Facts in Nutshell regarding proptosis from otorhinolaryngology point of view.

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BY,
DR.ASHWIN MENON

3.  Forward displacement or bulging of the eye.
 The word Proptosis is derived from Latin: propiptein
pro- forward + piptein- to fall
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4.  If protrusion of globe is 18 mm / less it is known as
proptosis.
 If protrusion of globe is more than 18 mm it is known
as exophthalmos.
 Proptosis + lid lag = exopthalmos.
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5.  This is caused due to decrease in the volume of orbit
causing the orbital contents to protrude anteriorly.
 Usually bilateral.
 Should be differentiated from proptosis /
exophthalmos.
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7.  Volume of orbit is fixed -
30 ml.
 Increase in soft tissue
volume of 5 ml will cause 5
mm of proptosis.
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8.  Resembles a four sided
pyramid
 Rim is 40 mm horizontally
and 35 mm vertical in an adult
male
 Medial walls are parallel and
25 mm apart in adults
 Lateral orbital walls angle
about 90 degrees from each
other
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9.  Superior orbital rim - Frontal bone.
 Inferior rim - Maxillary bone (medially)
Zygomatic bone (laterally)
 Lateral orbital rim – Zygoma.
 Superior rim contains a notch at the junction of medial
and lateral thirds (supraorbital notch).
 Medial portion of the rim is formed by frontal process of
maxilla.
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11.  Lodges the lacrimal sac
 This fossa is formed by
maxillary and lacrimal
bones
 Bounded by anterior and
posterior lacrimal crests
 Anterior crest is formed by
maxillary bone
 Posterior lacrimal crest is
formed by lacrimal bone
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12.  Lies anterior to lacrimal fossa.
 Also known as sutura longitudinalis imperfecta.
 This suture runs parallel to anterior lacrimal crest.
 Infraorbital nerve & artery pass through it to supply
nasal mucosa.
 Bleeding occurs from these vessels during lacrimal sac
surgeries.
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13.  7 bones involved in the formation
of orbit are derived from neural
crest cells.
 Ossification of orbit is complete at
birth except its apex.
 Lesser wing of sphenoid is
cartilaginous.
 Other bones undergo membranous
ossification.
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14.  Formed by frontal bone.
 Posterior 1.5cms of the roof is formed by lesser wing
of sphenoid.
 Optic foramen contains optic nerve.
 Optic nerve enters orbit at an angulation of 45 degrees.
 Lacrimal gland is located at the lateral end of orbital
roof.
 The trochlear fossa is located in the antero medial
portion of the orbital roof.
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16.  The medial wall of the orbit is formed from anterior to
posterior by:
1. Frontal process of maxilla
2. Lacrimal bone
3. Ethmoid bone
4. Lesser wing of sphenoid bone
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17.  The thinnest portion of the medial wall is the lamina
papyracea which separates the ethmoidal sinuses from
the orbit.
 The medial wall of the orbit is thicker posterior where
the sphenoid bone is present and anteriorly where the
posterior lacrimal crest is present.
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19.  Infections from ethmoidal sinus can easily breach lamina
papyracea and affect the orbital contents.
 Lacrimal bone at the level of lacrimal fossa is very thin.
 This bone can easily be penetrated during endoscopic
DCR.
 If the maxillary component is predominant then it is really
difficult to breach this bone during endoscopic DCR since
this bone is rather thick.
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20.  Very important surgical
landmark.
 Marks the approximate level
of ethmoidal roof.
 Dissection above this line
will expose the cranial
cavity.
 Anterior and posterior
ethmoidal foramina are
present in this suture line.
 Anterior and posterior
ethmodial arteries pass
throught these foramina.
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21.  It is the shortest of all the walls.
 Bounded laterally by infra orbital fissure.
 Medially bounded by maxilloethmoidal strut of bone.
 Almost entirely formed by orbital plate of maxilla with
minor contribution from orbital plate of palatine bone
posteriorly.
 Floor is thin medial to infra orbital groove.
 Infraorbital groove becomes infraorbital foramen
anteriorly.
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23.  Formed by greater wing of sphenoid.
 Zygoma & zygomatic process of frontal bone – minor
contribution.
 Recurrent meningeal branch of middle meningeal
artery is seen in this wall.
 4-5 mm behind the lateral orbital rim and 1 cm inferior
to the fronto zygomatic suture line lie the whitnall's
tubercle.
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25.  Lateral canthal tendon
 Lateral rectus check
ligament
 Suspensory ligament of
lower eyelid
(Lockwood's ligament)
 Orbital septum
 Lacrimal gland fascia
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26.  Orbit is related to paranasal sinuses in two
ways:
1. Anatomically by its location.
2. Venous drainage (They both share the same
venous drainage).
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27.  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.
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29.  Entire venous system is devoid of valves – hence two way
communication between orbit and sinuses is a reality.
 Superior ophthalmic vein connects facial vein to cavernous
sinus – causing spread of infections from face to cavernous
sinus.
 Inferior ophthalmic vein communicates with pterygoid
venous plexus and cavernous sinus by its two branches.
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31.  High myopia.
 Enophthalmos of
one eye may cause
apparent proptosis
of the other one.
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32.  Proptosis can be divided into following clinical groups:
 1. Unilateral proptosis.
 2. Bilateral proptosis.
 3. Acute proptosis.
 4. Intermittent proptosis.
 5. Pulsatile proptosis.
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33.  Causes of unilateral proptosis include-
1. Congenital conditions.
 Dermoid cyst, congenital cystic eyeball and orbital teratoma.
2. Traumatic lesions
3. Inflammatory lesions
4. Circulatory disturbances and vascular lesions
5. Cysts of orbit
6. Tumors of the orbit
7. Mucoceles of paranasal sinuses
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35.  Causes of bilateral proptosis include-
1. Developmental anomalies of the skull:
1. craniofacial dysostosis e.g., oxycephaly (tower skull).
2. Osteopathies.
3. Inflammatory conditions:
1. Mikulicz’s syndrome
2. Late stage of cavernous sinus thrombosis.
4. Endocrinal exophthalmos (eg; thyrotoxicosis)
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OXYCEPHALY EXOPHTHALMOS

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MIKULICZ’S SYNDROME

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CAVERNOUS SINUS THROMBOSIS

39. 5. Tumours:
These include symmetrical lymphoma or lymphosarcoma.
6. Systemic diseases:
◦ Histiocytosis
◦ Systemic amyloidosis
◦ Xanthomatosis
◦ Wegener’s granulomatosis
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Lymphoma – Bilateral involvement Wegener’s granulomatosis

41. . It develops with extreme rapidity (sudden onset).
Its common causes are :
1. Orbital emphysema
2. Fracture of the medial orbital wall
3. Orbital hemorrhage
4. Rupture of ethmoidal mucocele.
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ORBITAL EMPHYSEMA

43.  This type of proptosis appears and disappears of its
own.
Its common causes are:
1. Orbital varix
2. Periodic orbital oedema
3. Recurrent orbital haemorrhage
4. Highly vascular tumors.
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ORBITAL VARIX

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CAVERNOUS HEMANGIOMA

46.  It is caused by pulsating vascular lesions such as
◦ Carotico cavernous fistula.
◦ Saccular aneurysm of ophthalmic artery.
 Pulsating proptosis also occurs due to transmitted
cerebral pulsations in conditions associated with
deficient orbital roof. These include congenital
meningocele or meningoencephalocele,
neurofibromatosis and traumatic or operative hiatus.
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50.  Mnemonic – VEIN
V – Vascular causes
E – Endocrine causes
I – Inflammatory causes
N – Neoplastic causes
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51.  Classified into arterial and venous.
 Venous causes are due to dilated veins – Positional
proptosis is the classical feature in these patients. It
can also be induced by valsalva maneuver.
 Initially there may be atrophy of fat in these pts
causing enophthalmos.
 CT scan after jugular vein compression is diagnostic.
 Surgery is disastrous in these patients.
 Conservative management is the best modality.
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52.  Graves’ disease, the most common cause of bilateral proptosis
should be ruled out. These patients show clear clinical
evidence of thyrotoxicosis like:
 1. Bilateral proptosis
 2. Lid retraction
 3. Lid lag
 4. Descent of eyelid cheek complex
 5. Gritty sensation in the eye
 6. Retrobular pain
 7. Tearing
 8. Palpitation
 9. Sleeplessness
 10. Diarrhea
 11. Menstrual disturbances (in case of females)
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53.  Idiopathic inflammation – Pseudo tumor of orbit
 Due to specific causes of orbital inflammation
 These pts have pain during ocular movement
 Associated dacryoadenitis
 Perioptic neuritis can cause blindness
 Steroids may be helpful.
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54.  Inverted papilloma
 Fungal infections
 Mucoceles of paranasal sinuses
 Fibrous dysplasia of maxilla
 Osteomas involving frontal / ethmoidal sinuses
 JNA
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55.  I. Clinical evaluation
 (A) History. It should include: age of onset, nature of
onset, duration, progression, chronology of orbital
signs and symptoms.
 (B) Local examination. It should be carried out as
follows:
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56. 1. Inspection.
(i) To differentiate proptosis from pseudoproptosis which
is seen in patients with buphthalmos, axial high
myopia, retraction of upper lid and enophthalmos
of the opposite eye.
(ii) to ascertain whether the proptosis is unilateral or
bilateral.
(iii) to note the shape of the skull.
(iv) to observe whether proptosis is axial or eccentric.
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57. 2. Palpation.
It should be carried out for retrodisplacement of
globe to know compressibility of the tumour, for
orbital thrill, for any swelling around the eyeball,
regional lymph nodes and orbital rim.
3. Auscultation.
It is primarily of value in searching for abnormal
vascular communications that generate a bruit, such
as carotico cavernous fistula.
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58. 4. Transillumination.
It is helpful in evaluating anterior orbital
lesions.
5. Visual acuity.
6. Pupil reactions.
7. Fundoscopy.
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59. 8. Ocular motility.
It is restricted in thyroid ophthalmopathy,
extensive tumour growths and neurological
deficit.
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60.  The simplest instrument to
measure proptosis is Luedde’s
exophthalmometer . the
Hertel’s exophthalmometer ( is
the most commonly used
instrument.
 The distance between the
lateral orbital rim and the
corneal apex is used as a
measure for proptosis.
 Normal values vary between
10 and 21 mm and are
symmetrical in both eyes.
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61.  A difference of more than 2 mm between the two eyes is
considered significant.
 Its advantage is that it measures the two eyes simultaneously.
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62. C) Systemic examination.
A thorough examination should be conducted to
rule out systemic causes of proptosis such as
thyrotoxicosis, histiocytosis and primary tumors
elsewhere in the body (secondaries in orbits).
 Otorhinolaryngological examination is necessary
when the paranasal sinus or a nasopharyngeal mass
appears to be a possible etiological factor.

63. II. Laboratory investigations
 These should include:
◦ Thyroid function tests
◦ Haematological studies (TLC, DLC, ESR,VDRL test)
◦ Casoni’s test (skin test to rule out hydatid cyst),.
 Stool examination for cysts and ova.
 Urine analysis for Bence Jones proteins for
multiple myeloma.

64. III. Imaging Technique
(A) Non-invasive techniques
1. Plain X-rays.
2. Computed tomography scanning
3. Ultrasonography
4. Magnetic resonance imaging (MRI).

65.  CT / MRI may help in
identifying the cause
 Fat in the orbit serves
as a contrast medium
 3 mm cuts is ideal
 Ultrasound – A mode /
B mode can be done to
identify the cause
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66.  Imaging helps to identify:
1. Presence of sinusitis.
2. Septal deviation.
3. Hypoplastic maxillary sinuses .
4. Presence of inflammatory / mass lesions in the nose
and paranasal sinuses .
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67.  MRI is sensitive in identifying
extra ocular muscle oedema.
 Increased T2 relaxation time
indicates extra ocular muscle
oedema, these patients
respond well to steroid
therapy.
 Patients with normal T2
relaxation levels need orbital
decompression.
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68. (B) Invasive procedures
1. Orbital venography
2. Carotid angiography.
3. Radioisotope studies.

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71.  High flow shunts
 Can occur spontaneously / trauma
 Subjective bruit / proptosis / chemosis / vision loss
 Arterolization of conjunctival vessels causing
corkscrew pattern
 Intractable cases – shunt must be closed using
balloon / carotid artery ligation
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72. IV. Histopathological studies
The exact diagnosis of many orbital lesions cannot be made
without the help of histopathological studies,which can be
accomplished by following techniques.
1. Fine-needle aspiration biopsy (FNAB).
2. Incisional biopsy.
3. Excisional biopsy.

73.  Low dose irradiation (rarely used)
 Surgery
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74.  Visual disturbance due to proptosis
 Failure of steroids to improve vision
 If steroids are necessary on a long term basis for
maintaining vision
 To prevent exposure keratitis
 Diplopia
 Cosmetic
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75.  Lateral orbitotomy – Dollinger (1911)
 Superior orbitotomy – Naffziger (1931)
 Medial orbitotomy – Sewall (1936)
 Inferior orbitotomy – Hirsch (1950)
 Combined medial and inferior decompression –
Walsh – Ogura(1957)
 Endoscopic Technique – Kennedy(1990)
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77.  Diplopia
 Intractable strabismus
 Hypoglobus
 Injury to optic nerve due to prolonged globe retraction
 Retrobular hematoma – this can cause blindness
 Injury to infraorbital nerve
 Epistaxis
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78.  To enlarge the confining space of orbit by removing 1-
4 of its walls
 15 mm of decompression can be achieved by removing
all 4 walls of the orbit
 Usually successful surgery causes 3-7 mm
decompression of orbit
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79.  Naffzeiger technique (1931)
 Superior wall decompression
 Complete un roofing of orbit – frontal craniotomy
 Large amounts of bone can be removed creating more
space
 Craniotomy may be needed
 Used in pts with orbital trauma
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80.  In collaboration with neurosurgeon
 Optic nerve should be visualized to begin with
 The roof of the orbit is removed starting from the
optic foramen to the anterosuperior orbital rim
 Periosteum should be left intact to prevent injury to
levator muscle
 H shaped incision is made over superior periosteum
allowing orbital fat to prolapse through it
 Titanium mesh can be used to cover orbital roof
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81.  Also known as Sewell procedure (1936)
 Coronal incision / external ethmoidectomy incision
 Medial canthal tendon is identified and divided
 Anterior and posterior ethmoidal arteries identified and
clipped
 Complete ethmoidectomy is performed starting from
lacrimal fossa
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84.  Medial canthal tendon can be left intact
 Ethmoidectomy is performed from above
 Lacrimal sac and trochlea should not be damaged
 Medial periosteum is incised and orbital fat is allowed
to prolapse into the nasal cavity
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85.  Hisch and Urbanek procedure (1950)
 Artificial creation of blow out fracture of orbital floor
sparing infra orbital nerve
 Trans conjunctival / subciliary incision plus Caldwell
Luc procedure
 Laterally floor can be removed up to zygoma and
medially up to lacrimal fossa
 Posteriorly bone is thick – 3 cms of bone can be
removed from this area
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86.  Periosteum is incised to allow orbital fat to prolapse
into the maxillary antrum
 Forced duction test should be performed to ensure
orbital muscles are not entrapped.
◦ The forced duction test is performed in order to determine
whether the absence of movement of the eye is due to a
neurological disorder or a mechanical restriction.
◦ The anesthetized conjunctiva is grasped with forceps and an
attempt is made to move the eye ball in the direction where the
movement is restricted. If a mechanical restriction is present, it
will not be possible to induce a passive movement of the eye
ball.
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87.  Dollinger (1911) - removal of lateral orbital wall for
decompression into the temporal fossa
(Kroenlein’stechnique).
 Coronal incision, and lateral extension of subciliary
incision
 Extended lateral canthotomy
 Lateral orbital rim periosteum is exposed from zygomatic
arch to zygomatico frontal suture
 Periosteum incised along lateral orbital rim and orbital fat
is teased out
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93.  Any of the above said approaches can be combined for
optimal benefit
 Combination of approaches reduces the surgical risk
and provides more increase of space than one
procedure alone
 Combined medial and inferior decompression
(Walsh – Ogura):
◦ This approach like inferior one involves Caldwell – Luc /
Transantral approach. This technique was the most preferred
one during 1990’s. This procedure managed to achieve 5mm
proptosis reduction.
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95.  Kennedy (1990)
 Nose decongested and injected with 1% lidocaine with
1:100,000 epinephrine.
 middle turbinectomy performed
 Uncinectomy performed
 maxillary ostium enlarged anteriorly
 ethmoid bulla opened
 anterior and posterior ethmoidectomies performed
 Sphenoidotomy performed
 lamina papyracea identified and cleaned of mucosa
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97.  lamina papyracea penetrated and fragments elevated
 superiorly to ethmoid roof
 posteriorly to face of sphenoid sinus
 inferiorly to orbital floor
 anteriorly to frontal process of maxilla
 orbital floor removed
 laterally to infraorbital canal
 Periorbita incised with sickle knife
 any existing bands of periorbita that might be hidden
between lobules of fat are taken down
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100.  Nose blowing is to be avoided for 2 weeks following
surgery
 Bilateral decompression should be done within an
interval of a week
 For mild exophthalmos 2-3 mm any of the approaches
would suffice
 For moderate – 3-5mm inferior decompression is
sufficient
 For severe ones – 5-7 mm three wall decompression is
preferred
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101. DEPT. OF ENT,ACMETHANK YOU…