To the Editor.
—The case of Wang et al1 in the November Archives illustrated current confusion about causes and effects of orbital fistula. Infection, fistulas, and cysts (epidermoids, dermoids, cholesteatoma, and mucocele) coexist, but correlation has been used to infer cause, and one of the triad has dogmatically been assumed to cause the others. Thus, many presume that, in the ear, otitis media causes cholesteatoma with both causing fistulas without considering the simple alternative that fistulas may be primary.2,3 More generally, accepting that CSF fistulas are far more common than suspected or diagnosed and are a primary cause of infection or cysts, then a logically consistent scheme arises. Around the eye CSF fistulas might lead to the following: (1) local accumulation predisposing to secondary infection (eg, sinusitis3); (2) overloading and obstruction of drainage pathways through the sinuses (polyps, mucocele); (3) leakage from a CSF drainage pathway if
Gordon AG. Orbital Fistula, Infection, and Cysts. Arch Ophthalmol. 1984;102(7):970-972. doi:10.1001/archopht.1984.01040030778013