of the posterior wall of the right maxillary sinus. Her right maxillary sinus appeared normal in contour and without significant mucosal disease. The previously noted rarefied bone along the inferomedial orbit demonstrated significant remodeling with layering of new bone in this region. The patient decided not to pursue orbital surgery.
3. Discussion: The treatment of Silent Sinus Syndrome consists of functional endoscopic surgery to remove the maxillary sinus ostium obstruction with uncinectomy and antrostomy. The altered anatomy of the uncinate process and orbital
3
ACCEPTED MANUSCRIPT floor combined with rarefication of bone in this region places patients at risk for orbital complications during surgery 4. Clear identification of these key anatomic structures is critical to avoid orbital injury. For patients with significant enophthalmos, there is a clinical question of whether orbital reconstruction
T
should be performed in the same operative setting. Remodeling of the orbital floor with subsequent improvement in
RI P
enophthalmos has been observed, suggesting that endoscopic maxillary antrostomy alone may be adequate treatment and orbital reconstruction should be delayed1,5-8. Others argue that severe enophthalmos is likely to require orbital
SC
reconstruction and a single operation would be preferred 9. It has also been suggested that intra-sinus microorganisms may be present at the initial sinus drainage and could lead to orbital inoculation if the orbital floor is not corrected at
NU
the time of antrostomy, but sinus cultures at the initial drainage stage are often negative 10. Our findings of dynamic
MA
bone remodeling following ventilation of the maxillary sinus support a staged approach to orbital reconstruction.
4. Conclusion:
Significant bony remodeling of the maxillary sinus can occur following endoscopic maxillary antrostomy for
ED
treatment of silent sinus syndrome. The current literature generally only describes orbital floor changes after surgery because of the focus on resolving the enophthalmos and hypoglobus8. This case presentation demonstrates dynamic
PT
remodeling of the posterior wall of the maxillary sinus, which strengthens the argument for observation, rather than concurrent repair of the orbital floor. Furthermore, new bone formation along the orbit provides a more stable recipient
CE
location for any implants that may be required.
AC
5. Acknowledgments: none
4
ACCEPTED MANUSCRIPT 6. References: Bossolesi P, Autelitano L, Brusati R, Castelnuovo P. The silent sinus syndrome: diagnosis and surgical treatment. Rhinology. 2008;46(4):308–316.
2.
Whyte A, Chapeikin G. Opaque maxillary antrum: a pictorial review. Australas Radiol. 2005;49(3):203–213. doi:10.1111/j.1440-1673.2005.01432.x.
3.
Numa WA, Desai U, Gold DR, Heher KL, Annino DJ. Silent sinus syndrome: a case presentation and comprehensive review of all 84 reported cases. Ann Otol Rhinol Laryngol. 2005;114(9):688–694.
4.
Annino DJ, Goguen LA. Silent sinus syndrome. Current Opinion in Otolaryngology & Head and Neck Surgery. 2008;16(1):22–25. doi:10.1097/MOO.0b013e3282f2c9aa.
5.
Thomas RD, Graham SM, Carter KD, Nerad JA. Management of the orbital floor in silent sinus syndrome. Am J Rhinol. 2003;17(2):97–100.
6.
Ferri A, Ferri T, Sesenna E. Bilateral Silent Sinus syndrome case report and surgical solution. YJOMS. 2012;70(1):e103–e106. doi:10.1016/j.joms.2011.08.008.
7.
Ando A, Cruz AAV. Management of Enophthalmos and Superior Sulcus Deformity Induced by the Silent Sinus Syndrome. Aesth Plast Surg. 2005;29(2):74–77. doi:10.1007/s00266-004-0118-1.
8.
Sivasubramaniam R, Sacks R, Thornton M. Silent sinus syndrome: dynamic changes in the position of the orbital floor after restoration of normal sinus pressure. J Laryngol Otol. 2011;125(12):1239–1243. doi:10.1017/S0022215111001952.
9.
Sesenna E, Oretti G, Anghinoni ML, Ferri A. Simultaneous management of the enophthalmos and sinus pathology in silent sinus syndrome: A report of three cases. Journal of Cranio-Maxillofacial Surgery. 2010;38(6):469–472. doi:10.1016/j.jcms.2009.12.003.
10.
Vander Meer JB, Harris G, Toohill RJ, Smith TL. The silent sinus syndrome: a case series and literature review. Laryngoscope. 2001;111(6):975–978. doi:10.1097/00005537-200106000-00008.
AC
CE
PT
ED
MA
NU
SC
RI P
T
1.
5
ACCEPTED MANUSCRIPT Figure 1 Legend: A. Initial axial CT demonstrating loss of right maxillary sinus volume with complete opacification and partial opacification of the left maxillary sinus. Arrow indicates anterior bowing of the posterior wall of the right maxillary
T
sinus. Pterygopalatine fat fills volume created by the anterior displacement of the bone.
RI P
B. Repeat axial CT scan five months after operation showing resolution of the anterior bowing of the posterior lateral
SC
wall of the right maxillary sinus.
Figure 2 Legend:
bilaterally. Arrow indicating orbital wall bone resorption.
NU
A. Initial coronal CT demonstrating loss of right maxillary sinus volume and mucosal thickening of the ethmoid sinuses
MA
B. Repeat coronal CT scan five months after surgery. Arrowhead demonstrates new bone formation along the
AC
CE
PT
ED
inferomedial orbit.
6
ACCEPTED MANUSCRIPT
ED
MA
NU
SC
RI P
T
Figure 1
AC
CE
PT
Figure 2
7
S0196-0709(14)00115-X doi: 10.1016/j.amjoto.2014.05.007 YAJOT 1396
To appear in:
American Journal of Otolaryngology–Head and Neck Medicine and Surgery
Received date: Accepted date:
29 April 2014 12 May 2014
Please cite this article as: Kram Yoseph Aaron, Pletcher Steven D., Maxillary sinus posterior wall remodeling following surgery for silent sinus syndrome, American Journal of Otolaryngology–Head and Neck Medicine and Surgery (2014), doi: 10.1016/j.amjoto.2014.05.007
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Maxillary Sinus Posterior Wall Remodeling Following Surgery for Silent Sinus
T
Syndrome
RI P
Authors: Yoseph Aaron Kram BA1, Steven D. Pletcher MD1 1
Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco
SC
Running Title: Silent Sinus Syndrome
NU
Corresponding author: Steven D. Pletcher, MD
MA
Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco 2233 Post Street 3rd Floor, Box 1225
Phone Number: 415 476-4952
PT
Email: [email protected]
ED
San Francisco, CA 94115
CE
Keywords: Silent Sinus Syndrome, bony remodeling, maxillary antrostomy, maxillary sinus, enophthalmos,
AC
hypoglobus, posterior wall, sinus atelectasis, orbital floor, endoscopic surgery
1
ACCEPTED MANUSCRIPT Abstract: 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
T
current case report illustrates dramatic bony remodeling of the maxillary sinus following maxillary antrostomy.
RI P
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
SC
hypoglobus. Following maxillary antrostomy, observation with staged orbital surgery, if required, is recommended.
NU
1. Introduction:
Silent Sinus Syndrome is a clinical syndrome defined as progressive enophthalmos and hypoglobus
MA
secondary to maxillary sinus collapse with chronic hypoventilation. It is believed that the syndrome’s pathophysiology involves chronic negative pressure resulting from obstruction of the maxillary sinus ostium. In turn, atelectasis of the maxillary sinus pulls the orbital floor inferiorly and can affect ocular motor function and aesthetics. Patients often
ED
present with symptoms of facial asymmetry and diplopia1. Physical exam often reveals orbital asymmetry, deepening of the superior sulcus, sinking or pulling sensation of the eye, lid lag or nasal shift toward the affected sinus.
PT
Diagnosis is confirmed with imaging that demonstrates a loss of maxillary sinus volume, typically best seen with computed tomography (CT)1. The critical finding is inward retraction of the sinus walls with downward retraction
CE
of the orbital floor. Sinus wall bone resorption is also frequently noted. The differential diagnosis includes chronic sinusitis, which does not produce the same contraction of the sinus2. It has previously been asserted that the diagnosis
AC
of Silent Sinus Syndrome requires exclusion of chronic sinusitis, otherwise the term Chronic Maxillary Atelectasis should be used3. However, this distinction has not clearly persisted. An increase in infratemporal fossa fat has also been noted in Silent Sinus Syndrome, likely secondary to remodeling of the posterior maxillary sinus wall. An increase in the nasal and orbital volumes is another common finding. Given the uncommon nature of Silent Sinus Syndrome, optimal surgical management has not been clearly established. Specifically, the necessity for and timing of orbital reconstruction remains an open clinical question. Overall enophthalmos resolution rates are also unclear and may depend on disease variation not yet measured.
2. Case Report: A 27-year-old attorney presented to Otolaryngology Clinic with symptoms consistent with acute on chronic sinusitis. Previously she had reported chronic congestion and exacerbations with bilateral facial pressure and increased postnasal drainage and congestion. During these episodes, she also experienced anosmia and sore throat. Her
2
ACCEPTED MANUSCRIPT exacerbations frequently followed upper respiratory infections. She had been previously treated with guaifenesin, Fexofenadine, as well as Fluticasone and Mometasone nasal sprays. She also received Azithromycin and Sulfamethoxazole/Trimethoprim for exacerbations of her symptoms. Her past medical history was significant for
RI P
superior sulcus of the orbit on the right-side and corresponding enophthalmos.
T
anemia, migraines and hypothyroidism, and she was a non-smoker. On physical exam, she had deepening of the
A CT scan (Figure 1A, 2A) demonstrated partial opacification of the left maxillary sinus with mucosal
SC
thickening ethmoid sinuses bilaterally. The right maxillary sinus was completely opacified and there was inferior displacement of the right orbital floor and subsequent expansion of the bony orbit. The uncinate process was also
NU
lateralized. Remodeling of the posterolateral aspect of the maxillary sinus as well as low-density soft tissue enlargement of the inferotemporal fossa in this region was noted. Based on her clinical and radiographic findings, the
MA
patient was diagnosed with atelectatic maxillary sinus.
On 2/8/08, she underwent bilateral endoscopic sinus surgery including bilateral maxillary antrostomies. The uncinate process on the right side was noted to be atelectatic, and the right orbital floor was inferiorly displaced with
ED
rarefaction of the bone. A backbiter was used to remove the inferior aspect of the atelectatic uncinate process. This allowed visualization of thick mucus extruding through the natural ostium of the maxillary sinus. The antrostomy was
PT
enlarged posteriorly and inferiorly with care not to injure the inferiorly displaced orbital floor. Palpation of the globe confirmed absence of bone along the inferomedial aspect of the orbit. Although the maxillary sinus was full of thick
CE
cloudy mucus; no pathologic bacteria were identified on culture. Following surgery, the patient noted persistent, mild right-sided enophthalmos. Because of these cosmetic
AC
concerns, she decided to undergo evaluation with an oculoplastic surgeon for consideration of placement of an orbital implant to improve her enophthalmos. Although her appearance improved while awaiting her appointment, she did follow through with a CT scan ordered as part of her evaluation. Her CT scan (Figure 1B, 2B) five months after her operation (7/8/2009) showed remarkable resolution of the anterior bowing of the posterior wall of the right maxillary sinus. Her right maxillary sinus appeared normal in contour and without significant mucosal disease. The previously noted rarefied bone along the inferomedial orbit demonstrated significant remodeling with layering of new bone in this region. The patient decided not to pursue orbital surgery.
3. Discussion: The treatment of Silent Sinus Syndrome consists of functional endoscopic surgery to remove the maxillary sinus ostium obstruction with uncinectomy and antrostomy. The altered anatomy of the uncinate process and orbital
3
ACCEPTED MANUSCRIPT floor combined with rarefication of bone in this region places patients at risk for orbital complications during surgery 4. Clear identification of these key anatomic structures is critical to avoid orbital injury. For patients with significant enophthalmos, there is a clinical question of whether orbital reconstruction
T
should be performed in the same operative setting. Remodeling of the orbital floor with subsequent improvement in
RI P
enophthalmos has been observed, suggesting that endoscopic maxillary antrostomy alone may be adequate treatment and orbital reconstruction should be delayed1,5-8. Others argue that severe enophthalmos is likely to require orbital
SC
reconstruction and a single operation would be preferred 9. It has also been suggested that intra-sinus microorganisms may be present at the initial sinus drainage and could lead to orbital inoculation if the orbital floor is not corrected at
NU
the time of antrostomy, but sinus cultures at the initial drainage stage are often negative 10. Our findings of dynamic
MA
bone remodeling following ventilation of the maxillary sinus support a staged approach to orbital reconstruction.
4. Conclusion:
Significant bony remodeling of the maxillary sinus can occur following endoscopic maxillary antrostomy for
ED
treatment of silent sinus syndrome. The current literature generally only describes orbital floor changes after surgery because of the focus on resolving the enophthalmos and hypoglobus8. This case presentation demonstrates dynamic
PT
remodeling of the posterior wall of the maxillary sinus, which strengthens the argument for observation, rather than concurrent repair of the orbital floor. Furthermore, new bone formation along the orbit provides a more stable recipient
CE
location for any implants that may be required.
AC
5. Acknowledgments: none
4
ACCEPTED MANUSCRIPT 6. References: Bossolesi P, Autelitano L, Brusati R, Castelnuovo P. The silent sinus syndrome: diagnosis and surgical treatment. Rhinology. 2008;46(4):308–316.
2.
Whyte A, Chapeikin G. Opaque maxillary antrum: a pictorial review. Australas Radiol. 2005;49(3):203–213. doi:10.1111/j.1440-1673.2005.01432.x.
3.
Numa WA, Desai U, Gold DR, Heher KL, Annino DJ. Silent sinus syndrome: a case presentation and comprehensive review of all 84 reported cases. Ann Otol Rhinol Laryngol. 2005;114(9):688–694.
4.
Annino DJ, Goguen LA. Silent sinus syndrome. Current Opinion in Otolaryngology & Head and Neck Surgery. 2008;16(1):22–25. doi:10.1097/MOO.0b013e3282f2c9aa.
5.
Thomas RD, Graham SM, Carter KD, Nerad JA. Management of the orbital floor in silent sinus syndrome. Am J Rhinol. 2003;17(2):97–100.
6.
Ferri A, Ferri T, Sesenna E. Bilateral Silent Sinus syndrome case report and surgical solution. YJOMS. 2012;70(1):e103–e106. doi:10.1016/j.joms.2011.08.008.
7.
Ando A, Cruz AAV. Management of Enophthalmos and Superior Sulcus Deformity Induced by the Silent Sinus Syndrome. Aesth Plast Surg. 2005;29(2):74–77. doi:10.1007/s00266-004-0118-1.
8.
Sivasubramaniam R, Sacks R, Thornton M. Silent sinus syndrome: dynamic changes in the position of the orbital floor after restoration of normal sinus pressure. J Laryngol Otol. 2011;125(12):1239–1243. doi:10.1017/S0022215111001952.
9.
Sesenna E, Oretti G, Anghinoni ML, Ferri A. Simultaneous management of the enophthalmos and sinus pathology in silent sinus syndrome: A report of three cases. Journal of Cranio-Maxillofacial Surgery. 2010;38(6):469–472. doi:10.1016/j.jcms.2009.12.003.
10.
Vander Meer JB, Harris G, Toohill RJ, Smith TL. The silent sinus syndrome: a case series and literature review. Laryngoscope. 2001;111(6):975–978. doi:10.1097/00005537-200106000-00008.
AC
CE
PT
ED
MA
NU
SC
RI P
T
1.
5
ACCEPTED MANUSCRIPT Figure 1 Legend: A. Initial axial CT demonstrating loss of right maxillary sinus volume with complete opacification and partial opacification of the left maxillary sinus. Arrow indicates anterior bowing of the posterior wall of the right maxillary
T
sinus. Pterygopalatine fat fills volume created by the anterior displacement of the bone.
RI P
B. Repeat axial CT scan five months after operation showing resolution of the anterior bowing of the posterior lateral
SC
wall of the right maxillary sinus.
Figure 2 Legend:
bilaterally. Arrow indicating orbital wall bone resorption.
NU
A. Initial coronal CT demonstrating loss of right maxillary sinus volume and mucosal thickening of the ethmoid sinuses
MA
B. Repeat coronal CT scan five months after surgery. Arrowhead demonstrates new bone formation along the
AC
CE
PT
ED
inferomedial orbit.
6
ACCEPTED MANUSCRIPT
ED
MA
NU
SC
RI P
T
Figure 1
AC
CE
PT
Figure 2
7