Orbital Apex Lesions: A Diagnostic and Therapeutic Challenge

Sung-Woo Cho; Won-Wook Lee; Dae Joong Ma; Ji-hoon Kim; Doo Hee Han; Hyun Jik Kim; Dong-Young Kim; Seong-Joon Kim; Sang In Khwarg; Sung-Min Kim; Sun Ha Paek; Chae-Seo Rhee; Chul Hee Lee; Peter H. Hwang; Tae-Bin Won

doi:10.1055/s-0037-1612616

Journal of Neurological Surgery Part B: Skull Base, Table of Contents

J Neurol Surg B Skull Base 2018; 79(04): 386-393
DOI: 10.1055/s-0037-1612616

Original Article

Georg Thieme Verlag KG Stuttgart · New York

Orbital Apex Lesions: A Diagnostic and Therapeutic Challenge

Sung-Woo Cho

¹Department of Otorhinolaryngology, Head and Neck Surgery, Seoul National University Hospital, Seoul, Korea

,

Won-Wook Lee

¹Department of Otorhinolaryngology, Head and Neck Surgery, Seoul National University Hospital, Seoul, Korea

,

Dae Joong Ma

²Department of Ophthalmology, Seoul National University Hospital, Seoul, Korea

,

Ji-hoon Kim

³Department of Radiology, Seoul National University Hospital, Seoul, Korea

,

Doo Hee Han

¹Department of Otorhinolaryngology, Head and Neck Surgery, Seoul National University Hospital, Seoul, Korea

,

Hyun Jik Kim

¹Department of Otorhinolaryngology, Head and Neck Surgery, Seoul National University Hospital, Seoul, Korea

,

Dong-Young Kim

¹Department of Otorhinolaryngology, Head and Neck Surgery, Seoul National University Hospital, Seoul, Korea

,

Seong-Joon Kim

²Department of Ophthalmology, Seoul National University Hospital, Seoul, Korea

,

Sang In Khwarg

²Department of Ophthalmology, Seoul National University Hospital, Seoul, Korea

,

Sung-Min Kim

⁴Department of Neurology, Seoul National University Hospital, Seoul, Korea

,

Sun Ha Paek

⁵Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea

⁶Center for Minimally Invasive Skull Base Surgery, Seoul National University Hospital, Seoul, Korea

,

Chae-Seo Rhee

⁷Department of Otorhinolaryngology, Head and Neck Surgery, Seoul National University Bundang Hospital, Seongnamm, Korea

,

Chul Hee Lee

⁷Department of Otorhinolaryngology, Head and Neck Surgery, Seoul National University Bundang Hospital, Seongnamm, Korea

,

Peter H. Hwang

⁸Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California, United States

,

Tae-Bin Won

¹Department of Otorhinolaryngology, Head and Neck Surgery, Seoul National University Hospital, Seoul, Korea

⁶Center for Minimally Invasive Skull Base Surgery, Seoul National University Hospital, Seoul, Korea

› Author Affiliations

Abstract

Objective To analyze the clinical characteristics of and treatment outcomes for orbital apex lesions according to their pathological diagnosis and identify clinical characteristics that could aid in their differential diagnosis.

Design Retrospective analysis design was used for this study.

Setting The study was conducted in a single tertiary institution.

Participants Patients with pathologically confirmed lesions centered in the orbital apex who were admitted between January 2011 and December 2015.

Main Outcome Measures Clinical characteristics, including demographics, predisposing factors, presenting symptoms, radiological findings, intraoperative findings, biopsy results, and treatment outcomes.

Results Nine patients with invasive fungal sinusitis, six with inflammatory pseudotumor, and six with neoplastic or tumorous lesions were enrolled. The most common presenting symptom was orbital pain or headache, followed by ophthalmoplegia and vision loss, which exhibited overall recovery rates of 62.5% and 33.3%, respectively, after definitive treatment. The prognosis was worse for patients with invasive fungal sinusitis. There was no significant difference in age, underlying medical conditions, absolute neutrophil count, C-reactive protein level, and radiological findings among the three groups. Grossly necrotic tissues around the orbital apex area at biopsy were more frequently found in patients with invasive fungal sinusitis than in the other patients. In most cases, pain ameliorated after surgical intervention. There were no surgery-related morbidities.

Conclusions Lesions centered in the orbital apex included invasive fungal sinusitis, inflammatory pseudotumor, and tumorous lesions. However, clinical features that clearly differentiated chronic invasive fungal sinusitis from inflammatory pseudotumor could not be identified. Our findings suggest that prompt biopsy is warranted for timely diagnosis, symptom relief, and early implementation of definitive treatment.

Keywords

orbital apex - invasive fungal sinusitis - inflammatory pseudotumor - biopsy - prognosis

Full Text

References

References
1 Yeh S, Foroozan R. Orbital apex syndrome. Curr Opin Ophthalmol 2004; 15 (06) 490-498
2 Miller C, Suh JD, Henriquez OA, Schlosser RJ, Ramakrishnan VR, Chiu AG. Prognosis for sixth nerve palsy arising from paranasal sinus disease. Am J Rhinol Allergy 2013; 27 (05) 432-435
3 Thurtell MJ, Chiu AL, Goold LA. , et al. Neuro-ophthalmology of invasive fungal sinusitis: 14 consecutive patients and a review of the literature. Clin Experiment Ophthalmol 2013; 41 (06) 567-576
4 DelGaudio JM, Clemson LA. An early detection protocol for invasive fungal sinusitis in neutropenic patients successfully reduces extent of disease at presentation and long term morbidity. Laryngoscope 2009; 119 (01) 180-183
5 Chakrabarti A, Denning DW, Ferguson BJ. , et al. Fungal rhinosinusitis: a categorization and definitional schema addressing current controversies. Laryngoscope 2009; 119 (09) 1809-1818
6 Adelson RT, Marple BF. Fungal rhinosinusitis: state-of-the-art diagnosis and treatment. J Otolaryngol 2005; 34 (Suppl. 01) S18-S23
7 deShazo RD, Chapin K, Swain RE. Fungal sinusitis. N Engl J Med 1997; 337 (04) 254-259
8 Espinoza GM. Orbital inflammatory pseudotumors: etiology, differential diagnosis, and management. Curr Rheumatol Rep 2010; 12 (06) 443-447
9 Li Y, Lip G, Chong V, Yuan J, Ding Z. Idiopathic orbital inflammation syndrome with retro-orbital involvement: a retrospective study of eight patients. PLoS One 2013; 8 (02) e57126
10 Iaconetta G, Fusco M, Cavallo LM, Cappabianca P, Samii M, Tschabitscher M. The abducens nerve: microanatomic and endoscopic study. Neurosurgery 2007; 61 (3, Suppl) 7-14 , discussion 14
11 deShazo RD, O'Brien M, Chapin K, Soto-Aguilar M, Gardner L, Swain R. A new classification and diagnostic criteria for invasive fungal sinusitis. Arch Otolaryngol Head Neck Surg 1997; 123 (11) 1181-1188
12 Aribandi M, McCoy VA, Bazan III C. Imaging features of invasive and noninvasive fungal sinusitis: a review. Radiographics 2007; 27 (05) 1283-1296
13 Desai SV, Spinazzi EF, Fang CH. , et al. Sinonasal and ventral skull base inflammatory pseudotumor: a systematic review. Laryngoscope 2015; 125 (04) 813-821
14 Jiang N, Zhao G, Yang S. , et al. A retrospective analysis of eleven cases of invasive rhino-orbito-cerebral mucormycosis presented with orbital apex syndrome initially. BMC Ophthalmol 2016; 16: 10
15 Ingley AP, Parikh SL, DelGaudio JM. Orbital and cranial nerve presentations and sequelae are hallmarks of invasive fungal sinusitis caused by Mucor in contrast to Aspergillus. Am J Rhinol 2008; 22 (02) 155-158