Secondaries from retromolar trigone carcinoma leading to orbital apex disorders

Abstract

Orbital apex disorders (OADs) are uncommon and they include – orbital apex syndrome (OAS), superior orbital fissure syndrome (SOFS), and cavernous sinus syndrome (CSS). They all share similar etiologies, diagnostic evaluation, and management strategies. These syndromes can occur isolated or combined – where SOFS progresses and develops into OAS or CSS. Combined presentation has been reported with infective etiologies, but no literature is available for neoplasms. OAD secondary to head and neck cancer is exceptionally rare. A 44-year-old male post left hemi-mandibulectomy with modified neck dissection, radiotherapy, and chemotherapy for left retromolar trigone carcinoma presented with complaints of inability to open left eye (LE) and defective vision in the same eye. On examination of LE, visual acuity was 6/24 NIP with complete ptosis, extraocular movements were restricted in all gaze, corneal sensation was diminished, and pupil was 5 mm and not reacting to light. LE fundus examination showed blurring of disk margins. The primary diagnosis was made as OAS. Contrast enhanced-MRI neck showed features suggestive of recurrence with intracranial extend involving left cavernous sinus, orbital apex, and left orbit. Later considering the extend of spread in MRI and the clinical presentation, diagnosis was made to be OAD. The patient was given third cycle of chemotherapy – injection paclitaxel, injection cisplatin, and injection fluorouracil, along with injection dexamethasone. The patient was provided temporary eye crutch glasses and asked to review after 3 weeks for repeat assessment. Although individual syndromes of OAD are rare, they are closely related entity. Hence, it is important to know that SOFS can progress to OAS causing visual dysfunction or to CSS, leading to systemic ailments. Or else, they can present as combined syndromes also.