Endoscope Assisted Combined Drainage of Sino-Orbital Abscess: Technique Revisited

Abstract

Orbital complications of acute rhinosinusitis may present with painful proptosis and ophthalmoplegia. Surgical management, when required comprises of endonasal endoscopic sinus clearance with or without external orbital abscess drainage. External drainage involves blind dissection and carries a risk of iatrogenic injury to periorbital structures. We describe a novel technique of endoscope guided orbital abscess drainage under direct visualisation via the external incision site. Patients with orbital cellulitis secondary to rhinosinusitis and planned for surgical intervention were recruited. After endonasal endoscopic sinus surgery, the orbital abscess cavity was opened and an endoscope was inserted externally. The cavity was examined; loculi were opened under direct visualisation till drainage was complete. This procedure was performed in seven patients with a successful outcome. The mean time to resolution was 1.5 months (36.4 ± 18.2 days). None of the patients had any recurrence or residual disease on follow up. In addition, in two cases with obstructed sinus drainage and “walling off” of frontal sinus, visualisation of the instrument placed in the drained abscess cavity via endo-nasally inserted endoscope confirmed the re-establishment of continuity of sinus opening. This approach may allow the surgeon to drain multiloculated abscess completely under direct visualization while minimising iatrogenic damage to periorbital structures. Real time display using endoscopic camera on the monitor screen also serves as a teaching and training tool during the procedure. Technique utilises the existing endoscopic set-up without the need for additional instrumentation.

Introduction

Orbital complications in the setting of acute rhinosinusitis are fairly common across all age groups. Patients may present with proptosis, lid swelling, diplopia or vision deterioration depending upon the anatomic location of the abscess [1]. Mixed bacterial infections are most frequent; a fungal aetiology, though common in immunocompromised patients, may rarely be found in immunocompetent patients. Management includes imaging with computed tomography (CT) to delineate the extent of orbital and sinus involvement followed by external abscess aspiration and a nasal smear for microbiological evaluation including bacterial and fungal cultures. Initial medical treatment with broad spectrum antimicrobials is started which are then adjusted as per culture and sensitivity reports. Most cases respond well to medical management with antibiotics. When surgical intervention is required, the procedure of choice is endoscopic sinus surgery with or without external drainage of orbital abscess. In children, most small, medially located subperiosteal abscesses can be observed. Drainage is required if age is > 9 years, large abscess causing mass effect and/or optic neuropathy, suspicion of anaerobic infection (secondary to dental infections), chronic sino-nasal polyposis, presence of frontal sinusitis and non-response to antibiotic therapy. In contrast, subperiosteal orbital abscesses in adults usually require external drainage as they may deteriorate rapidly leading to intracranial extension, cavernous sinus thrombosis and vision loss [2–4].

In patients with isolated medial abscess, endoscopic sinus drainage followed by endonasal endoscopic medial orbital wall (ethmoids) approach for abscess drainage is performed. However when the abscess is non medial in location or is multi-loculated, drainage via endonasal approach alone is often inadequate and a combined approach—endoscopic sinus surgery along with external orbital abscess drainage is required. The external incision is usually via a stab wound at the most dependent and tense region of the abscess, avoiding major neurovascular structures. After the pus is aspirated, an artery forceps is introduced to break the septae of a multiloculated abscess. This procedure is often blind and may result in inadvertent damage to vital periorbital structures, with residual complications including haemorrhage, ptosis and eyelid malposition. In addition, failure to drain a large multi-loculated abscess may result in persistence of collection leading to mass effect and delay in recovery [5, 6].

In order to overcome these limitations of external drainage, we describe a novel technique of introducing an endoscope from the external incision site. We postulate that this approach allows the surgeon to drain the multiloculated abscess completely under direct visualization and magnification via a small, safe and cosmetically suitable external incision. We describe the use of this technique in patients with orbital cellulitis and subperiosteal abscess secondary to acute rhinosinusitis who were taken up for functional endoscopic sinus surgery (FESS).

Methods

Patients with clinical diagnosis of orbital cellulitis secondary to acute rhinosinusitis with radiographically confirmed one or more paranasal sinus disease and orbital abscess(es) who were planned for endoscopic sinus surgery were recruited. This study adhered to the principles of Declaration of Helsinki and institute ethics committee permission was obtained. A written informed consent for the procedure as well as video and photographic documentation was obtained prior to the intervention. A combined surgery was performed by the otorhinolaryngology and ophthalmology team. Under hypotensive general anaesthesia, FESS of the involved sinuses was done to clear the unhealthy mucosa or collection within the sinuses and establish adequate drainage. After endonasal endoscopic sinus surgery, the orbital abscess was palpated. A stab incision was made with a 11 no. blade at the most dependent and tense site, while avoiding major neurovascular structures and initial pus drained was sampled for microbiological cultures. A rigid nasal endoscope (2.7/4 mm; 0/30 degrees) with xenon light source was attached to a three chip high definition camera and AIDA® documentation system (Karl Storz, Tuttlingen, Germany). The illumination was reduced to 30% in order to prevent photopic and thermal damage to periorbital structures by the xenon light source. The endoscope was then introduced via the stab incision into the abscess cavity (Fig. 1). Under visualisation, the loculi were first identified, then opened carefully using a blunt tipped instrument and a suction tip for ear surgery since the shorter length of the suction makes handling easier. A complete drainage was established and the surgery was concluded. Antibiotic wash was performed and the external incision was not sutured. Nasal packing was done using Merocel sponge (Medtronic Xomed, Jacksonville, Florida, USA) and the patient was extubated and shifted to the recovery. The nasal packing was removed after 24 h. Post- operatively, patients received antibiotics and analgesics for seven days. Nasal douching, antibiotic application over external stab wound and topical lubricating eyedrops were continued for 3 weeks.

Fig. 1.

a A multiloculated inferior orbital abscess viewed on the coronal section of the computed tomography scan (Case 3). b The endoscope inserted into the orbital abscess via a stab incision along the lower eyelid (red arrow). The loculi were dissected with a blunt instrument under endoscopic visualisation

Serial follow up evaluation included regular endoscopic nasal cavity examination, vision assessment, evaluation of ocular motility, blepharoptosis and scar at external incision site. The time to complete resolution was noted and the minimum follow up period was 4 months from date of surgery.

Results

Seven patients with orbital cellulitis secondary to sinusitis and a radiographically confirmed orbital abscess were included in this study. The clinical case summaries are detailed in Table 1.

Table 1.

Clinical case summaries including demographic, clinical and outcome details

	Age/ Gender/ Duration/ Eye	Clinical presentation	Sinus and orbit quadrant involvement on imaging	Time to resolution	Follow up and visual acuity (OD; OS)
Case 1	5 years/Male/ 10 days/ OD	Proptosis, complete ptosis, restricted ocular motility in all gazes	Maxillary & Ethmoid sinusitis, Superior subperiosteal abscess (SPA)	52 days	5 months 6/126/6 (−1.5 DS); 6/96/6 (−1 DS)
Case 2	2 years/Female/ 7 days/OD	Upper eyelid swelling with ptosis and restricted ocular motility in up gaze	Maxillary & Ethmoid sinusitis, Supero-temporal pre-septal collection	35 days	8 months 6/6; 6/6 (on Cardiff)
Case 3	4 years/Male/3 days/OS	Upper and lower eyelid swelling; maximum motility limitation in downgaze	Maxillary & Ethmoid sinusitis, Multiloculated SPA involving upper and lower eyelid	70 days	7 months 6/6; 6/6
Case 4	18 years/Male/5 days/OS	Complete ptosis, eyeball displaced down and in, maximum motility limitation in upgaze	Maxillary & Ethmoid sinusitis; Superior SPA	26 days	9 months 6/96/6; 6/96/6 (– 0.5DS OU)
Case 5	5 months/Female/ 3 days/OD	Tense upper eyelid swelling with proptosis	Maxillary & Ethmoid sinusitis, Superior SPA	21 days	5 months Uncooperative for assessment
Case 6	76 years/Female/2 months/OS	Persistent headache, ptosis and recurrent upper eyelid abscess × 2 months; acute presentation with spontaneous rupture × 5 days	Frontal, Ethmoid and Sphenoid sinusitis, Superior quadrant SPA	30 days	4 months 6/12; 6/12 Complete resolution of ptosis and headache with no lid malposition
Case 7	48 years/Female/ 6 months/ OS	Recurrent discharge from upper eyelid with eyelid retraction, lagophthalmos and a non-healing ulcer × 6 months	Frontal sinusitis, Superior temporal quadrant SPA	21 days	6 months 6/6; 6/12 No recurrence of eyelid abscess, Underwent skin graft, eyelid contour normal, no lagophthalmos

All patients presented with painful periocular swelling and limitation of ocular movements. Contrast enhanced CT scan of paranasal sinus and orbit were performed in all patients. Three patients (42.8%) had proptosis and four (57%) had eyelid swelling. Multiloculated periocular swellings were present in five patients (71.4%) and confirmed radiologically. Two patients (28.5%) (Case 6,7) presented with a ruptured upper eyelid abscess. Radiography confirmed the involvement of frontal sinus with “walling off” of the sinus from the nasal cavity and drainage into the upper eyelid in both these patients (Fig. 2). The reasons for surgical intervention were multifactorial—large multiloculated abscess with mass effect (5), non-response to medical management (5), cellulitis in adult age group (3) and presence of frontal sinusitis (2). The external drainage site was sub-brow (3), upper eyelid crease (3) and lower eyelid (1). In cases 6 and 7, intraoperative use of endoscope was also helpful in determining the re-establishment of frontal sinus opening into the nasal cavity. This was achieved by visualising the instrument placed in the drained abscess cavity via endonasal endoscope to confirm the re-establishment of continuity of the frontal sinus opening into the nasal cavity (Fig. 3). This helped in adequately addressing the problem of the “walled off” frontal sinus opening which had led to upper eyelid abscess formation in these two patients. Mean time to complete resolution was 36.4 ± 18.2 days and the mean follow up period was 6.28 ± 1.79 months. Scarring was noted in three -mild in two and significant in one (Case 7). This patient had presented with a 6 month long history of non-healing ulcer on the left upper eyelid, with periods of exacerbation of discharge and partial remissions. This was a consequence of acute on chronic frontal sinusitis with superior quadrant sub-periosteal abscess in continuation with the frontal sinus, draining externally onto the eyelid skin. She had upper eyelid retraction, a lagophthalmos of 4 mm on eyelid closure leading to exposure keratopathy. At the 4 months follow-up after surgery, she has had no recurrence of discharge. Due to upper eyelid skin shortening, there was upper eyelid retraction, lid lag on downgaze and mild lagophthalmos, though the exposure keratopathy had resolved. She underwent a upper eyelid reconstruction with skin graft with a successful outcome at 2 months after grafting (Fig. 3).

Fig. 2.

Computed Tomography scan of a Case 6 with left sided frontal abscess (*) which had ruptured onto the upper eyelid skin (black arrow). The frontal sinus opening into the nasal cavity is blocked or “walled off” (white arrow)

Fig. 3.

Photographic summary of Case 7. a At presentation with a chronic left upper eyelid abscess leading to skin scarring with upper eyelid retraction and ectropion. b, c intraoperative photographs. The endoscope has been inserted endo-nasally to visualise the frontal sinus. The second instrument, a ball tipped probe, has been inserted via the upper eyelid abscess opening (b) and is being visualised via the nasal endoscope in the frontal sinus cavity (c), thus determining the end point of the surgery. D: Two months after left upper eyelid full thickness skin graft with improvement in ectropion and a nearly symmetrical upper eyelid contour. The lagophthalmos also resolved

Discussion

Surgical management of orbital cellulitis involves endoscopic sinus surgery with or without external drainage of the orbital abscess [2–4]. Isolated medial abscesses may be approached endonasally via the medial orbital wall, after draining the ethmoid sinuses. However when the abscess is non medial in location or is multi-loculated, external drainage is required. Failure to drain a large multi-loculated abscess may result in persistence of collection leading to mass effect and delay in recovery [5, 6].

The use of endoscope in orbital surgeries was first described in 1981 by Norris and Cleasby [7].

Few authors have described an endoscopic approach to orbital roof lesions such as cholesterol granuloma and orbital dermoid where an endoscope inserted from an eyelid crease incision helped visualisation and complete removal of the lesion from the inner surface of the frontal bone and the dura, obviating the need for bone removal or craniotomy [8, 9]. Balakrishnan et al. described transorbital endoscopic approach in 107 patients including four patients with orbital abscesses. They concluded that the direct axial view with an orbital endoscope provided a magnified and well illuminated surgical field of view compared with a conventional naked-eye visualization in the small spaces of the orbit and skull base [10].

We describe our technique of utilisation of an endoscope for external abscess drainage under direct visualisation as opposed to ‘blind blunt dissection’. As the abscess cavity is a potential fluid filled space in itself and once the fluid content is suctioned out, the endoscope can be comfortably used without soft tissue or bone hinderance requiring their removal. The illumination and magnification provided by the endoscope allows the surgeon to assess the surrounding tissue in detail. In addition, in two cases, this technique helped establish an objective surgical end point as follows. Visualisation of the instrument in the drained abscess cavity via endonasal endoscope confirmed the re-establishment of continuity of the frontal sinus opening into the nasal cavity while ensuring complete upper eyelid abscess drainage.

All seven patients in our group had a successful outcome without any need for repeat intervention. The mean time to resolution of 1.5 months (36.4 ± 18.2 days) and none of the patients had any recurrence or residual disease on follow up. The limitation of our study is the small sample size and lack of a comparative control group. Therefore, a larger study evaluating both the conventional technique and endoscope assisted abscess drainage can help determine the possible advantage of our technique for achieving complete and speedier resolution.

The main advantages of this technique lie in enabling the surgeon to visualise the abscess cavity, open each individual loculi, avoid damage to periocular structures and establish an objective end point for the surgery. In addition, the technique utilises the routine instruments used in endoscopic sinus surgery without the need for procuring additional equipment.

Intraoperative, real time display via endoscopic camera on the monitor screen also serves as a teaching and training tool. Video-endoscope has been described as a useful adjunct in teaching orbital surgery especially for procedures being performed in the sub periosteal space where direct supervision is not possible and visualisation is of critical importance, as described by Malhotra et al. They reported that video endoscope was of particular benefit in surgical procedures involving the posterior orbital floor, orbital roof and medial orbital wall [11].

Conclusion

We report a successful outcome in seven patients with this technique utilising the existing endoscopic set-up without the need for additional equipment. Surgeon’s familiarity and comfort with use of endoscopic techniques is an essential prerequisite for utilising this method of direct intraoperative visualisation or orbital abscesses.

Authors' contributions

AM: concept, patient management, data collection, manuscript preparation. RR, KA: patient management, data collection, manuscript preparation. RSV: concept, patient management, manuscript design and review. NH, AB, MSh: patient management, data collection, manuscript review. MSa, MSi: patient management, manuscript review.

Declarations

Ethics approval

Obtained.

Consent to participate and for publication

All subjects consented for participation as well as use of clinical and investigation photographs for publication.