Silent sinus syndrome-Radiological point of view

1. Silent Sinus Syndrome
Dr.Santosh Atreya
Phase-B
Resident-Department of Radiology &
Imaging
Bangabandhu Sheikh Mujib Medical
University

3. Clinical photo of the
patients frontal view -
showing “Typical facial
asymmetry seen in silent
sinus syndrome”.
Right globe is displaced
downward (hypoglobus)
with associated upper lid
retraction and deepening
of upper lid sulcus

5. EVIDENCE. (1) 32-year-old
woman was referred for
Radiologist for evaluation of an
acquired right upper eyelid
ptosis.
(2A) Coronal CT image shows
thinning and retraction of the
right orbital floor;
(2B) coronal CT image (posterior
cut) shows right maxillary sinus
hypoplasia and opacification
with lateralization of the
uncinate process (arrow).
The axial CT image shows
inward bowing and retraction of
the posterolateral and medial
walls of the right maxillary
sinus.

6. Introduction
• Silent sinus syndrome
(SSS) is a rare clinical
condition that can
pose a diagnostic
challenge for a
Radiologist.

7. History
• The first two reported cases
were reported in 1964, but
the term “silent sinus
syndrome” was coined 30
years later by Dr.Soparkar and
colleagues.
• Since that time, several case
series have been published.

8. EPIDEMIOLOGY
• Third to fifth decade of life.
• No gender predilection.
• May be idiopathic.
• In a small number of
patients, trauma to the
lateral nasal wall and
ostiomeatal complex may be
the cause, e.g. endonasal
intubation

9. Clinical Presentation
• Painless,relatively long-standing
facial asymmetry,
• Enophthalmos and hypoglobus .
• Symptoms of sinusitis are not
always present .
• Significant deformity of the
orbital floor-May
develop diplopia.
• Extraocular movements are
usually normal

10. Clinical Presentation of my Patient
• My patient 30-year-old
male with chief
complain of orbital
asymmetry & headache.
• Visual acuity was 6/6
and was normal.
• All routine lab.
Investigations were
normal.

11. Pathogenesis
• Chronic occlusion of the maxillary sinus
ostium/ostia results in gradual resorption of the
air.
• Subsequently, negative pressure is generated
within the sinus . This, in turn, results in gradual
inward bowing of all four of the maxillary walls.
• Orbital volume increases with resultant
enophthalmos and variable flattening of the
malar eminence .
• Other hypotheses - inflammatory erosion and
softening of walls due to chronic sinusitis.

12. Radiographic features
• Imaging of the sinuses
confirms the findings.
• Additionally, the diagnosis
may be made incidentally
by a Radiologist on
imaging of the region for
other reasons.

13. Plain radiograph
• Plain radiographs are no longer considered
sufficiently sensitive or specific for the
assessment of paranasal sinus disease by
Radiologist.
• However, they are still not infrequently
performed. The findings are the same as those
seen on CT .

14. CT
• inferior bowing of the orbital
floor: increased orbital volume
and enophthalmos
• lateral bowing of the medial
wall: lateral displacement of the
middle and inferior turbinate
• The uncinate process is usually
superiorly and laterally
displaced, in direct contact with
the inferomedial wall of the
orbit, and the ostiomeatal
complex is occluded

15. MRI
• Radiologist do not prefer MRI
for diagnosis of this disease.
• If performed, will demonstrate
a fully opacified sinus with
thickening and enhancement
of the mucosa. The secretions
are of variable intensity.
Axial T2-weighted MRI image showing fluid
level in right maxillary sinus with reduction in
its volume

16. Treatment and prognosis
• The condition is benign but may result in
diplopia. Treatment involves the creation of a
drainage route for the sinus. This can be with
a nasal antral window or maxillary
antrostomy.
• Once drainage is established, no further
volume loss will develop.

17. Differential diagnosis
• congenital maxillary sinus
hypoplasia
• post traumatic maxillary
sinus deformity
• Orbital trauma
• Mucocele
• chronic sinusitis with
mucoperiosteal thickening

18. Take Home
Messages
• An acquired condition,occurs in adults with
unilateral, progressive, spontaneous enophthalmos
and hypoglobus secondary to maxillary sinus
hypoventilation caused by blockage of the
ostiomeatal complex.
• Patient often presents with a droopy eyelid and a
deep superior sulcus.
• Important to have orbitofacial with PNS imaging
• Radiological Consultation