Medical and surgical management of subperiosteal orbital abscess secondary to acute sinusitis in children

Characteristics and management of pediatric medial subperiosteal orbital abscesses

INTRODUCTION

Subperiosteal orbital abscesses (SPOA) are the most common suppurative complications of acute bacterial sinusitis. Medial SPOAs arise from infection of the ipsilateral ethmoid sinus and favor initial conservative management reserving surgical drainage for patients who do not demonstrate clinical improvement. No standard algorithm defining medical versus surgical treatment of medial SPOAs exist in the pediatric population.

OBJECTIVES

To identify a size cutoff for medial SPOAs to predict the likelihood for surgical drainage.

METHODS

This is a retrospective review of patients with medial SPOAs at a tertiary care center from 2003 to 2017. Diagnosis of SPOA was based on radiographic findings. Variables included are patient demographics, antibiotic therapy, surgical intervention, and length of stay.

RESULTS

82 patients with a medial SPOA were included with an average age at presentation of 6.27 (range 0-15) years were included in this study. 62 patients were male (75.6 %), and 20 were female (24.4 %). The average abscess length was 16.1 mm, range 4.5-30.7 mm. The average abscess width was 4.17 mm, range 1.5-14.6 mm. The odds ratio for surgical treatment with every 1 mm increase in abscess width was 1.89 (95CI:1.33-2.69, p < 0.001). Abscesses over 3.6 mm width were 6.65 times more likely to undergo surgical drainage than those less than 3.6 mm (OR:6.65, 95CI:2.52-17.54, p < 0.001). The average(SD) length of stay was 5.4(3.0) days for patients who underwent surgery and 4.0(0.9) days for patients treated with conservative measures, p < 0.001.

CONCLUSION

Medial SPOAs greater than 3.6 mm were more likely to undergo surgical drainage; however there was no difference in the likelihood of drainage between anteriorly and posteriorly based medial abscesses. These findings help further characterize the landscape of pediatric subperiosteal abscesses that are managed with surgical drainage.

Orbital subperiosteal abscess in adolescents and adults: predictors and outcomes of nonsurgical management and surgical approaches

PURPOSE

The aim of this study was to assess predictors and outcomes of subperiosteal abscess (SPA) management in adolescents and adults at two tertiary care centers.

METHODS

This retrospective cohort study included cases of SPA from January 1 2000 to October 9 2022 at two institutions. Patients 9 years or older were categorized into surgical and nonsurgical cohorts. Surgical subgroups included those who underwent functional endoscopic sinus surgery (FESS) alone, external (transcutaneous or transconjunctival) orbitotomy alone, or combined FESS and external surgery. The presented features were assessed as potential treatment predictors. Outcomes included length of stay (LOS), final best-corrected visual acuity (BCVA), readmission rate, and reoperation rate.

RESULTS

Of the 159 SPA cases included, 127 (79.9%) underwent surgery and 32 (20.1%) were managed nonsurgically. The nonsurgical cohort was younger (p = .003) with smaller abscesses (p < .001) that were more likely to be medial (p < .001). The nonsurgical cohort had shorter LOS (p < .001); final BCVA and readmission rates were similarly favorable. Abscess location was correlated with surgical approach. Superior SPA that underwent FESS or external surgery alone had higher reoperation rates (57.1.0% and 58.3%, respectively) than combined (17.9%). External approach and FESS alone resulted in lower reoperation rates (15.4% and 15.0%, respectively) than combined (27.3%) for medial SPA. Subgroup analysis in the sinusitis cohort yielded similar results.

CONCLUSIONS

A trial of nonsurgical management may be safe and effective for select patients aged 9 years and older with sinusitis-derived, medial, and small SPA. When surgery is indicated, approach should be guided by abscess location to minimize reoperation risk.

Subperiosteal and Orbital Abscesses: A Comparison of Clinical Features, Management, and Outcomes

PURPOSE

To compare the clinical features, management, and outcomes between orbital cellulitis patients with subperiosteal abscess (SPA) and those with orbital abscess (OA).

METHODS

A retrospective study was conducted at a tertiary care center through medical record search to identify patients with orbital cellulitis from January 1, 2000 to December 31, 2022. Charts were screened for those with radiographic evidence of SPA or OA. Demographic data and presenting clinical features were compared between the 2 cohorts. Primary outcomes compared included rates of surgical intervention, reoperation, and readmission; and length of hospital stay and final vision.

RESULTS

A total of 189 patients, 162 with SPA and 27 with OA, met the criteria. The OA group (mean 46.5 ± 18.6 years) was older than the SPA group (mean 19.1 ± 21.4 years). Comorbid sinusitis was significantly more common in the SPA cohort (95.7% SPA; 70.4% OA; p < 0.001), while OA was more likely to occur with orbital trauma (29.6% vs. 8.0%; p = 0.003), implanted hardware (11.1% vs. 0.6%; p = 0.005), and comorbid diabetes (22.2% vs. 4.3%; p = 0.001). OA patients more often presented with a relative afferent pupillary defect (21.7% vs. 3.9%; p = 0.005), vision worse than 20 of 50 (42.3% vs. 16.2%; p = 0.005), and methicillin-resistant Staphylococcus aureus infection (20.8% vs. 5.8%; p = 0.036). OA was associated with a higher reoperation rate (47.8% vs. 21.3%; p = 0.019), readmission rate (18.5% vs. 5.6%, p = 0.047), and limited extraocular motility at follow-up (4.3% vs. 25%; p = 0.013); while mean length of hospital stay and final visual acuity were similar.

CONCLUSION

OA may affect an older population with a divergent risk factor profile compared with SPA. OA may cause more severe functional impairment on presentation, warranting more aggressive management to achieve visual outcomes similar to SPA.

Pediatric orbital subperiosteal abscess outbreak in Iran: characteristics and causes

PURPOSE

To evaluate demographics, characteristics, and management of pediatric patients with subperiosteal abscesses (SPA) secondary to orbital cellulitis and discuss the etiology of a dramatic rise in SPA.

METHODS

Data were gathered by retrospective chart review of patients admitted to a tertiary referral eye hospital (Farabi Eye Hospital) diagnosed with orbital cellulitis with subperiosteal abscess from October 2022 to March 2023 (six months). Data on demographic information, clinical examination, radiographic evidence of sinusitis, orbital cellulitis, SPA, surgical and non-surgical management taken, isolated bacteria, and duration of hospital stay were gathered.

RESULTS

24 patients were admitted during these six months, with a diagnosis of orbital SPA secondary to paranasal sinusitis, confirmed by an orbital Computed Tomography (CT) scan. The age range was 11 months to 16 years. 75% of patients were male. All patients had a history of flu-like illness before developing orbital cellulitis. All patients had concurrent sinusitis, and 18 underwent initial surgical abscess drainage. The ethmoid sinus was the most involved, and most patients had a medially located SPA. Abscess volume ranged from 0.78 to 7.81 cm3 (mean: 3.52 cm3). One patient had concurrent central retinal artery occlusion due to orbital cellulitis.

CONCLUSIONS

In this study, we report a dramatic increase in the incidence of SPA referred to our hospital. Larger abscess volumes and an increased number of cases that needed initial surgical drainage are also of note. An influenza outbreak in the autumn and winter, undiagnosed Corona Virus Disease 2019 (COVID-19) infection, increased antimicrobial resistance due to excessive off-label use of antibiotics during the COVID-19 pandemic, and more virulent bacterial infections are the most probable hypotheses to justify this observation.

Aspergillosis Causing Orbital Subperiosteal Abscess in an Immunocompetent Child: A Rare Presentation

Orbital abscesses are primarily seen in children as complication of ethmoid bacterial sinusitis. We report a case of invasive aspergillosis causing orbital abscess in an immunocompetent child which resolved with surgery followed by antifungal therapy. This case highlights need for histopathological, and microbiological examination, including fungal culture in such cases.

Artificial Intelligence Automation of Proptosis Measurement: An Indicator for Pediatric Orbital Abscess Surgery

INTRODUCTION

To evaluate the ability of artificial intelligence (AI) software to quantify proptosis for identifying patients who need surgical drainage.

METHODS

We pursued a retrospective study including 56 subjects with a clinical diagnosis of subperiosteal orbital abscess (SPOA) secondary to sinusitis at a tertiary pediatric hospital from 2002 to 2016. AI computer software was developed to perform 3D visualization and quantitative assessment of proptosis from computed tomography (CT) images acquired at the time of hospital admission. The AI software automatically computed linear and volume metrics of proptosis to provide more practice-consistent and informative measures. Two experienced physicians independently measured proptosis using the interzygomatic line method on axial CT images. The AI software and physician proptosis assessments were evaluated for association with eventual treatment procedures as standalone markers and in combination with the standard predictors.

RESULTS

To treat the SPOA, 31 of 56 (55%) children underwent surgical intervention, including 18 early surgeries (performed within 24 h of admission), and 25 (45%) were managed medically. The physician measurements of proptosis were strongly correlated (Spearman r = 0.89, 95% CI 0.82-0.93) with 95% limits of agreement of ± 1.8 mm. The AI linear measurement was on average 1.2 mm larger (p = 0.007) and only moderately correlated with the average physicians' measurements (r = 0.53, 95% CI 0.31-0.69). Increased proptosis of both AI volumetric and linear measurements were moderately predictive of surgery (AUCs of 0.79, 95% CI 0.68-0.91, and 0.78, 95% CI 0.65-0.90, respectively) with the average physician measurement being poorly to fairly predictive (AUC of 0.70, 95% CI 0.56-0.84). The AI proptosis measures were also significantly greater in the early as compared to the late surgery groups (p = 0.02, and p = 0.04, respectively). The surgical and medical groups showed a substantial difference in the abscess volume (p < 0.001).

CONCLUSION

AI proptosis measures significantly differed from physician assessments and showed a good overall ability to predict the eventual treatment. The volumetric AI proptosis measurement significantly improved the ability to predict the likelihood of surgery compared to abscess volume alone. Further studies are needed to better characterize and incorporate the AI proptosis measurements for assisting in clinical decision-making.

Predictors for surgical intervention in orbital complications of pediatric rhinosinusitis

OBJECTIVES

Orbital complications are the most common complication of acute rhinosinusitis, especially among pediatric patients. While most cases are treated with antibiotics alone, severe presentation may demand surgical intervention. Our goal was to determine which factors predict the need for surgery and to investigate the role of computerized tomography in the decision process.

METHODS

A retrospective review of all children hospitalized between 2001-2018 with orbital complications of acute rhinosinusitis in a university-affiliated children's hospital.

RESULTS

A total of 156 children were included. Mean age was 7.9 years (1-18 years). Twenty-three children (14.7%) were surgically treated, and the rest were conservatively treated. High fever, ophthalmoplegia and diplopia in association with minimal or no response to conservative treatment were predictive for surgical intervention, as well as higher inflammatory indices. Eighty-nine children (57%) underwent imaging during hospitalization. Presence of a subperiosteal abscess, as well as its size and its location were not found to be predictors for surgery.

CONCLUSION

Clinical and laboratory findings in association with minimal or no response to conservative treatment predict the need for surgical intervention in cases of orbital complications of acute rhinosinusitis. As Computerized Tomography scans can have long-term implications in the pediatric population, caution and patience should be practiced when deciding on the timing of imaging in this population. Thus, close clinical and laboratory monitoring should lead the decision-making process in these cases and imaging should be reserved for when the decision for surgery has been made.

Progression of Subperiosteal Orbital Abscess after Clinical Resolution on Intravenous Antibiotics and Steroids

We present a case of a 7-year-old boy who was presented with a small medial subperiosteal orbital abscess (SPOA) and trace superior phlegmon and who was initially treated with intravenous (IV) antibiotics, corticosteroids, and observation. After clinical resolution and discharge, the patient returned with superior migration of his abscess requiring surgical drainage. Potential factors leading to readmission are discussed, including the anti-inflammatory and immunosuppressant effects of steroids, and presence of early surgical indictors such as bony dehiscence and proptosis. This case highlights the need for careful consideration of initial imaging and presence of a non-medial phlegmon prior to initiation of steroids.

Orbital Complications of Chronic Rhinosinusitis: Two Years' Experience in a Tertiary Referral Hospital

PURPOSE

To investigate the different clinical manifestations in Egyptian patients with orbital complications of rhinosinusitis (RS) according to the pathology within the paranasal sinuses.

METHODS

The medical records of patients presented with chronic RS between August 2018 and December 2020 were retrospectively reviewed.

RESULTS

This study included 64 patients: 28 patients with subperiosteal abscess (SPA), 10 with allergic fungal RS, 6 with isolated fungal RS, 6 with invasive fungal RS, and 14 with mucocele. The most common manifestation was proptosis, limitation of ocular motility, periorbital swelling, and pain. A relative afferent pupillary defect was present in all cases of invasive fungal sinusitis. Surgical interventions were performed in 63 out of 64 cases. All the ophthalmological manifestations were reversible except for patients with invasive fungal rhinosinusitis.

CONCLUSION

Orbital complications of RS may require early surgical intervention with multidisciplinary counseling between ophthalmologists, otorhinolaryngologists, radiologists, and neurologists.

Surgical Approaches in Odontogenic Orbital Cellulitis (OOC): Our Experience and Review of Literature

Aims Odontogenic orbital cellulitis represents a complication of root infections of upper pre-molars and molars. The severity depends on the orbital structure involved. The treatment is based on antibiotic therapy associated or not to surgery. Through the presentation of three cases and a review of literature, we purpose as aim of our study to underline the necessity of a timely diagnosis and to provide the correct surgical approach in each different types and stages of orbital infections. Methods We present three patients that were affected by dental infection evolved in orbital cellulitis. In two cases the disease was solved with the extraction of infected tooth and a surgical endoscopic drainage of the abscess through antrostomy of maxillary sinus. In the third patient the disease had already induced a bulbar perforation and endophthalmitis, so an orbit evisceration was necessary. Results Review of literature showed that the standard treatment of orbital cellulitis is the transnasal approach associated or not by a transoral and/or transcutaneous procedure depending on the stage of the disease and on the causes. In our 3 cases these indications were followed without relapses of the disease. Conclusion An early diagnosis is mandatory in odontogenic orbital cellulitis specially to avoid serious complications. Surgical treatment can be simple and effective mostly in early-stage infection: it is based on extraction of infected tooth and on the drainage of abscess. Surgical approach consists in transnasal procedure flanked or not by transoral and transcutaneous procedures based on the stage of the infection considering involved structures.

Odontogenic Sinusitis is a Common Cause of Operative Extra-Sinus Infectious Complications

BACKGROUND

Orbital, intracranial, and osseous extra-sinus complications can arise from bacterial or fungal sinusitis. Odontogenic sinusitis (ODS) can cause extra-sinus complications, but its prevalence remains poorly characterized.

OBJECTIVE

To determine the frequency of ODS as a cause of operative extra-sinus infectious complications and describe clinical features of all complicated sinusitis cases.

METHODS

A multi-institutional retrospective review was performed on all operative sinusitis-related extra-sinus complications from 2011 to 2020. ODS was diagnosed by sinus computed tomography (CT) and dental evaluations when available. Demographics, complication types, sinusitis etiologies, and various clinical features were analyzed.

RESULTS

Forty-five patients were included (mean age 55.5 years, 56% male). Of the extra-sinus complications, 40% were orbital only, 22% intracranial only, 13% osseous only, and 25% involved combined complications. The 2 most common causes of extra-sinus complications were ODS (40%) and mucopyocele (27%). When invasive fungal etiologies were excluded, and only unilateral maxillary opacification on CT was considered, nearly 60% of extra-sinus complications were due to ODS. Unilateral maxillary sinus opacification on CT was present in 100% of complicated ODS compared to 44% of nonodontogenic cases, and oral anaerobes were only identified in ODS cases. No complicated ODS patients underwent dental interventions during hospitalization.

CONCLUSION

ODS was the most common cause of operative extra-sinus infectious complications. Clinicians should consider ODS high on the differential diagnosis of all patients presenting with complicated sinusitis, especially when sinusitis is unilateral and invasive fungal infection is not suspected.

Predictors of Surgical Intervention for Pediatric Acute Rhinosinusitis with Periorbital Infection

Background: Medical versus surgical management of pediatric periorbital infection secondary to acute bacterial rhinosinusitis (ABRS) can be a dilemma for clinicians. This study aimed to evaluate the prognostic factors related to the need for surgical drainage and to help direct management decisions. Methods: Children admitted for periorbital infection secondary to ABRS between 2001 and 2019 were retrospectively reviewed. Demographics, clinical presentations, laboratory data, comorbidities, and computed tomography results were collected from medical records. Results: A total of 141 pediatric patients were enrolled. Forty-two patients (29.8%) required surgical intervention. Multivariate logistic regression analysis identified that delayed initiation of intravenous antibiotics from the onset of periorbital swelling (odds ratio [OR] = 1.94; p < 0.001) and proptosis at initial presentation (OR = 6.63; p = 0.008) were significantly associated with the need for surgical intervention. A C-reactive protein value of > 55.73 mg/L and initiation of intravenous antibiotic treatment > 2 days from the onset of periorbital swelling showed the best predictive power for surgery. Conclusions: Pediatric patients with delayed initiation of intravenous antibiotic treatment and initial presentation of proptosis had worse outcomes and required surgical intervention.

Orbital Complications of Acute Sinusitis in Pediatric Patients: Management of Chandler III Patients

Background

Surgery is often avoided in the setting of pediatric orbital complications from acute sinusitis unless necessitated by alarming ophthalmological signs. Criteria for surgical intervention are not well-defined.

Objective

We aim to review our experiences, management practices and patient outcomes over a ten-year period for Chandler III patients.

Methods

A retrospective review was performed from January 1, 2007 through December 31, 2016 of patients treated for orbital symptoms secondary to acute sinusitis at a free-standing tertiary-care pediatric hospital.

Results

Of the 186 patients reviewed, 42 Chandler III patients were included. Average age was 82.6 months (SD 50.6) with a slight male predominance (M to F, 1.8 to 1). 27 patients (64.3%) underwent intervention including endoscopic sinus surgery (ESS) with or without orbitotomy. Late surgical intervention (>48hrs from admission) demonstrated significant increase in overall length of stay (LOS) when compared with early surgical intervention and/or medical management (median, 6.9 vs 3.6 vs 3.7 days; p < 0.01). Postoperative LOS was also higher in the late surgery group compared with patients who had surgery within 48 hours of admission, but this did not reach statistical significance [median, 3.8 vs 2.8 days, p= 0.12]. There was no significant difference in overall abscess volume between patients who underwent intervention and those who did not (1019 mm³ vs 805 mm³, p = 0.5), but abscess width ≥ 1.2 cm was associated with higher rates of intervention. An alarming extraocular exam was the most common factor associated with surgical intervention.

Conclusion

Pediatric subperiosteal orbital abscess may prompt surgical intervention by ESS. An alarming ophthalmologic exam should prompt consideration of early intervention, which may lead to decreased overall and post-operative length of hospital stay.

Level of Evidence

4

Meeting Information

American Rhinologic Society, Fall National Meeting. Chicago, IL, USA. September 8–9, 2017.

Management of post-septal complications of acute rhinosinusitis in children: A 14-year experience in a tertiary hospital

INTRODUCTION

Acute rhinosinusitis accounts for most of the cases of orbital infections and is the most common cause of periorbital oedema in children. Up to 10% of patients with orbital complications of acute rhinosinusitis may experience vision loss and other complications such as meningitis, intracranial abscess or even death. Therefore, these patients require prompt diagnosis and proper treatment.

OBJECTIVES

This study aims to report the clinical presentation and management of post-septal orbital complications of acute rhinosinusitis in the paediatric population.

MATERIALS AND METHODS

A retrospective medical chart review of all children aged under 18 years old who were diagnosed with post-septal orbital complications of acute rhinosinusitis at a tertiary academic hospital, between 01/2007 and 12/2020. Patients were grouped according to the Chandler Classification (groups 2-5).

RESULTS

Fifty-five children (mean age of 6.91 ± 4.61 years) fulfilled the entry criteria for post-septal orbital complications of acute rhinosinusitis, based on clinical evaluation by an otorhinolaryngologist and CT-scan findings. Forty (72.72%) patients were also evaluated by an ophthalmologist. Most patients were male (76.36%). Twenty-four patients had post-septal cellulitis (43.63%), 21 patients had a subperiosteal abscess (38.18%) and 10 patients had an orbital abscess (18.18%). Eyelid swelling was the most frequent sign, followed by fever. Microbiology varied considerably and gram-positive agents were clearly predominant. Eighteen (32.73%) patients had been treated with oral antibiotics prior to hospital admission, exhibiting a significantly higher risk of recurrence of orbital infection (p = 0.020). Ethmoid and maxillary sinuses were the most involved paranasal sinuses (90.91%). Thirty-three patients (60%) were successfully treated medically, and 22 patients (40%) required surgical drainage. Seven patients (12.73%) developed further complications and six recovered without sequelae. The mean length of hospital stay was 8.0 ± 5.0 days and recurrence of orbital infection occurred in six patients (10.91%). The absolute neutrophil blood count was significantly different amongst Chandler groups (p = 0.021), with higher counts in patients with subperiosteal abscess. The duration of hospitalization was significantly higher in patients submitted to surgery (p < 0.001).

CONCLUSION

Post-septal orbital complications of acute rhinosinusitis are infrequent but dangerous events in the paediatric population. Close collaboration with Ophtalmology is paramount, as the child's vision is at risk. Eyelid swelling and proptosis are early signs. CT-scan imaging plays an invaluable role in the diagnosis and decision-making. Predictive indicators for surgery were not found. However, emergency endoscopic nasal surgery with abscess drainage should be considered whenever vision is at risk, if there is no improvement after aggressive medical treatment, and in cases of intracranial complications.

Management of orbital and brain complications of sinusitis: A practical algorithm

The aim of this work was to present a practical management algorithm for orbital and brain complications of sinusitis. According to the inclusion criteria, a sample of 68 patients was collected between 2008 and 2018 (39 males and 29 females). Among them, 44 were adults, with a mean age of 50.46 years, and 24 were pediatric patients, with a mean age of 10.33 years. Oral or intravenous antibiotic therapy was administered to all patients. Pharmacological resolution was observed in 14 cases. Early surgical treatment within 48 hours was necessary in 10 cases. Surgery consisted of abscess drainage, associated or not with functional endoscopic sinus surgery. Delayed surgery within 15-30 days was performed in 44 patients. The core procedure was functional endoscopic sinus surgery. Subsidiary procedures were abscess drainage, tooth extraction or cranial base repair. The combination of two or more of these procedures was case selected. Median follow-up was of 46.36 months. Sinusitis complications necessitate rapid diagnosis and prompt treatment. Antibiotic therapy alone is enough for mistreated rhinosinusitis with no anatomical predisposing factor. Surgery is mandatory for altered nasal and paranasal sinus anatomy or odontogenic infections.

Extrasinus Complications From Odontogenic Sinusitis: A Systematic Review

OBJECTIVE

Odontogenic sinusitis (ODS) can cause infectious orbital, intracranial, and osseous complications. Diagnosis and management of complicated ODS have not been discussed in recent sinusitis guidelines. The purpose of this systematic review was to describe epidemiological and clinical features, as well as management strategies of complicated ODS.

DATA SOURCES

PubMed, EMBASE, and Cochrane Library.

REVIEW METHODS

A systematic review was performed to describe various features of complicated ODS. All complicated ODS studies were included in qualitative analysis, but studies were only included in quantitative analysis if they reported specific patient-level data.

RESULTS

Of 1126 studies identified, 75 studies with 110 complicated ODS cases were included in qualitative analysis, and 47 studies with 62 orbital and intracranial complications were included in quantitative analyses. About 70% of complicated ODS cases were orbital complications. Only 23% of complicated ODS studies were published in otolaryngology journals. Regarding ODS-related orbital and intracranial complications, about 80% occurred in adults, and 75% were male. Complicated ODS occurred most commonly from apical periodontitis of maxillary molars. There were no relationships between sinusitis extent and orbital or intracranial complications. High rates of anaerobic and α-hemolytic streptococcal bacteria were identified in complicated ODS. Management generally included systemic antibiotics covering aerobic and anaerobic bacteria, and surgical interventions were generally performed to address both the complications (orbital and/or intracranial) and possible infectious sources (dentition and sinuses).

CONCLUSION

ODS should be considered in all patients with infectious extrasinus complications. Multidisciplinary management between otolaryngologists, dental specialists, ophthalmologists, and neurosurgeons should be considered to optimize outcomes.

Automated delineation of orbital abscess depicted on CT scan using deep learning

OBJECTIVES

To develop and validate a deep learning algorithm to automatically detect and segment an orbital abscess depicted on computed tomography (CT).

METHODS

We retrospectively collected orbital CT scans acquired on 67 pediatric subjects with a confirmed orbital abscess in the setting of infectious orbital cellulitis. A context-aware convolutional neural network (CA-CNN) was developed and trained to automatically segment orbital abscess. To reduce the requirement for a large dataset, transfer learning was used by leveraging a pre-trained model for CT-based lung segmentation. An ophthalmologist manually delineated orbital abscesses depicted on the CT images. The classical U-Net and the CA-CNN models with and without transfer learning were trained and tested on the collected dataset using the 10-fold cross-validation method. Dice coefficient, Jaccard index, and Hausdorff distance were used as performance metrics to assess the agreement between the computerized and manual segmentations.

RESULTS

The context-aware U-Net with transfer learning achieved an average Dice coefficient and Jaccard index of 0.78 ± 0.12 and 0.65 ± 0.13, which were consistently higher than the classical U-Net or the context-aware U-Net without transfer learning (P < 0.01). The average differences of the abscess between the computerized results and the experts in terms of volume and Hausdorff distance were 0.10 ± 0.11 mL and 1.94 ± 1.21 mm, respectively. The context-aware U-Net detected all orbital abscess without false positives.

CONCLUSIONS

The deep learning solution demonstrated promising performance in detecting and segmenting orbital abscesses on CT images in strong agreement with a human observer.

Tobey A. Pediatric subperiosteal orbital abscess characterization and prediction of size, location, and management

INTRODUCTION

Subperiosteal orbital abscess (SPOA) is a serious suppurative complication of pediatric sinusitis. The objective of this study is to stratify patient selection into those best treated medically versus surgically based on clinical outcomes.

METHODS

This is a retrospective review of patients diagnosed with SPOA complicating sinusitis treated at a tertiary care pediatric hospital from 2002 through 2016. SPOA was diagnosed by CT scan. Characteristics evaluated include demographics, abscess size, location, and measurements, length of hospital stay, medical and surgical interventions, presenting symptoms, and complications.

RESULTS

A total of 108 total SPOA secondary to sinusitis patients were included. A majority, 72.2%, were male with an average age at presentation of 6.8 years. The mean ± standard deviation abscess cubic volume was 0.98 ± 1.27 cm³ (median(range) = 0.44(0.01-7.34 cmcm³)). With an abscess volume of 0.510 cm³, there was a sensitivity of 71.2% and a specificity of 84.4% for needing surgical drainage. Those with large abscesses at our volume threshold were 13 times more likely to require surgery than those with small abscesses, OR: 13.41, 95%CI: 5.02-35.86, p < .001. Patients that required surgery had an abscess closer to the orbital apex with the majority, 25 (61.0%), being the most proximal to the apex, p = .004. The likelihood of surgery decreased with increased distance from the orbital apex in medial abscesses (OR:.92, 95%CI: 0.86-0.98, p = .009).

CONCLUSION

In the pediatric population, SPOA is a serious consequence of sinusitis. This study provides evidence supporting that larger abscess size is a significant risk factor for requiring surgery. The appeal of our study is that it provides evidence and support that employ clinical parameters already assessed as standard practice in evaluating these patients. In summarizing the clinical translational relevance of our study, when determining whether to treat a patient with surgery and antimicrobial/medical therapy vs. non-surgical medical therapy alone, the clinician should focus on size of 0.510 cm³ or larger for abscesses in any location as a relative indication for surgery.

Lesion-Mapping Software for the Measurement of Subperiosteal Abscess Volume for Pediatric Orbital Cellulitis: A Retrospective Chart Review

Introduction

Our objective was to assess the utility of using lesion-mapping software to calculate precise orbital volumes to predict patients who would benefit from early surgical intervention.

Methods

We retrospectively reviewed patients diagnosed with subperiosteal orbital abscess (SPOA) secondary to sinusitis at a tertiary pediatric hospital from 2005 to 2016. Diagnoses were confirmed by CT scans. Lesion-mapping software was used to measure SPOA volume using initial CT images. Data collected included patient demographics, length of hospital stay, and subsequent medical or surgical treatment.

Results

Thirty-three (52%) patients ultimately underwent surgical intervention, while 30 (48%) were managed medically. Between the surgical and medical groups, there were no differences in gender, age, or comorbidities. The surgical group had larger abscess volumes than the medically managed group (0.94 mL vs. 0.31 mL, p < 0.01). Overall, increased SPOA volume was associated with increased age (Pearson’s coefficient = 0.374, p ≤ 0.01) and increased total days of intravenous (IV) antibiotic administration (Pearson’s coefficient = 0.260, p = 0.039). Patients who underwent surgery on the day of admission had 25% shorter hospital stay than patients who had delayed surgery (p < 0.01). Our calculated sensitivity-optimized SPOA volume cutoff of 0.231 mL yielded sensitivity of 90.9% and specificity of 70.0%.

Conclusions

This is the first study to use lesion-mapping software for precise calculation of SPOA volumes, which can help refine indications for early surgical intervention and help decrease length of hospital stay.

Cavernous Sinus Thrombosis related to Orbital Cellulitis Serious Complication to Prevent: a case report and literature review

Introduction

The authors report a case which aims to underline the importance of multidisciplinary management and rapid diagnosis of orbital cellulitis, for an adequate treatment of ocular damages and related complications, to prevent serious and permanent sequelae and avoid a fatal prognosis.

Presentation of case

A 61-year-old female reported to the oral and maxillofacial surgery department after she was dragged around for two months. She presented with a right facial swelling and orbital apex syndrome including proptosis, ophthalmoplegia and ptosis.

Discussion

Complications of orbital cellulitis may be limited to the orbit, such as subperiosteal or orbital abscess, optic neuritis, blindness, or intracranial such as meningitis, sinus cavernous thrombosis, cerebral abscess and even death.

Conclusion

Maxillofacial surgeons must be aware of this complication in a multidisciplinary context to adopt adequate treatment as soon as possible.

•

Orbital cellulitis is a rare ophthalmic disease due to pansinusitis with hard maxillofacial management.

•

Cavernous sinus thrombosis is a rare but highly fatal complication of orbital cellulitis.

•

Early and appropriate treatment can improve the bad prognosis of this condition and avoid visual sequelae.

•

Maxillofacial surgeons must be aware of this complication in a multidisciplinary context to adopt adequate treatment as soon as possible.

Microbiology of orbital cellulitis with subperiosteal abscess in children: Prevalence and characteristics of Streptococcus anginosus group infection

Purpose: To evaluate the predominant pathogens and clinical course in pediatric patients with orbital cellulitis (OC) complicated by subperiosteal abscess (SPA).Methods: This is a single-center retrospective chart review evaluating pediatric patients with OC complicated by SPA treated at a tertiary care center in the Pacific Northwest. Data were analyzed for characteristics, rates of infection, and antibiotic resistance of the predominant pathogens in pediatric patients.Results: Twenty-seven children were identified with OC complicated by SPA and bacterial cultures drawn. The average age (SD) of the patients was 9.2 years (4.8), median 9.6; 15 range 5 months to 17.2 years. Seventeen (63.0%) were male. Sinusitis was present in all patients. Streptococcus species were the most common pathogen accounting for 52% (17/33) of isolates. Streptococcus anginosus group (SAG) was the predominant species and were isolated in 10 out of 27 (37%) children in the study. Twenty-one (78%) patients required surgery for the treatment of SPA. Among surgically treated patients, females tended to be younger than males (p = .068). Pediatric patients with SAG infections required more surgery than children without this isolate, 100% and 65%, respectively (p = .030). Female patients tended to have SAG infections more often than males (p = .063).Conclusions: Orbital infections caused by SAG require surgical management more often than those caused by other pathogens. Our results suggest a difference in pathogenic organisms in male and female patients with SPA. SAG is one of the most common pathogens isolated in orbital cellulitis complicated by SPA in children.

Iatrogenic orbital cerebrospinal fluid leak in a young pediatric patient: Factors to consider

Orbital abscess and subperiosteal abscess are pathologies which may require surgical treatment in the pediatric patient. Though rare, orbital cerebrospinal fluid (CSF) leak is a serious complication of abscess drainage. This paper presents a unique 5-month-old male with transorbital abscess drainage complicated by CSF leak. An endoscope was used to repair the defect through the orbitotomy incision. There was no evidence of persistent leak at follow-up. The surgical approach likely contributed to the complication, and the otolaryngologist played a key role in the leak repair. This case should serve to raise the awareness regarding considerations to avoid orbital CSF leak.

Cost comparison between surgical and conservative management for pediatric sinogenic subperiosteal abscesses

BACKGROUND

There remains variation in management of orbital complications of acute bacterial rhinosinusitis (ABRS); specifically, those subperiosteal abscesses that present without immediate surgical indication. Recent systematic reviews on management and proposed treatment algorithms are helpful but do not consider the financial implications for healthcare systems and patients.

METHODS

A retrospective chart review of pediatric patients from a tertiary care children's hospital between 2002 and 2020 was performed, identifying patients via ICD coding corresponding to acute bacterial sinusitis and orbital involvement classified as Chandler 3 confirmed by contrasted computed tomography (CT). Two groups of patients were identified: intravenous (IV) antibiotics alone and IV antibiotics plus surgery. Billing records of total hospital charges and physician fees were recorded for financial analysis. Demographic, length of stay, and charges were analyzed.

RESULTS

58 patients with ABRS and Chandler 3 orbital involvement were confirmed by CT imaging. Twenty-nine (50%) were treated with IV antibiotics alone, and twenty-nine (50%) underwent surgery in addition to IV antibiotics. There were no significant differences in patient demographics. The average total hospital charges for the medically managed group were $9262 ± 4831 compared to $30,830 ± 11,397 for the surgical group (p < 0.0001). In the medically managed group, the average hospital fees were $7305 ± 4048 and the average physician fees were $1543 ± 799. In the surgical group, the average hospital and physician fees were also significantly higher at $23,071 ± 7305 (p < 0.0001) and $7763 ± 3335 (p < 0.0001), respectively. Patients who were treated medically and had a longer than average LOS still had significantly fewer charges than those treated with antibiotics plus surgery and a shorter than average length of stay [$15,311 and $27,723, respectively (p = 0.02)].

CONCLUSION

Pediatric ABRS with orbital involvement requires prompt attention and management. Controversy persists over subperiosteal abscess management that present without overt surgical indications. Surgical intervention is expensive. Our subgroup analysis demonstrates the magnitude of this cost difference. Specifically, longer inpatient stays with IV antibiotics alone appear to be significantly cheaper than shorter ones that include surgery. Not all Chandler 3 patients are candidates for non-surgical management; however, clinicians are encouraged to keep these data in mind for those patients where further medical management is safe and may yield less expensive clinical resolution.

Non-medial infectious orbital cellulitis: etiology, causative organisms, radiologic findings, management and complications

BACKGROUND

Orbital cellulitis is an ophthalmic emergency, which is associated with vision-threatening adverse effects. The purpose of this study is investigating etiology, radiologic findings, management and complications of patients with non-medial orbital cellulitis.

METHOD

A retrospective medical record and radiologic file review of patients with infectious orbital cellulitis was performed to detect all patients with non-medial orbital cellulitis who referred to Khalili hospital from 2016 to 2019. Age, sex, origin of infection, size of collection or abscess, medical or surgical management, microbiology, first and final best-corrected visual acuity, duration of admission, and complications was recorded. Patients divided into two groups; medical management and surgical management groups and all of data compared between in this groups.

RESULTS

Of ninety-six patients with infectious orbital cellulitis, 23 cases (14 male, 9 female) were included. Five patients (21.7%) were managed medically and 18 patients (78.3%) were managed surgically. Patients' age range was 5-70 years old. Most common location for non-medial cellulitis was superior space (66.7% in surgical and 40% in medical group; p = 0.511). In 13 cases of surgical group (72.3%) were detected microorganisms. The mean ± SD of collection volume in medical group were 476.5 ± 290.93 mm³ and 2572.94 ± 1075.75 mm³ in surgical group (p < 0.001). Ten patients in surgical group had compressive optic neuropathy. The mean ± SD of collection volume was 3204.97 ± 879.88 mm³ in patient with compressive optic neuropathy and 1280.43 ± 880.68 mm³ in patient without compressive optic neuropathy (P < 0.001). One case complicated by subdural empyema and another case progressed to necrotizing fasciitis.

CONCLUSION

Non-medial orbital cellulitis is an uncommon but sight-threatening and life-threatening condition. Timely diagnosis and accurate management reduce morbidity and mortality. Combined surgery for patients with superior or supra-temporal and large non-medial abscess is recommended.

The Role of Endoscopic Sinus Surgery in Children Undergoing External Drainage of Non-Medial Subperiosteal Orbital Abscess

BACKGROUND

The extent of surgery required in the management of pediatric non-medial subperiosteal orbital abscess (SPOA) due to medically refractory complicated acute sinusitis is unknown.

OBJECTIVES

The primary objective is to compare operative outcomes of children treated with combined endoscopic sinus surgery (ESS) and external orbital drainage (EOD) versus those treated with EOD alone.

METHODS

Retrospective case series from a tertiary children's hospital analyzing outcomes in children requiring surgical management for acute sinusitis complicated by non-medial SPOA between November 2007 and September 2019.

RESULTS

Sixteen children with a mean age of 9.4 years (95% CI: 7.3-11.4) met inclusion. Eleven (68.8%) underwent combined EOD and ESS, while five (31.2%) underwent EOD alone. Groups were similar in age, symptom duration, white blood cell count, C-reactive protein level, intraocular pressure, Lund-Mackay score, and abscess volume. There was no significant difference in median length of stay between patients treated with a combined approach versus those treated by EOD alone. Cultures identified non-beta-hemolytic Streptococcus species in 56.3% of patients, with Streptococcus intermedius representing the most common organism in 37.5%. In one case, ESS identified a pathogen not acquired via concomitant EOD, which did influence management. No child required a subsequent surgical procedure and there were no operative complications.

CONCLUSIONS

The addition of ESS in the management of pediatric non-medial SPOA was not associated with a statistically different duration of hospitalization. Cultures from concomitant ESS rarely aided in diagnosis or antibiotic therapy. Further study should delineate the indications for ESS in these cases.

Orbital complications of acute bacterial rhinosinusitis in the pediatric population: A systematic review and meta-analysis

OBJECTIVES

Assess characteristics and outcomes of orbital complications of acute bacterial rhinosinusitis (ABRS) in the pediatric population and evaluate trends over time.

METHODS

A literature search of pediatric orbital complications was performed in the following databases: Ovid MEDLINE, Scopus, and Cochrane Database of Systematic Reviews. Studies reporting data for at least 10 subjects with orbital complications of sinusitis under 18 years old were included. Studies were grouped by publication year; before 2010 and after and including 2010. Studies that only included patients with subperiosteal abscess (SPA) were grouped in a separate category. Data collected include demographics, Chandler class complications, intra-operative culture, treatment, and outcomes. Meta-analysis of proportion was performed to compare data from studies published before 2010 and data published in 2010 and after.

RESULTS

Thirty-five studies met inclusion criteria. No significant difference was observed over time in gender of subjects in the all Chandler complications or SPA only groups (P > 0.72). The proportion of subjects presenting with Chandler IV complications decreased from 6.8% to 2.9% in recent studies (P = 0.019). The proportion of subjects treated surgically decreased from 45.2% to 21.7% in the all Chandler complications group (P < 0.0001) and from 90.0% to 47.9% in the SPA only group, P < 0.0001. The proportion of S. pneumoniae positive cultures decreased from 20.5% to 9.1% (P = 0.02).

CONCLUSION

The demographics of pediatric patients treated for orbital complications of ABRS in published literature has been stable. Patients reported in more recently published studies are less likely to present with orbital abscess and more likely to receive conservative treatment. The proportion of positive Streptococcus pneumoniae cultures have decreased.

Management Patterns in Pediatric Complicated Sinusitis

OBJECTIVES

Sinusitis is a common pediatric illness that can be complicated by periorbital or intracranial extension. Patients can be managed with antimicrobials alone or in conjunction with surgical intervention. This article examines management patterns and outcomes in pediatric patients presenting with complicated sinusitis.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care pediatric hospital.

SUBJECTS AND METHODS

An evaluation of 168 pediatric patients with complicated sinusitis with periorbital complications presenting at a single institution from 2008 to 2018 was performed. Demographics, disease characteristics, in-hospital management, and outcomes were recorded and analyzed.

RESULTS

The most common complication was orbital cellulitis, seen in 49% of children. Surgical intervention occurred in 49% of patients, with 36% receiving medical therapy followed by surgery (MTS). Chandler I patients underwent surgical intervention 30% of the time, Chandler II patients 29%, and Chandler III patients 83%. Nineteen percent of initially nonoperative patients started on ampicillin-sulbactam required MTS vs 57% of those started on other antibiotic regimens (P = .01). Twelve percent of initially nonoperative Chandler I to II patients started on ampicillin-sulbactam needed MTS vs 40% started on other antibiotic regimens. Hospital charges for operative patients were $45,056 vs $14,311 for nonoperative patients (P < .01). Hospital charges for patients with surgery followed by medical therapy (SMT) were $45,563 vs $44,393 for MTS (P = .92).

CONCLUSION

Nonoperative early stage patients started on ampicillin-sulbactam had a lower risk of MTS. MTS did not cost significantly more than SMT, and there were no significant outcome differences seen.

Pediatric Subperiosteal Abscess Secondary to Acute Sinusitis: A Systematic Review and Meta-analysis

OBJECTIVES/HYPOTHESIS

The surgical versus medical management of subperiosteal abscess can be controversial. The purpose of this study was to summarize current literature and provide pooled analyses to help direct management decisions.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Patients <18 years old with subperiosteal abscess secondary to acute sinusitis were reviewed, and a meta-analysis was conducted. Studies including five or more patients written in English were the primary search focus.

RESULTS

Thirty-eight studies met inclusion criteria for the systematic review, and seven studies contained sufficient data for the meta-analysis. A total of 1,167 patients between the ages of 10 days and 18 years were included. Eleven sign/symptom categories were identified, with restricted ocular motility (n = 289, 45.9%), proptosis (n = 277, 44%), and fever (n = 223, 35.4%) being most frequent. Staphylococcus aureus was the most common pathogen isolated from cultures. Patients with abscess volume greater than the threshold specified in each individual study were over three times more likely to require surgical intervention compared to those with smaller abscess volume (pooled risk ratio [RR] = 3.61, 95% confidence interval [CI]: 2.40-5.44). Proptosis and gaze restriction also significantly predicted surgical intervention (pooled RR = 1.65: 95% CI: 1.29-2.12 for proptosis/pooled RR = 1.90; 95% CI: 1.20-3.00 for gaze restriction).

CONCLUSIONS

Approximately half of patients with a subperiosteal abscess undergo surgical drainage. Abscess volume appears to be the most significant predictive risk factor. Detailed data from future studies regarding radiologic and ophthalmologic parameters are needed to provide more definitive values predictive of which patients are likely to fail medical therapy.

LEVEL OF EVIDENCE

2a Laryngoscope, 2020.

Trends in complications of pediatric rhinosinusitis in the United States from 2006 to 2016

OBJECTIVES

1) Evaluate the changing prevalence of complications from pediatric acute bacterial rhinosinusitis and 2) elucidate factors associated with the development of complicated acute rhinosinusitis in this population.

STUDY DESIGN/SETTING

Cross-sectional analyses of the Kids' Inpatient Database.

SUBJECTS AND METHODS

Children <20 years with a diagnosis of acute rhinosinusitis were included. Diagnosis codes pertaining to acute rhinosinusitis-related complications were then queried for each subject. All patients were ultimately categorized into one of four groups: uncomplicated acute rhinosinusitis, orbital complications, intracranial complications, or both orbital and intracranial complications. Weighted measures were applied to provide national estimates.

RESULTS

Over the decade studied, national estimates for children admitted with acute rhinosinusitis decreased from 8,312 cases in 2006 to 5,592 in 2016. There was an increase in the rate of orbital complications from 8.9% to 19.3% and intracranial complications from 2.2% to 4.3%. Children with both complications increased from 0.5% to 1.0% of cases. Children with orbital complications were significantly younger (8.6 years) compared to those with intracranial complications (12.4 years) and both complication types (12.2 years) (p < 0.001).

CONCLUSION

Despite an overall decrease in cases of acute rhinosinusitis, rates of orbital and intracranial complications continued to increase over a ten-year period. Antibiotic prescribing patterns, vaccination effects, and evolving practice patterns may help explain these observations. Further studies warrant investigation into the cause of these trends.

LEVEL OF EVIDENCE

4.

Effectiveness of endoscopic versus external surgical approaches in the treatment of orbital complications of rhinosinusitis: a systematic review protocol

OBJECTIVE

This review aims to investigate and compare the effectiveness of endoscopic drainage techniques against external drainage techniques for the treatment of orbital and subperiosteal abscesses as a complication of rhinosinusitis.

INTRODUCTION

Transnasal endoscopic drainage and external drainage techniques have been used in the management of subperiosteal orbital abscesses secondary to rhinosinusitis. Each of these approaches has its own advantages and disadvantages, with extensive literature describing each technique separately. However, there is a lack of guidance in the studies on assessing and comparing the safety, effectiveness and suitability of these techniques. This review aims to compare the effectiveness of these techniques based on measuring outcomes in the literature such as: length of postoperative hospital stay, rate of revision surgery and complication rates.

INCLUSION CRITERIA

Eligible studies will include people of all ages diagnosed with subperiosteal abscess, orbital abscess or cavernous sinus thrombosis (Chandler stages III-V) secondary to rhinosinusitis disease, who have also undergone drainage via either an endoscopic approach, external approach or combined surgical approach.

METHODS

A comprehensive search of both published and unpublished literature will be performed to uncover studies meeting the inclusion criteria. Reference lists of studies included in final analyses will also be manually searched and subject matter experts contacted to investigate other sources of literature. Two reviewers will screen studies and a third reviewer will resolve disagreements. Studies will, where possible, be pooled in statistical meta-analysis with heterogeneity of data being assessed using the standard Chi-squared and I tests.

Management of Orbital Complications of Acute Rhinosinusitis in Pediatric Patients: A 15-Year Single-Center Experience

BACKGROUND

The major clinical dilemma managing acute rhinosinusitis (ARS) in pediatric population is distinguishing uncomplicated rhinosinusitis from a complicated bacterial ARS and orbital complications, the latter requiring antimicrobials and surgical intervention. However, factors associated with severe orbital complications and the optimum management strategy remains controversial. The objectives of this study were to characterize the clinical outcomes of children with orbital complications of ARS and to identify risk factors associated with disease severity.

METHODS

This retrospective cohort analysis evaluated the clinical outcomes of 61 children admitted for orbital complications between January 1, 2002 and December 31, 2017. Descriptive statistics were performed to examine the demographics and clinical findings. We compared groups using Mann-Whitney U test for continuous variables and χ for categorical variables.

RESULTS

Although two-thirds of children had received prehospital antibiotics, half of the cohort presented with post-septal orbital complications. While 83% of isolates obtained from the same patients were susceptible to the prehospital antibiotics given, the majority of those who received prehospital antibiotics nevertheless required surgical intervention. We observed significant association between the age of presentation and disease severity. Children >5 years of age presented with more severe orbital complications despite prehospital antibiotics and were more likely to require surgical intervention (P < 0.001).

CONCLUSIONS

In this study, stage II/III orbital complications at presentation and older age were the most important determinants of medical treatment failure. Early referral to eye, nose and throat (ENT) should be considered for children >5 years with ARS due to worse orbital complications despite prehospital antibiotics.

Premaxillary abscess without bony erosion: An unusual complication of pediatric acute maxillary sinusitis

OBJECTIVES

To report an unusual complication of pediatric acute maxillary sinusitis: premaxillary abscess. To describe clinical, radiological and biological presentation, treatment strategy and progression.

MATERIAL AND METHODS

A retrospective study included all pediatric patients treated for premaxillary abscess complicating acute maxillary sinusitis in two ENT reference centers between 1999 and 2017. Disease history, clinical presentation, biological and radiological findings, treatment modalities and progression were studied.

RESULTS

Ten patients were included, with a mean age of 10±4.2 years. All presented with fever, rhinorrhea and premaxillary edema. Contrast-enhanced CT scan systematically found complete opacity of the maxillary sinus, without bone lysis, and extensive effusion along the intersinonasal wall up to the premaxillary region, extending in 3 cases back toward the parapharyngeal space. Bacteriology isolated Streptococcus anginosus most frequently (n=4; 40%). Treatment comprised intravenous wide-spectrum antibiotics, with surgical drainage of the abscess if>10mm (n=9; 90%). Seven of these 9 patients (78%) had recurrent abscess requiring surgical revision and 3 (33%) required a third drainage. All patients were cured without sequelae at 1 month.

CONCLUSION

In case of acute maxillary sinusitis with premaxillary edema, premaxillary abscess should be suspected. The high recurrence rate argues for maximalist surgery associated to close clinical monitoring with radiological examination.

Orbital Complications of Rhinosinusitis in the Adult Population: Analysis of Cases Presenting to a Tertiary Medical Center Over a 13-Year Period

BACKGROUND

Orbital complications of rhinosinusitis in adults are scarcely discussed in the literature.

OBJECTIVE

To review our experience with the management of orbital complications of rhinosinusitis in the adult patient population and identify key factors in the characteristics and management of these patients.

DESIGN

Retrospective case series during the years 2004 to 2016 in a tertiary referral center including all patients with rhinosinusitis and orbital complications.

MAIN OUTCOMES AND MEASURES

Severity of complications, risk factors, clinical, imaging and microbiological data, treatment outcomes.

RESULTS

Seventy patients were identified. Median age at diagnosis was 38 years. In 57%, complications were associated with acute rhinosinusitis and in 43% with chronic rhinosinusitis, most of whom had a history of previous sinus surgery. Thirty-five percent of patients received antibiotics prior to admission. The majority of the previously operated patients (61%) had some form of orbital wall dehiscence noted on imaging. Preseptal cellulitis was the most common complication (61.5%) encountered, followed by orbital cellulitis (23%), sub-periosteal abscess (11.5%), orbital abscess (3%), and cavernous sinus thrombosis (1.5%). Gram-positive bacteria were more commonly isolated from acute rhinosinusitis patients and gram-negative bacteria from chronic rhinosinusitis (CRS) patients. Complete recovery was noted in all patients, of whom 85% were managed conservatively. All, but 1 patient, with an abscess or cavernous sinus thrombosis required surgical drainage. Older age was the only risk factor identified for severe complications.

CONCLUSIONS

In contrast to the pediatric population, CRS is very common in adults with orbital complications of rhinosinusitis, with previous sinus surgery and orbital wall dehiscence being noticeably common. Older patients are at risk for more severe complications. Conservative treatment suffices in patients with preseptal and orbital cellulitis. In more advanced stages, surgical drainage is advocated with excellent results. Larger cohort studies are needed to further investigate this patient group.

Common Community-acquired Bacterial Skin and Soft-tissue Infections in Children: an Intersociety Consensus on Impetigo, Abscess, and Cellulitis Treatment

PURPOSE

The main objective of this article was to offer practical suggestions, given the existing evidence, for identifying and managing bacterial impetigo, abscess, and cellulitis in ambulatory and hospital settings.

METHODS

Five Italian pediatric societies appointed a core working group. In selected conditions, specially trained personnel evaluated quality assessment of treatment strategies according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Only randomized controlled trials (RCTs) and observational studies were included for quality assessment according to the GRADE methodology. MEDLINE, Ovid MEDLINE, EMBASE, and Cochrane Library databases were searched with a strategy combining MeSH and free text terms.

FINDINGS

The literature review included 364 articles focusing on impetigo, skin abscess, and cellulitis/orbital cellulitis. The articles included for quality assessment according to the GRADE methodology for impetigo comprised 5 RCTs and 1 observational study; for skin abscess, 10 RCTs and 3 observational studies were included; for cellulitis and erysipelas, 5 RCTs and 5 observational studies were included; and for orbital cellulitis, 8 observational studies were included. Recommendations were formulated according to 4 grades of strength for each specific topic (impetigo, skin abscesses, cellulitis, and orbital cellulitis). Where controversies arose and expert opinion was considered fundamental due to lack of evidence, agreement according to Delphi consensus recommendations was included.

IMPLICATIONS

Based on a literature review and on local epidemiology, this article offers practical suggestions for use in both ambulatory and hospital settings for managing the most common bacterial SSTIs.

Sinonasal-Related Orbital Infections in Children: A Clinical and Therapeutic Overview

Sinonasal-related orbital infections (SROIs) are typically pediatric diseases that occur in 3⁻4% of children with acute rhinosinusitis. They are characterised by various clinical manifestations, such as peri-orbital and orbital cellulitis or orbital and sub-periosteal abscesses that may develop anteriorly or posteriorly to the orbital septum. Posterior septal complications are particularly dangerous, as they may lead to visual loss and life-threatening events, such as an intracranial abscess and cavernous sinus thrombosis. Given the possible risk of permanent visual loss due to optic neuritis or orbital nerve ischemia, SROIs are considered ophthalmic emergencies that need to be promptly recognised and treated in an urgent-care setting. The key to obtaining better clinical outcomes in children with SROIs is a multi-disciplinary assessment by pediatricians, otolaryngologists, ophthalmologists, radiologists, and in selected cases, neurosurgeons, neurologists, and infectious disease specialists. The aim of this paper is to provide an overview of the pathogenesis, clinical manifestations, diagnosis, and treatment of pediatric SROIs, and to make some practical recommendations for attending clinicians.

Urgent Infections of the Head and Neck

Infections of the head and neck are common and appropriately managed by primary care providers in most cases. However, some infections are associated with significant morbidity and require urgent recognition and management by specialty services. These include deep neck space infections originating in the oral cavity, pharynx, and salivary glands, as well as complicated otologic and sinonasal infection. This article provides a review of these conditions, including the pathophysiology, presenting features, and initial management strategy.

A Rare Orbital Complication of Sinusitis in a Pregnant Patient: Orbital Inflammatory Granulation

Development of orbital inflammatory granulation in pregnant patients as an orbital complication of acute sinusitis is extremely rare. Herein, we describe the case of a patient with a complication of acute sinusitis that mimicked orbital tumors. The patient presented with left orbital protrusion. Magnetic resonance imaging revealed pansinusitis with a well-defined mass lesion in the extraconal space of the left orbit. Endoscopic endonasal sphenoethmoidectomy and orbital decompression were performed. Histopatological examination revealed acute inflammatory granulation tissue. To the best of our knowledge, this is the first report to describe orbital inflammatory granulation in a pregnant patient as an orbital complication of sinusitis.

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.

Microbiology and antibiotic therapy of subperiosteal orbital abscess in children with acute ethmoiditis

OBJECTIVE

The objective of this study was to investigate the microbiological cultures and the management of acute ethmoiditis complicated by subperiosteal orbital abscess (SPOA) in a pediatric population.

METHODS

The medical records of children under 18 years old was performed in a tertiary referral pediatric center from January 2009 to April 2017. Clinical examination, computed tomography scans, medical and surgical treatments were reviewed and compared to other studies in literature.

RESULTS

One hundred and twenty-nine children were hospitalized for acute ethmoiditis. Among them, forty eight were complicated by SPOA. The mean age of these children were 7 years (range 10 months-16 years). Thirtyfour underwent surgical drainage; for the others the medical treatment was sufficient. Microbiological samples were obtained during the surgical intervention and were contributive in 91% of cases. Streptococcus spp was the most frequently encountered bacteria (60% of cases). We also found anaerobic bacteria (12%), and Staphylococcus aureus (12%). 94% of children received two intravenous antibiotics (a third-generation cephalosporin and metronidazole) for a mean duration of four days. Then the oral treatment was based on amoxicillin-clavulanate during about 8.5 days. All children were cured without sequelae.

CONCLUSIONS

For five years Streptococcus milleri, Staphylococcus spp and anaerobic bacteria are on the rise in acute ethmoiditis complicated by SPOA. That is why antibiotics must be adapted to these bacteria even in children under ten years old.

Hospital cost analysis of children with preseptal cellulitis

OBJECTIVE

Hospitalization of the children with preseptal cellulitis creates a burden on healthcare costs. This study aimed to analyze the hospital costs for preseptal cellulitis and determine the factors contributing.

METHODS

Children, between 1 and 18 years old, who were admitted to hospital for preseptal cellulitis from May 2013 to December 2016 were included in the study. Patients were divided into groups by age (under or equal to five years and older than five years) and by the presence of sinusitis. Demographics, length of stay and total and categorical hospital costs were evaluated retrospectively.

RESULTS

The study included 54 patients with a mean age of 5 years. Thirty one of the patients were under five years of age. The most common symptoms were swelling (94.4%) and redness (83.3%) around eye. Among the predisposing factors, sinusitis was the most common one (37%). The average length of stay was 4.5 days. Total hospital cost of all patients was $11,841. Antibiotic costs (37%) and inpatient floor costs (36%) were the greatest expenditures. Between age groups, length of stay was longer, and inpatient floor and antibiotic costs were significantly higher in the group of >5 years (p = 0.007, p = 0.004 and p = 0.001, respectively). In the group with sinusitis, length of stay was longer, and all hospital costs were significantly higher compared to the group without sinusitis (p < 0.001). There was a strong, positive correlation between length of stay and hospital costs (r = 0.854, n = 53, p < 0.001). Sinusitis was a significant factor (p < 0.001) for longer length of stay, but age was not (p = 0.841).

CONCLUSION

Sinusitis was found to be an important factor contributing to longer length of stay and higher hospital costs for preseptal cellulitis. Oral or ambulatory intravenous antimicrobial treatment strategies might decrease the hospital expenditure in these patients; however care should be taken in the presence of sinusitis.

Infection rates of MRSA in complicated pediatric rhinosinusitis: An up to date review

INTRODUCTION

Published studies have reported a rise in MRSA isolates in head and neck infections, but the microbiology of complicated pediatric rhinosinusitis is unclear. One study of such patients showed that MRSA isolates were seen only in the last three years of data collection, suggesting a possible recent increased prevalence. Given the public health concerns of increasing rates of antimicrobial resistance, the goal of this study was to investigate the microbiologic patterns and outcomes of complicated pediatric rhinosinusitis.

METHODS

Retrospective cohort of pediatric patients admitted to our children's hospital with complicated acute rhinosinusitis from 2004 to 2014.

RESULTS

The mean age of 250 hospitalized children with complicated rhinosinusitis was 7.6 ± 4.9 years; 109 of these (43%) underwent surgical procedures. Although MRSA prevalence was highest in 2014, no significant trend in overall MRSA prevalence occurred when considering the entire study period. No significant relationship was identified between MRSA and intra-orbital versus intra-cranial complications. Interestingly, 22.7% of patients with anaerobes detected by culture had persistent abnormal physical examination (PE) findings versus 6.1% of patients without anaerobes (p = 0.025). Furthermore, multivariate analysis also revealed that detection of anaerobes or MRSA was associated with persistent PE findings being 21.8 and 14.8 times more likely, respectively, when compared to other detected pathogens.

DISCUSSION

Our data indicate modest variability in the annual rates of MRSA associated pediatric rhinosinusitis, however there was no statistically significant pattern of change in MRSA prevalence during 2004-2014. Although detection of MRSA was not significantly associated with either intraorbital or intracranial complications of sinusitis, a significant association with a poorer outcome was observed by multivariate analysis for patients from whom MRSA or anaerobes were detected. These data raise the question as to whether clindamycin is adequate for MRSA and anaerobic coverage.

Management of Large-Volume Subperiosteal Abscesses of the Orbit: Medical vs Surgical Outcomes

Objectives To compare clinical variables and outcomes for children with subperiosteal abscesses of the orbit (SPAO) managed medically vs surgically to identify clinical prognosticators. Study Design Case series with chart review. Setting Tertiary children's academic institution. Subjects and Methods The study included 48 children between the age of 1 month and 14 years, with SPAO from 2003 to 2013. Variables included age, sex, physical examination findings, laboratory results, computed tomography (CT) findings, hospital length of stay, length of antibiotic therapy, and placement of a peripherally inserted central catheter (PICC). Intended methods for comparison were the Student t test for continuous variables and Fisher's exact test for categorical variables, and a forward stepwise multiple logistic regression. Results Thirty-two (67%) children were successfully treated with antibiotic therapy only, and 16 (33%) required surgery. Abscess volume, abscess width, and the presence of gaze restriction were statistically different between the 2 groups. A multivariate analysis found abscess volume as the only predictor for surgical intervention. A subgroup analysis including only patients with an abscess volume of ≥500 mm³ (n = 26) was performed. Eleven patients were treated medically and 15 treated surgically, with the medical group having longer hospital stays ( P = .048), duration of antibiotic therapy ( P = .035), and higher incidence of PICC placement ( P = .005). Conclusions This is the first study to report that abscess volume has clinical implications, as children with SPAO volume ≥500 mm³ treated medically have longer inpatient admissions, antibiotic therapy durations, and PICC placement. When children present with an abscess ≥500 mm³, early surgical intervention should be strongly considered, even in the absence of other surgical criteria, to shorten duration of hospitalization and accelerate clinical improvement.

[Complications of sinusitis]

The complications of sinusitis are essentially secondary to ethmoidal and frontal sinusitis, occurring in patients weakened, particularly in case of immunodeficiency or anatomical defects. The gravity is due to the risk of spreading infection in intracranial tissues and orbital cavity. The diagnosis is always to discuss any symptomatology resistant to treatment and the appearance of orbital or neurological signs. The scanner and MRI contribute greatly to the orientation and diagnostic evaluation of the extent of the lesions. Treatment is based on prolonged antibiotic therapy and surgery and requires a multidisciplinary approach involving ENT, ophthalmologist, neurosurgeon and anesthesiologist resuscitator.

Clinical profile and outcomes of management of orbital cellulitis in Upper Egypt

Background

The purpose of this paper is to study the etiology, clinical findings, and outcomes of management of cases of orbital cellulitis treated in Minia University Hospital in Upper Egypt over the period of 6 years from July 2009 to July 2015. One-hundred two patients diagnosed to have orbital cellulitis were admitted to the hospital and treated on inpatient basis from July 2009 to July 2015. All patients were subjected to full ophthalmological examination, systemic evaluation, and ear, nose, and throat (ENT) consultation. Axial and coronal CT scan and orbital echography were done for all patients. All patients received medical treatments, and 20 patients needed surgical intervention.

Results

The source of infection was paranasal sinusitis in 66 patients, trauma in 14 cases, panophthalmitis in 6 patients, and dental infection in 2 cases, and no definite source was detected in 14 cases. Subperiosteal abscess (SPA) developed in 16 patients. The final best corrected visual acuity improved in 58% of the cases, decreased in 4%, and remained unchanged in 38% of cases. No intracranial complication was recorded.

Conclusions

Good presenting visual acuity and appropriate medical treatment together with early surgical intervention in cases of SPA are important factors to achieve favorable outcomes in orbital cellulitis. All cases with SPA had paranasal sinusitis, and contrary to previous studies, superior SPA location was the most common followed by the medial location.