Endoscopic Ultrasonic Dacryocystorhinostomy for Recurrent Dacryocystitis Following Rhinoplasty

Abstract: The lacrimal sac is the structure most vulnerable to injury when performing osteotomies for rhinoplasty. When performed in a low lateral position or along the frontal process of the frontal-maxillary suture, osteotomies have the potential to tear the medial canthal ligament and injure the underlying lacrimal sac resulting in dacryocystitis. We report a case of dacryocystitis in a 19 year old male who presented with recurrent episodes of pain, tearing, and discharge from his left eye following primary rhinoplasty. He was found to have obstruction of the lacrimal system secondary to a low lateral osteotomy with an impinging bone fragment on imaging. Endoscopic dacryocystorhinostomy was performed using a Sonopet® ultrasonic bone aspirator under image guidance to remove the bone fragments posing risk to further injury to the lacrimal sac and orbit. Patency of the nasolacrimal duct was achieved and the patient remained symptom free at 6 month follow up. We describe the first case of recurrent dacryocystitis following rhinoplasty requiring treatment by an endoscopic dacryocystorhinostomy (DCR). Endoscopic DCR with the use of the ultrasonic bone aspirator provides several advantages over open DCR, including the lack of an external incision and decreased risk of injury to the adjacent orbital soft tissue anatomy including the lacrimal system

NUT Midline Carcinoma in a Pregnant Woman

NUT midline carcinoma is a rare, highly aggressive tumor that involves midline structures, particularly in the head, neck and mediastinum. It is characterized by NUT gene translocations on chromosome 15. It typically impacts teenagers or young adults, and has a fulminant course leading to death in less than a year in most cases despite aggressive chemoradiotherapy. Due to its location, this tumor is frequently considered inoperable. We present a case of a sinonasal NUT midline carcinoma with orbital invasion discovered during the workup of sinusitis in a young, pregnant woman. The tumor was managed with definitive excision to negative margins followed by aggressive chemoradiation, with no evidence of recurrence for 12 months. We propose that diagnosis of NUT midline carcinoma should prompt recognition of the limitations of current medical therapy and rapid surgical intervention should be undertaken when possible

Paradoxical Worsening of Ocular Symptoms after Spontaneous Closure of a Carotid Cavernous Fistula: Case Report

We report an interesting case of a spontaneous occlusion of a carotid cavernous fistula (CCF) causing a paradoxical worsening of orbital symptoms. A 59-year-old woman presented to our institution with conjunctival injection, raised intraocular pressures (IOP) and mild exophthalmos of her left eye. A digital subtraction angiography (DSA) demonstrated a Type-D CCF draining into the left superior ophthalmic vein (SOV). The patient declined endovascular treatment. She presented 15 months later with acute exacerbation of her orbital signs and symptoms. A DSA showed no evidence of arteriovenous fistula, and a brain MRI was consistent with spontaneous thrombosis of the SOV. At her 2-week clinical assessment, the patient showed clinical improvement and her IOP were within normal limits. Spontaneous thrombosis of the SOV can trigger the obliteration of a CCF with possible paradoxical worsening of orbital symptoms. DSA is the gold standard of diagnosis and management is directed toward decreasing IOP. Introduction We present an interesting case of a type-D carotid cavernous fistula (CCF) that closed spontaneously with a paradoxical worsening of the symptoms due to thrombosis of the superior ophthalmic vein (SOV). The authors also give directives for the management of these extremely rare cases

Enophthalmos and Diplopia with a History of Breast Cancer (CT)

DiplopiaAn 82-year old female with a 2-month history of painless double vision. Previous history significant for bilateral cataract surgery, mastectomy and lymph node dissection for breast carcinoma.VA: 20/25 OU; Exophthalmometry: 15 OD, 18 OSCTFibrous proteins in intraconal fat and inferior rectus muscle.Surgery1. Goldberg RA, Rootman J. Clinical characteristics of metastatic orbital tumors. Ophthalmology, 1990;97:620-4. 2. Murdoch IE, Sullivan TJ, Moseley I et al. Primary localised amyloidosis of the orbit. Br J Ophthalmol 1996;80:1083-6. 3. Raflo GT, Farrell TA, Siousat RS. Complete ophthalmoplegia secondary to amyloidosis associated with multiple myeloma. Am J Ophthalmol 1981;92:221-4.VBamyloidosi

Enophthalmos and Diplopia with a History of Breast Cancer (Pathology)

DiplopiaAn 82-year old female with a 2-month history of painless double vision. Previous history significant for bilateral cataract surgery, mastectomy and lymph node dissection for breast carcinoma.VA: 20/25 OU; Exophthalmometry: 15 OD, 18 OSCTFibrous proteins in intraconal fat and inferior rectus muscle.Surgery1. Goldberg RA, Rootman J. Clinical characteristics of metastatic orbital tumors. Ophthalmology 1990;97:620-4. 2. Murdoch IE, Sullivan TJ, Moseley I et al. Primary localised amyloidosis of the orbit. Br J Ophthalmol 1996;80:1083-6. 3. Raflo GT, Farrell TA, Siousat RS. Complete ophthalmoplegia secondary to amyloidosis associated with multiple myeloma. Am J Ophthalmol 1981;92:221-4.VBamyloidosi

Enophthalmos and Diplopia with a History of Breast Cancer (Pathology)

DiplopiaAn 82-year old female with a 2-month history of painless double vision. Previous history significant for bilateral cataract surgery, mastectomy and lymph node dissection for breast carcinoma.VA: 20/25 OU; Exophthalmometry: 15 OD, 18 OSCTFibrous proteins in intraconal fat and inferior rectus muscle.Surgery1. Goldberg RA, Rootman J. Clinical characteristics of metastatic orbital tumors. Ophthalmology 1990;97:620-4. 2. Murdoch IE, Sullivan TJ, Moseley I et al. Primary localised amyloidosis of the orbit. Br J Ophthalmol 1996;80:1083-6. 3. Raflo GT, Farrell TA, Siousat RS. Complete ophthalmoplegia secondary to amyloidosis associated with multiple myeloma. Am J Ophthalmol 1981;92:221-4.VBamyloidosi

Enophthalmos and Diplopia with a History of Breast Cancer

DiplopiaAn 82-year old female with a 2-month history of painless double vision. Previous history significant for bilateral cataract surgery, mastectomy and lymph node dissection for breast carcinoma.VA: 20/25 OU; Exophthalmometry: 15 OD, 18 OSCTFibrous proteins in intraconal fat and inferior rectus muscle.Surgery1. Goldberg RA, Rootman J. Clinical characteristics of metastatic orbital tumors. Ophthalmology, 1990;97:620-4. 2. Murdoch IE, Sullivan TJ, Moseley I et al. Primary localised amyloidosis of the orbit. Br J Ophthalmol 1996; 80:1083-6. 3. Raflo GT, Farrell TA, Siousat RS. Complete ophthalmoplegia secondary to amyloidosis associated with multiple myeloma. Am J Ophthalmol 1981;92:221-4.curriculum_fellow; VBenophthalmo

Enophthalmos and Diplopia with a History of Breast Cancer (Pathology)

DiplopiaAn 82-year old female with a 2-month history of painless double vision. Previous history significant for bilateral cataract surgery, mastectomy and lymph node dissection for breast carcinoma.VA: 20/25 OU; Exophthalmometry: 15 OD, 18 OSCTInfiltrate in the intraconal spaceSurgery1. Goldberg RA, Rootman J. Clinical characteristics of metastatic orbital tumors. Ophthalmology 1990;97:620-4. 2. Murdoch IE, Sullivan TJ, Moseley I et al. Primary localised amyloidosis of the orbit. Br J Ophthalmol 1996;80:1083-6. 3. Raflo GT, Farrell TA, Siousat RS. Complete ophthalmoplegia secondary to amyloidosis associated with multiple myeloma. Am J Ophthalmol 1981;92:221-4.VBamyloidosi

Ocular adnexal metastases from renal cell carcinoma: An update and comprehensive literature review

PURPOSE: The purpose of this study was to review the clinical presentation, systemic work-up, and outcomes of all previously reported ocular adnexal (OA) metastases from renal cell carcinoma (RCC). METHODS: This was a literature review. PubMed and Google Scholar databases were searched for all well-documented cases of OA metastases from RCC. RESULTS: Final analysis identified 44 patients with either biopsy-confirmed (41/44, 93%) or treatment response-documented (3/44, 6%) OA metastases from RCC. Thirty-four (77%) patients were male. The median age was 60 years (mean: 60, range: 22-87 years). The most common presenting signs were proptosis (19/44, 43%) and OA mass (14/44, 32%). Metastases most frequently involved the orbital bones (10/44, 23%) and adjacent extraconal fat, extending from the sinonasal tract in 7/10 (70%) of these cases. OA metastases were initial manifestation of RCC in 18/44 (41%) patients. At the time of primary tumor diagnosis, 22 of 30 (73%) patients had American Joint Committee on Cancer Stage IV disease with metastases to 2 or more sites in 13 (57%) patients. Seventeen of 42 (40%) patients underwent local therapy only, which most commonly included excision/exenteration with margin control (10/17, 59%). Twenty-five of 42 (60%) patients had systemic therapy, which included biologic agents and chemotherapy. The absolute 5-year survival rate was 66% with significantly improved survival in patients reported after 2006 (92% vs. 42%, P = 0.04) and in those with isolated OA metastases (100% vs. 27%, P = 0.02) at 30 months. CONCLUSION: Although RCC metastases to OA occur in a setting of advanced disease, the recent advances in diagnostic modalities and targeted therapies resulted in improved survival