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Diplopia: an uncommon presentation of silent sinus syndrome.

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A 53-year-old woman presented to our institution with a 2-month history of diplopia, followed by bouts of intermittent vertical diplopia that were more pronounced later in the day. She also reported drooping of her left eyelid, occasional gait instability and headaches that were possibly indicative of myasthenia gravis.

Acetylcholine levels and neuroimaging studies were ordered to rule out intracranial pathology. The patient denied cognitive or speech difficulty, hearing loss, vertigo, focal weakness, and visual disturbances. Her medical history included rheumatoid arthritis and bilateral blepharoplasty but was otherwise insignificant. Physical examination revealed normal pupils with normal reaction to light, full extraocular movements with prominent gaze-evoked nystagmus, and slight left eyelid droop with no ptosis. Magnetic resonance imaging (MRI) of the head and orbits demonstrated an unexpected atelectatic left maxillary sinus with a contracted orbital floor and ipsilateral enophthalmos, consistent with silent sinus syndrome (figure).

Silent sinus syndrome is an uncommon clinical condition characterized by gradual and spontaneous retraction of the maxillary sinus with progressive enophthalmus and hypoglobus resulting from collapse of the orbital floor. (1) It was first described by Montgomery in 1964 as a mucocele of the maxillary sinus,2 and in 1994, the term silent sinus syndrome was introduced by Soparkar et al. (3)

The etiology of the disease is based on the primary predisposing factor, which is an obstruction of the ostiomeatal complex that results in hypoventilation of the maxillary sinus gases. This generates a negative pressure that draws sterile fluid from the mucosa, resulting in inflammation with posterior development of osteopenia secondary to bone resorption, leading to inward retraction of the maxillary sinus walls. (1,4)

The association between diplopia and silent sinus syndrome is uncommon. (5) Diplopia in this syndrome is secondary to the displacement of the globe interiorly as the maxillary sinus contracts. (5,6) Another cause of diplopia is the displacement of the orbital floor, which increases tension on the muscle cone and the orbital septum. (6)

Silent sinus syndrome is more frequently identified in the third and fifth decades of life with no sex predominance. (4) Asymptomatic individuals can develop progressive, painless enophthalmus with hypoglobus. (4) As previously mentioned, diplopia is an unusual symptom in this disease. (5) The differential diagnosis of silent sinus syndrome includes atrophy of the orbital contents secondary to Wegener granulomatosis, scirrhous metastasis, chronic sinusitis, and osteomyelitis, among others. (2,7) Clinical findings and imaging studies with computed tomography and MRI are essential for the adequate diagnosis of this disease process.

Silent sinus syndrome treatment is based on relieving the ostiomeatal obstruction with endoscopic uncinectomy, which results in evacuation of the maxillary sinus. (7)

References

(1.) Guillen DE, Pinargote PM, Guarderas JC. The silent sinus syndrome: Protean manifestations of a rare upper respiratory disorder revisited. Clin Mol Allergy 2013;11(1):5.

(2.) Montgomery WW. Mucocele of the maxillary sinus causing enophthalmos. Eye Ear Nose Throat Mon 1964;43:41-4.

(3.) Soparkar CN, Patrinely JR, Cuaycong MJ, et al. The silent sinus syndrome. A cause of spontaneous enophthalmos. Ophthalmology 1994;101(4):772-8.

(4.) Kilty SJ. Maxillary sinus atelectasis (silent sinus syndrome): Treatment with balloon sinuplasty. J Laryng Otol 2014;128(2):189-91.

(5.) Saffra N, Rakhamimov A, Saint-Louis LA, Wolintz RJ. Acute diplopia as the presenting sign of silent sinus syndrome. Ophthal Plast Reconstr Surg 2013;29(5):e130-1.

(6.) Zhang C, Phamonvaechavan P, Christoff A, Guyton DL. Silent sinus syndrome causing cyclovertical diplopia masquerading as superior oblique paresis in the fellow eye. JAAPOS 2010;14(5):450-2.

(7.) Annino DJ Jr., Goguen LA. Silent sinus syndrome. Curr Opin Otolaryngol Head Neck Surg 2008;16(1):22-5.

Juan Gomez, MD; David Liu, MD; Enrique Palacios, MD; Jeremy Nguyen, MD

From the Department of Radiology, Tulane School of Medicine, New Orleans.
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Title Annotation:IMAGING CLINIC
Author:Gomez, Juan; Liu, David; Palacios, Enrique; Nguyen, Jeremy
Publication:Ear, Nose and Throat Journal
Article Type:Case study
Geographic Code:1USA
Date:Jul 1, 2015
Words:624
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