Elsevier

Ophthalmology

Volume 110, Issue 4, April 2003, Pages 811-818
Ophthalmology

Regular article
Clinical and radiologic characteristics of the imploding antrum, or “silent sinus,” syndrome

https://doi.org/10.1016/S0161-6420(02)01993-0Get rights and content

Abstract

Objectives

To present the clinical and radiologic details of a series of patients with the imploding antrum, or silent sinus, syndrome, together with examples of the surgical findings and management.

Design

Retrospective, noncomparative case series.

Participants

Fourteen patients assessed in the Orbital Service at Moorfields Eye Hospital.

Main outcome measures

Changes of clinical signs, symptoms, and radiologic signs.

Results

Seven men and seven women, between the ages of 25 and 78 years (mean, 41.3 years), had unilateral enophthalmos, their having noted the anomaly for an average of 8 months (range, 1–36 months). All patients were nonsmokers. There was no evidence of progression of the condition in eight cases followed up for up to 63 months. On the affected side, there was 1 to 4 mm enophthalmos and up to 4 mm hypoglobus, with secondary narrowing of the vertical palpebral aperture in some cases, but no effect on visual function, and there was significant disturbance of ocular motility in only one case. The condition is characterized radiologically by a smooth inward bowing of the walls of the maxillary antrum on the affected side, with secondary enophthalmos and hypoglobus. In all 14 cases, the maxillary roof (orbital floor) was drawn downwards, and the medial and posterolateral walls of the maxilla were concave in 13 cases where it could be assessed. In one patient, there was associated inward collapse of the ipsilateral ethmoid complex. There was a patchy loss of mineral from the maxillary roof in 9 of 13 cases and, where the posterolateral maxillary wall was affected, there was a concomitant increase in the radiolucency (fat) of the pterygopalatine fossa. Some soft-tissue changes were present in the affected antrum in all 14 patients, and there was an air–fluid level in three patients. In 12 patients where septal deviation was present, this was to the affected side in 10 (83%), and an abnormally directed middle turbinate was also frequently observed (10 of 14 cases).

Conclusions

The silent sinus syndrome mainly presents as unilateral enophthalmos in younger people and has very characteristic clinical and radiologic signs with, in many cases, abnormal intranasal anatomic characteristics on the affected side. The condition may be exclusive to nonsmokers. The acute onset and long-term stability of the condition suggests that, although chronic and largely asymptomatic sinus disease may be the underlying cause, an acute event precipitates collapse of the orbital floor or (in fact) a widespread “implosion” of all antral walls resulting from maxillary atelectasis. Therefore, we prefer the term imploding antrum syndrome—describing the relatively acute, symptomatic, event—rather than the name silent sinus syndrome, which relates to a putative underlying mechanism.

Section snippets

Patients and methods

The clinical records were reviewed for all patients who, between 1990 and 2000, had been given a diagnosis of imploding antrum syndrome after attending the Orbital Clinic at Moorfields Eye Hospital. The presenting symptoms and signs were recorded and, in those not choosing surgical treatment, the natural history noted.

The radiologic changes on computed tomographic scans of the orbit (and sinuses, where available) were reviewed—independently of clinical details—by two radiologists (LH, IM).

Patient 4

A 42-year-old man was referred to the Orbital Clinic, having noted a rapidly progressive painless “dropping” of the right eye approximately 3 months before the clinic visit. With the exception of a brief episode of diplopia, he was otherwise asymptomatic and had no past medical problems, injuries, or surgery.

He had a Snellen acuity of 6/5 in either eye, with no optic neuropathy and no intraocular disease on either side. There was 2 mm of right relative enophthalmos and 4 mm of right hypoglobus,

Clinical features

Fourteen patients (seven men) between the ages of 25 and 78 years (mean, 41.3 years; median, 39 years) who had been symptomatic for between 1 and 36 months (mean, 8 months; median, 6.5 months; Table 1) were treated for imploding antrum syndrome. The right eye was affected in 8 of 14 (57%) cases.

All patients had noted a change in facial appearance, either a ‘sunken eye’ appearance or deepening of the upper lid sulcus, and six patients mentioned intermittent vague discomfort around the affected

Discussion

The pathognomonic clinical features of the imploding antrum, or silent sinus,2 syndrome are spontaneous, fairly rapidly progressive, unilateral enophthalmos and hypoglobus resulting from a downward bowing of the orbital floor in the absence of significant symptomatic chronic sinonasal disease. In both the previously reported cases2 and the present series, the condition would seem to present almost exclusively in the third through fifth decades of life, with symptoms resulting from an expansion

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