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Editor,—Spontaneous displacement of the eyeball caused by maxillary sinusitis is rare but is well documented. Different treatments have been suggested but all are surgical. Spontaneous enophthalmos due to maxillary sinusitis was first described by Montgomery; there have since been a series of reports describing this condition. The mechanism appears to arise from obstruction of the osteomeatal complex which impairs sinus ventilation. The resorption of retained secretions within the sinus produces a negative pressure which results in erosion of the thin orbital floor. In the absence of trauma the triad of obstructive sinus disease, diminished antral volume, and enophthalmos has been thought to be caused by inflammatory resorption and inferior displacement of the orbital floor. The globe is also displaced downwards and backwards such that the patient will have a narrow palpebral fissure and a deep superior sulcus above the eye.
A 29 year old white male presented to the ophthalmology clinic having noticed that his right eye had been at a lower level than left one for the previous 2 years. There was no history of trauma. There were no nasal complaints or past history of sinusitis. On examination, the right globe was displaced inferiorly by 5–6 mm. Ophthalmic examination, including a visual acuity cover test and ocular movements were otherwise normal. A computed tomograph (CT) scan showed an opaque right maxillary antrum which was hypoplastic. The floor of the orbit was eroded and the right eyeball had sunk into the antrum (Fig1).
He was seen in the ENT clinic and listed for an endoscopic middle meatal antrostomy and repair of the orbital floor. The patient changed his address and we were unable to contact him. Three years later, he contacted the ENT department to inquire about his appointment. We advised him that a further review might be beneficial. When reviewed the right eye was noted to be in a normal position. A repeat scan was undertaken which showed a well aerated right maxillary sinus which was larger than on the previous CT scan. The right orbital floor appeared well ossified and at a higher level than before (Fig 2). In view of these findings, it was decided that no further management was required.
In this case report the support of the orbital floor was presumably lost secondary to blockage of osteomeatal complex and subsequent inflammatory changes and/or pressure changes within the antrum. Previous reports have advocated the surgical reconstitution of the orbital floor at an early stage. Maxillary sinusitis is frequently a self resolving disease, as occurred in this case. Resolution of maxillary sinusitis, inflammatory and pressure components that produced the displacement of eyeball appears to have taken place. In the absence of negative pressure in the maxillary antrum and with orbital floor periosteum intact, new bone was laid down to reform the orbital floor with subsequent repositioning of the globe.
This case raises the question as to whether surgical intervention is required in these cases if the maxillary sinus disease can be treated or resolves of its own accord. Should medical or conservative management be inadequate then it can be hypothesised that a simple middle meatal antrostomy may be enough, following which the orbital floor might reform without need for reconstruction. The authors suggest this as a hypothesis extrapolating from the events that occurred in this patient.