Paranasal sinus infection causing orbital subperiosteal abscess: surgical management of this devastating entity

Epidemiology and Management of Orbital Cellulitis in Children

BACKGROUND

The epidemiology of orbital cellulitis likely has evolved due to the emergence of methicillin-resistant Staphylococcus aureus (MRSA) and the adoption of pneumococcal conjugate vaccination. In the absence of published guidelines, management is highly variable. We characterized epidemiology and management over an 11-year period.

METHODS

A retrospective cohort study of children 0 to 21 years of age with orbital cellulitis +/- subperiosteal orbital abscess hospitalized at a large quaternary children's hospital from January 2008 to June 2018. We reviewed charts for demographic characteristics, clinical features, management, and outcomes. Using multivariable logistic regression, we evaluated predictors of surgical intervention and assessed whether corticosteroid use or antibiotic duration was related to clinical outcomes.

RESULTS

Among 220 patients, methicillin-susceptible S. aureus was the most common organism (26.3%), with MRSA found in only 5.0%. Rates of vancomycin use fluctuated annually from 40.9% to 84.6%. Surgery was performed in 39.5% of the patients. Corticosteroids, used in 70 patients (32.1%), were unrelated to treatment failure (n = 9), defined as persistent signs and symptoms or initial clinical improvement followed by worsening (P = .137). The median antibiotic duration was 17 days (interquartile range 14-26). After controlling for age, gender, proptosis, eye pain with movement, eyelid swelling, neutrophil count, and corticosteroid use, treatment failure was not significantly associated with receipt of ≥ 3 weeks of antibiotic therapy (8/84, 9.5%) compared with > 2 but < 3 weeks (0/51, 0.0%) or ≤ 2 weeks (1/85, 1.2%) (adjusted odds ratio = 5.83 for ≥ 3 vs ≤2 weeks; 95% confidence interval: 0.58, 59.0).

CONCLUSIONS

Although MRSA was rare, empiric vancomycin use was high. Treatment failure was uncommon in patients who received ≤ 2 weeks of therapy, suggesting that shorter durations are adequate in some patients.

Sinogenic Orbital Complications

BACKGROUND

The term "orbital complication" does not designate an independent nosological entity, but is rather a collective designation for diseases or disease effects that involve the orbit and its internal structures by extension from outside. In general, their most prominent manifestation is swelling of the orbital soft tissues, usually unilaterally. The incidence of sinogenic orbital complications is approximately 1.6 per 100 000 children and 0.1 per 100 000 adults per year.

METHODS

This review is based on publications retrieved by a selective search of the literature on the epidemiology, diagnosis, and treatment of sinogenic orbital complications.

RESULTS

Acute sinusitis is the most common cause of orbital complications. These are diseases of the orbit with potentially serious consequences for the eye and the risk of intracranial complications such as cavernous sinus thrombosis, meningitis, or brain abscess. Aside from acute sinusitis, many other infectious and non-infectious diseases can extend to and involve the orbit. Because of the complexity and severity of the condition, its diagnosis and treatment are always an interdisciplinary matter. The treatment is primarily conservative, under observation in a hospital, and generally consists of the treatment of acute sinusitis with measures to combat edema along with the administration of broad-spectrum antibiotics. Surgical intervention is needed in severe cases or if there is an abscess. An endonasal approach is usually used for drainage.

CONCLUSION

In 95-98% of cases in stages I-IV, healing is complete and without further sequelae. Even if vision is affected preoperatively, it usually recovers fully when therapy is appropriate. Approximately 15% of the patients who undergo surgery need more than one operative procedure.

Ocular bacterial infections: Pathogenesis and diagnosis

The human eye is a rigid asymmetric structure with unique defence system. Despite considerable resident microbiota, eye is exposed to external environment where a range of microorganisms also inhabits. Opportunistically, some of these microorganisms could associate with eye pathogen that could contact incidentally, leading to destructive visual consequences. Among such microbiota, bacteria form the major proportion concerning ocular complications worldwide. The succession of genome based approach through 16S rRNA gene based identification tremendously augmented the knowledge on diversity of ocular surface bacteria. Such evidence suggests that while few bacteria contribute towards normal ocular functions, considerable number of bacteria play active role in pathophysiology of ocular diseases. Thus, understanding the complexity of ocular microflora not only throw light on their critical role towards normal function of the eye, but also enlighten on certain visual exigencies. Under these circumstances, development of a rapid, reliable and cost effective method is essential that eventually evolve as a routine diagnostic protocol. Such precise prognostic modalities facilitate ophthalmologists to formulate pioneering therapeutics towards challenging ocular diseases.

[Orbital complications]

A disease or symptom of disease spreading from the vicinity of the orbit to the internal structures of the orbit is referred to as an orbital complication. Orbital complications can have a traumatic, inflammatory, allergic, or autoimmunologic cause. They are more frequent in children than adults. The present review aims to provide a description of orbital complications, their etiology, pathogenesis, and treatment. Recent literature in the field is acknowledged and discussed, and results from the authors' own patient groups are analyzed. Particular attention is paid to orbital complications due to acute sinusitis and those caused by acute hemorrhage. The term "orbital phlegmon" frequently used for orbital complications with inflammatory causes is confusing and should be replaced by differentiated grading. Diagnosis and treatment of orbital complications requires interdisciplinary collaboration, whereby inclusion of ophthalmologists is particularly important. Treatment of orbital complications depends on their cause. In inflammatory cases affecting only the preseptal tissues and compartment, conservative therapy is indicated. If clinical findings worsen within 24 h of conservative therapy, or if the patient presents with a high-grade orbital complication with loss of visual acuity or impairment of globe mobility, surgery is required. In cases of acute hemorrhage into the orbit, a procedure for decreasing intra-orbital pressure is mandatory (i. e., canthotomy, cantholysis, orbital decompression).

Factors that prolong the duration of recovery in acute rhinosinusitis with orbital complications

BACKGROUND

Regarding prognostic factors of acute rhinosinusitis (ARS) with orbital complications, there are few studies including adult cases.

OBJECTIVES

The present study aims to delineate prognostic factors of ARS with orbital complications.

MATERIAL AND METHODS

We conducted a retrospective analysis of medical records of 21 patients (6 pediatric and 15 adult patients) with ARS with orbital complications. The duration of recovery was defined as the time from initial diagnosis to complete resolution of local findings and all symptoms. Orbital complications due to postoperative cysts or mycosis were excluded.

RESULTS

Twenty-one patients comprised 11 males and 10 females. Chandler's classification showed group I in 4, group II in 8, and group III in 9. None of six pediatric patients required any surgical intervention, whereas five adult patients (23.8%) underwent surgical intervention. The average period of recovery was 8.1 days. In univariate analysis, the duration of recovery was significantly longer among adult cases (p < .01) and cases with Chandler's groups II-III (p = .019). In multivariate analysis, adult patients had a significantly longer duration of recovery than pediatric patients (p = .027).

CONCLUSION AND SIGNIFICANCE

The present study suggested that ARS with orbital complications may have prolonged clinical course in adults.

Surgical Treatment of Rhinosinusitis-Related Orbital Complications: Factors Affecting Irreversible Blindness

If left untreated, rhinosinusitis can rarely cause a devastating complication irreversible blindness (IB). Despite new technologies in endoscopic sinus surgery and use of new broad-spectrum antibiotics, IB outcome is still a problem for surgically treated orbital complication of paranasal sinus infection (OCPSI) patients, and factors leading to IB outcome are not actually known. The aim of this study was to assess the factors leading to the IB outcome for surgically treated OCPSI patients. Results of 25 surgically treated OCPSI patients in our clinic were combined with surgically treated OCPSI patients reported through the PubMed database search from the year 2007. Patients were divided into 2 groups: IB group and recovery group. Patients having at least 1 immune status-related additional risk factor (ARF) were more common in the IB group, having an at least 1 ARF had 1.683 risk value of IB outcome (RR: 1.683, P = 0.006). IB patients had statistically significant higher mean (21.87 ± 40.35, P = 0.005) time interval (days) (TI) between onset of ophthalmological symptoms and surgical intervention compared to recovery group patients (2.92 ± 2.53). ROC curve analysis for an estimation of IB outcome according to the TI value demonstrated that a cut-off value of ≥2.5 days had the ideal sensitivity (87.5%) and specificity (71.9%) that resulted in IB outcome. (80.5% power, P = 0.008) IB and recovery group patients did not differ according to orbital complication type according to Chandler's classification (P = 0.492) and white blood cell count status (P = 0.584). In conclusion, OCPSI patients with ARFs and delayed admission after onset of orbital symptoms have a higher risk of IB outcome. These patients deserve prompt evaluation and early surgical intervention to prevent blindness. With future studies, new surgical criteria, including the ARF status and onset of ophthalmological symptoms (≥2.5 days) may be added to classical surgical criteria to prevent IB for OCPSI cases.

Management of pediatric orbital cellulitis: A systematic review

OBJECTIVES

Orbital complications account for 74-85% of all complications from acute sinusitis, more often affect the pediatric population, and can result in devastating consequences. Therefore these patients require prompt diagnosis and proper management. We review and summarize the current literature to determine the appropriate management of each stage of pediatric orbital cellulitis and offer a new comprehensive literature-based algorithm.

METHODS

Data sources were PubMed/MEDLINE, and Google Scholar. Studies relevant to the management of each subcategory of the Chandler criteria in the pediatric population, limited to the period 1997 through Jan 2018, were compiled and interpreted. Seventy-one studies were reviewed in total.

RESULTS

Pre-septal and post-septal cellulitis can generally be managed non-surgically, while orbital abscess and cavernous sinus thrombosis are managed surgically. For subperiosteal abscess, non-surgical medical management has been successful in certain patients. Results of the literature review were summarized, and subsequently developed into a comprehensive algorithm for management, including criteria for age, location, and volume of abscess on imaging.

CONCLUSIONS

Orbital cellulitis, particularly subperiosteal abscesses, in children is not an absolute indication for immediate surgical intervention. Conservative measures can be safe and effective if appropriately used, depending on patient characteristics, clinical course, and imaging.

True abscess formation is rare in bacterial orbital cellulitis; consequences for treatment

BACKGROUND

Pre- or retroseptal bacterial orbital cellulitis (pOC/rOC) is not an uncommon orbital disease. Treatment consists of antibiotics with or without surgical drainage. Several questions regarding course, complications and outcome of treatment are unanswered and the indication for surgery is not well defined. The aim of this study is to: 1. describe the outcome of orbital cellulitis (OC) in a large cohort, 2. assess the significance of Chandler's classification, 3. assess the incidence of abscess formation in OC, and 4. redefine criteria for surgery.

METHODS

Retrospective case series of patients with OC seen between 1-1-2007 and 1-1-2014 in a tertiary referral center.

RESULTS

Sixty-eight patients presented with (presumed) bacterial pOC. Two out of these 68 developed rOC. All 68 patients had a full recovery. Forty-eight patients presented with rOC. Four out of 48 (8%) had intracranial extension of the infection at the time of admission. No admitted patient developed distant seeding. Only four (8%) patients with rOC had a true orbital abscess. In the other 92% we found a diffuse orbital inflammation or a subperiosteal empyema. Forty-four (92%) patients with rOC had a full recovery.

CONCLUSIONS

1. The prognosis of both pOC and rOC nowadays is generally favorable. 2. Chandler's classification is of little use. 3. True abscess formation in OC is rare. 4. The indication for surgical intervention must be based on the clinical presentation and the assessment of true orbital abscess formation.

Characteristics of patients treated for orbital cellulitis: An analysis of inpatient data

OBJECTIVES/HYPOTHESIS

Orbital cellulitis represents a spectrum of diseases, some of which may progress to potentially serious complications. The authors used the Nationwide Inpatient Sample (NIS) database to analyze the epidemiologic features of pediatric and adult patients admitted for the treatment of orbital cellulitis and to examine associations with surgical management.

METHODS

The NIS was queried for patients admitted for treatment of orbital cellulitis from 2002 to 2010. Patient demographics, length of stay, hospital charges, and concomitant diagnoses were analyzed.

RESULTS

There were 14,149 cases of orbital cellulitis identified with 1,717 (12.1%) having undergone surgical management. Surgical patients were older (29.6 ± 23.4) and more commonly male (62.0%) (P = 0.004 and < 0.001, respectively). Patients who had surgical intervention had longer length of stay and higher hospital charges than nonsurgical patients (P < 0.001). Our study showed that the proportion of pediatric patients age 10 to 19 years (22.1%) undergoing surgery was four times that of patients < 5 years of age (5.1%) (P < 0.001). Patients with concomitant diagnoses of acute and chronic sinusitis, acute osteomyelitis, exophthalmos, diplopia, and conjunctival edema had significantly increased odds ratio of surgical intervention. Frontal sinusitis was the site most commonly associated with surgical intervention among sinusitis patients.

CONCLUSION

This study describes the characteristics of pediatric and adult patients admitted for orbital cellulitis from a national perspective. Patients 10 to 19 years of age were most likely to undergo surgical management. Acute and chronic sinusitis, acute osteomyelitis, exophthalmos, diplopia, and conjunctival edema were concomitant diagnoses associated with significantly increased odds ratio of surgical intervention.

LEVEL OF EVIDENCE

2C. Laryngoscope, 126:554-559, 2016.