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A 30-year-old man initially presented to the otolaryngologists with headaches and symptoms of chronic sinusitis. He underwent multiple endoscopic and external sinus operations in an attempt to alleviate his symptoms. Erythematous swelling of the right eyelid and anterior orbit was noted at this time, presumed to be related to pansinusitis. The swelling had persisted for more than a year when he was referred to the orbital clinic. He had a past history of asthma and seasonal atopy. The patient was of South Asian origin with no recent history of travel. Initial examination revealed uncorrected visual acuity of 20/20 in both eyes, and normal anterior segment and fundus examination. An indurated mass was noted above the right eyebrow with associated lid swelling and 2mm of right proptosis. Examination of eye movements revealed limitation on upgaze of the right eye as shown above.

* In this exercise, more than one answer can be correct for each question.

1.	What investigations would you perform for this patient?
	a. assessment of optic nerve function b. CT scan of orbits c. MRI scan of orbits d. blood work (to include CBC) e. incisional biopsy
2.	Inflammatory cell infiltrates with Touton cells are classically seen in:
	a. Wegener’s granulomatosis b. sarcoid c. orbital xanthogranuloma d. necrobiosis lipoidica e. Kimura’s disease
3.	This condition is associated with the following systemic disorders:
	a. Erdheim-Chester disease b. rheumatoid arthritis c. sarcoid d. necrobiotic xanthogranuloma e. Chediak-Higashi disease

For answers to the above, click here on or after August 25, 2009.