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Orbitotemporofacial Meningioma*: A Case Report
847
NOTES, CASES, INSTRUMENTS
ORBITOTEMPOROFACIAL MENINGIOMA* A CASE REPORT
R. K. SHRIVASTAVA, F . R . C . S . M . C. N A H A T A , D . O . M . S . AND RAM
SINGH, M . B .
Bhopal, India Meningiomas of the orbit, whether pri mary or extending into it, are rare. Still rarer are meningiomas that originate in or
C A S E REPORT
G. L., an 18-year-old Hindu farmer, was ad mitted to Hamidia Hospital, Bhopal, on March 19, 1962, complaining of swelling in the left cheek and temple for the last three years. The patient noticed the swelling in the left temple about three years ago. It gradually ex tended into the left cheek (figs. 1 and 2). Vision in the left eye also started failing and, for about the last two years, the patient was totally blind in his left eye. There was no history of epileptic fits, con vulsions, headaches or vomiting. Investigations. Blood: RBC, 4.3 million c.mm. ; Hb., 84 percent; WBC, total 8,700 c.mm—polymorphonuclear leukocytes 75 percent, eosinophiles three percent, lymphocytes 22 percent ; ESR, 16 mm. first hr.; KT, negative; VDLR, negative. Urine. No appreciable disease. Skiagrams. Chest, no appreciable disease; skull and face, no appreciable disease; postoperatively, after the tumor was diagnosed to be a meningioma, skiagrams of both the optic foramen were done and did not reveal any widening of the left optic foramen. Operation. Preliminary external carotid artery ligation was done. The incision ran from the level of the left nasal ala along the root of the nose to just below the inner canthus of the left eye. There it made a smooth angulation and proceeded along the margin of bony orbit to the region of the outer canthus, whence it was extended up to the tragus as a semicircle of upward convexity. The facial skin flap was raised to expose the lobulated and well-encapsulated tumor, which did not present much difficulty in dissection. As the dissection of the facial tumor was com pleted, a thick tongue of tumor was seen to pass
Fig. 1 (Shrivastava, et al.). The facial and temporal tumors. extend into orbit and also present on the face and temporal region. Meningiomas, espe cially those of the base of the skull, have a tendency to insinuate themselves out of the crevices and foramen of this area (Cushing, et al., 1938) but massive invasions involving the orbit, infratemporal region, temporal fossa and face are exceptional (Conley, et al., 1956; Pertuiset, et al., 1958). I n this communication we report a case in which the meningioma originated in or ex tended into the orbital cavity and presented itself on the temporal region and face. *From the Gandhi Medical College.
Fig. 2 (Shrivastava, et al.). The facial and temporal tumors.
848
NOTES, CASES, INSTRUMENTS
under the anterior edge of the masseter muscle and the inferior edge of the zygoma, into the temporal region. At this stage the temporal skin flap was raised and the temporal fascia was divided along its in sertion into the upper border of the zygomatic arch. The zygomatic arch with masseter attached to it was reflected downward by dividing it near its bases, to expose the tongue of the facial tumor disappearing under the anterior edge of the temporalis muscle. The muscle-tendon insertion of the temporalis muscle into the coronoid process was severed to expose both the temporal tumor and the prolonga tion of the facial tumor. Further dissection re vealed that both tumors formed a common stalk which entered the orbit through the inferior orbital foramen (fig. 3). It was decided to remove only the temporofacial portion of the tumor and leave the orbital portion to be operated on at a later date. The stalk was transfixed and the temporofacial portion of the tumor was excised. The temporalis muscle was stitched to the portion of its tendon left attached to the coronoid process. The zygo matic arch was snugly fitted back into its original place and skin flaps were stitched. Pathology report. Macroscopic appearance. The tumor is grayish white in appearance, with multiple lobulations, and measures 10 by 4 by S cm. It is firm in consistency. The cut section shows caver-
Fig. 3 (Shrivastava, et al.). The temporofacial extension of the meningioma as exposed after the reflection of the zygomatic arch.
Fig. 4 (Shrivastava, et al.). The excised temporo facial portions of the meningioma. nous vascular spaces (fig. 4) distributed irregularly throughout the tumor. Microscopic appearance. The tumor is com posed chiefly of fibroangiomatous tissue. The fibro blasts are long and spindle-shaped and have a tendency to form whorls at places. The tumor is highly vascular and shows thin-walled vessels dis tributed throughout (fig. 5). Pathologic diagnosis. Fibroangioblastic menin gioma. The postoperative course was uneventful. We could not, however, persuade the patient to submit to the proposed second-stage operation.
Fig. 5 (Shrivastava, et al.). The high vascularity of the tumor can be seen. The fibroblasts show a tendency to form whorls.
NOTES, CASES, INSTRUMENTS
849
COMMENTS
SUMMARY
With such massive orbital and temporofacial extensions, it is hardly likely that the global type of intracranial meningioma would not give rise to neurologic signs and symp toms. In our opinion, therefore, this case was most probably one of primary orbital menin gioma, with infratemporal, temporal and fa cial extension. We have no positive proof, however, that there was no cranial extension.
A very unusual case of meningioma in volving the orbital cavity and extending into the infratemporal region, temporal fossa and face is presented. Gandhi Medical College. ACKNOWLEDGMENT
We are grateful to Dr. Narendra Singh, Dean, Gandhi Medical College, Bhopal, for permitting us to use hospital records.
REFERENCES
Conley, J. J., Pack, G. T., and Trinidad, S. S.: Surgical technic of removal of infratemporal men ingioma. Laryngoscope, 66:540, 1956. Cushing, H., and Eisenhardt, L. : Meningioma. Springfield, III., Thomas, 1938. Pertuiset, B., Guillamat, L., Pialoux, P., and Hirsch, J. F.: (abst.) Surg. Gynec. & Obstet., 109:230, 1959.
E O S I N O P H I L I C GRANULOMA* W I T H OCULAR MANIFESTATIONS U. C. BEHERA,
M.S.
AND
M. C. MISRA, D.O.M.S. (LOND.) Berhampur, Orissa, India Although various workers have advanced a number of hypotheses regarding the causa tive agent of eosinophilic granuloma, there is, as yet, no clear concept of its pathogenesis. In the following case the eosinophilic granuloma involved the orbit. CASE REPORT
A boy, aged five years, was admitted to the S.C.B. Medical College hospital on August 11, 1961 (fig. 1). There was a two-month history of * From the Department of Ophthalmology, Burla Medical College.
swelling of the upper eyelid of the left eye and ptosis had been present in this eye for the past one and one-half months. The child had been quite normal until the last of June when a small swelling was noticed at the outer aspect of the left upper eyelid. The swelling gradually increased in size, the upper eyelid drooped down and the child began to experience visual discomfort. One month after onset of the swelling, the child contracted measles but recovered completely and showed no attendant complications. Neither past nor family histories were relevant to the present affection. As the swelling, which first appeared as a small nodule over the outer limit of the left orbit, in creased in size, it extended both upward toward the temporal region and medially toward the inner canthi, involving the entire upper eyelid. Subse quently, the outer aspect of the lower eyelid became swollen. The swelling extended toward the medial canthi and involved the outer half of the lower eye lid. Examination showed the swelling to be soft and compact. The skin overlying the circumscribed lesion was taut and shiny but could easily be sepa rated from the growth which could be moved from side to side and from above downward. The upward
NOTES, CASES, INSTRUMENTS
ORBITOTEMPOROFACIAL MENINGIOMA* A CASE REPORT
R. K. SHRIVASTAVA, F . R . C . S . M . C. N A H A T A , D . O . M . S . AND RAM
SINGH, M . B .
Bhopal, India Meningiomas of the orbit, whether pri mary or extending into it, are rare. Still rarer are meningiomas that originate in or
C A S E REPORT
G. L., an 18-year-old Hindu farmer, was ad mitted to Hamidia Hospital, Bhopal, on March 19, 1962, complaining of swelling in the left cheek and temple for the last three years. The patient noticed the swelling in the left temple about three years ago. It gradually ex tended into the left cheek (figs. 1 and 2). Vision in the left eye also started failing and, for about the last two years, the patient was totally blind in his left eye. There was no history of epileptic fits, con vulsions, headaches or vomiting. Investigations. Blood: RBC, 4.3 million c.mm. ; Hb., 84 percent; WBC, total 8,700 c.mm—polymorphonuclear leukocytes 75 percent, eosinophiles three percent, lymphocytes 22 percent ; ESR, 16 mm. first hr.; KT, negative; VDLR, negative. Urine. No appreciable disease. Skiagrams. Chest, no appreciable disease; skull and face, no appreciable disease; postoperatively, after the tumor was diagnosed to be a meningioma, skiagrams of both the optic foramen were done and did not reveal any widening of the left optic foramen. Operation. Preliminary external carotid artery ligation was done. The incision ran from the level of the left nasal ala along the root of the nose to just below the inner canthus of the left eye. There it made a smooth angulation and proceeded along the margin of bony orbit to the region of the outer canthus, whence it was extended up to the tragus as a semicircle of upward convexity. The facial skin flap was raised to expose the lobulated and well-encapsulated tumor, which did not present much difficulty in dissection. As the dissection of the facial tumor was com pleted, a thick tongue of tumor was seen to pass
Fig. 1 (Shrivastava, et al.). The facial and temporal tumors. extend into orbit and also present on the face and temporal region. Meningiomas, espe cially those of the base of the skull, have a tendency to insinuate themselves out of the crevices and foramen of this area (Cushing, et al., 1938) but massive invasions involving the orbit, infratemporal region, temporal fossa and face are exceptional (Conley, et al., 1956; Pertuiset, et al., 1958). I n this communication we report a case in which the meningioma originated in or ex tended into the orbital cavity and presented itself on the temporal region and face. *From the Gandhi Medical College.
Fig. 2 (Shrivastava, et al.). The facial and temporal tumors.
848
NOTES, CASES, INSTRUMENTS
under the anterior edge of the masseter muscle and the inferior edge of the zygoma, into the temporal region. At this stage the temporal skin flap was raised and the temporal fascia was divided along its in sertion into the upper border of the zygomatic arch. The zygomatic arch with masseter attached to it was reflected downward by dividing it near its bases, to expose the tongue of the facial tumor disappearing under the anterior edge of the temporalis muscle. The muscle-tendon insertion of the temporalis muscle into the coronoid process was severed to expose both the temporal tumor and the prolonga tion of the facial tumor. Further dissection re vealed that both tumors formed a common stalk which entered the orbit through the inferior orbital foramen (fig. 3). It was decided to remove only the temporofacial portion of the tumor and leave the orbital portion to be operated on at a later date. The stalk was transfixed and the temporofacial portion of the tumor was excised. The temporalis muscle was stitched to the portion of its tendon left attached to the coronoid process. The zygo matic arch was snugly fitted back into its original place and skin flaps were stitched. Pathology report. Macroscopic appearance. The tumor is grayish white in appearance, with multiple lobulations, and measures 10 by 4 by S cm. It is firm in consistency. The cut section shows caver-
Fig. 3 (Shrivastava, et al.). The temporofacial extension of the meningioma as exposed after the reflection of the zygomatic arch.
Fig. 4 (Shrivastava, et al.). The excised temporo facial portions of the meningioma. nous vascular spaces (fig. 4) distributed irregularly throughout the tumor. Microscopic appearance. The tumor is com posed chiefly of fibroangiomatous tissue. The fibro blasts are long and spindle-shaped and have a tendency to form whorls at places. The tumor is highly vascular and shows thin-walled vessels dis tributed throughout (fig. 5). Pathologic diagnosis. Fibroangioblastic menin gioma. The postoperative course was uneventful. We could not, however, persuade the patient to submit to the proposed second-stage operation.
Fig. 5 (Shrivastava, et al.). The high vascularity of the tumor can be seen. The fibroblasts show a tendency to form whorls.
NOTES, CASES, INSTRUMENTS
849
COMMENTS
SUMMARY
With such massive orbital and temporofacial extensions, it is hardly likely that the global type of intracranial meningioma would not give rise to neurologic signs and symp toms. In our opinion, therefore, this case was most probably one of primary orbital menin gioma, with infratemporal, temporal and fa cial extension. We have no positive proof, however, that there was no cranial extension.
A very unusual case of meningioma in volving the orbital cavity and extending into the infratemporal region, temporal fossa and face is presented. Gandhi Medical College. ACKNOWLEDGMENT
We are grateful to Dr. Narendra Singh, Dean, Gandhi Medical College, Bhopal, for permitting us to use hospital records.
REFERENCES
Conley, J. J., Pack, G. T., and Trinidad, S. S.: Surgical technic of removal of infratemporal men ingioma. Laryngoscope, 66:540, 1956. Cushing, H., and Eisenhardt, L. : Meningioma. Springfield, III., Thomas, 1938. Pertuiset, B., Guillamat, L., Pialoux, P., and Hirsch, J. F.: (abst.) Surg. Gynec. & Obstet., 109:230, 1959.
E O S I N O P H I L I C GRANULOMA* W I T H OCULAR MANIFESTATIONS U. C. BEHERA,
M.S.
AND
M. C. MISRA, D.O.M.S. (LOND.) Berhampur, Orissa, India Although various workers have advanced a number of hypotheses regarding the causa tive agent of eosinophilic granuloma, there is, as yet, no clear concept of its pathogenesis. In the following case the eosinophilic granuloma involved the orbit. CASE REPORT
A boy, aged five years, was admitted to the S.C.B. Medical College hospital on August 11, 1961 (fig. 1). There was a two-month history of * From the Department of Ophthalmology, Burla Medical College.
swelling of the upper eyelid of the left eye and ptosis had been present in this eye for the past one and one-half months. The child had been quite normal until the last of June when a small swelling was noticed at the outer aspect of the left upper eyelid. The swelling gradually increased in size, the upper eyelid drooped down and the child began to experience visual discomfort. One month after onset of the swelling, the child contracted measles but recovered completely and showed no attendant complications. Neither past nor family histories were relevant to the present affection. As the swelling, which first appeared as a small nodule over the outer limit of the left orbit, in creased in size, it extended both upward toward the temporal region and medially toward the inner canthi, involving the entire upper eyelid. Subse quently, the outer aspect of the lower eyelid became swollen. The swelling extended toward the medial canthi and involved the outer half of the lower eye lid. Examination showed the swelling to be soft and compact. The skin overlying the circumscribed lesion was taut and shiny but could easily be sepa rated from the growth which could be moved from side to side and from above downward. The upward