КТ орбіт, ока, очей зробити записатись пройти Хмельницький

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CT FINDINGS OF AN ENDO-ORBITAL OSTEOMA PRODUCING PROPTOSIS AND
THE OPTIC NERVE’S COMPRESSION
Roberto Corona-Cedillo1, Melanie-Tessa Saavedra-Navarrete2,
Arturo Albrandt-Salmeron1, Ernesto Roldan-Valadez 3,4
steoma is a benign bone tumour, with an incidence of 2% of all orbital tumours.
Osteomas located in orbit remain asymptomatic until they reach a size that
originates mass effect signs such as exophthalmos, diplopia, and unilateral
blindness.
Materials and methods. In this case, a male patient presented to the emergency
room with progressive proptosis, worsening headaches, and swelling of the left anterior
periorbital and frontal sinus region one year after the beginning of the symptoms.
Results. Imaging studies revealed a hyperdense mass in the left orbital floor displacing the left globe superiorly and anteriorly with the optic nerve’s compression.
Conclusion. Osteoma may represent an emergency in the long term when left untreated; it may destruct the eye due to direct pressure on the optic nerve and disturbance
of the ocular blood supply.
Keywords: orbital osteoma; proptosis; mass effect; optic nerve.
Corresponding author: Ernesto Roldan-Valadez, e-mail: ernest.roldan@usa.net
For citation: Roberto Corona-Cedillo, Melanie-Tessa Saavedra-Navarrete, Arturo
Albrandt-Salmeron, Ernesto Roldan-Valadez. CT findings of an endo-orbital osteoma producing proptosis and the optic nerve’s compression. REJR 2021; 11(1):200-205. DOI:
10.21569/2222-7415-2021-11-1-200-205.
Received: 10.02.21 Accepted: 01.04.21
КОМПЬЮТЕРНАЯ ТОМОГРАФИЯ ЭНДООРБИТАЛЬНОЙ ОСТЕОМЫ,
ВЫЗЫВАЮЩЕЙ ПРОПТОЗ И КОМПРЕССИЮ ЗРИТЕЛЬНОГО НЕРВА
Роберто Корона-Седильо1, Мелани-Тесса Сааведра-Наваррете2,
Артуро Альбрандт-Салмерон1, Эрнесто Ролдан-Валадес3,4
стеома – доброкачественная опухоль костей, в 2% случаев встречающаяся в
области орбиты. Остеомы, расположенные в орбите, остаются бессимптомными до тех пор пока не достигнут размера, вызывающего такие признаки
объемного обрзования, как экзофтальм, диплопия и односторонняя слепота.
Материалы и методы. Представлено клиническое наблюдение пациента, мужчины, который обратился в отделение неотложной помощи с прогрессирующим проптозом, усилением головных болей и отеком левой передней периорбитальной области
и области лобного синуса через год после появления первых симптомов.
Результаты. Методы лучевой диагностики выявили гиперденсное образование в
обасти дна левой орбиты, смещающее левое глазное яблоко кверху и кпереди, с компрессией зрительного нерва.
Вывод. Остеома орбиты может представлять опасность в долгосрочной перспективе, если вовремя не провести соответствующее лечение, так как остеома может
вызвать повреждение глазного яблока из-за прямого давления на зрительный нерв и
нарушения кровоснабжения глаза.
Ключевые слова: остеома орбиты, проптоз, массовый эффект, оптический нерв.
O
О
СЛУЧАЙ ИЗ ПРАКТИКИ

 

1 - Departamento de
Imagenologia, Salud
Digna.
Mexico City, Mexico.
2 - Facultad de
Ciencias de la Salud,
Universidad Anahuac
Mexico.
Mexico City, Mexico.
3 - Hospital General
de Mexico “Dr
Eduardo Liceaga”,
Directorate of
Research.
Mexico City, Mexico.
4 - I.M. Sechenov
First Moscow State
Medical University
(Sechenov University), Department of
Radiology.
Moscow, Russia.
1 - Отдел лучевой
диагностки, Салюд
Дигна.
г. Мехико, Мексика.
2 - Факультет медицинских наук Мексиканского университета Анауак.
г. Мехико, Мексика.
3 - Главный госпиталь
Мексики "Доктор
Эдуардо Лисеага".
г. Мехико, Мексика.
4 - Первый Московский государственный медицинский
университет им. И.М.
Сеченова
(Сеченовский
университет).
г. Москва, Россия.
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Контактный автор: Эрнесто Ролдан-Валадес, e-mail: ernest.roldan@usa.net
Для цитирования: Роберто Корона-Седильо, Мелани-Тесса Сааведра-Наваррете,
Артуро Альбрандт-Салмерон, Эрнесто Ролдан-Валадес. Компьютерная томография
эндоорбитальной остеомы, вызывающей проптоз и компрессию зрительного нерва.
REJR 2021; 11(1):200-205. DOI: 10.21569/2222-7415-2021-11-1-200-205.
Статья получена: 10.02.21 Статья принята: 01.04.21
ntroduction.
Primary bone tumours constitute up to 2%
of all orbital neoplasia [1]. Osteomas are benign, slow-growing, bone-forming tumours
involving craniofacial bones [2]. Primary
orbital osteomas are rare; endo-orbital osteoma
most frequently originates from a secondary orbital extension of the paranasal sinuses [3]. Up to
seven different types of orbital osteoma have been
reported [4]. Generally, osteomas are asymptomatic or incidentally discovered; a computed tomography (CT) scan is the imaging modality of choice
for diagnosis [3, 5]. This case is relevant because
it describes an unusual case of a young adult with
primary orbital osteoma associated with eye compression. During the past ten years, approximately 15 case reports have been published.
Case Report.
A 36-year-old man attended the emergency
room complaining of progressive proptosis, worsening headaches, and ocular pain. During the
physical examination, he presented left eye
movement limitations associated with diplopia
and pressure-like sensation. Swelling that involved the left anterior periorbital and frontal sinus region was present; the patient observed this
sign during last year. He also presented a downward deviation and limitations of lateral and vertical gaze. No papilledema or optic atrophy was detected on fundoscopic examination.
Computed tomography revealed a hyperdense frontal mass of the left orbital floor displacing the left globe inferiorly and displacing the orbital soft tissues superiorly (Fig. 1).
Besides, severe anterior dislocation of the
left eye, the optic nerve’s compression, and the
right medial rectus muscle were seen (Fig. 2).
The imaging features of the lesion were suggestive of osteoma. The patient was referred to the
neurosurgery and ophthalmology departments
where the diagnosis was confirmed and scheduled
follow-up.
Discussion.
Epidemiology.
Osteomas are benign, slow-growing tumours; orbital involvement usually results from
invasion from adjacent sinuses, with an incidence
ranging from 0.9% to 5.1%; primary orbital involvement is infrequent. These tumours are commonly small and asymptomatic; only 5% of cases
become symptomatic or require surgery. Most osteomas are diagnosed during the fourth and fifth
decades of life. There is a slight preference for
males [3, 6].
Mass effect.
Osteomas prevail silent until they reach a
specific size. Lesion within the orbit can cause a
variety of ocular anomalies secondary to mass effects, such as exophthalmos, diplopia, swelling,
amaurosis, and acquired Brown syndrome. In exceptional scenarios, the tumour may grow intracranially and originate neurological complications
[6, 7].
Structure compression.
The orbit is a cavity that contains many
structures in a relatively narrow space; when osteoma is present, it commonly displaces extraocular muscles, presenting as diplopia and eye
movement impairment. Additionally, the globe is
markedly compressed, causing disk oedema, ophthalmic vein compression, and choroidal folds that
will eventually cause optic atrophy and visual
loss. Osteoma may represent an emergency in the
long term because, if left untreated, they may destruct the eye due to direct pressure on the optic
nerve and disturbance of the ocular blood supply,
manifesting as unilateral blindness [8].
Imaging diagnosis.
Radiography is the basis of osteoma diagnosis; many times, it is the first imaging method to
identify the tumour. Osteoma manifests as a radiopaque lesion with a nidus with a radiolucent centre enveloped by dense sclerosis [5].
A CT scan is the imaging modality of choice;
it allows us to determine the tumour’s anatomic
position and its extensions precisely [5]. Osteomas
appear as highly circumscribed osteoblastic
masses. They conform to the internal contour of
the bone wall and may have an irregular bulging
surface. The bone window reveals a central trabecular area with a dense sclerotic periphery [1].
With magnetic resonance imaging (MRI),
I
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findings depend on the amounts of nidus calcification, fibrovascular zone size, sclerosis, and
bone oedema; the lesion’s signal void peripheral
zone may not be recognizable from the air in the
sinuses, interfering with the evaluation of tumour
extension. Besides, MRI shows optic nerve invasion and damage to local tissue. Additionally, a
radionuclide bone scan may differentiate an active
growing lesion from a stable one [6, 9].
Although it is rarely reported, it is possible
to evaluate this lesion with ultrasound (US). The
US depicts an irregular and incompressible mass
without internal vascularity. The anterior surface
is very dense with excellent attenuation of sound,
while the posterior surface has a characteristic
sound attenuation. The orbital fat is comparatively less compared to the healthy orbit or sinus [10].
Table 1 presents a summary of the findings obtained with imaging techniques most commonly
used in orbital osteoma.
Complications before treatment.
Serious complications have reported intracranial pneumatocele, pneumocephalus, meningitis, subdural abscesses and compressive neuropathies [11].
Treatment.
There are traditional two modalities of
treatment: for tumour localized close to the optic
nerve, total or subtotal surgical resection is done
immediately; for asymptomatic cases, especially in
elderly patients, the initial treatment consists of
observation and follow up with periodic imaging
controls considering the slow growth pattern of
the osteoma. External surgical approaches include
coronal, transcaruncular, tranconjunctival, and
transblepharoplasty incisions [12, 13]. The most
appropriate method is selected according to location, tumour volume, anatomical situation, and
sinus extension [14]. Table 2 presents a summary
of the most common surgical approaches to orbital osteoma.
Recent studies have evinced the efficacy and
safety of percutaneous CT-guided cryoablation of
osteoid osteoma at different sites [15]. The technique known as Magnetic resonance-guided focused ultrasound (MRgFUS), that was initially
used in the ablation of uterine fibroids, has reported complete clinical success observed in 90%
Fig. 1 а (Рис. 1 а) Fig. 1 b (Рис. 1 б) Fig. 1 c (Рис. 1 в)
Fig. 1 d (Рис. 1 г) Fig. 1 e (Рис. 1 д) Fig. 1 f (Рис. 1 е)
Fig. 1. CT.
A, B – axial views, showing a bone lesion located in the orbit’s posteromedial region; the lesion was displacing the
eye globe anteriorly (yellow lines). C, D – coronal view of the orbit showing the lesion rising from the orbit floor and
its internal wall with concomitant displacement the rectus muscles and vascular structures (yellow line). E, F –
sagittal view evincing the lesion extending along the orbit’s floor (yellow line) with an upper displacement of the
optic nerve and vascular structures (white arrow).
Рис. 1. МСКТ.
А, Б – акстальные реконструкции, показывающие поражение кости, расположенное в заднемедиальной области орбиты; определяется смещение глазного яблока остеомой кпереди (желтые линии). В, Г – корональные
реконструкции, выявляющие остеому, исходящую из нижней стенки орбиты и ее внутренней стенки с сопутствующим смещением прямых мышц и сосудистых структур (желтая линия). Д, Е – сагиттальные реконструкции, демонстрирующие поражение, простирающееся по дну орбиты (желтая линия) со смещением зрительного нерва и сосудистых структур вверх (белая стрелка).
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of cases of non-spinal osteoid osteoma [16-18].
However, its use has still not been reported for
orbital osteomas.
Post-surgical complications.
They include recurring frontal sinusitis, iatrogenic paralysis of the IV cranial pair, postoperative frontal sinusitis with bone resorption in
tardive phase and, eventually, loss of the anterior
wall of the frontal sinus [19].
Follow-up.
Because osteomas have a slow growth rate
of (average 1.6 mm/year), patients should be
monitored for recurrence with annual clinical exams and biannual imaging with radiograph or CT.
Once clinical and radiographic stability is reached
after at least three to five years, imaging can be
reserved only for new symptoms [3, 9].
Differential diagnosis.
Osteoblastoma is usually a central differential diagnostic consideration; other benign lesions
include fibrous dysplasia and ossifying fibroma
[20]. Osteoblastoma radiographically appears as a
lytic and blastic mass with a peripheral ring of
sclerotic bone and internal mineralization lesions
[6, 21, 22]. Another differential diagnosis is fibrous dysplasia, and its CT findings usually show
a homogenous ground-glass appearance. An ossifying fibroma is observed as a defined mass with
Fig. 2 а (Рис. 2 а) Fig. 2 b (Рис. 2 б) Fig. 2 c (Рис. 2 в)
Fig. 2. CT, multiplanar reconsructions.
A – axial view, showing the bone lesion in the left orbit displacing the globe laterally and causing proptosis with
compression of the medial rectus muscle and the optic nerve (black arrow). B – coronal view, depicts the orbital
wall’s deformation and compression of inferior rectus muscle (white arrowhead). C – sagittal view of the orbit with
a soft-tissue window displays the lesion’s heterogenous bone composition (white ellipse).
Рис. 2. КТ, мультипланарные реконструкции.
А – аксиальная реконтрукция, показывающий поражение кости левой орбиты, смещающее глазное яблоко
латерально и вызывающее проптоз со сжатием медиальной прямой мышцы и зрительного нерва (черная
стрелка). Б – корональная реконструкция, демонстрирующая деформацию стенки орбиты и компрессию
нижней прямой мышцы (белая стрелка). В – сагиттальная реконструкция, орбита, мягкотканное окно, выявляется неоднородная стурктура остеомы (белый эллипс).
Table №1. Summary of the findings obtained with imaging techniques most commonly
used in orbital osteoma.
Imaging Modality Findings
Radiography
A radiopaque lesion with a nidus which has a radiolucent centre enveloped by dense
sclerosis [5].
CT
Circumscribed osteoblastic masses conform to the bone’s internal wall and may have
an irregular bulging surface [1, 5].
CT-Bone window Trabecular central area with a dense sclerotic periphery [1].
MRI
Imaging findings depend on calcification, fibrovascular zone, sclerosis, and oedema to
show optic nerve invasion and local tissue damage [6, 9].
Radionuclide bone scan It can discriminate against an active lesion from a stable one [9].
Ultrasound
Irregular and incompressible mass without internal vascularity.
Orbital fat is less compared to the healthy orbit [10].
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osteoblastic and osteolytic areas surrounded by a
thin sclerotic margin [20, 22].
Conclusions.
Despite orbital osteoma is considered a benign condition, with a conservative attitude, preferred to asymptomatic osteomas; readers should
be aware of the need to perform periodic control of
growth using serial, contemporary imaging techniques. If there is significant growth or intracranial or orbital extension or facial deformities, the
attitude should become more aggressive, consisting of surgical removal using open or endoscopic
techniques.
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Type of approach Indications
Transconjunctival inferior fornix Inferior orbital lesions
Anterior orbitotomy by lateral
canthotomy with swinging lower
eyelid
Provides exposure to inferior anterior orbital lesions
Upper eyelid crease incision Superior lesions
Coronal incision
Extensive lesions may require wider exposure, requiring reconstruction for optimal
functional and cosmetic result
Transcaruncular Superomedial osteomas
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