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A Young Man with Unilateral Proptosis Presented by: Dr. Md. Kamal Hossen Asstt. Registrar A Young Man with Unilateral Proptosis Presented by: Dr. Md. Kamal Hossen Asstt. Registrar Dept. of Neurosurgery, MMCH

“A Young Man with Unilateral Proptosis” “A Young Man with Unilateral Proptosis”

Chairperson Prof ( Dr. ) M A Gafur Miah Professor & Head Department of Chairperson Prof ( Dr. ) M A Gafur Miah Professor & Head Department of Surgery Mymensingh Medical College Coordinator Dr Saumitra Sarkar Assistant Professor & Head Deptt. of Neurosurgery Mymensingh Medical College

Particulars of the patient Particulars of the patient

Particulars of the Patient: l l l l l Name Age Sex Religion : Particulars of the Patient: l l l l l Name Age Sex Religion : Md. Shafayet : 27 years : Male : Islam Address Marital status Occupation Date of admission Date of examination : Purbadhola, Netrokona : Unmarried : Unemployed : 21 st November 2011

Presenting complaints : (Pre-Operative) l l l Irritation and watering of the left eye Presenting complaints : (Pre-Operative) l l l Irritation and watering of the left eye for 10 month. Forward displacement of left eye ball for 3 months Gradual dimness of vision in left eye for 3 months

History of present illness : According to the statement of the patient he was History of present illness : According to the statement of the patient he was reasonably well about 10 months back. Then he complained about irritation and watering of the left eye which was prominent in day time. In last 3 months he developed forward displacement of left eye ball,

History of present illness : - which was gradually increasing and not associated with History of present illness : - which was gradually increasing and not associated with pain and pulsation. He also complained gradual dimness of vision in left eye and occasional double vision for 3 months.

History of present illness (Cont. ) Patient had no history of Headache, vomiting, vertigo, History of present illness (Cont. ) Patient had no history of Headache, vomiting, vertigo, fever, night sweats, weight loss, cough or haemoptysis, haematuria or per rectal bleeding, bone pain. There was no history of trauma.

ü H/O of Past illness – The patient has a history of jaundice 2 ü H/O of Past illness – The patient has a history of jaundice 2 years back. ü Personal history – The patient is a smoker. He took 5 sticks per day.

ü Immunizations History – Completed immunization. ü Family history – No such diseases found ü Immunizations History – Completed immunization. ü Family history – No such diseases found in the other family members.

Treatment History At first he was treated by Ophthalmologist at BNSB, Mymensingh for watering Treatment History At first he was treated by Ophthalmologist at BNSB, Mymensingh for watering and irritation and he used eye drop and took some medicine for his illness but he couldn’t mention any name. Then he got treatment at Dr. Muktadir Eye Hospital, Gauripur and After doing the CT scan, the patient was referred to a Neurosurgeon of Dhaka. But, according to the advise of a physician he got admitted in the Neurosurgery dept. of MMCH.

General Examination (Preoperative) l l l l Appearance – ill looking Body build – General Examination (Preoperative) l l l l Appearance – ill looking Body build – Average Anemia – Absent Cyanosis – Absent Jaundice – Absent Oedema – Absent Dehydration – Absent Lymph nodes – not palpable l l l l l Thyroid gland – not enlarged Neck vein – not engorged Clubbing – Absent Koilonychia – Absent Leukonychia – Absent Pulse – 76/min B. P – 130/80 mm of Hg Temp – Normal Respiration – 16/min

Local Examination (Preoperative) Local Examination of the Left Eye - Inferonasal globe displacement and Local Examination (Preoperative) Local Examination of the Left Eye - Inferonasal globe displacement and fullness of the superotemporal lid and orbit. - Proptosis – 4 mm - A S-shaped contour to the upper lid. - Tenderness absent. - Motility of the left globe restricted in superior and lateral direction. - Intraocular pressure (IOP)- Not measured - Preauricular lymphadenopathy - Absent

Systemic examination (Preoperative) Nervous system examination – ü ü ü Higher Psychic function – Systemic examination (Preoperative) Nervous system examination – ü ü ü Higher Psychic function – Normal Speech – Normal Gait – Normal

Systemic examination (Preoperative) Nervous system examination – Examination of cranial nerve l Olfactory nerve Systemic examination (Preoperative) Nervous system examination – Examination of cranial nerve l Olfactory nerve – sense of smell is intact l Optic nerve – Visual acuity : 6/6 (Rt) Finger counting at 2 feet (Lt) Field of vision : reduced Color vision : normal l Ophthalmoscopic examination : Disc swelling on left eye l Light reflex : normal

Systemic examination (Preoperative) Nervous system examination – l l l Oculomotor nerve : normal Systemic examination (Preoperative) Nervous system examination – l l l Oculomotor nerve : normal Trochlear nerve : normal Abducent nerve : normal Trigeminal nerve : normal Facial nerve : normal

Systemic examination (Preoperative) Nervous system examination – l l l Vestibule-cochlear nerve : normal Systemic examination (Preoperative) Nervous system examination – l l l Vestibule-cochlear nerve : normal Glossopharyngeal nerve : normal Vagus nerve : normal Accessory nerve ( spinal part) : normal Hypoglossal nerve : normal

Systemic examination – Motor function Upper limbs – Lt. q ü ü ü Bulk Systemic examination – Motor function Upper limbs – Lt. q ü ü ü Bulk of muscle – Normal Tone of muscle – Normal Muscle Power – Grade ‘ 5` Lower limbs – q ü ü ü Lt. Bulk of muscle – Normal Tone of muscle – Normal Muscle Power – Grade ‘ 5` Rt. Normal G-5

Systemic examination – Co ordination of movement : l Finger nose test – intact Systemic examination – Co ordination of movement : l Finger nose test – intact l Heel shin test – intact l Involuntary movement : absent

Systemic examination – Jerks All jerks are Normal Planter response: Flexor (B/L) Clonus- Absent Systemic examination – Jerks All jerks are Normal Planter response: Flexor (B/L) Clonus- Absent (B/L)

Systemic examination – ü l l l ü Sensory function test : Pain, touch, Systemic examination – ü l l l ü Sensory function test : Pain, touch, temperature – intact Joint position sense – intact Vibration sense – intact Autonomic function Normal

Systemic examination – Signs of meningeal irritation : l Neck rigidity : absent l Systemic examination – Signs of meningeal irritation : l Neck rigidity : absent l Kerning’s sign : negative l Brudzinski’s sign : negative

Systemic examination – Cardiovascular system Nothing abnormalities are detected l Respiratory system Nothing abnormalities Systemic examination – Cardiovascular system Nothing abnormalities are detected l Respiratory system Nothing abnormalities are detected l Alimentary system Nothing abnormalities are detected l

Salient feature A young man, 27 years of age right handed hailing from Purbadhola, Salient feature A young man, 27 years of age right handed hailing from Purbadhola, Netrogona presented with irritation and watering of the left eye for 10 months, forward displacement of left eye ball for 3 months and gradual dimness of vision in left eye for 3 months.

Salient feature (Cont. ) He complained about irritation and watering of the left eye Salient feature (Cont. ) He complained about irritation and watering of the left eye which was prominent in day time. In last 3 months he noticed forward displacement of left eye ball which was gradually increasing and not associated with pain and pulsation. He also complained gradual dimness of vision in left eye and occasional double vision.

Salient feature (Cont. ) The patient had no history of Headache, vomiting, vertigo, fever, Salient feature (Cont. ) The patient had no history of Headache, vomiting, vertigo, fever, night sweats, weight loss, cough or haemoptysis, haematuria or per rectal bleeding, bone pain. There was no history of trauma.

Salient feature (Cont. ) On examination, the patient was ill looking and his pulse Salient feature (Cont. ) On examination, the patient was ill looking and his pulse was 76/min & BP was 130/80 mm Hg. On local examination of the left eye he was found Inferonasal globe displacement and fullness of the superotemporal lid and orbit with 4 mm proptosis of left eye and A S-shaped contour to the left upper lid. Tenderness was absent. The motility of the left globe restricted in superior and lateral direction with absent preauricular lymphadenopathy.

Salient feature (Cont. ) He was found with visual acquity 6/6 (Rt), finger counting Salient feature (Cont. ) He was found with visual acquity 6/6 (Rt), finger counting from 2 feet (Lt) & with restricted field of vision. He was found disc swelling in left eye.

Provisional Diagnosis Left sided Retrobulbar Benign Tumour Provisional Diagnosis Left sided Retrobulbar Benign Tumour

Diferential Diagnosis Pseudotumour Malignant Retrobulbar tumour Carotido- Cavernous Fistula Orbital vein thrombosis Haemangioma Neurofibroma Diferential Diagnosis Pseudotumour Malignant Retrobulbar tumour Carotido- Cavernous Fistula Orbital vein thrombosis Haemangioma Neurofibroma Optic Nerve Glioma

Investigation Investigation

Investigations (Preoperative) CBC : l TC – 10, 300/cmm l DC – N 68% Investigations (Preoperative) CBC : l TC – 10, 300/cmm l DC – N 68% L 26% M 02% E 04% l Hb% - 12 gm/dl l ESR – 18 mm in 1 st hour

Investigations (Cont…) l Serum creatinine - 1. 2 mg/dl l RBS- 5. 4 m. Investigations (Cont…) l Serum creatinine - 1. 2 mg/dl l RBS- 5. 4 m. M/L l Urine R/M/E- Normal l ECG – Within normal limit l CXR P/A - Within normal limit

CT Scan of Brain CT Scan of Brain

Clinical Diagnosis Clinical Diagnosis

Clinical Diagnosis Retrobulbar solid tumour on left orbit Clinical Diagnosis Retrobulbar solid tumour on left orbit

Treatment Transcranial Orbitotomy and Removal of the Tumour was done under G/A on 11 Treatment Transcranial Orbitotomy and Removal of the Tumour was done under G/A on 11 th December, 2011

Operative Procedure Operative Procedure

Confirm Diagnosis by Histopathology Pleomorphic Adenoma Confirm Diagnosis by Histopathology Pleomorphic Adenoma