Combined lateral orbitotomy and endoscopic transnasal orbital decompression in a case of orbital aspergillosis with impending intracranial invasion

Abstract

A 64-year-old man with a known history of diabetes and hypertension presented to the Accident and Emergency Department with a 2-day history of sudden decreased vision in the right eye. Temporal arteritis was suspected with an elevated erythrocyte sedimentation rate (71 mm/h), and oral prednisolone was started immediately. Four days later, the patient's right eye vision deteriorated from 0.6 to 0.05, with a grade-4 relative afferent pupillary defect and ophthalmoplegia. Computed tomography showed a contrast-enhancing orbital apex mass in the right orbit abutting the medial and lateral portions of the optic nerve with extension to the posterior ethmoid and sphenoid sinuses. A transethmoidal biopsy was performed which yielded septate hyphae suggestive of Aspergillus infection. Ten days later, the patient's right eye vision further deteriorated to hand movement with total ophthalmoplegia. MRI of the orbit showed suspicion of cavernous sinus thrombosis. A combined lateral orbitotomy and transethmoidal orbital apex drainage and decompression were performed to eradicate the orbital apex abscess. Drained pus cultured Aspergillus. The patient was prescribed systemic voriconazole for a total of 22 weeks. The latest MRI scan, performed 8 months after surgery, showed residual inflammatory changes with no signs of recurrence of the disease. To our knowledge, this is the first case report which describes the use of a combined open and endoscopic approach for orbital decompression and drainage in a case of orbital aspergillosis. We believe the combined approach gives good exposure to the orbital apex, and allows the abscess in this region to be adequately drained.

Keywords: Lateral orbitotomy; Orbital aspergillosis; Transethmoidal orbital apex drainage.

Fig. 1

a Axial contrast CT scan of the orbit showing a right orbital apex mass (white arrow) abutting the right posterior ethmoid and sphenoid sinuses. Lamina papyracea was eroded. b Axial T1 contrast MRI scan (3 months after surgery) showing residual inflammatory and infective changes (black arrow) at the right orbital apex just anterior to the cavernous sinus (white arrow).

Fig. 2

a Endoscopic view of the right orbital apex. Pus was released near the orbital apex (black arrow). 1: anterior wall of sphenoid sinus; 2: lamina papyracea; 3: pituitary fossa of the sphenoid sinus; 4: periorbita. b Endoscopic decompression of the right medial and inferior orbital walls. Medial rectus (black arrow) and intraconal fat (white arrow) exposed.

Fig. 3

a Microscopy photos of the right orbital apex lesion, for frozen sections, showing fungal hyphae (black arrow). Grocott's staining. ×600 magnification. b Microscopic photos of the right orbital apex lesion biopsy specimen showing fungal hyphae with regular caliber and occasional septae (white arrow) and spore formation (black arrow). Grocott's staining. ×600 magnification.