Anatomy of the orbit

ANATOMICAL ASPECTS OF ENT IN RELATION TO EYEDR. SATINDER PAL SINGH

ANTERIOR VIEW OF THE SKULL

RIGHT ORBIT SHOWS THE 7 BONES THAT CONTRIBUTE TO ITS STRUCTURE

MEDIAL WALL OF ORBITStankiewick sign- By pressing the eye check lamina

Related to ethmoidsLamina is 2mm above the maxillary ostium

Lacrimal bone is smallest and most fragile of the cranial bones.

CHANDLER’S CLASSIFICATION OF ORBITAL INFLAMMATION

PRESEPTAL CELLULITIS ORBITAL CELLULITIS

5. CAVERNOUS SINUS THROMBOSIS.

3. SUBPERIOSTEAL ABSCESS

4. ORBITALABSCESS .

PATHOPHYSIOLOGY OF THE SPREAD OF INFECTIONDirect invasion through compromised

bony barriersRetrograde septic thrombophlebitis

(ophthalmic vein via the pterygoid venous plexues).

Erosive osteomyelitis (osteomyelitic bone erosion).

DIRECT INVASION THROUGH COMPROMISED BONY BARRIERS

Infection spreads to the ethmoid labyrinth

Lamina papyracea has two openings Ant./Post. Ethmoid canal

for NV bundle

Orbitalinvolvement

LATERAL VIEW OF THE MEDIAL WALL OF THE RIGHT ORBIT.

Lacrimal bone

Lamina papyracea

Posteriorethmoidalforamen

Anteriorethmoidalforamen

ORBITAL COMPLICATIONS OF SINUSITIS.COMPUTED TOMOGRAPHY SCAN OF A PATIENT WITH A RIGHT ORBITAL ABSCESS.

SEQUENCE OF SPREAD Sinusitis

Orbitalinvasion

Preseptalcellulitis

Subperiostea

l abscess

Orbital cellulitis

Orbital abscess

Superior orbital fissure

syndrome

Orbital apex syndrome

Cavernous sinus

thrombosis

Ophthalmoplegia

blindness

 RIGHT ORBIT SHOWS SUPERFICIAL LANDMARKS

A PATIENT WITH CAVERNOUS SINUS THROMBOSIS. THIS IMMUNOCOMPROMISED DIABETIC 76-YEAR-OLD MAN WITH FUNGAL SINUSITIS PRESENTED WITH MARKED PROPTOSIS, CHEMOSIS, OPHTHALMOPLEGIA, AND COMPLETE VISUAL LOSS.

AXIAL CONTRAST (CT) SCAN REVEALING (A) THROMBOSIS OF THE SUPERIOR OPHTHALMIC VEIN (SINGLE ARROW) AND RIGHT CAVERNOUS SINUS (DOUBLE ARROWS) IN AN 11-YEAR-OLD WHO PRESENTED WITH RIGHT ORBITAL PAIN AND PERIORBITAL EDEMA.

AXIAL (H) AND CORONAL (I) CT OF A LEFT ANTERIOR ETHMOIDAL MUCOCELE, DEMONSTRATING THINNING/DEHISCENCE OF THE FOVEA ETHMOIDALIS, CRIBRIFORM PLATE, AND LAMINA PAPYRACEA, AND INVASION OF THE MEDIAL LEFT ORBIT.

Coronal (j) bone and soft tissue algorithmCT of a left anterior ethmoidal mucocele, demonstrating thinning/dehiscence of the fovea ethmoidalis, cribriform plate, and lamina papyracea, and invasion of the medial left orbit.

CORONAL CT OF AN IMMUNOCOMPROMISED PATIENT WITH INVASIVE FUNGAL RHINOSINUSITIS. NOTE THE AGGRESSIVE-APPEARING MORPHOLOGY, WITH INVASION OF ADJACENT STRUCTURES. A HALLMARK OF FUNGAL INFECTION.

A PATIENT WITH LARGE TUMOR PROBABLY ARISING ON THE LATERAL WALL OF THE NOSE AND ETHMOIDS, EXTENDING LATERALLY INTO THE MAXILLARY SINUS AND ANTERIORLY INTO THE SOFT TISSUES OF THE CHEEK, DISPLACING THE EYE LATERALLY AND SUPERIORLY.CORONAL CT SCAN OF THE SAME PATIENT SHOWING A LARGE"ANTROETHMOIDAL" TUMOR.

FRONTAL SINUS TREPHINATIONEYE MOVED DOWNWARDFARWARD LATERALLY

AXIAL (LEFT) AND CORONAL (RIGHT) T1-WEIGHTED CONTRAST-ENHANCED MAGNETIC RESONANCE IMAGES FOR A PATIENT WITH PROGRESSIVE VISION LOSS AND A

LARGE CAVERNOUS HEMANGIOMA OF THE LEFT ORBITAL APEX (WHITE ARROWS).

(CT) SCAN OF THE ORBITS OF A 35-YEAR-OLD FEMALE A MASS IN THE LEFT ORBIT THAT OBLITERATES SUPERIOR AND MEDIAL STRUCTURES OF THE ORBIT, COMPARED WITH NORMAL STRUCTURES IN RIGHT ORBIT. THE MASS ALSO INVOLVES THE LEFT ETHMOID SINUSES.

OPTIC NERVEDECOMPRESSION

Descendingprocess for /.nasal concha

Crest

Lacrimal hamulus

Groove for lacrimal

Articulates withfrontal bone

Left Lacrimal bone

THE LACRIMAL APPARATUS

LANDMARKS FOR DCRAnterior lacrimal crestPosteroir lacrimal crestLacrimal fossaMedial canthus Medial palpebral ligament

GRAVES DISEASE Exophthalmos Proptosis and diplopia Corneal ulceration from exposure and

Keratopathy Visual loss from optic neuropathy. Fusiform swelling of muscles COCA COLA SIGN During endoscopic orbital decompression for

treatment of Graves orbitopathy, the maxillary sinus serves as the gateway to the orbital floor.

Successful endoscopic decompression depends on the creation of a wide maxillary antrostomy.

DALRYMPLE’S SIGN-RETRACTION OF UPPER LID

VON GRAEFE’S SIGN- LID LAG

GIFFORD’S SIGN- DIFFICULTY IN EVERSION OF LID

STELLWAG’S SIGN-INFREQUENT BLINKING

EXTRAOCULAR MUSCLE ENLARGEMENT MARKED WITH WHITE ARROW IN CORONAL SOFT TISSUE CT SCAN (A) AND AXIAL CT SCAN (B). NOTE THE ORBITAL APEX CROWDING.

FACIAL NERVE PARALYSIS Incomplete closer of eye results in Epiphora Exposure keratitis Bells phenomenon ( eyeball turn up and

out) Crocodile tears ( gustatory lacrimation)

SJOGREN’S SYNDROME Xerostomia Keratoconjunctivitis sicca Rhinitis sicca

OTITIC HYDROCEPHALUSo Dilplopiao Papilledeoma and otic atrophyo Nystagmus

TRAUMA PARTNASO-ORBITAL FRACTURES Telecanthus, due to lateral displacement of

medial wall of orbit. Peri orbital ecchymosis Orbital haematoma

FRACTURE OF ZYGOMA (TRIPOD FRACTURE)•Step deformity of infraorbital margin•Oblique palpebral fissue •Restricted ocular movments•Diplopia•Periorbibal Emphysema

FRACTURES OF ORBITAL FLOOR Also known as Blow out fractures Ecchymosis of lid, conjunctiva and sclera Enophthalmos with inferior displacement of eyeball Diplopia due to Inferior rectus trapped Tear drop sign on WATER’S VIEW. Infraorbital/Trasnantral reduction of fracture.

FRACTURES OF MAXILLA Le Fort I (transverse) fracture Le Fort II (pyramidal) fracture Le Fort III (craniofacial dysjunction)

TRAUMATIC FACIAL PALSY OF A CHILD WITH COMPLETE FACIAL PARALYSIS OWING TO BELL’S PALSY, TOP ROW. RESULTS 2 MONTHS AFTER MIDDLE CRANIAL FOSSA DECOMPRESSION OF THE LABYRINTHINE SEGMENT AND GENICULATE GANGLION OF THE FACIAL NERVE, BOTTOM ROW.

CSF RHINORRHOEA

SLEEP APNEA Primary open angle glaucoma P.O.A.G. Due to decreased oxygenation of optic nerve

during sleep apnea.

LABYRINTHITIS• Vestibular imbalance• Nystagmus

COGAN’S SYNDROME• Episodic vertigo• Interstitial keratitis• SNHL • -ve serology for syphilis.

JUVENILE NASOPHARYNGEAL ANGIOFIBROMA Frog-Face Deformity It extend to inferior orbital fissure and

destroy Apex of orbit. Enter the orbit via Superior orbital fissure

Nasopharyngeal carcinoma• Squint and diplopia due to C.N. VI m/c.• Ophthalmoplegia C.N. III, IV and VI• Reduced corneal reflex invasion of C.N. V

through F. Lacerum.• Exophthalmos and blindness due to direct

invasion of C.N. II.• C.N. IX, X and XI Jugular foramen syndrome

OPTIC CANAL AND SUPERIOR ORBITAL FISSURE.

CT (C) AND MRI (D) DEMONSTRATI NG DIRECT SKULL BASE AND ORBITAL INVASION OF AN ADENOID CYSTIC CARCINOMA. NOTE THE INTRINSIC T2 HYPERINTENSITY OF THE LESION, UNUSUAL AMONG SINONASAL SOFT TISSUE MALIGNANCIES.

OCULOMOTOR (III) NERVE DAMAGE

AT REST•LATERAL STRABISMUS DUE TO PARALYZE MEDIALRECTUS• PTOSIS-DROOPING EYELID

ABDUCENS (VI): AT RESTMEDIAL STYLABISMUS(CROSS-EYED) DUE TODAMAGE/PARALYZELATERAL RECTUS

A. ABDUCENS(VI) NERVEDAMAGE

WALLENBERG SYNDROME (PICA) Vertigo, nausea and vomiting Horner’s syndrome Dysphaiga Dysphoina Ataxia with tendency to fall to involved side Loss of pain and temperature sensations on

same side of face and contralateral sides of limibs.

GARDENIGO SYNDROME EAR DISCHARGE (S.O.M.) DIPLOPIA(C.N. VI paralysis) RETRO-ORBITAL PAIN (C.N. V involve)

LATERAL SINUS THROMBOPHLEBITIS

•Papilledema •Blurring of disc margins•Retinal hemorrhage•Crowe-Beck test

ALLERGIC RHINITIS

o EDEMA OF LIDSo CONGESTIONo COBBLESTONE CONJUNCTIVAo ALLERGIC SHINERS (dark circles under the

eyes)

USHER’S SYNDROME Hearing loss Retinitis pigmentosa

RACOON SIGN• Ecchymosis around eye’s in case of head injuries

VAN DER HOEVE SYNDROME OSTEOGENESIS IMPERFECTA OTOSCLEROSIS AND BLUE SCLERA

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