Case 41: What is the most likely diagnosis?
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DDx: Dacryoadenitis 1. 2. 3. 4. 5.
Case 41: What is the most likely diagnosis?
Orbital dermoid Choristoma Lacrimal Gland carcinoma Hordeolum Chalazion
Dacryoadenitis-Lacrimal Gland Abscess Dacryoadenitis is thought to be caused by ascension of an inciting agent from the conjunctiva through the lacrimal ductules. Patients often present with unilateral severe pain, redness, and pressure in the supratemporal region of the orbit. Acute dacryoadenitis has a rapid onset (hours to days). CT is helpful for showing diffuse enlargement of the lacrimal gland with oblong shape and marked enhancement with contrast for acute cases. Chronic cases show no enhancement with contrast. No compressive changes in the contiguous bone or globe are noted.
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DDx
Case 42: What is the most likely diagnosis?
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DDx: Orbital Cellulitis 1. 2. 3. 4.
Case 42a: What is the most likely diagnosis?
Allergic Reaction Fungal ds Orbital Tumor, metastasis Orbital Pseudotumor
Subperiosteal and Orbital Abscess-Orbital Cellulitis and Myositis Subperiosteal abscess typically starts as an infection of the ethmoid sinus. The infection spreads into the subperiostal lining of the orbit through the ethmoid bone. Radiographic studies may show opacification (red arrows) of the ethmoid, sphenoid, maxillary, or frontal sinuses. Even in severe cases a relatively sharp demarcation line, corresponding to the periosteal attachment of the bone is clearly visible. Patients commonly present with a significant fever, leukocytosis, and evidence of sinusitis. As the infection worsens, the globe itself becomes involved with injection and edema leading to proptosis.
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DDx
Case 43: What is the most likely diagnosis?
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Orbital Cellulitis and Myositis
Case 43: What is the most likely diagnosis?
Orbital cellulitis is an infection of the tissues posterior to the orbital septum. Myositis usually begins acutely, unilaterally. Patients often present with periorbital pain, pain on movement of the eye, and diplopia. In idiopathic myositis, the enlargement extends anteriorly to involve the tendons with an ill-defined border of the affected muscle (red arrows). The exophthalmos and muscle enalrgement are often less pronounced than in endocrine orbitopathy, and the retrobulbar fat volume is not increased. The affected ocular muscles show an irregular expansion that differs from the symmetric enlargement found in endocrine orbitopathy.
DDx: Orbital Cellulitis 1. 2. 3. 4.
Thyroid ophthalmopathy Orbital Pseudotumor Lymphoma Metastasis
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DDx
Case 44: What is the most likely diagnosis?
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Orbital Mucormycosis- Cavernous Sinus Thrombosis
Case 44: What is the most likely diagnosis?
Cavernous Sinus Thrombosis may present with decreased vision, chemosis, exophthalmos, headache, and cranial nerve 3-6 impairment. Staphylococcus aureus and streptococcus are the major causative bacteria. Mucor or aspergillus are the common fungal agents, typically from sinus infections. The entity can be life threatening and typically requires immediate treatment. MR or CT may be obtained typically showing non enhancement of the involved sinus with expansion ( red arrow ) and narrowing of the cavernous carotid as well as concomitant enlargement of the ipsilateral superior ophthalmic vein.
DDx: Cavernous Sinus Thrombosis 1. 2. 3. 4.
Optic neuritis Tolosa-Hunt Meningioma Fungal infection (Aspergillosis, Mucor)
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DDx
DDx: Idiopathic orbital inflammatory disease 1. 2. 3. 4. 5.
Case 45: What is the most likely diagnosis?
Graves Orbitopathy Atypical Lymphoma Post-septal cellulits Arteriovenous fistulas Vasculitis (e.g. Wegener’s Granulomatosis)
Idiopathic Orbital Inflammatory Disease Also known as Orbital Pseudotumor, idiopathic orbital inflammatory disease is the third most common orbital disease, following Graves orbitopathy and lymphoproliferative disorder. Common presentation includes acute onset of painful proptosis with possible diplopia, decreased vision, and conjunctival injection. On CT, extraocular muscles are enlarged with involvement of associated tendons, diffuse infiltration of orbital fat (red arrows) possibly surrounding the globe, and possible nerve sheath involvement. An orbital mass of heterogeneous composition often extends along the optic nerve sheath from the globe to the optic canal. Idiopathic orbital inflammatory disease encompasses a broad spectrum of disease entities with a high degree of variability in clinical presentation and outcome.
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DDx
Case 46: What is the most likely diagnosis?
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DDx: Orbital Inflammatory Disease 1. 2. 3. 4.
Case 46: What is the most likely diagnosis?
Thyroid ophthalmopathy Orbital cellulitis/myositis Lymphoma Metastasis
Idiopathic Orbital Inflammatory Disease Idiopathic Orbital Inflammatory Disease (IOID) , aka orbital pseudotumor, is a non-specific inflammation of the orbit. Pathologically it is polymorphic inflammatory cells with variable amounts of fibrosis. It is categorized by area of involvement. Myositic is most common involving any or all EOMs with tendinous insertions. Lacrimal is second most common with diffuse enlargement of the gland, particularly anteroposterior enlargement. Anterior involves globe and retrobulbar tissues. Third most common with a uveal-scleral and perineuritic subtypes. Diffuse type overlaps with other forms involving intraconal and multicompartmental spaces. Apical type involves the apex with possible intracranial extension. Some consider Tolosa-Hunt an intracranial variant of IOID.
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DDx
Case 47: What is the most likely diagnosis?
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Graves Disease (CT)
Case 47: What is the most likely diagnosis?
Graves disease is the most common cause of hyperthyroidism in the US and additionally, Graves disease can cause severe thyrotoxicosis. As with most autoimmune diseases, Graves is seen more commonly in females with a female-to-male ratio of 7-8:1. In the orbit, patients usually present with impairment of extraocular motion, visual loss in severe optic nerve involvement, and periorbital edema. In radiographic study, swelling in each extraocular muscle can be seen (red arrows) with an increase in the amount of fat surrounding the extraocular muscles and the optic nerve. Also commonly seen is forward bulging of the thick layer of connective tissue holding the orbit in place, preferential involvement of specific extraocular muscles, and enlargement of the middle portions of extraocular muscles.
DDx: Graves Disease 1. 2. 3. 4. 5.
Lymphoma Pseudotumor Arterivenous malformation Carotid cavernous fistula Wegener’s
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DDx
Case 48: What is the most likely diagnosis?
Initial Scan
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Graves Disease (MRI)
DDx: Graves Disease
Case 48: What1.isLymphoma the most likely diagnosis?
Graves disease is the most common cause of hyperthyroidism in the US and additionally, Graves disease can cause severe thyrotoxicosis. As with most autoimmune diseases, Graves is seen more commonly in females with a female-to-male ratio of 7-8:1. In the orbit, patients usually present with impairment of extraocular motion, visual loss in severe optic nerve involvement, and periorbital edema. In radiographic study, swelling in each extraocular muscle can beScan seen with an increase in the F/U amount of fat surrounding the extraocular muscles (red arrows) and the optic nerve. Also commonly seen is forward bulging of the thick layer of connective tissue holding the orbit in place, preferential involvement of specific extraocular muscles (blue arrows), and enlargement of the middle portions of extraocular muscles. Patients with active Graves disease undergoing orbital CT scans should not receive any form of intravenous contrast dye, as the iodine may be taken up by overactive thyroid tissue.
2. Pseudotumor 3. AVM 4. Post septal infection
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DDx
Case 49: What is the most likely diagnosis?
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DDx: Graves Disease 1. 2. 3. 4.
Case 49: What is the most likely diagnosis?
Pseudotumor Lymphoma AVM/CCFistula Wegener’s
Graves Disease (MRI) Graves disease is the most common cause of hyperthyroidism in the US and additionally, Graves disease can cause severe thyrotoxicosis. As with most autoimmune diseases, Graves is seen more commonly in females with a female-to-male ratio of 7-8:1. In the orbit, patients usually present with impairment of extraocular motion, visual loss in severe optic nerve involvement, and periorbital edema. In radiographic study, swelling in each extraocular muscle can be seen with an increase in the amount of fat surrounding the extraocular muscles and the optic nerve. Also commonly seen is forward bulging of the thick layer of connective tissue holding the orbit in place, preferential involvement of specific extraocular muscles (red arrows), and enlargement of the middle portions of extraocular muscles. Patients with active Graves disease undergoing orbital CT scans should not receive any form of intravenous contrast dye, as the iodine may be taken up by overactive thyroid tissue.
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DDx
Case 50: What is the most likely diagnosis?
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Case 50: What is the most likely diagnosis?
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DDx: Wegener’s Granulomatosis 1. 2. 3. 4. 5.
Case 50: What is the most likely diagnosis?
Pseudotumor Post septal infection/inflammation Lymphoma SLE Rheumatoid arthritis
Wegener’s Granulomatosis Ocular/orbital involvement is ultimately seen in 50% of cases of generalized Wegener’s Granulomatosis (WG). Orbital involvement in WG occurs wither due to contiguous spread from the sinuses or due to primary involvement (small vesicle vasculitis). Common ocular features include proptosis, scleritis, peripheral corneal ulceration, nasolacrimal duct obstruction, optic nerve vasculitis, retinal artery occlusion, conjunctivitis, and uveitis. There is a histopathological triad of granulomatosis inflammation, tissue necrosis (red arrow), and vasculitis. Limited WG of the orbit is a rare disease, but with overall good prognosis.
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DDx
DDx: Lipodermoid of Lacrimal Gland 1. 2. 3. 4. 5.
Case 51: What is the most likely diagnosis?
Ectopic Lacrimal Gland Squamous Cell Carcinoma Papilloma Herniation of Orbital Fat Epithelioma
Lipodermoid of Lacrimal Gland Lipodermoids consist of collagen tissue and adipose tissue (red arrows) lined by stratified squamous epithelium. They are less dense than solid dermoids and contain more adipose tissue. These lesions are often noncystic and can contain tissues derived from multiple germ layers. Lipodermoids can infiltrate into the peribulbar region, lid, and surrounding tissues. Lipodermoids are choristomas and are congenital, and about 10% of patients with such choristomas of the eye may have Goldenhar-Gorlin syndrome.
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DDx
DDx: Orbital Wall Epidermoid 1. 2. 3. 4.
Case 52: What is the most likely diagnosis?
Sphenoid meningioma Lymphoepithelioma Frontal Mucocele Mixed Tumors of the Lacrimal Gland
Orbital Wall Epidermoid Secondary or acquired epidermoid cysts are usually caused by post-traumatic inclusion of surface epithelium. Epidermoid tumors consist of capsule and contents, and can produce sharply demarcated bone defects (red arrows) on radiologic images. Typical radiologic appearance of an epidermoid cyst is a widening of diploic space and boen defect with smooth demarcated edges associated with thickened sclerotic margins.
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DDx
Histiocytosis- Eosinophilic Granuloma
Case 53: What is the most likely diagnosis?
Diagnosis of eosinophilic granuloma is usually based on radiographic demonstration of a destructive bone lesion arising from the marrow cavity (red arrows). The disease is also commonly multifocal. Rarely, the growing epiphysis is involved with eosinophilic granuloma. Skull lesions are lytic, with a beveled edge or sharp and serrated margins. Sclerosis may occur around orbital lesions. A hole-within-a-hole appearance may occur as a result of uneven erosion of bone.
DDx: Histiocytosis- Eosinophilic Granuloma 1. 2. 3. 4. 5.
Bone Infarct Osteosarcoma Fibrous Dysplasia Bone metastases Epidermoid Cyst
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DDx
Chalazion
Case 53: What is the most likely diagnosis?
Chalazion, (red arrows) or meibomian cyst, is a cyst within the eyelid caused by inflammation and obstruction of a meibomian gland. They are different from styes as they are subacute to chronic and painless. Can present with increased tearing (epiphora), sensitivity to light, “heavy” eyelid. Most resolve in a few months with no treatment.
DDx: Chalazion 1. Dacryocystocele 2. Dermoid/epidermoid 3. Stye (hordeola)
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DDx