"Silent sinus syndrome": One more indication for functional endoscopic sinus surgery

Abstract

Introduction. Silent sinus syndrome is a rare condition, characterized by spontaneous and progressive enophthalmos and hypoglobus associated with atelectasis of the maxillary sinus and downward displacement of the orbital floor. Patients with this syndrome present with ophthalmological complaints, without any nasal or sinus symptoms. Silent sinus syndrome has a painless course and slow development. It seems to be a consequence of maxillary sinus hypoventilation due to obstruction of the ostiomeatal unit. The CT scan findings are typical and definitely confirm the diagnosis of silent sinus syndrome. Case report. We present the case of a 35-year-old woman, with no history of orbital trauma or surgery. She had slight righthemifacial pressure with no sinonasal symptoms. The patient had no double vision nor other ophthalmological symptoms. The diagnosis of silent sinus syndrome was based on the gradual onset of enophthalmos and hypoglobus, in the absence of orbital trauma (including surgery) or prior symptoms of sinus disease. On paranasal CT scans there was a complete opacification and atelectasis of the right maxillary sinus with downward bowing of the orbital floor. The patient was treated with functional endoscopic sinus surgery, with no orbital repair. Conclusion. Silent sinus syndrome presents with orbithopaties but is in fact a rhinologic disease, so all ophthalmologists, rhinologists and radiologists should know about it. The treatment of choice for silent sinus syndrome is functional endoscopic sinus surgery, which should be performed with extra care, by an experienced rhinosurgeon.

Silent sinus syndrome: One more reason for an ophthalmologist to have a rhinologist as a good friend

“…The general agreement is that sinus pathology should be treated as the first stage of the treatment. It is the functional endoscopic sinus surgery (FESS) that should be performed in patients with SSS, because it restores sinus drainage with no or minimal collateral damage 1,9,12,29,30 . The procedure must be done with extreme caution, since unintentional entry into the orbit happens much more often.…”

“…The procedure must be done with extreme caution, since unintentional entry into the orbit happens much more often. Surgery starts as usually with uncinectomy which should be performed with extra care, as the inward implosion of the antral walls, in combination with a depressed orbital floor, places the orbital contents at particular risk of injury 1,9,30 . Then, a wide meatalantrostomy must be made, which provides aeration to the maxillary sinus.…”

“…A wide antrostomy prevents future reobstructions, and good reaeration of the sinus helps to avoid recurrent enophthalmos 4,16,29 . So, a rhinosurgeon should perform a complete uncinectomy, anterior ethmoidectomy (adds exposure of the hiatus semilunaris and medial orbital wall), trimming of the inferior third of the middle nasal turbinate with gentle medial displacement (if it is lateralized)to prevent reocclusion of the natural maxillary ostium and wide middle meatal antrostomy 1,16,29,30 . In some cases an inferior meatal antrostomy with even endoscopic medial maxillectomy are done 9 .…”

“…In some cases an inferior meatal antrostomy with even endoscopic medial maxillectomy are done 9 . Inside the maxillary sinus with SSS, the mucus secretion (thick glue like) is often found, and removed 15,30 .…”

“…As suggested by some authors, orbital floor reconstruction should be performed simultaneously with sinus treatment 4,32 . Most other authors think that drainage of the sinus as a single step should be enough 1,4,16,29,30,32 . The maxillary sinus usually remodels after FESS, so it is rarely necessary to do the secondary repair of the orbital floor for aesthetic reasons.…”