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Balasubramanian, Thiagarajan

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Volume 3 Issue 2  2013                                                          ISSN:2250-0359
Proptosis due to otolaryngology causes a study
*Balasubramanian Thiagarajan        *Kamakshi Kothandaraman
* Stanley Medical College
Abstract:
Proximity of orbit to nose and paranasal sinuses makes it rather vulnerable to insults due to 
otolaryngological causes.  The medial wall of orbit (Lamina papyracea) is rather paper thin and it 
happens to form the lateral wall of anterior ethmoid air cells.  Infections / tumors involving 
paranasal sinuses can involve orbit also causing proptosis.  The aim of the article is to study the 
common otolaryngological causes of proptosis in our Institution during 2009 – 2012.
Introduction:
Proptosis is defined as abnormal protrusion of eyeball.  It has in fact been used interchangeably 
with exophthalmos.  Purists consider exophthalmos as proptosis with lid lag (since it is commonly 
associated with Grave's disease).  According to Epstein in Proptosis the globe protrudes out by 18 
mm or less and exophthalmos is globe  protrusion of  more than 18 mm
 1.   Henderson prefers 
reserving the term exophthalmos to proptosis caused by endocrine causes
 2.  Proptosis should be 
differentiated from exorbitism which is caused by decrease in the volume of orbit causing the 
orbital contents to protrude anteriorly.  In exorbitism proptosis is always anterior.
Anatomy of orbit and its relationships with paranasal sinuses:
Orbit is related to paranasal sinuses in two ways:
1. Anatomically by its location and by
2. 2. venous drainage (They both share the same venous drainage).
The paranasal sinuses surround the orbit from 11 o clock position superiorly to 6 o clock position 
inferiorly.
The orbit is pyramidal shaped formed by several bones. The superior wall of the orbit is shared by 
the floor of the frontal sinus, the floor of the orbit is shared by the roof of the maxillary sinus, the 
medial wall of the orbit is shared by the lateral wall of ethmoidal sinus. These shared bones are 
really thin enabling infections to travel from either direction. The medial wall of the orbit is so thin 
that it is termed as lamina papyracea.
Anatomical uniqueness of orbit:
1. It is a closed space2. It is devoid of lymphatics
3. Intraorbital pressure may increase to a limit of breaking point
4. Main constituents of orbit are muscle and fat
5. Extraocular muscles are fine voluntary muscles with excessive interstitial tissue
Peculiarities of venous drainage in this area: The veins draining this area are peculiar in the 
following aspects:
1. The whole venous system in this area is devoid of valves, consequently a two way pathway of 
infection between the orbit, nasal cavity and paranasal sinuses become a reality.
2. The superior ophthalmic vein connects the facial veins to the cavernous sinus thus causing 
infections from face to spread to the cavernous sinus.
3. One branch of the inferior ophthalmic vein connects the orbit with that of the veins of pterygoid 
plexus and the other branch connects the orbit with that of the cavernous sinus.
The approximate volume of the orbital cavity is about 30 ml. Since the contents of the orbit are 
within a rigid confines of the orbital walls any disease process within the orbit or adjacent region 
has a tendency to displace the orbital contents forwards, this displacement of the globe is known as 
the proptosis. Other symptoms of globe displacement include diplopia, and visual loss.
   Exopthalmos due to Graves disease                            Proptosis due to frontoethmoidal mucocele
Methadology:
All patients who present to otolaryngology department outpatient during the period 2009 – 2012 
were taken up for study.  Bilateral proptosis (exopthalmos) was excluded from our study.
Type of study: Retrospective
Aim:
1. To ascertain various otolaryngological causes of proptosis
2. To ascertain the various otolaryngological clinical presentations of these patients with 
proptosisAll these patients under went radiological imaging to prove the exact cause for proptosis.
Opthalmologist opinion was sought for all these patients to rule out ophthalmoligical cause for 
proptosis.  
Results:
Number of patients presented to Otolaryngology department with proptosis: 62
Male – 46
Female – 16
Fungal sinusitis – 12
Fronto ethmoidal mucocele – 8
Maxillary sinus malignant tumors – 11
Ethmoidal malignancy – 2
Nasal polyposis – 9
Fibrous dysplasia
 5 – 6
Juvenile nasopharyngeal angiofibroma – 8
Osteoma frontal sinus
 4 – 4
Orbital cellulitis – 1
Cavernous sinus thrombosis – 1
This study reveals fungal sinusitis to be commonest otolaryngological cause for proptosis.  Fungal 
sinusitis were initially considered as ethmoiodal polyposis causing proptosis
 3.  
Graph showing various otolaryngological causes of proptosisDiscussion:
This study reveals changing trends in the causative factors of proptosis
 6  (This reference illustrates 
JNA to be the common otolaryngological cause for proptosis).  Fungal sinusitis is gradually 
emerging as one of the common otolaryngological causes of proptosis.
The mnemonic VEIN is helpful in remembering the causes of proptosis.
V - Vascular causes
E - Endocrine causes
I - Inflammation and infective causes
N - Neoplastic causes
Imaging studies:
CT scan and MRI scan of the orbit may prove beneficial in diagnosing the cause for proptosis. The 
presence of fat in the orbit serves as an inherent contrast medium for the study. 3 mm cuts are ideal 
for the study of orbit. Ultrasound studies using either A or B mode may help in rapid diagnosis of 
the cause for proptosis.
Vascular causes of proptosis:
Vascular causes of proptosis can be classified into arterial and venous causes. Venous causes are 
due to the formation of dilated veins known as varices. Patients with these varices give a classic 
history of positional proptosis (proptosis varying with positions) or proptosis being induced by 
valsalve manuver. In patients with long standing varices there is also an associated orbital fat 
atrophy leading on to a transient stage of enophthalmos. In these patients a valsalva maneuver may 
reveal proptosis. CT scan performed with jugular venous compression or during a valsava maneuver 
may prove diagnostic. Surgical intervention in these patients may prove disastrous, hence 
observation and treatment of complications is advisable.
In dural venous sinus fistula the shunt is low flow in type and proptosis is insiduous in onset, high 
index of suspicion is necessary in diagnosing these patients.
Carotid cavernous fistula (high flow shunts) may arise as a result of trauma or spontaneously. These 
patients have subjective bruits, proptosis, chemosis and vision loss. The conjunctival vessels 
become arteriolised assuming a cock screw pattern. A fistula of spontaneous occurrence has a better 
chance of spontaneous resolution, but in intractable cases the shunt must be closed with a balloon or 
carotid artery ligation.
Endocrine causes of proptosis: are the most common cause of exophthalmos. The diagnosis is fairly 
simple because it is invariable associated with lid signs like lid lag. The major endocrine cause for 
proptosis is thyrotoxicosis. This condition is also known as Graves disease.
Characteristic features of endocrine causes of proptosis:
1. Presence of lid lag / lid retraction
2. Presence of temporal flare in the upper eyelid
3. Presence of orbital congestion
CT scan of the orbit show enlarged extra ocular muscles, there may also be a bulging of orbital 
septum due to protrusion of fat. This is pathognomonic of Grave's disease. TSH estimation show 
elevated levels in the serum.
Inflammatory causes of proptosis: In inflammatory proptosis the lesion could be either an idiopathic 
inflammatory orbital pseudotumor, or due to specific orbital inflammation. Proptosis in these patients appear suddenly and acutely. These patients are invariably toxic and febrile. Myositis of 
extra ocular muscles may cause pain when eyes are being moved. There may also be associated 
acute dacryo adenitis. There may also be peri optic neuritis causing blindness. Orbital inflammation, 
perioptic neuritis and dacryo adenitis are highly responsive to oral prednisolone.
Inflammations involving the paranasal sinuses may involve the orbit causing proptosis. The 
interveining walls between the medial orbital wall and the ethmoidal sinuses is paper thin (lamina 
papyracea) which can be easily breached by infections from the ethmoidal sinuses causing spread to 
the orbit. In proptosis caused by ethmoidal sinus pathology the eye is pushed laterally, where as 
proptosis due to maxillary sinus pathology causes deviation of the eye upwards and outwards. In 
frontal sinus pathology the eye is deviated downwards and outwards. Commonest sinus 
inflammatory cause for proptosis is the formation of mucoceles in the paranasal sinuses. This 
commonly occur in the fronto ethmoidal regions.
Neoplastic causes of proptosis: Neoplasms involving orbit may cause proptosis. Here the eye is 
pushed directly forwards. This type of proptosis is known as axial proptosis. Tumors involving the 
optic nerve can cause axial proptosis. These patients have pain free disease. The only exception to 
lack of pain is patients with adenocystic carcinoma of lacrimal gland. These patients have excessive 
pain because the tumor infiltrates the nerves.
Neoplastic lesions involving the paranasal sinuses can also cause proptosis. The common benign 
tumor involving the sinuses causing proptosis are:
1. Inverted papilloma
2. Fungal infections involving the paranasal sinuses
3. Mucoceles involving the paranasal sinuses
4. Fibrous dysplasia of the maxilla
5. Osteomas involving the frontal and ethmoidal sinuses
6. Juvenile nasopharyneal angiofibroma
Coronal CT scan showing proptosis due to frontoethmoidal mucoceleImage showing proptosis due to fibrous dysplasia
Figure showing proptosis due to frontoethmoidal mucocele
Figure showing proptosis due to fungal sinusitisFigure showing proptosis due to JNA
Measuring proptosis using exopthalmometer:
Hertel mirror exophthalmometers are used to measure the degree of protrusion of the eyeball. The 
distance between the lateral orbital rim and corneal apex is used as an index for measuring 
proptosis. Under normal conditions this distance is roughly 18 mm, there may be individual and 
racial variations.
Procedure: The examiner is seated infront of the patient at the eye level of the patient. The 
exophthalmometer is then positioned with the blue arched support at the temporal lateral orbital 
walls. The instrument is maneuvered using both hands and firmly propped first against the 
right-hand orbital wall on the temporal side (which should be felt against the lowest part of the 
support point). The movable part is then set in such a way that the left-hand orbital wall lies against 
the lowest part of the arched support. The distance between the lateral orbital walls can then be read 
from the upper side of the scale; this distance can be noted for future reference. The examiner asks 
the patient to look straight ahead with eyelids wide open. The examiner measures for proptosis in 
each eye Separately by looking into the mirror (which has a millimeter scale marked on it) with one 
eye and moving the head horizontally until the red fixations line is at 22mm. The examiner can now 
determine the position of the corneal apex of the patient from the millimeter reading.
Conclusion:
This study reveals that fungal sinusitis is emerging as a common otolaryngological cause for 
proptosis.  A large sample study will throw more light on this problem.  In all the previous studies 
reviewed Malignant tumors involving nose and sinuses was cited to the most common 
otolaryngological cause for proptosis.References:
1. Epstein O, Perkin D, Cookson J, deBono DP. Clinical Examination. 3Rd ed. Mosby; 2003.
2. Henderson JW. Orbital Tumors. 3Rd ed. New York: Raven Press; 1994.
3. Calcaterra TC, Trapp KT, Unilateral proptosis Otoaryngologic Clinics of North America 
1988; 21: 53- 63.
4. Atallah N and Jay M.M.. (1981) Osteomas of the paranasal sinuses. Journal of Laryngology 
and Otology 95, 291-304.
5. THIAGARAJAN, Balasubramanian. Fibrous dysplasia of Faciomaxillary region case 
reports and review of literature. Otolaryngology online journal, US, v. 1, n. 1.5, oct. 2012. 
ISSN 2250- 0359. Available at: <http    ://    jorl    .    net    /    index    .    php    /    jorl    /    article    /    view    /9    >. Date 
accessed: 24 Nov. 2012.
6. PROPTOSIS THROUGH EYES OF E.N.T. SURGEON Vikas Sinha, Deepak Bhardwaj, 
Ajay George, Rizwan A. Memon Indian Journal of Otolaryngology and Head and Neck 
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