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Diagrammatic representation of the right superior orbital fissure with its content. (Image modified from Rai S and Rattan V. Natl J Maxillofac Surg 2012; 3: 222-225, copyright 2012, Wolters Kluwer). 49
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Orbital apex disorders include orbital apex syndrome, superior orbital fissure syndrome and cavernous sinus syndrome. These disorders result from various etiologies, including trauma, neoplastic, developmental, infectious, inflammatory as well as vascular causes. In the past, these have been described separately based on anatomical locations of dis...
Context in source publication
Context 1
... to SOF is the cavernous sinus ( Figure 1). The medial portion of the SOF contains CN III and VI, and the nasociliary nerve, which are enclosed in the annulus of Zinn, the tendinous ring for four of the six extraocular muscles (Figure 3). Superior and medial to the SOF, the annu- lus of Zinn contains the optic nerve and ophthalmic artery in the optic foramen. ...
Citations
... The main focus of the surgeon is to locate the lesion and identify the etiological factor. Thorough and careful clinical examination is of utmost importance [9]. Ophthalmological evaluations must be done to establish ophthalmoplegia, vision status, and ptosis [7]. ...
Purpose To present a case report of orbital apex syndrome secondary to Noma destructive processes. Method A case of 7-year-old child who presented with an ulcerative defect on the left cheek region and left orbital pain with reduced vision in the left eye has been presented. There was a history of cheek swelling, fever and, loss of appetite with a recent history of malaria treatment. Clinical examination revealed a cone shaped buccal ulcerative defect involving both the left outer and inner cheek walls with extension to the dentoalveolar segment, the maxilla and, the posterior palatal region with an observable sequestrum. Ophthalmological examination revealed loss of vision, complete ptosis and, ophthalmoplegia. There was loss of sensation in the frontal and preorbital region and, absolute pupillary defect in the same eye. A clinical diagnosis of orbital apex syndrome secondary to noma destruction was made. Result Management was instituted by a team of maxillofacial surgeons, ophthalmologists and, nutritionists. Antibiotics, serial debridement, and sequestrectomy were the predominant treatments given and there was resolution of the symptoms except persistent ptosis, loss of vision and, ophthalmoplegia. Conclusion Noma is a rapidly progressive disease that is capable of destroying oral and surrounding soft and, hard tissues with serious functional and cosmetic complications. Orbital apex syndrome was seen as a complication in this case report. This reinstates the need for early detection and treatment of noma.
... Many reports concerning cavernous sinus syndrome have been published in human medicine and veterinary medicine (1,(3)(4)(5)(6)(9)(10)(11). The purpose of this case study is to describe the ophthalmic presentation and note the diagnosis of a cavernous sinus tumor in a dog with neuro-ophthalmologic deficits. ...
... In humans, three disorders are associated with the orbital apex region: CSS, orbital apex syndrome, superior orbital fissure syndrome (1,4,11). Because these disorders affect CN III-VI and have comparable etiologies and diagnostic criteria, it is essential to conduct a differential diagnosis. ...
... Because these disorders affect CN III-VI and have comparable etiologies and diagnostic criteria, it is essential to conduct a differential diagnosis. Compared to CSS, orbital apex syndrome is distinguished by the presence of visual impairment, which results from impairment of CN II (1,4,8,11). Superior orbital fissure syndrome, which is characterized by lesions situated anterior to the orbital apex, shares similar clinical presentations with CSS, including ophthalmoplegia, mydriasis, and corneal hypoesthesia (1,4,7,11). ...
... syndrome is characterized by ophthalmoplegia, proptosis and ptosis for the involvement of the III, IV and VI cranial nerves, hypoesthesia of the cornea, upper eyelid and ipsilateral forehead for compression of the terminal branches of the ophthalmic nerve, and possible visual impairment from optic neuropathy (Goyal et al., 2018). In many respects, the SOF syndrome is similar to the previous one, but it spares the optic nerve as it is generated by pathologies immediately anterior to the orbital apex (Jin et al., 2018). ...
... In the fractures of the lateral wall of the orbit, the involvement of structures traversing the region can be particularly severe and may require emergency decompression in the attempt to preserve sight and eye motility (Bun et al., 1996;Imaizumi et al., 2014;Warburton et al., 2016). Both syndromes can also be secondary to neoplasia, infection, aneurysms of the intracavernous internal carotid artery growing anteriorly into the orbit, inflammatory and autoimmune diseases like sarcoidosis, thyroid ophthalmopathy, and granulomatosis with polyangiitis, formerly known as Wegener's granulomatosis (Goyal et al., 2018). It is evident that, in all these conditions, compression can be more severe in the presence of a well-developed SMRL which reduces the room for neurovascular structures. ...
Background: The spina musculi recti lateralis (SMRL) is often visible along the lateral rim of the superior orbital fissure (SOF). Aim of this study is to characterize SMRL morphology and topography relative to known bony landmarks. Methods: Orbits from 291 adult dry skulls and from 60 CT scans were analyzed to measure the distance between the SMRL and the SOF or the inferior orbital fissures (IOF) as well as its height, width and orientation. Processes other than SMRLs were also recorded. Fetal skulls were observed for comparison with adult samples. Results: Forty-one per cent of orbits on dry skulls and 43.3% by CT showed an SMRL. Additional 32.9% of orbits on dry skulls had processes with a different shape. On average, SMRL were orientated almost along the transverse plane and showed implant bases as wide as 141.9 • or as narrow as 36.8 •. SMRLs were close to the infero-posterior angle of the orbital plate of the sphenoid, 1.21 ± 0.84 mm in front of the SOF, 5.8 ± 1.9 mm above the IOF and 12 ± 2.3 mm from the anterior end of the SOF. They were 1.58 ± 0.64 mm high and did not show any age or sex-related prevalence. By CT, the SMRL appeared as the insertion site for the lateral rectus, tendinous ring and, sometimes, inferior rectus. Conclusions: The SMRL is a process of the sphenoidal orbital plate rather than of the SOF. It is also a reliable landmark for the insertion of the tendinous ring and lateral rectus. Orbital surgeons should be aware of this common variant of the orbital apex.
... The latter can be divided into orbital, orbital apex, bony and other complications. The infection of the skull base or regions outside the confines of paranasal sinuses (i.e., invasive form) and the involvement of the central nervous system are more common in immunocompromised than immunocompetent patients [9][10][11][12]. Table 1. ...
... Table 1. Classification of rhinosinusitis complications [6,[9][10][11][12][13][14][15][16][17]. Since there is a paucity of literature describing rare and severe complications of RS, this paper presents a literature review (Table 2) and a case of a patient with an orbital apex syndrome (Jacod's syndrome), Horner syndrome, and pterygopalatine fossa infection due to the acute invasive fungal RS, which developed from sphenoid sinus fungal ball. ...
... Numerous neurovascular structures communicate with it through the superior orbital fissure and the optic canal. Disorders of orbital apex comprise three syndromes depending on the lesion's location: orbital apex syndrome, superior orbital fissure syndrome (Rochon-Duvigneaud syndrome) and cavernous sinus thrombosis (CST) ( Table 1) [11]. Orbital apex syndrome encompasses CN II, III, IV, V1 and VI impairment due to inflammatory damage or direct compression [10]. ...
This paper presents a literature review and a case of an 83-year-old otherwise healthy female patient with a history of recent syncope, a sudden-onset right-sided temporal headache, diplopia, and vision loss. An exam revealed right-sided upper eyelid ptosis, myosis, vision loss, ophthalmoplegia, and a positive relative afferent pupillary defect on the right eye. CT showed sphenoid sinus opacification, eroded lateral sinus wall, Vidian canal, disease extension to the posterior ethmoid air cells, orbital apex, medial orbital wall, and pterygopalatine fossa. An orbital apex syndrome (Jacod's syndrome), Horner syndrome, and pterygopalatine fossa infection were diagnosed due to the acute invasive fungal sinusitis developed from a sphenoid sinus fungal ball. The patient was treated with antimicrobial therapy and transnasal endoscopic surgery twice to decompress the orbital apex, drain the abscess and obtain specimens for analysis. The right-sided ptosis, visual loss, ophthalmoplegia, and headache resolved entirely. No immune or comorbid diseases were identified, microbiological and histopathological analyses were negative, and MRI could not be performed on the presented patient. For that reason, the diagnostic procedure was non-standard. Nevertheless, the treatment outcome of this vision and life-threatening disease was satisfactory. Treating the fungal ball in an older or immunocompromised patient is essential to prevent invasive fungal rhinosinusitis and fatal complications.
... Knowledge of neuro-arterial relation, gross feature and normal morphometry of parasellarregioin and optic canal are of immense important for the surgeons treating the vascular lesions in this area 5 . Orbital apex disorder, tumorssurrounding the greater and lesser wing of sphenoid and in the posterior part of orbit such as angioma, malignant tumor, meningioma, neuroma ,pneumosinuscan be operated at optic canal, posterior part of orbit or the superior orbital fissure 6,7,8 . Optic canal and the associated osseous structures like anterior clinoid process (ACP), optic strut (OS) and the petrous temporal bone are the important anatomical structures due to their central locations and critical function, which are often included in the neurosurgical operations 9 . ...
Objective-The main objective of this research is to study the morphometry of the optic canal and the surrounding bony structures in adult human dry skulls and compare it with the parameters obtained from computer tomography (CT) scan. Methodology-The optic canal of 90 adult dry skull were examined by digital vernier caliper and 110 CT scans were observed by thin layer CT scan images in coronal and axial plane using high resolution matrix and bone algorithm. 3D reconstruction images were also used. The height, width and length of medial wall and lateral wall of the optic canal were measured. The distance between optic canal and apex of petrous part of temporal bone, distance between optic canal from midline, distance between optic canal and tip of anterior clinoid process, and distance between both optic canals were also calculated. The data was tabulated and analysed statistically. Result-The mean height of optic canal (OC) in CT and dry skull was 3.96±1.35mm and 4.90±1.04mm respectively. The meanwidth in CT and dry skull was 3.97±1.45mm and 4.30±0.93mm. The mean length of medial wall and lateral wall in CT and dry skull was 9.10±2.01mm, 8.10±1.93mm and 5.89±1.39mm, 4.41±1.35mm respectively. The mean distance of OC to the apex of petrous temporal bone in CT and dry skull was 24.73±2.98mm and 24.64±2.88mm whereas the mean distance 5737
... Knowledge of neuro-arterial relation, gross feature and normal morphometry of parasellarregioin and optic canal are of immense important for the surgeons treating the vascular lesions in this area 5 . Orbital apex disorder, tumorssurrounding the greater and lesser wing of sphenoid and in the posterior part of orbit such as angioma, malignant tumor, meningioma, neuroma ,pneumosinuscan be operated at optic canal, posterior part of orbit or the superior orbital fissure 6,7,8 . Optic canal and the associated osseous structures like anterior clinoid process (ACP), optic strut (OS) and the petrous temporal bone are the important anatomical structures due to their central locations and critical function, which are often included in the neurosurgical operations 9 . ...
... OAS is also known as Jacod syndrome characterized by ophthalmoplegia; proptosis; ptosis; palsy of III, IV, and VI cranial nerves; hypoesthesia of ipsilateral forehead, upper lid, and cornea (V1-division of trigeminal nerve); and visual deficit. [1] Superior orbital fissure is a bony cleft between the roof and lateral wall at the orbital apex. SOFS is also known as Rochon-Duvigneaud syndrome includes all signs of OAS except optic nerve involvement. ...
... SOFS is also known as Rochon-Duvigneaud syndrome includes all signs of OAS except optic nerve involvement. [1] Cavernous sinus is located on either side of pituitary fossa and body of sphenoid bone. CSS includes all signs of OAS except optic nerve involvement and, in addition, has hypoesthesia of cheek and lower lid also (V2-division of trigeminal nerve). ...
... CSS may present with Horner's syndrome, if sympathetic chain adjacent to the cavernous segment of the internal carotid artery is involved. [1] Various etiologies for OAD are infective, inflammatory process, neoplasms, trauma, iatrogenic, and vascular disorders. Management is toward the causative process. ...
Orbital apex disorders (OADs) are uncommon and they include – orbital apex syndrome (OAS), superior orbital fissure syndrome (SOFS), and cavernous sinus syndrome (CSS). They all share similar etiologies, diagnostic evaluation, and management strategies. These syndromes can occur isolated or combined – where SOFS progresses and develops into OAS or CSS. Combined presentation has been reported with infective etiologies, but no literature is available for neoplasms. OAD secondary to head and neck cancer is exceptionally rare. A 44-year-old male post left hemi-mandibulectomy with modified neck dissection, radiotherapy, and chemotherapy for left retromolar trigone carcinoma presented with complaints of inability to open left eye (LE) and defective vision in the same eye. On examination of LE, visual acuity was 6/24 NIP with complete ptosis, extraocular movements were restricted in all gaze, corneal sensation was diminished, and pupil was 5 mm and not reacting to light. LE fundus examination showed blurring of disk margins. The primary diagnosis was made as OAS. Contrast enhanced-MRI neck showed features suggestive of recurrence with intracranial extend involving left cavernous sinus, orbital apex, and left orbit. Later considering the extend of spread in MRI and the clinical presentation, diagnosis was made to be OAD. The patient was given third cycle of chemotherapy – injection paclitaxel, injection cisplatin, and injection fluorouracil, along with injection dexamethasone. The patient was provided temporary eye crutch glasses and asked to review after 3 weeks for repeat assessment. Although individual syndromes of OAD are rare, they are closely related entity. Hence, it is important to know that SOFS can progress to OAS causing visual dysfunction or to CSS, leading to systemic ailments. Or else, they can present as combined syndromes also.
... 1,2 OAS is presented with proptosis, ophthalmoplegia, and ptosis due to oculomotor, trochlear, and abducens cranial nerve palsies; hypoesthesia can occur along the area of the distribution of the ophthalmic division (V1) of the trigeminal nerve; and visual loss from the optic neuropathy. 1,3,4 Due to anatomical proximity, two other syndromes that can have overlapping features are the Superior orbital fissure syndrome and the cavernous sinus syndrome. ...
... CSS may also present with oculosympathetic paresis (Horner's syndrome) because of sympathetic chain involvement near to internal carotid artery (ICA). 1,6,7 Our study attempted to give updated information on the advancement of diagnosis facilities and recent management options for OAS. ...
... The thin section contrasts enhanced MRI (CEMRI) or CT scan of the orbit with contrast is the modality of the choice. 1,19 Churg -Strauss syndrome (CSS) may also beget orbital apex syndrome. A case with Churg Strauss Syndrome, having a history of asthma, developed severe headaches, progressive left-sided ophthalmoplegia, and visual loss. ...
An orbital apex syndrome (OAS) has been described previously as a syndrome involving damage to the ocular motor and sensory nerves in association with optic nerve dysfunction. Patients usually present with signs and symptoms derived from the involvement of structures within the orbital apex, the superior orbital fissure, and the cavernous sinus. Visual loss from optic neuropathy and ophthalmoplegia involving multiple cranial nerves are the hallmarks of orbital apex syndrome. Historically, superior orbital fissure, orbital apex, and cavernous sinus are being used to define the anatomical locations of a disease process. However, the diagnostic evaluation and management are similar for each of these entities. The authors reviewed the literature on evaluating disorders involving the orbital apex and it’s diagnosis.
... At present, treatment for odontogenic OAS is primarily empirical based on case reports and case series. Along with broad-spectrum antibiotic therapy, an interdisciplinary collaboration among departments of ophthalmology, stomatology, and neurology is essential [10]. ...
Background
Orbital apex syndrome (OAS) is a rare disease with a noticeable mortality rate. Although its etiology has been repeatedly assessed, few reports have concentrated on odontogenic infection. We presented a rare case of OAS secondary to apical periodontitis.
Case presentation
A 61-year-old male was admitted to our hospital for a 3-day history of left orbital and head pain, along with diplopia for 1-day. He also had toothache symptoms before his admission. Due to the atypical early symptoms of orbital apex and cranial nerve injury, no timely and effective diagnosis and treatment were initially provided. However, as the disease progressed and complications occurred, we timely adjusted the diagnosis and successfully controlled the infection. During the one-year follow-up, no recurrence of inflammation was observed; nevertheless, the ptosis and ophthalmoplegia persisted.
Conclusions
OAS is a rare, while severe complication of odontogenic infection. This case had various symptoms and nerve injury in the orbital apical area. When disease is atypical in its early stages, treatment is easily overlooked. Early detection and suspicion of orbital apex-related complications should be heightened.
... 3 These disorders result from various etiologies, including trauma, neoplastic, developmental, infectious, inflammatory as well as vascular causes. 4 To report a case of unilateral orbital apex syndrome with periorbital abscess secondary to osteomyelitis of maxilla following right upper molar dental caries. To highlight the importance of careful diagnosis and early treatment of simple dental caries in order to prevent severe complications threatening vision. ...
... Ptosis results from impaired cranial nerve III innervation to the levator palpebrae superioris muscle or by loss of sympathetic innervation to the superior tarsal muscle. 4 Proptosis is caused by the loss of extraocular muscle tension on the globe, retrobulbar swelling, or venous congestion. Impaired parasympathetic innervation from cranial nerve III results in mydriasis. ...
... Injury to the optic nerve occurs most commonly at the intracanalicular portion of the optic nerve, especially in traumatic damage. 4 ...
To report a case of unilateral orbital apex syndrome with periorbital abscess secondary to osteomyelitis of maxilla following right upper molar dental caries
A 37 years old female patient presented with fever and toothache 1 month ago treated in a local hospital following which she developed facial swelling, dropping of left eyelid and sudden, progressive diminution of vision in left eye. Patient underwent tooth extraction following which facial swelling worsened. She was newly diagnosed as diabetic. Visual acuity in Right eye was 6/6 and in Left eye was PL negative. Detailed Slit lamp examination, fundus examination and cranial nerve examination was done. CT and MRI scan was done.
This case highlights the importance of early diagnosis and timely management of dental caries to prevent dreaded complications like orbital apex and cavernous sinus involvement.
