Silent sinus syndrome: lack of orbital findings in early presentation

Silent sinus syndrome (SSS) is an uncommon disease process, classically described as unilateral maxillary sinus opacification that presents with enophthalmos and atelectasis of bony sinus walls from chronic negative pressure. Patients are largely free of characteristic rhinosinusitis symptoms.

Operative reports, clinic notes, and radiological studies were reviewed for cases of SSS treated in a tertiary care institution over a 7-year period. Presenting symptoms, radiological features, and surgical findings were evaluated.

Seventeen cases of SSS were identified. Presentation ranged from incidental computed tomography (CT) scan findings to unilateral enophthalmos with altered midface anatomy. Facial pain ipsilateral to the disease process occurred in 30% of cases. Vision changes were uncommon. Radiological studies universally revealed an opacified maxillary sinus on the affected side. Maxillary sinus walls were contracted and demineralized with significant orbital floor depression in 11 advanced cases. Four early cases revealed only lateralized uncinate process on CT scan without increased orbital volume, and two moderate cases showed increased orbital volumes on CT scan without clinical enophthalmos. All patients had a significantly lateralized uncinate process at surgery, often closely apposed to demineralized orbital walls.

Some authors maintain that SSS presentation must include enophthalmos. However, our series shows cases of lateralized uncinate processes and increased orbital volumes on CT scan, as would be seen in classic SSS, but lacking clinical enophthalmos. Such cases should be considered as potentially representing early SSS, before the development of clinical orbital findings.