Journal of

Case Reports and Images in Medicine

 
     
Clinical Image
 
Clinical dilemma of unilateral popping eye
Parag H. Mehta1, Siddharth R. Bhesania2, Hojoon you3
1MD, Senior Vice Chairman, Department of Medicine, New York Methodist Hospital, NY USA.
2MD, MPH, IT data coordinator, Department of Medicine, New York Methodist Hospital, NY USA.
3MD, Resident PGY3, Department of Medicine, New York Methodist Hospital, NY USA.

Article ID: 100029Z09PM2017
doi:10.5348/Z09-2017-29-CL-1

Address correspondence to:
Siddharth Ravinbhai Bhesania
MD, MPH, NY Methodist Hospital
506 6th Street Brooklyn
NY 11215

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How to cite this article
Mehta PH, Bhesania SR, You H. Clinical dilemma of unilateral popping eye. J Case Rep Images Med 2017;3:1–3.



Case Report

A 36-year-old male was presented in emergency department with worsening left eye protrusion since two and a half years (Figure 1). He also complained of left eye dull pain (3/10) and headaches for two weeks without any visual changes. No symptoms suggestive of thyroid disease. He had no significant past medical history. His visual field and rest of the physical examinations were normal. Patient's blood pressure was elevated (171/112 mmHg) in the emergency department but came down to normal eventually. On computed tomography scan of the head (Figure 2A), he had a large soft tissue homogenous mass extending into the left orbit measuring 5x3.8 cm in axial dimension. Patient had endoscopic sinus surgery and resection of the left ethmoid mucocele and orbital decompression that he tolerated well with improvement of his proptosis (Figure 2B). Postoperatively, patient complained of diplopia, which resolved eventually.


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Figure 1: Patient photo showing popping of left eye.



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Figure 2: (A) Presurgery computed tomography scan of head showing large mucocele evading left eye socket pushing eye ball out, and (B) Postsurgery computed tomography scan of head showing mucocele removed via endoscopic sinus surgery.


Discussion

Para-nasal sinus mucocele is described as slowly expanding benign cystic lesion. Frontal and ethmoidal sinuses are being the most commonly affected with the condition. Most of the time it is filled with mucus and respiratory epithelium. The exact mechanism causing mucocele is unclear, however, obstruction of ostia due to inflammation, fibrosis, trauma, anatomical anomaly or polyps may be the cause [1] [2]. It may occur at any time but most commonly prevalent in 30–70 years of age irrespective of gender. If left untreated gradually it expands and may push surrounding structures especially bony walls of affected sinus, occasionally affecting orbit and intracranial cavity. Usually, when it is small, it is asymptomatic. As it expands it can cause headaches, facial asymmetry, orbital pain, and vision problem depending on the site of expansion. In this case, the cause for mucocele was unclear and patient had headaches with left eye pain without any vision problem. When mucocele expands in orbital cavity pushing the structures behind the eyeball, it can cause proptosis. There can also be visual acuity problem if the optic nerve is compressed.

Computed tomography scan is the confirmatory diagnostic test showing low density, soft tissue homogenous mass. Magnetic resonance imaging scan can be useful to differentiate the cause especially if it is neoplasm. If mucocele is infected, it can rapidly expand and compress surrounding structures. Culture of the aspiration can confirm infection [3].

Treatment always consists of surgery, which can be external approach or endoscopic depending upon size and location of mucocele. In recent years, endoscopic approach has been widely used due to its advantage of minimal damage to mucosa and maintenance of a patent sphenoethmoidal recess [4].


Conclusion

In conclusion, most common cause of proptosis is thyroid disease. History is important to identify other causes. Mucocele is relatively rare to develop up to this stage, where it gives proptosis. The situation can be prevented if there is early intervention.

Keywords: Diplopia, Mucocele, Popping eye, Unilateral proptosis


References
  1. Manaka H, Tokoro K, Sakata K, Ono A, Yamamoto I. Intradural extension of mucocele complicating frontoethmoid sinus osteoma: Case report. Surg Neurol 1998 Nov;50(5):453–6.   [CrossRef]   [Pubmed]    Back to citation no. 1
  2. Nakajima Y, Yoshimine T, Ogawa M, et al. A giant intracranial mucocele associated with an orbitoethmoidal osteoma. Case report. J Neurosurg 2000 Apr;92(4):697–701.   [CrossRef]   [Pubmed]    Back to citation no. 2
  3. Brook I, Frazier EH. The microbiology of mucopyocele. Laryngoscope 2001 Oct;111(10):1771–3.   [CrossRef]   [Pubmed]    Back to citation no. 3
  4. Kuhn FA, Javer AR. Primary endoscopic management of the frontal sinus. Otolaryngol Clin North Am 2001 Feb;34(1):59–75.   [CrossRef]   [Pubmed]    Back to citation no. 4
Suggested Reading
  • Canalis R, Zajtchuk J, Jenkins H. Ethmoidal Mucoceles. [Available at:]
  • Erini M, Nouredine G. Exophthalmos caused by an ethmoidal mucocele. [Available at:]
  • Paranasal sinus mucocele. [Available at:]
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Author Contributions
Parag H. Mehta – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Siddharth R. Bhesania – Substantial contributions to conception and design, Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Hojoon You – Substantial contributions to conception and design, Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of submission
The corresponding author is the guarantor of submission.
Source of support
None
Conflict of interest
Authors declare no conflict of interest.
Copyright
© 2017 Parag H. Mehta et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.



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