Treatment of Orbital Complications Following Acute Rhinosinusitis in Children

Abstract

Background:

The orbital complications account for about 80% of all complications secondary to acute rhinosinusitis. If the treatment is not correct and in time, orbital complications could progress rapidly, leading to optic neuritis, cavernous sinus thrombophlebitis or life-threatening intracranial complications.

Aims:

To evaluate the therapeutic efficacy of conservative therapy for the patients with orbital cellulitis and endoscopic sinus surgery (ESS) performed on patients with subperiosteal abscess (SPA) secondary to acute rhinosinusitis in children.

Study Design:

Retrospective cross-sectional study.

Methods:

The retrospective study included 31 pediatric patients with orbital complications secondary to acute rhinosinusitis. In all cases, intensive treatment was initiated with a combination of oral or intravenous antibiotics, glucocorticoid and gelomyrtol forte after admission. ESS was performed if an improvement in the condition of patients did not occur after 48 hours. However, the patients with orbital SPA, motility disorders of eyeball or decreased vision received ESS immediately within 24 hours.

Results:

Sixteen patients were cured by conservative therapy and 15 patients by ESS. All of the signs and symptoms disappeared after conservative therapy or ESS. There were no recurrences within the follow-up period of 1 to 8 years.

Conclusion:

Conservative therapy is an effective method for patients with inflammatory edema and most cases of orbital cellulitis in children. SPA can be cured by ESS.

In children, acute rhinosinusitis represents acute infection of the nose and paranasal sinuses. It is commonly associated with upper respiratory tract infections due to viruses such as adenovirus, influenza virus, rhinovirus and parainfluenza virus. Progression of acute sinusitis may result in serious complications such as soft tissue infection, inflammation of the bone, orbital complications, intracranial complications, and so on (1). The orbital complications, as a result of the spread of infection from the sinuses to adjacent tissues, are the most frequent complications, which accounts for about 80% of all complications. If the treatment is not correct and in time, orbital complications could progress rapidly, leading to optic neuritis, cavernous sinus thrombophlebitis or life-threatening intracranial complications (2,3). In order to explore the correct treatment of orbital complications secondary to acute rhinosinusitis, a retrospective analysis of 31 pediatric patients with orbital complications was made in our hospital. The effect and prognosis of conservative therapy and ESS were displayed in this article.

MATERIALS AND METHODS

A retrospective medical chart review was performed on patients aged 12 years-old or younger who were treated for orbital complications secondary to acute rhinosinusitis in our hospital between March 2006 and March 2013. The study was approved by the local Ethical Committee on Human Experimentation of the Hospital. All patients sought medical help initially for orbital infections in the ophthalmology, pediatrics or ENT departments. Orbital or sinus computed tomography (CT) or magnetic resonance imaging (MRI) scans were performed to confirm the diagnosis of orbital complications and concomitant sinusitis. Cases of orbital cellulitis without concomitant sinusitis were excluded. There was an immediate consultation with the ophthalmologist when there was a suspicion of orbital complications or the clinical diagnosis was an orbital complication. Additional informed consent was obtained from all individual participants for whom identifying information is included in this article.

Table 1 summarizes relevant clinical and operative details of the 31 patients (23 males and 8 females). The age of patients ranged from 11 months to 12 years (mean age 8.7 years). In total, 17 and 8 patients made their first visit to the ophthalmologic and pediatric department, respectively, before a final diagnosis was made. The most common orbital complications diagnosed were orbital cellulitis (14 cases), subperiosteal abscess (13 cases), and inflammatory edema (4 cases). No patient with orbital abscess or cavernous sinus thrombosis was observed in this series. The most common presenting symptoms were eyelid edema, proptosis (Figure 1,2) and fever. Three patients (cases 6, 8 and 9) had reduced visual acuity, and one had diminished eye movements. CT scanning of the orbits or sinuses was performed after operation in some patients.

TABLE 1.

Clinical and surgical details of the 31 cases in this series

No.	Age	Sex	Complication	Sinus	Signs and symptoms	Treatment	Department
1	3	M	subperiosteal abscess	ethmoid	proptosis, ptosis, eyelid edema, headache, fever	ethmoidectomy, abscess drainage	ophthalmology
2	6 1/2	M	subperiosteal abscess	ethmoid, sphenoid, maxillary	proptosis, chemosis, fever	ethmoidectomy, intranasal antrostomy, abscess drainage	pediatrics
3	4	F	subperiosteal abscess (L)	ethmoid, maxillary	eyelid edema, fever, cough, nasal obstruction	ethmoidectomy, abscess drainage	ENT
4	3 1/12	F	orbital cellulitis	ethmoid, maxillary	eyelid edema, fever	conservative therapy	pediatrics
5	5 3/12	M	subperiosteal abscess	ethmoid, maxillary Sphenoid	eyelid edema, fever, maxillofacial swelling	ethmoidectomy, abscess drainage	ophthalmology
6	10	M	orbital cellulitis	ethmoid, maxillary	proptosis, decreased vision (0.05)	sphenoidotomy	ophthalmology
7	2 8/12	M	subperiosteal abscess	maxillary	eyelid edema, proptosis, fever, diminished movement	ethmoidectomy, abscess drainage	ophthalmology
8	11 7/12	F	orbital cellulitis, optic neuritis	ethmoid, frontal	proptosis, headache decreased vision	intranasal antrostomy	ophthalmology
9	12	M	subperiosteal abscess	maxillary	proptosis, eyelid edema, nasal obstruction, decreased vision	ethmoidectomy, abscess drainage	ENT
10	0 11/12	M	inflammatory edema	ethmoid, maxillary	eyelid edema, nasal obstruction	conservative therapy	ophthalmology
11	11 9/12	M	inflammatory edema	ethmoid, maxillary	eyelid edema, nasal obstruction	conservative therapy	ophthalmology
12	11	M	inflammatory edema	ethmoid, frontal maxillary	eyelid edema, nausea, headache	conservative therapy	ENT
13	4 5/12	M	orbital cellulitis	ethmoid, sphenoid, maxillary	proptosis, fever, eyelid edema	conservative therapy	ophthalmology
14	10	M	orbital cellulitis	ethmoid, maxillary	eyelid edema, fever, nasal obstruction	conservative therapy	ophthalmology
15	10 2/12	M	subperiosteal abscess	ethmoid, maxillary	proptosis, headache, eyelid edema, fever	ethmoidectomy, abscess drainage	pediatrics
16	10	M	inflammatory edema	ethmoid maxillary	eyelid edema, headache	conservative therapy	ophthalmology
17	5 8/12	M	orbital cellulitis	ethmoid, maxillary	proptosis, eyelid edema	conservative therapy	pediatrics
18	4 4/12	M	orbital cellulitis	ethmoid, maxillary	proptosis, fever, eyelid edema	conservative therapy	pediatrics
19	9	M	subperiosteal abscess	ethmoid, sphenoid, maxillary	nausea, proptosis, headache, eyelid edema	ethmoidectomy, abscess drainage, intranasal antrostomy	ENT
20	3 7/12	F	orbital cellulitis	ethmoid, maxillary	proptosis, fever, nasal obstruction	conservative therapy	ophthalmology
21	12	M	subperiosteal abscess	ethmoid, sphenoid, maxillary	proptosis, headache	sphenoidotomy, ethmoidectomy, abscess drainage	ENT
22	11	M	orbital cellulitis	ethmoid, sphenoid	proptosis, headache, eyelid edema	conservative therapy	ophthalmology
23	6 9/12	F	orbital cellulitis	ethmoid, maxillary	proptosis, fever, eyelid edema	conservative therapy	ophthalmology
24	7 2/12	F	orbital cellulitis	ethmoid, maxillary	proptosis, headache, eyelid edema	conservative therapy	pediatrics
25	3	M	subperiosteal abscess	ethmoid, maxillary	proptosis, headache, eyelid edema	ethmoidectomy, intranasal antrostomy	ophthalmology
26	5 6/12	M	subperiosteal abscess	ethmoid	proptosis, headache, eyelid edema, fever	ethmoidectomy, abscess drainage	ophthalmology
27	2 10/12	F	orbital cellulitis	ethmoid	proptosis, fever, nasal obstruction	conservative therapy	ENT
28	9 3/12	F	orbital cellulitis	sphenoid, maxillary	proptosis, fever, eyelid edema	conservative therapy	pediatrics
29	6	M	subperiosteal abscess	ethmoid, maxillary	nausea, proptosis, eyelid edema, fever	ethmoidectomy, abscess drainage	pediatrics
30	11	M	orbital cellulitis	ethmoid, sphenoid, maxillary	proptosis, fever, nasal obstruction	conservative therapy	ophthalmology
31	5	M	subperiosteal abscess	ethmoid, maxillary	proptosis, fever, eyelid edema	ethmoidectomy, intranasal antrostomy	ophthalmology

M: male; F: female; L: left; B: bilateral

FIG. 1.

Indicating left eyelid edema and proptosis (Case 5)

FIG. 2.

Arrow indicating SPA located in the left orbit (Case 5)

The diagnoses were determined based on anamnesis, signs and symptoms, CT or MRI scans with coronal and axial projections.

In all cases, intensive treatment was initiated with intravenous antibiotics (flucloxacillin), glucocorticoid (methylprednisolone) and oral gelomyrtol forte after admission (4). ESS was performed when an improvement in the patient’s condition did not occur after 48 hours. But patients with orbital SPA, motility disorders of the eyeball or decreased vision received ESS immediately within the first 24 hours. ESS included opening of sinus and intranasal drainage of the SPA. After undergoing general anesthesia, a complete opening of the sinuses associated with orbital complication was performed and part of the lamina papyracea near the abscess was removed (Figure 3). Then, the abscess could be found in the superiomedial, medial or below orbit, and purulent secretion was cleared off. The cavity of orbital SPA was rinsed repeatedly. Then, the nasal cavity was filled with NasoPore (Polyganics; Netherlands) and cleared off on day 3 after surgery.

FIG. 3.

Arrow indicating the small defect in the lamina papyracea removed by ESS (Case 1)

Oral antibiotics (roxithromycin) and gelomyrtol forte were used for one to four weeks and mometasone furoate aqueous nasal spray was used for one to three months on patients (above 3 years-old) with allergic rhinitis.

RESULTS

In total, 16 patients were cured by conservative therapy and 15 patients by ESS in our department. The eyelid edema of 4 patients (cases 10, 11, 12 and 16) with inflammatory edema disappeared after 3 days of conservative therapy. The symptoms of 12 patients with orbital cellulitis, such as eyelid edema, proptosis and fever were improved after 7 days of intravenous antibiotics, glucocorticoid and oral gelomyrtol forte. The patients were discharged from hospital on appropriate oral antibiotics for 4 weeks. The decreased vision of two patients (cases 6 and 8) with orbital cellulitis returned to normal on day 7 after sphenoidotomy and intranasal antrostomy was performed immediately after admission. The symptoms of 13 patients with SPA, such as proptosis, headache, fever, diminished movement disappeared on 4 to 8 days after the opening of ethmoidal cellules and abscess drainage. The sinusitis and SPAs of one patient (case 2) who had two SPAs (Figure 4) located in the superiomedial orbit were cured at the same time. All signs and symptoms of the patients disappeared after conservative therapy or ESS. The CT scans revealed that the SPA disappeared and sinusitis was improved after surgery. There were no recurrences within the follow-up period of 1 to 8 years.

FIG. 4.

MRI scan of two SPAs (Case 2), Arrow indicating two SPAs located in the medial and superior orbit

DISCUSSION

Acute orbital complication is a severe disease, which may cause mortality if it is not treated correctly and in a timely manner. Orbital complications seem to be more frequent in children than in adults and are directly related to the intimate anatomical relations between the paranasal sinuses and orbital contents (5). The orbit is intimately associated with the sinuses, especially the maxillary, ethmoid and frontal sinuses. Also, the optic canal is closely adjacent to the posterior ethmoid and sphenoid sinuses; the lamina papyracea of children is a very thin layer of bone plate which is between the eye and ethmoid sinuses. There are many small bone dehiscences on it. The lamina papyracea are rich in a venous system which lacks valves and constitutes a vascular network, so that the blood can move freely between ethmoid sinuses and orbit content (4,6). The nasal cavity of children is narrower and the nasal mucosa is tenderer than that of adults; thus, the sinuses are easily blocked by edematous mucosa during an acute infection, and the infection can spread from sinuses to the orbit (7).

The mode of infection spread from the sinuses to the orbits is usually by bacterial thrombophlebitis through valveless veins, direct extension from bony erosion, or via congenital or acquired bony dehiscences (8).

The original classification of Chandler et al. (9), which was published in 1970 and had been one of the most employed classifications, divided orbital infections into five categories: inflammatory edema, orbital cellulitis, subperiosteal abscess, orbital abscess and cavernous sinus thrombosis.

In recent years, the incidence of orbital complications had been greatly reduced because of the early application of broad-spectrum antibiotics (10).

At present, there is still a lot of debate about the effect of conservative therapy or surgical intervention of orbital complications secondary to acute rhinosinusitis in children. Most scholars have suggested that inflammatory edema could be cured only by conservative therapy. Orbital SPA, orbital cellulitis and orbital abscess should be treated by surgery, which should be performed in time to avoid causing more serious irreversible complications. Cavernous sinus thrombosis is a serious condition requiring enhanced medical treatment (11).

Conservative treatment, which included oral or intravenous antibiotics in combination with topical decongestants or mucus thinning agents, was the first option for the inflammatory edema and orbital cellulitis in our study (7). However, ESS should be performed immediately for patients with orbital cellulitis concomitant optic neuritis, decreased vision or motility disorders of the eyeball (12).

Inflammatory edema is an inflammation before the orbital septum and generally tends to being isolated from the orbital contents. Sometimes an abscess can form in this region, but such inflammation is not a threat to patients and usually responds to medical treatment (9). In our series, all 4 patients with inflammatory edema recovered after conservative therapy.

Orbital cellulitis is inflammation of the orbital contents and without abscess formation. The symptoms of 12 patients with orbital cellulitis were improved after 7 days of intravenous antibiotics in combination with glucocorticoid and oral gelomyrtol forte, and the patients were discharged from hospital on appropriate oral antibiotics for 4 weeks. All signs and symptoms of the 16 patients who received conservative therapy disappeared and there were no recurrences within the follow-up period of 1 to 8 years. The decreased vision of two patients (cases 6 and 8) with orbital cellulitis returned to normal on day 7 after sphenoidotomy or intranasal antrostomy. The nasal cavity of children is narrow, so nasal secretions cannot be cleaned timely and the incidence of nasal cavity adhesion will be obviously higher in pediatric patients than in the adult group after surgery. Accordingly, conservative therapy is more suitable for pediatric patients than surgical intervention. However, the symptoms and signs of orbital cellulitis should be closely observed and surgical intervention should be performed immediately if conservative therapy does not produce a rapid resolution of symptoms (13). We suggest that the surgical intervention should be performed as soon as possible for orbital SPA. SPA is an collection of pus which forms between the orbital periosteum and the bony wall of the orbit (Figure 2, 4). The abscess is usually between the lamina papyracea and the periorbita, occasionally on the superior orbital wall. Proptosis, chemosis and limited movement of the eyeball are common clinical manifestations (10). Orbital SPA is the most common indication for surgical drainage. Pond and Berkowitz (14) suggested that complete ethmoidectomy is not necessary for SPA since ethmoid disease can be cured by antibiotic therapy, but anterior ethmoidectomy is necessary to allow intranasal drainage of the SPA. In our opinion, complete opening of ethmoidal cellules is necessary for the drainage of the SPA in patients. Thus, the cases of sinusitis would be cured and the recurrence rate of SPA would be reduced. In our study, opening of ethmoidal cellules and abscess drainage were performed by ESS on 13 patients with SPA; the symptoms disappeared after 4 to 8 days.

Case 2 had two SPAs (Figure 4) located in the superiomedial orbit; sinusitis and the SPAs were cured at the same time. When part of the lamina papyracea was removed and orbital periosteum was detached from the superiomedial orbital wall, the abscess could be found in the roof of the orbit and purulent secretion was cleared off. In order to prevent serious orbital infection, orbital periosteum must be well protected. CT images should to be evaluated carefully before surgery and the best approach should be selected to reach the SPA.

It should be emphasized that initial symptoms of 10 patients were related to the eye, such as eyelid edema, proptosis and chemosis. Therefore, 25 of the patients were consulted initially by ophthalmologists or pediatricians. This could be the reason for a delay in diagnosis for some cases. Thus, close cooperation between ophthalmologists, pediatricians and otolaryngologists is very important for the correct diagnosis and treatment.

In conclusion, orbital complications secondary to acute rhinosinusitis are severe diseases. The initial symptoms are orbital rather than nasal in most pediatric patients. Therefore, close cooperation between ophthalmologists, pediatricians and otolaryngology doctors is very important for the correct diagnosis and treatment.

Conservative treatment is more suitable for inflammatory edema and orbital cellulitis in children than surgical intervention. However, surgical intervention should be applied to patients with orbital SPA as soon as possible.