Differential Diagnosis of Diseases Associated with Exophthalmos – Clinical Cases and Literature Review

clinical cases

Katarzyna Bogusiak

_{, Piotr arkuszewski}

Differential Diagnosis of Diseases Associated with

Exophthalmos – Clinical Cases and Literature Review

Różnicowanie chorób przebiegających z wytrzeszczem

– opis dwóch przypadków i przegląd piśmiennictwa

Department of craniomaxillofacial and Oncological surgery, Medical University of lodz, lodz, Poland

A – research concept and design, B – collection and/or assembly of data, C – data analysis and interpretation, D – writing the article, E – critical revision of the article, F – final approval of article

Abstract

exophthalmos is a forward displacement of an eyeball. it is observed in the course of a number of diseases. The reason for its occurrence, among others, are inflammation, genetically conditioned congenital defects, cancer, trauma, or parasitic diseases. a multitude of reasons, and the rare occurrence of certain types of diseases that can manifest exophthalmos make the correct diagnosis difficult and diagnostic process complicated, often requiring the involvement of many specialists. The purpose of this paper is to describe two cases of patients with bulging eyeball, with special emphasis on diagnostics (Dent. Med. Probl. 2014, 51, 1, 109–118).

Key words: zoonosis, zoonotic diseases, exophthalmos.

Streszczenie

Wytrzeszcz to przemieszczenie gałki ocznej ku przodowi. Pojawia się on w przebiegu wielu jednostek chorobo-wych. Jego powodem może być między innymi stan zapalny, uwarunkowania genetyczne, nowotwory, urazy lub choroby pasożytnicze. Mnogość przyczyn i rzadkie występowanie niektórych jednostek chorobowych, które mogą się manifestować wytrzeszczem sprawia, iż postawienie prawidłowego rozpoznania w tych przypadkach jest trudne, a proces diagnostyczny skomplikowany i często wymaga zaangażowania wielu specjalistów. celem niniejszej pracy jest przedstawienie opisu 2 przypadków chorych z wytrzeszczem gałki ocznej, ze szczególnym uwzględnieniem problemów diagnostycznych (Dent. Med. Probl. 2014, 51, 1, 109–118).

Słowa kluczowe: zoonozy, choroby odzwierzęce, wytrzeszcz.

Dent. Med. Probl. 2014, 51, 1, 109–118

issn 1644-387X © copyright by Wroclaw Medical University and Polish Dental society

exophthalmos is a forward displacement of an eyeball. There are 2 distinguished types of ex-ophthalmos: true exophthalmos, caused by dis-ease-related lesions occurring within the orbit, or pseudo-exophthalmos, when lesions are connect-ed solely to the eyeball, making it too big (in se-vere short-sightedness, hydrophthalmos) or when the orbit is too shallow (turricephaly and in ge-netically conditioned congenital defects – ap-ert syndrome, crouzon syndrome, Pfeiffer syn-drome, Treacher collins syndrome) or as a result of upper eyelid retraction [1–5]. exophthalmos resulting from endocrine disorders, observed in

the form of thyroid associated orbitopathy in the course of Graves’ disease is the most commonly reported form of exophthalmos. in such cases it usually is a bilateral exophthalmos, although it may also affect only one eyeball. This condition is caused by oedema within the orbital fat tissue and muscles, as well as their secondary fibrous tis-sue proliferation. in 5–10% of cases this disorder may have a severe course [6–8]. Furthermore, ex-ophthalmos can occur in the course of inflamma-tory conditions – the so-called inflammainflamma-tory ex-ophthalmos, which is associated with periorbital cellulites, subperiosteal abscess, orbital abscess or

orbital phlegmon. in most cases the inflammato-ry process diffusing from surrounding sinuses in-stigates it [9]. inflammatory conditions in orbital tissues can be associated with infectious diseases, including zoonotic diseases. exophthalmos is ob-served when extraocular muscles are attacked by parasites – for example parasites causing dirofi-lariasis Dirofilaria immitis and Dirofilaria repens (carnivorous animals are main carriers of these diseases, while mosquitoes are the disease vectors) or Gnathostoma spinigerum and Gnathostoma hispidum causing gnathostomiasis [10–12]. Oth-er causes of true exophthalmos include retrobul-bar abscesses and retrobulretrobul-bar tumours. as far as exophthalmos caused by the presence of an orbit-al tumour is concerned, eyeborbit-all displacement and double vision can be observed only when the tu-mour is about 1 cm large. This location is a place where lymphomas, vascular tumours (cavernoma, lymphangioma) and other solid tumours (fibromatic tumours, adipomas, fibromas, neuro-mas, meningioneuro-mas, gliomas and metastatic tu-mours) can be found [13, 14]. Metastases to the or-gan of sight are diagnosed in the course of breast cancer, lung cancer, gastrointestinal cancers, pros-tate cancer and, less commonly, in case of oth-er solid tumours [15–23]. Orbital pseudotumour (granuloma) stands as a common reason underly-ing asymmetry in eyeball location. it is a disease entity of unknown aetiology, characterized by a chronic, non-specific orbital inflammatory con-dition [17, 24]. Trauma may be yet another reason underlying exophthalmos – emphysema, haema-toma or such bone fragments position that leads to forward displacement of the eyeball [25]. injury of the facial skeleton may be followed by pulsating exophthalmos. nevertheless, this particular dis-ease entity can appear idiopathically as a result of a ruptured internal carotid artery within the cav-ernous sinus [26, 27]. apart from all the above-mentioned reasons underlying exophthalmos, it is essential to consider intermittent exophthalmos, occurring when the head is bent down or during the Valsalva manoeuvre and it may be caused by the presence of varices, aneurysms, deformed arte-riovenous connections, neurofibromatic tumours, meningocele, a large mucous cyst or cystic lym-phoma located in the orbital cavity [5, 27]. Disor-ders related with the activity of extraocular mus-cles resulting from paresis or paralysis of straight and oblique muscles also lead to the forward dis-placement of the eyeball. among infrequent rea-sons causing exophthalmos, it is recommended to indicate polymyositis or inflammation of ex-traocular muscles [17, 28]. Diagnosing and treat-ing common diseases associated with

exophthal-mos usually does not pose considerable problems. However, multitude of causes, next to rare occur-rence concerning certain disease entities that may be manifested with exophthalmos make it diffi-cult to establish a proper diagnosis in these cases, and hence the diagnostic process is very long and frequently requires engaging many various spe-cialists.

The aim of this thesis is to present 2 case stud-ies of patients suffering from exophthalmos, with a particular consideration of diagnostic issues. additionally, authors reviewed the literature con-cerning disease entities where exophthalmos is enumerated among possible symptoms.

Case Presentation

Patient 1

76-year-old female patient, l.s., was admit-ted to the clinic in 1982 due to facial asymmetry, observed for about 18 months, caused by a swell-ing of the cheek and parotid-masseter area on the right side, as well as exophthalmos (Fig. 1). The long period that had passed between initial symp-toms and hospitalisation was caused by the lack of clear indications to undertake surgical treatment, as well as by irregular control visits of the patient.

Course of Ambulatory

Diagnostics

initially the patient had ambulatory consulta-tions in the outpatient clinic, where maxillary si-nus X-ray was performed in Water’s projection. Due to the slight severity of symptoms and lack of pathological lesions visible on the X-ray image, no therapeutic procedures were administered. af-ter about 8 months the patient reported to the out-patient clinic for the second time, and at that time it was due to clear exophthalmos of the right eye-ball and severe asymmetry within the right half of her face. Ophthalmological and laryngological consultations performed at admittance in ambu-latory conditions did not add any information to the diagnosis; however, a pantomographic X-ray revealed quite an intense shadow visible on the right side, located externally to the ramus of man-dible, which suggested a suspicion that the patient has a soft tissue tumour in the parotid-masseter area. The patient had a puncture to the parotid-masseter area and this allowed tissue shreds to be collected. a histopathological examination did not reveal any atypical cells. Then the patient had sialography and scintigraphy performed in to

or-der to locate the tumour. sialography indicated an expanding tumour, whereas isotope examination showed a symmetrical accumulation of technet isotope in both parotid glands. after performing all the above-mentioned examinations, the patient was admitted to the Department with a suspicion of the tumour in the right parotid gland.

Diagnostic Procedures

Performed in the Clinic

During hospitalisation in the clinic the pa-tient had laboratory tests performed, which did not reveal any abnormalities. additionally, an X-ray image of orbits performed in layered struc-tures presented shadowing with delicate satura-tion, covering the lower part of the right orbital cavity, but not crossing the right innominate line, which could suggest bone structure densification in the area of sphenoid bone wings.

Both the previous diagnostic examinations (mainly contrast radiological examination of pa-rotid gland and layered X-ray of orbital cavities), as well as clinical symptoms could suggest a benign, expanding tumour of the parotid gland, a tumour in the sphenoid bone area or an inflammatory or metastatic lymph node. summing up, the initial diagnosis included an inflammatory process or

a neoplastic tumour. The patient was qualified to undergo a surgical procedure in order to collect a specimen of the tumour palpable in the parotid gland. During the surgery, the operating team re-vealed macroscopically a limited tumour in the pa-rotid gland area. a histopathological examination revealed features of chronic sialadenitis (siaload-enitis chronica). since this diagnosis did not cor-respond to the clinical image, and the exophthal-mos was still maintained, the patient underwent a scheduled revision of the right maxillary sinus. During the operation, the operating team revealed an aeration of maxillary sinus with a slight pari-etal thickening of the mucous membrane. a scarce amount of material was collected for a histopatho-logical examination, which revealed features of chronic inflammation with ulceration and fibrosis within the mucous membrane of the sinus. What is worth mentioning among components in the infiltration was the large number of eosynophilic granulocytes. nonetheless, this examination also did not provide significant grounds to state the fi-nal diagnosis. after the surgical procedure, the pa-tient experienced a certain relief and the exophthal-mos decreased slightly; yet, after several days it be-gan to increase without any tangible reasons, but this time it was associated with lacrimation and double vision, as well as tinnitus. Histopatholog-ical examinations revealed features of an

inflam-Fig. 1. Patient l.s. with

right eye exophthalmos and right eye swollen eyelids

Ryc. 1. Pacjentka

l.s. z wytrzeszczem prawej gałki ocznej i obrzękiem powiek oka prawego

matory process – both in the parotid gland and in the mucous membrane of the maxillary sinus. nevertheless, it was still impossible to exclude the neoplastic process. in this situation an empirical anti-inflammatory treatment and antibiotic thera-py was introduced. The patient obtained an intra-venous antibiotic from beta-lactam group – i gen-eration cephalosporins with a wide spectrum of antibacterial properties (sefril) together with an oral and local administration of Dexamethasone and a local administration of neomycin ointment and 3% boric acid compresses on the right eye. Precise observation of the patient revealed a vis-ible, gradual improvement. 2 weeks of therapy led to almost complete relief of the above-mentioned symptoms. However, the cause of the disease still remained unknown. at the end of the hospitalisa-tion period the patient remembered that she has a turtle at home, which she took care of during his long-lasting disease, associated with symptoms of exophthalmos in the left eye and uplifting of this area, hence symptoms quite similar to the ones the patient had. Following our request, the tur-tle was brought to the clinic and then the above-mentioned symptoms were confirmed. since the clinical condition of the turtle worsened signif-icantly, and the animal did not ingest any food, the patient decided to humanely put the turtle to death in Veterinary clinic. Tissues of the animal sampled for examination revealed macroscopic le-sions in internal organs, while microscopic evalu-ation showed only renal lesions as in gromelural nephritis, as well as features of chronic inflamma-tion with a significant collecinflamma-tion of eosynophilic granulocytes.

a control clinical examination performed six months after the patient had been discharged from the clinic did not reveal any noteworthy ab-errations.

Patient 2

81-year-old male patient, J.O., was referred to cranio-Maxillo-Facial surgery and Oncology clinic from the Department of Ophthalmology in 2012 to undergo a consultation due to an ex-ophthalmos of the left eyeball, double vision in all directions of vision, as well as swollen left eyelids increasing for about 2 weeks. a month before the occurrence of the ocular symptoms, the patient stated that he suffered from bilateral otitis media, which he associated with his trip to serbia. The pa-tient was also hospitalised at General surgery De-partment in order to diagnose abdominal pain lo-cated within the mesogastrium, which appeared suddenly, without dietary error, and relieved after several days of conservative therapy. a cT scan of

the abdominal cavity performed at that time re-vealed a slight lesion, with 8 mm diameter, within the head of pancreas.

apart from the swollen eyelids, exophthalmos of the left eye, diplopia and tenderness in the place of the left infra-orbital nerve outlet, local exami-nation of the head and neck did not reveal any sig-nificant aberrations from normal condition.

Laboratory and Imaging

Diagnostics

laboratory tests performed during the hos-pitalisation at the Department of Ophthalmology only revealed slightly increased cRP values, while the remaining blood morphology and biochemistry parameters remained within the reference values.

The patient’s diagnostics were expanded with imaging examinations. The following examina-tion was performed in order to evaluate the disease process of the left orbital cavity: a cT scan of the head and orbital cavities without contrast. com-puted tomography of the head – showed the image of the brain without focal lesions, without features of compression process and bleeding. a cT scan of orbital cavities without contrast revealed path-ological mass located within the lower and later-al part of the left orbitlater-al cavity (in the bottom part it was up to 13 mm thick, and in the lateral part it was 7 mm thick), extending from the posterior wall of the orbital cavity to the front and passing un-der the lower eyelid. The described lesion covered oculomotor muscles – lateral rectus and inferior rectus. The examination unveiled damages with-in the bottom-lateral wall of the left orbital cavity, with the diameter reaching about 6 mm, and later-al wlater-all with diameter equlater-alling about 4 mm. no fo-cal lesions were noted within the right orbital cav-ity or both eyeballs. Optic nerves were symmetric, of proper thickness, without pathological lesions (Fig. 2). since there was a suspicion of a neoplas-tic process of a possible metastaneoplas-tic character within the left orbital cavity from the primary focus locat-ed in the abdominal cavity (lesions within pancre-as in abdominal cT performed at General surgery Department), an ultrasound examination of the abdominal cavity was performed. This examina-tion revealed the presence of fluid in the peritone-al cavity (up to 26 mm thick liquid layer surround-ing the liver, up to 9 mm around the spleen, and up to 2 cm in the interloop space), as well as heteroge-neous echogenicity of the pancreas. in the poste-rior outline of the head and body of the pancreas there was a visible tumour mass, 40 × 36 × 32 mm. What is more, within the body and tail of the pan-creas, there were several hypoechogenic focuses

ob-served, with diameters reaching about 8 mm – sus-picion of cysts. Therefore, the lesion within the pan-creas inpan-creased considerably when compared with the previous cT scan performed about a month be-fore. The patient underwent another surgical con-sultation. To exclude the presence of focal lesions in lungs, the patient had a chest X-ray performed in two projections, which revealed the following path-ological changes: adhesions at the basis of the right lung, calcified arteriosclerotic plaques in the aor-tic ring, as well as a condition after fracturing 4th to 7th ribs on the right side. Following the sugges-tion of the radiologist describing the cT scans of orbital cavities, the patient had a cT of orbital cav-ities with contrast. in the repeated cT with con-trasting agent, the lesion described in the previous scans and located in the bottom and lateral part of the orbital cavity corresponded to the irregular fat-ty infiltration of this area with the infiltration of straight muscles – lateral rectus and inferior rec-tus. The infiltration covered tissues surrounding the lower eyelid. Unlike the previous scans, this cT did not reveal clear characteristics of orbital wall damage, which supported the presence of inflam-matory lesions (Fig. 3).

Due to the presence of an inflammatory com-ponent in the ongoing disease process located in the area of the orbital cavity, the patient obtained anti-inflammatory treatment in the form of Dexa-methasone, 8 mg 1 × a day administered

system-ically, as well as locally in the form of eye drops. since a considerable improvement was observed after administering the first dose, Dexametha-sone therapy was continued. a week-long steroid therapy led to decreased exophthalmos and re-lief of double vision. The patient was discharged home with the recommendation to continue ther-apy based on Dexamethasone, with decreasing doses, for the next two weeks, and further ambu-latory care in general surgery clinic. examination performed 2 weeks after finished treatment, dur-ing the followdur-ing control visit, revealed no double vision or exophthalmos.

Discussion

We have presented the above-mentioned cas-es of patients with single sided exophthalmos be-cause of diagnostic difficulties, resulting not only from the clinical image, but also from the results of additional examinations. in the case of the first patient, diversifying the aetiology underlying the exophthalmos was difficult due to the fact that the performed imaging tests supported the suspicion of a tumour within the parotid gland, whereas the clinical image suggested rather the presence of an inflammatory process within the parotid gland and orbital cavity, and during the period of extremely severe symptoms – tissues of half of the face with

Fig. 2. cT image of the patient’s orbits J.O. – Pathological mass located at the bottom and side of the left orbit Ryc 2. Obraz TK oczodołów pacjenta J.O. – patologiczna masa położona w dolnej i bocznej części oczodołu lewego

considerable oedema. The results of a histopatho-logical examination performed on the specimen sampled from a palpable tumour in the parotid gland supported the suspicion of the inflamma-tory process. The result contained a description concerning an infiltration from the inflammatory cells and the lack of atypical cells. Whereas a sia-lography enabled us to diagnose an expanding tu-mour, it was possible to assume that this is a neo-plastic tumour in an inflammatory condition. The modern parotid tumour diagnostic algorithm dif-fers from the one used in the 80s, mainly due to the development of diagnostic techniques – today sialography and scintigraphy are no longer rou-tinely used. nowadays, an ultrasound examina-tion of parotid glands is performed to exclude pa-rotid gland tumour, and the diagnosis is based on a histopathological examination. it is worth em-phasizing that as far as this patient is concerned, exophthalmos turned out to be caused by an in-flammatory process, most probably evoked by an infection from a turtle. To a major extent it was the patient’s history that facilitated giving such a di-agnosis. Unfortunately, only after several months of therapy, the patient admitted that she has an ill turtle. Both the patient and her animal had

sim-ilar clinical symptoms and, what is more, histo-pathological (section) examination of the turtle and the owner (specimen from parotid gland and changes from the maxillary sinus) – revealed fea-tures of chronic inflammation. currently, clini-cal practice faces an increased number of zoonot-ic diseases, and this is mainly caused by the great-er prevalence and breeding of animals, including exotic ones. What has also increased is the num-ber of zoonotic infectious diseases among peo-ple. The most common infectious diseases report-ed in europe are shown in Table 1 [29–31]. liter-ature describes the following diseases observed in animals, which can be associated with exophthal-mos and which can lead to similar symptoms in humans: 1) bacterial infections, abscesses (among turtles the most common aetiological factors in-clude Micrococcus luteus, Morganella morganii,

Mycoplasma sp., Citrobacter braakii, Pasteurella

sp., Proteus mirabilis, Corynebacterium sp.,

Liste-ria monocytogenes, Staphylococcus sp., Staphylo-coccus epidermidis, StreptoStaphylo-coccus sp., StreptoStaphylo-coccus viridans; and favouring conditions cover traumas,

bites, vitamin a insufficiency, improper breeding conditions), 2) retocular abscesses (among ro-dents they result in quite frequent exophthalmos

Fig. 3. image of orbits cT with

con-trast – visible fat infiltration with muscle infiltration (lateral rectus, bottom rectus)

Ryc. 3. Obraz TK oczodołów z

kon-trastem – widoczny nieupostaciowa-ny naciek tłuszczu z infiltracją mięśni (prostego, bocznego i dolnego)

and they may be caused by the following bacte-ria: Pasteurella multocida, Proteus, Staphylococcus and Pseudomonas), 3) retro-ocular tumours (most commonly described in cats and dogs, f. ex. op-tic nerve meningiomas, cancers of mesenchymi-al origin), 4) orbitmesenchymi-al cysts (inflammatory cysts, skin cysts and iridial cysts), 5) injuries of the or-bital cavity with the possibility of emphysema and haemorrhage to the orbital cavity, 6) parasitic dis-eases [29, 32–37]. as far as the above-mentioned disease units in our patient and her turtle are con-cerned, it is recommended to consider mainly the bacterial and parasitic infections.

in the case of the second patient, performed imaging examinations suggested contradictory diagnoses. Orbital cavity cT scans without con-trast supported the presence of a neoplastic tu-mour in the orbital cavity, especially due to the im-age suggesting infiltration of orbital cavity walls. The co-existence of ocular symptoms and patho-logical mass in the pancreas indicated a metastatic

Table 1. The most frequently observed zoonotic diseases

in europe

Tabela 1. najczęściej odnotowywane w europie choroby

zakaźne

Zoonosis number of cases

campylobacteriosis 220.209 salmonellosis 95.548 VTec 9.485 Yersiniosis 7.017 listeriosis 1.476 echinococcosis 781 Brucellosis 330 Trichinellosis 268

Tuberculosis caused by M. bovis 132

Rabies 1

Table 2. Diseases with concomitant inflammation of the orbital tissues

Tabela 2. stany chorobowe, w przebiegu których może dojść do zapalenia tkanek okołooczodołowych

autoimmune diseases – Graves’ disease

– systemic lupus erythematosus – rheumatoid arthritis

– crohn’s disease (chronic inflammatory bowel disease) – sarcoidosis

– systemic sclerosis (scleroderma) – sclerosing cholangitis

autoimmune vascular inflammation – Wegener’s granulomatosis – disease churg-stroussa – Giant cell arteritis – polyarteritis nodosa Orbital pseudotumour

inflammation diseases (bacterial, fungal) – chronic inflammation of the upper respiratory tract – chronic sinusitis

– odontogenic inflammatory diseases – Whipple’s disease

– periorbital oedema – subperiosteal orbital abscess – orbital abscess

– orbital phlegmon Parasitic diseases located in the organ of sight – gnathostomiasis

– dirofilariasis injuries to the orbit

in patients with cancer – metastases to the orbit

– paraneoplastic syndrome – primary tumors of the eye

Others – hemangiomas and lymphangioma

– neurofibromas – dermoid cyst

– gliomas of the optic nerve – meningiomas

– multiform lacrimal gland adenomas – histiocytosis X

– erdheim-chester syndrome The data in the table is based on the Report of the chief

sanitary inspector – sanitary status 2010 for Poland and from the report of the european Food safety authority (2006).

tumour rather than the occurrence of a separate, primary focus of the tumour. When diagnosing oc-ular tumours, it is essential to examine the bottom of the eye; however, in the case of the described pa-tient, this examination did not reveal typical symp-toms characteristic of neoplastic presence: corneal detachment, with colour changes and ecchymoses, or a surface that may correspond to the surface of a neoplastic focus. The result of the additional or-bital cavity cT scan with contrast performed in J.O. patient supported the diagnosis of an ongoing inflammatory process, concerning periorbital tis-sues. it is worth indicating that the neoplastic pro-cess in the eyeball may lead to the occurrence of a secondary inflammation within the orbital cav-ity [38, 39]. Many authors emphasize that metas-tases to the organ of sight often appear as the first symptom associated with a neoplastic process and are diagnosed before determining the initial fo-cus [20–23]. This may be related with the fact that subclinically developing cancers, such as lung can-cer or pancreatic cancan-cer, often spread to the organ of sight [18, 19]. False tumours in oncological pa-tients cause particular difficulties relating differ-entiating diagnostics [17]. according to some au-thors, this idiopathic inflammation of the orbital cavity is the third most common disease concern-ing the orbital cavity [40, 41]. some authors relat-ed the occurrence of this condition in the course of cancers with presence of paraneoplastic syn-dromes [42, 43]. This disease entity should be dif-ferentiated from those that may lead to the inflam-mation of periorbital tissues [40–43] (Table 2).

Conclusion

To conclude, the presentation of the above-mentioned cases of patients, with consideration and precise recreation of the diagnostic process, makes one realize how difficult it can be to differ-entiate between inflammation and a neoplastic tu-mour, especially in the case when the disease pro-cess develops quite slowly (in the case of the female patient, it lasted for more than 8 months, which would indicate a neoplastic rather than an inflam-mation process). Usually the inflaminflam-mation cover-ing soft tissues of the head and face develops very quickly and within several days an abscess occurs, next to typical symptoms, which at that point pose no diagnostic difficulties. Taking into consider-ation the increased number of patients contract-ing zoonotic diseases as observed durcontract-ing the past few years, it is worth taking zoonosis into consid-eration when performing differentiating diagnos-tics of inflammations. Tissue and organ damage caused by zoonotic factor leads to inflammation, which quite often requires differentiating between a neoplastic tumour. This kind of differentiation is particularly important in exophthalmos, as this symptom may result both from the inflam-matory condition, as well as from the ongoing neoplastic process. in each case of exophthalmos and when orbital tissue inflammation is suspect-ed, it is also essential to consider the occurrence of orbital pseudo tumour during differentiating diagnostics.

References

[1] Kreiborg s., cohen M.M. Jr: Ocular manifestations of apert and crouzon syndromes: qualitative and quantita-tive findings. J. craniofac. surg. 2010, 21, 1354–1357.

[2] Jimenez D.F., Barone c.M.: Bilateral endoscopic craniectomies in the treatment of an infant with apert syn-drome. J. neurosurg. Pediatr. 2012, 10, 310–314.

[3] Koga H., suga n., nakamoto T., Tanaka K., Takahashi n.: clinical expression in Pfeiffer syndrome type 2 and 3: surveillance in Japan. am. J. Med. Genet. a. 2012, 158a, 2506–2510.

[4] Munro i.R.: correction of severe facial deformity. can. Med. assoc J. 1975, 113, 531–535.

[5] Kokot F.: Diagnostyka różnicowa objawów chorobowych. Wydawnictwo lekarskie PZWl. Warsaw 1998. [6] saraci G., Treta a.: Ocular changes and approaches of ophthalmopathy in basedow-graves-parry-flajani disease.

Maedica (Buchar). 2011, 6, 146–152.

[7] Gould D.J., Roth F.s., soparkar c.n.: The diagnosis and treatment of thyroid-associated ophthalmopathy. aes-thetic. Plast. surg. 2012, 36, 638–648.

[8] Filipowicz e.: Operacyjne leczenie zeza i podwójnego widzenia w orbitopatii w przebiegu choroby Gravesa-Base-dowa. Okulistyka 2005, 2, 52–54.

[9] Zborowska-skrobanek J., Misiuk-Hojło M.: Zakażenia tkanek oczodołu – problem interdyscyplinarny oku-listów, laryngologów i chirurgów szczękowo−twarzowych. Dent. Med. Probl. 2007, 44, 373–376.

[10] Janjetović Z., arar Z.V., Paradzik M.T., sapina l., Bitunjac M., lojen G., Marinculić a.: Ocular dirofilar-iasis: a case report. acta. Med. croatica. 2010, 64, 41–45.

[11] Preechawat P., Wongwatthana P., Poonyathalang a., chusattayanond a.: Orbital apex syndrome from gnathostomiasis. J. neuroophthalmol. 2006, 26, 184–186.

[12] Braun H., Koele W., stammberger H., Ranner G., Gröll R.: endoscopic removal of an intraorbital „tumor”: a vital surprise. am. J. Rhinol. 1999, 13, 469–472.

[13] Xue Z., Tian Y.M., Qiao l., Gao X.W., Guo n., liu G.Y.: clinical analysis for the treatment of 63 cases of orbital tumors in Xinjiang. Zhonghua Yan Ke Za Zhi. 2012, 48, 1073–1076.

[14] Xian J., Zhang Z., Wang Z., li J., Yang B., Man F., chang Q., Zhang Y.: Value of MR imaging in the differen-tiation of benign and malignant orbital tumors in adults. Radiol. 2010, 20, 1692–1702.

[15] Kostrzewska M., nowak-Gabryel M., Gabryel M.: całkowita remisja przerzutów do gałek ocznych w prze-biegu raka niedrobnokomórkowego płuca po zastosowanej chemioterapii cisplatyną i vinorelbiną. Pol. Merk. lek. 2011, 31, 171–174.

[16] shinder R., al-Zubidi n., esmaeli B.: survey of orbital tumors at a comprehensive cancer center in the United states. Head. neck. 2011, 33, 610–614.

[17] Duchnowska R., Żarnowski T.: Rzekomy guz oczodołu u chorej na raka piersi w trakcie leczenia kepecytabiną. Onkologia w Praktyce lekarskiej. 2005, 1, 165–168.

[18] eliassi-Rad B., albert D.M., Green W.R.: Frequency of ocular metastases in patients dying of cancer in eye bank populations. Br. J. Ophthalmol. 1996, 80, 125–128.

[19] amemiya T., Hayashida H., Dake Y.: Metastatic orbital tumors in Japan: a review of the literature. Ophthalmic. epidemiol. 2002, 9, 35–47.

[20] Hartstein M.e., Grove a.s. Jr, Woog J.J.: The role of the integrin family of adhesion molecules in the develop-ment of tumors metastatic to the orbit. Ophthal. Plast. Reconstr. surg. 1997, 13, 227–238.

[21] Reeves D., levine M.R., lash R.: nonpalpable breast carcinoma presenting as orbital infiltration: case presenta-tion and literature review. Ophthal. Plast. Reconstr. surg. 2002, 18, 84–88.

[22] lell M., schulz-Wendtland R., Hafner a., Magener a., Bautz W.a., Tomandl B.F.: Bilateral orbital tu-mour as the presentation of mammographically occult breast cancer. neuroradiology. 2004, 46, 682–685. [23] Mohadjer Y., Holds J.B.: Orbital metastasis as the initial finding of breast carcinoma: a ten-year survival.

Oph-thal. Plast. Reconstr. surg. 2005, 21, 65–66.

[24] ahn Yuen s.J., Rubin P.a.D.: idiopathic Orbital inflammation. arch. Ophtalmol. 2003, 121491–121499. [25] Rzymska-Grala i., Palczewski P., Błaż M., Zmorzyński M., Gołębiowski M., Wanyura H.: a peculiar

blow-out fracture of the inferior orbital wall complicated by extensive subcutaneous emphysema: a case report and re-view of the literature. Pol. J. Radiol. 2012, 77, 64–68.

[26] Juszkat R., liebert W., smól s., Kociemba W.: Wewnątrznaczyniowe leczenie tętniaka tętnicy szyjnej wewnątrznej, pękniętego do zatoki jamistej. neuroskop. 2005, 7, 71–74.

[27] Obuchowska i., Mariak Z.: Objawy okulistyczne przetoki szyjno-jamistej. Okulistyka. 2010, 3, 4–14.

[28] leib M.l., Odel J.G., cooney M.J.: Orbital polymyositis and giant cell myocarditis. Ophthalmology. 1994, 101, 950–954.

[29] Gliński Z., Kostro K., Buczek J.: Zoonozy. PWRil. Warsaw 2008.

[30] Osek J.: Występowanie chorób odzwierzęcych i ich czynników etiologicznych w 2006r. w świetle raportu europe-jskiego Urzędu do spraw Bezpieczeństwa Żywności. Życie Weterynaryjne. 2008, 83, 192–201.

[31] Report of the chief sanitary inspector. The sanitary state of the country in 2010. in www.gis.gov.pl

[32] schumacher J.: selected infectious Diseases of Wild Reptiles and amphibians. Journal of exotic Pet Medicine. 2006, 15, 18–24.

[33] Trbolova a., Balicki i.: Wytrzeszcz u psów – diagnostyka i terapia. Magazyn Weterynaryjny. 2011, 168, 464–468. [34] Buczek e., Garncarz J.: Różnicowanie chorób przebiegających z wytrzeszczem lub ze zmianą wielkości gałek

oc-znych. Magazyn Weterynaryjny. 2005, 107, 52–56.

[35] Dembele K., Przysucha a.: Dermatofity (Microsporum canis) u psów i kotów – saprofity czy chorobotwórcze? Magazyn Weterynaryjny. 2011, 164, 6–10.

[36] sapierzyński R.: nowotwory narządu wzroku u psów i kotów. Życie Weterynaryjne. 2007, 82, 985–990.

[37] ippen R., Zwart P.: infectious and parasitic diseases of captive raptiles and amphibians, with special emphasis on husbandry practices which prevent or promote diseases. Rev. sci. Tech. Off. int. epiz. 1996, 15, 43–54.

[38] Foley M.R., Moshfeghi D.M., Wilson M.W., Haik B.G., Pappo a.s., Hill D.a.: Orbital inflammatory syn-dromes with systemic involvement may mimic metastatic disease. Ophthal. Plast. Reconstr. surg. 2003, 19, 324– 327.

[39] Goh a.s., Francis i.c., Kappagoda M.B., Filipic M.: Orbital inflammation in a patient with extrascleral spread of choroidal malignant melanoma. clin. experiment. Ophthalmol. 2001, 29, 97–99.

[40] Weber a.l., Romo l.V., sabates n.R.: Pseudotumor of the orbit. clinical, pathologic, and radiologic evaluation. Radiol. clin. north. am. 1999, 37, 151–168.

[41] Weinstein G.s., Dresner s.c., slamovits T.l., Kennerdell J.s.: acute and subacute orbital myositis. am. J. Ophthalmol. 1983, 96, 209–217.

[42] eckel F., Ugi i., schmidt T., lersch c.: a 44-year-old patient with cardial carcinoma and paraneoplastic orbital disease. Dtsch. Med. Wochenschr. 1998, 123, 1103–1106.

[43] Harris G.J., Murphy M.l., schmidt e.W., Hanson G.a., Dotson R.M.: Orbital myositis as a paraneoplastic syn-drome. arch. Ophthalmol. 1994, 112, 380–386.

Address for correspondence:

Department of craniomaxillofacial and Oncological surgery Medical University of lodz

Kopcińskiego 22 90-153 lodz Poland Tel.: +48 42 677 67 88 e-mail: katarzyna.bogusiak@gmail.com Received: 4.11.2013 Revised: 29.01.2014 accepted: 31.01.2014

Praca wpłynęła do Redakcji: 4.11.2013 r. Po recenzji: 29.01.2014 r.