Abstract
Due to close anatomical relationship of eye with nose and sinuses it is liable to get involved secondary to sinonasal and nasopharyngeal pathology. Sinonasal and nasopharyngeal pathology may present with varied ophthalmic manifestations. Ocular involvement from sinonasal diseases occur due to direct spread to orbit, venous spread due to valveless nature of veins, cranial nerve involvement, nasolacrimal apparatus involvement and intracranial spread. The present study is to determine the sociodemographics, ocular manifestations due to sinonasal and nasopharyngeal pathology, etiological factors and routes of spread. The most common etiology in present study was sinonasal squamous cell carcinoma followed by nasal vestibulitis. The most common ocular pathology was proptosis followed by preseptal cellulitis. The most common route was erosion followed by compression and vascular. To conclude sinonasal and nasopharyngeal pathology can spread to orbit and increase the mortality and morbidity.
Keywords: Sinonasal, Nasopharyngeal, Ocular manifestations, Proptosis, Preseptal cellulitis
Introduction
Due to close anatomical relationship of eye with nose and sinuses it is liable to get involved secondary to Sinonasal and nasopharyngeal pathology [1]. About 3/5th–4/5th of orbital wall is related to sinuses, superiorly being floor of frontal sinus, medially being lateral wall of the ethmoid labyrinth, inferiorly being the roof of the maxillary sinus and posteromedially being the anterolateral wall of the sphenoid sinus [2]. Sinonasal and nasopharyngeal pathology may present with varied ophthalmic manifestations [3]. Ocular involvement from sinonasal diseases occur due to direct spread to orbit, venous spread due to valveless nature of veins, cranial nerve involvement, nasolacrimal apparatus involvement and intracranial spread [4]. Hence anatomical knowledge is essential in understanding the spread of sinonasal and nasopharyngeal pathology, to prevent complications during surgery and to chose different management strategies [5].
Aims and Objectives
To describe the demographic characteristics of ocular manifestations due to sinonasal and nasopharyngeal pathology.
To evaluate the etiology and clinical profile of ocular involvement due to sinonasal and nasopharyngeal pathology.
To identify the routes of spread to eye from nose, sinuses and nasopharynx.
Inclusion Criteria
All age group of patients presenting with ocular symptoms due to sinonasal and nasopharyngeal pathology.
Patients who has given informed consent.
Exclusion Criteria
Patients with ocular manifestations secondary to allergic rhinitis.
Patients with primary ocular and Central nervous system pathology.
Patients with ocular manifestations secondary to trauma and iatrogenic etiology.
Patients who has not given informed consent.
Materials and Methods
Study design: Prospective study.
Study duration: 2 years (June 2017–June 2019).
Study area: Department of ENT, Gandhi Hospital and Govt. ENT hospital, Telangana.
Sample size: 75.
These patients were subjected to detailed history taking, detailed clinical examination, Diagnostic nasal endoscopy, haematological and radiological investigations including CT paranasal sinuses and orbit, contrast imaging and MRI imaging, ophthalmologists and neurologists opinion and management after taking consent. The imaging and surgical exploration helped in identifying the various routes of spread.
Results
See Tables 1, 2; Figs. 1, 2, 3, 4 and 5; and Table 3.
Table 1.
Age and gender distribution of study population
| Number | Percentage | |
|---|---|---|
| Age | ||
| 0–15 years | 7 | 9 |
| 16–30 years | 10 | 13 |
| 31–50 years | 23 | 31 |
| > 50 years | 35 | 47 |
| Gender | ||
| Males | 50 | 67 |
| Females | 25 | 33 |
Table 2.
Etiology and ocular pathology distribution of study population
| Number | Percentage | |
|---|---|---|
| Etiology | ||
| Nasal furunculosis | 5 | 7 |
| Nasal vestibulitis | 8 | 11 |
| Acute bacterial rhinosinusitis | 3 | 4 |
| Acute ethmoidal sinusitis | 3 | 4 |
| Allergic fungal rhinosinusitis | 6 | 8 |
| Acute invasive fungal sinusitis | 3 | 4 |
| Fungal granuloma | 4 | 5 |
| Wegener’s granulomatosis | 2 | 3 |
| Ethmoid mucocele | 1 | 1 |
| Sphenoid mucocele | 2 | 3 |
| Fibrous dysplasia of maxilla | 3 | 4 |
| Fibrous dysplasia of ethmoid | 1 | 1 |
| Frontal sinus osteoma | 1 | 1 |
| Inverted papilloma | 1 | 1 |
| Sinonasal schwannoma | 2 | 3 |
| Juvenile nasopharyngeal angiofibroma | 7 | 9 |
| Sinonasal squamous cell carcinoma | 12 | 16 |
| Sinonasal adenoid cystic carcinoma | 2 | 3 |
| Sinonasal adenocarcinoma | 2 | 3 |
| Olfactory neuroblastoma | 1 | 1 |
| Embryonal rhabdomyosarcoma | 1 | 1 |
| Nasopharyngeal carcinoma | 5 | 7 |
| Ocular pathology | ||
| Proptosis | 49 | 65 |
| Enophthalmos | 2 | 3 |
| Preseptal cellulitis | 17 | 23 |
| Orbital cellulitis | 1 | 1 |
| Epiphora | 10 | 13 |
| Diplopia | 9 | 12 |
| Ophthalmoplegia | 7 | 9 |
| Ptosis | 2 | 3 |
| Blurring of vision | 3 | 4 |
| Loss of vision | 1 | 1 |
Fig. 1.
Routes of spread distribution of study population
Fig. 2.
MRI paranasal sinuses and orbit axial depicting sphenoid mucocele causing compression over right optic nerve
Fig. 3.
CT paranasal sinuses sagittal showing sinonasal schwannoma causing erosion and intracranial spread and resultant eye involvement
Fig. 4.
MRI paranasal sinuses and orbit axial depicting the spread of nasopharyngeal carcinoma via foramen lacerum and leading involvement of cavernous sinus
Fig. 5.
CT paranasal sinuses and orbit coronal depicting embryonal rhabdomyosarcoma causing erosion of lamina papyracea
Table 3.
Etiopathogenesis of Ocular involvement distribution of study population
| Etiopathogenesis | Number | Percentage |
|---|---|---|
| Direct orbital involvement | 27 | 36 |
| Compression | 24 | 32 |
| Cavernous sinus involvement | 2 | 3 |
| Cranial nerve involvement | 10 | 13 |
| Intracranial spread | 4 | 5 |
Discussion
In the present study 75 patients presented to hospital with ocular involvement secondary to sinonasal and nasopharyngeal pathology.
Demographics
Highest incidence was noted in more than 50 years of age group accounting to 35 cases. The least incidence was noted in 0–15 years of age group accounting to 7 cases. The youngest age was 9 months and the eldest was 75 years in present study. Male to female ratio was 2:1. This is in accordance to Malik et al. [6] in which male predominance was noted and largest group was more than 50 years of age group.
Etiology
The etiology responsible for ocular pathology in the present study included Sinonasal Squamous Cell Carcinoma, Nasal Vestibulitis, Juvenile Nasopharyngeal Angiofibroma, Allergic Fungal Rhinosinusitis, Nasal Furunculosis, Nasopharyngeal Carcinoma, Fungal Granuloma, Acute Invasive Fungal Sinusitis, Acute Bacterial Rhinosinusitis, Acute Ethmoidal Sinusitis, Fibrous Dysplasia of Maxilla, Wegener’s Granulomatosis, Sphenoid Mucocele, Sinonasal Schwannoma, Sinonasal Adenoid Cystic Carcinoma, Sinonasal Adenocarcinoma, Ethmoid Mucocele, Fibrous Dysplasia of Ethmoid, Frontal Sinus Osteoma, Inverted Papilloma, Olfactory Neuroblastoma, Embryonal Rhabdomyosarcoma in descending order. The most common etiology responsible for ocular manifestations were Sinonasal Squamous Cell Carcinoma (12) followed by Nasal Vestibulitis (8). Various studies Sabharwal [7] and Johnson et al. [8] state that Squamous cell carcinoma of sinuses involves the orbit.
Ocular Pathology
The ocular pathology in the present study were Proptosis, Preseptal Cellulitis, Epiphora, Diplopia, Ophthalmoplegia, Blurring of vision, Enophthalmos, Ptosis, Orbital cellulitis, Loss of vision. The most common Ocular pathology secondary to Sinonasal and nasopharyngeal etiology was Proptosis (49) followed by Preseptal cellulitis (17). This is in accordance to Sinha et al. [9] who concluded that proptosis is the commonest clinical presentation in neoplastic lesions of nose and paranasal sinuses. This is also similar to Ghosh et al. [10] according to which Proptosis followed by Preseptal cellulitis was the most common ocular manifestation secondary to ENT disorders.
Routes of Spread
The most common route of spread in present study noted was erosion of anatomical barriers (30) followed by compression of anatomical barriers (24), vascular spread (13). Sinonasal and nasopharyngeal malignancies accounted for highest number of erosions whereas infective causes i.e. nasal vestibulitis and furunculosis accounted to vascular spread. Benign tumors like nasopharyngeal angiofibroma, frontal sinus osteoma, inverted papilloma accounted to highest number of compressions. The least common route of spread was through fissures (3) followed by foramens (5). In present study 27 cases had direct orbital involvement, 4 cases had intracranial spread, 2 cases had cavernous sinus involvement, 10 cases had cranial nerve involvement which were responsible for ophthalmic manifestations. One case of acute bacterial pansinusitis and one nasal furunculosis complicated to cavernous sinus thrombosis. One case of acute bacterial pansinusitis complicated to orbital cellulitis.
Conclusion
Majority of sinonasal and nasopharyngeal pathologies involved the orbit secondarily leading to high morbidity and mortality. The anatomical knowledge and imaging proved helpful in identifying the routes of spread. Routes of spread is crucial to understanding the etiopathogenesis of disease. Early diagnosis and treatment can limit the complications and decrease the morbidity and mortality.
Compliance with Ethical Standards
Conflict of interest
The authors declare that they have no competing interests.
Human and Animal Rights
No animals are involved in research.
Informed Consent
Informed consent has been taken from all the patients who were included.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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