A review on silent sinus syndrome

T Sridhar; B Karthika; M Pavani; A Srinithi Iswarya; D Shoban; A Priya

doi:10.4103/jdas.jdas_8_18

REVIEW ARTICLE

Year : 2018 | Volume : 7 | Issue : 2 | Page : 81-83

A review on silent sinus syndrome

T Sridhar, B Karthika, M Pavani, A Srinithi Iswarya, D Shoban, A Priya
Department of Oral Medicine and Radiology, Priyadarshini Dental College and Hospital, Tiruvallur, Tamil Nadu, India

Date of Web Publication

1-Nov-2018

Correspondence Address:
Dr. A Srinithi Iswarya
Department of Oral Medicine and Radiology, Priyadarshini Dental College and Hospital, Tiruvallur, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jdas.jdas_8_18

Abstract

Silent sinus syndrome (SSS) is a rare condition that causes facial asymmetry, unilateral painless enophthalmos, orbital floor collapse, and diplopia, which represent the chronic maxillary sinus atelectasis with chronic negative pressure within the sinus. SSS is also known as imploding antrum. Some believe that congenital development of the maxillary sinus may also be responsible for the development of SSS. Its characteristic imaging features are maxillary sinus outlet obstruction, sinus opacification, and volume loss caused by inward retraction of the sinus wall. Ostium obstruction appears to play a critical role in the development of SSS. Treatment involves reconstructive procedure of orbital floor and functional endoscopic sinus surgery.

Keywords: Atelectasis, displacement, endoscopy, enophthalmos, reconstruction

How to cite this article:
Sridhar T, Karthika B, Pavani M, Iswarya A S, Shoban D, Priya A. A review on silent sinus syndrome. J Dent Allied Sci 2018;7:81-3

How to cite this URL:
Sridhar T, Karthika B, Pavani M, Iswarya A S, Shoban D, Priya A. A review on silent sinus syndrome. J Dent Allied Sci [serial online] 2018 [cited 2023 Mar 27];7:81-3. Available from: https://www.jdas.in/text.asp?2018/7/2/81/244763

Introduction

Silent sinus syndrome (SSS) was described by Montgomery,^[1] but the name was given 30 years later by Soparkar et al.^[2],[3] SSS is chracterised as painless involution of maxillary infundibulum;associated enophthalmos differentes syndrome. Condition always presents to be unilateral and affects the third and fifth decade of an adult patient. The presenting symptom is spontaneous. One side enophthalmos slightly over the course of several months, even rare case of sudden onset are also described.^[4] The term imploding antrum is another term used for SSS.^[5] Recently, in 2008, Brandt and Wright required SSS to be included under the common term chronic maxillary atelectasis.^[6] Ocular manifestations are asymmetry due to exophthalmos in uninvolved contralateral eye or enophthalmos or ptosis of the affected eye. No histories of rhinosinusitis or significant sinus symptoms are evident. An orbital/paranasal sinus view in computerized tomography (CT) and magnetic resonance imaging (MRI) demonstrates opacification and collapse of orbit floor.^[7]

Epidemiology

The average age of occurrence is between third and fourth decade (range19–82 years). There is no bias in gender, and there is a slight predominance of right-sided disease (57% cases).^[2],[8]

Pathophysiology

The etiology of SSS is not unclearly understood. Several theories have been proposed to explain the cascade of event. The most popular theory suggested by several authors^{[2],[9],[10],[11],[12],[13],[14],[15]} is that hypoventilation of the maxillary sinus secondary to obstruction of ostium leads to the formation of chronic negative pressure. Several mechanisms of ostial occlusion propose that occlusion by persistent mucoid impaction, hypermobile infundibular wall or lateralized middle turbinate,^[11] mucocele or nasal polyp results in occluding of ostium or antrum.^[2] In the presence or absence of sinusitis, the inflamed mucosa of hypoplastic maxillary sinus and antrum causes decreased ostial width, resulting in more frequent occurrence of occlusion.^[35] The hypoventilation and occlusion of the sinus may lead to the development of negative pressure. This negative pressure may cause thinning and serious structural damage to sinus walls, including the orbital floor, leading to hypoglobus. In case of opening of maxillary ostium, the sinus fluid, which initially provided support for the thin orbital floor, may drain, resulting in further depression of the globe and orbital floor. Secondary enophthalmos after bone removing orbital decompression, the severe nasal inflammation with marked expansion, and pressure of altered turbinate may cause prolonged impairment of antral drainage. Subatmospheric pressure associated with retained secretions causes the implosion.^[16]

Clinical features

Patients present to an ophthalmologist for evaluation of a change in facial appearance, either with the “sunken eye” appearance or deepening of sulcus of the upper lid or with discomfort of an intermittent vague around the affected orbits.^[17],[18] The most common findings in all the patients with SSS are nasal mucosal lining with mild or normal inflammation, enlargement of middle meatus, and uncinate process completely adherent to the lateral wall causing the obstruction of maxillary natural ostium. Along the ethmoid-maxillary drainage pathway, no pathologic secretion is present.^[19]

Radiological features

The diagnosis is usually done by otolaryngologists and ophthalmologists; imaging of the sinus confirms the finding. For assessment of sinus disease, plain radiographs are no longer considered. CT scan and MRI may be used to access orbital and paranasal sinus [Figure 1] and [Figure 2].^[9] Focal absence of the sinus wall is most commonly seen in the medial wall and less frequently in the posterior, anterior, and lateral walls. The most characteristic feature of SSS is inward retraction of sinus wall into the lumen causes diminishing of sinus volume, and complete opacification of the affected maxillary sinus.^[2] And also, there is an evidence of downward retraction of the orbital floor into the maxillary sinus that leads to eye and facial deformity which can be identified by the patient.^[11] This eye deformity in turn results in hypoglobus formation.^{[2],[9],[10],[20]}

Figure 1: Computed tomography section

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Figure 2: Magnetic resonance imaging^[9]

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Differential diagnosis

The most common causes of SSS include osteomyelitis, chronic sinusitis, orbital trauma, malignant sinus infiltration, false or pseudoenophthalmos, atrophy of orbit, Parry–Romberg syndrome, and linear scleroderma. In case of Parry–Romberg syndrome and scleroderma, there is no marked hypoglobus, and periorbital soft-tissue or contour changes are more frequent than in SSS.^[21] Clinical findings of often occurring and otherwise painless inward and downward sinking of a diseased eye are usually not specific in cases of SSS, and further, other causes must be excluded. The mandatory criteria for diagnosis of SSS include the patient with spontaneous enophthalmos or hypoglobus in the absence of symptoms. Alternatively, patients with Parry–Romberg syndrome are associated with pseudoretraction of the upper eyelid and less hypoglobus when compared with that of SSS.^[21],[22]

Treatment

Management of SSS is mainly by two steps: (a) clearing the sinus and recontouring a functional drainage passage and (b) reconstructing the normal orbital architecture. Most authors suggested a Caldwell–Luc procedure or functional endoscopic sinus surgery (FESS) as an initial treatment followed by the reconstructive procedure with the placement of titanium mesh, autogenous nasal septal cartilage, spilt-thickness bone, or auricular concha cartilage onto the floor of the orbit.^{[2],[11],[12],[13],[23],[24],[25],[26]} Some suggest, inferior displacement of orbital floor is self-reversed and remodeling occurs.^{[27],[28],[29]} In some patients, the FESS alone can minimize the enophthalmos.^[26] The progression of diseases has been arrested without any further deformity of sinus after FESS.^[32] Endoscopic antrostomy in combination with orbital floor repair – a single-stage procedure – is preferred when severe enophthalmos is present.^{[6],[30],[31]} Reduced morbidity, reduced patient discomfort, and less time of hospitalization are advantages of single-stage procedure.^[30] Postoperative complications including implant impact infection, postoperative diplopia, vision loss, or hematoma are much lower in the case of single-stage procedure.^[30],[31] Common material of choice for floor reconstruction of SSS are Medpor implant, silicone blocks, and Teflon sheets.^[3] Using silicon blocks, the size and shape of the silicon should be evenly distributed on the adjacent healthy bone without causing any pressure.^[33] In 2011, nonsurgical approach using hyaluronic acid gel to correct enophthalmos after middle–meatal antrostomy was reported.^[34]

Conclusion

SSS is a rare condition and often misdiagnosed with controversial pathology. The diagnosis is concluded after the complete study of imaging. There is the need for all clinicians exposed to head and neck pathology to be familiar with SSS to ensure the correct diagnosis is made and optimal treatment is provided. Treatment of disease consists of restoration of maxillary sinus aeration and reconstruction of the orbital floor in case needed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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