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

Acute rhinosinusitis during Hajj season 2014: Prevalence of bacterial infection and patterns of antimicrobial susceptibility

BACKGROUND

The presence of large number of pilgrims during Hajj in Makkah region increases the risk of respiratory diseases. In this study, we aimed to assess the bacteriology of acute rhinosinusitis (ARS) during Hajj season and to demonstrate the antimicrobial susceptibility patterns that should guide the clinicians towards more appropriate antibiotic use.

METHODS

Patients with ARS presenting during Hajj season of 2014 were prospectively enrolled. According to EPOS2012 criteria. Sampling of sinus secretions was performed from the middle meatus adjacent to the maxillary sinus ostium via endoscopic guidance. Over all, the study has covered all ENT, emergency and outpatient departments in Hajj.

RESULTS

Two hundred and twenty six patients with ARS were enrolled in the study. Pathogenic bacteria were identified in 93 (41.2%) patients. Of the 93 patients with bacterial ARS, Staphylococcus aureus was isolated in 46 (49.5%) patients, out of which 13 (28.3%) were methicillin-resistant Staphylococcus aureus (MRSA).The second most common group of bacterial isolates was Enterobacteriaceae such as Escherichia coli, and various Klebsiella species. Antibiotic sensitivity showed that methicillin-sensitive Staphylococcus aureus (MSSA) was also sensitive to cephalosporins, quinolones and clindamycin, while exhibiting relatively less sensitivity rates to amoxicillin-clavulinic acid and macrolides.

CONCLUSION

Our study demonstrates the importance of assessing the bacteriology of ARS to help implement guidelines for proper treatment and prevention protocols during Hajj season.

Assessment and management of orbital cellulitis

Orbital cellulitis is a medical emergency requiring multidisciplinary team involvement. Early diagnosis and intervention is imperative to avoid serious complications. This article provides an evidence-based approach to the assessment and management of patients with orbital cellulitis.

Microbiology and choice of antimicrobial therapy for acute sinusitis complicated by subperiosteal abscess in children

OBJECTIVES

Review past studies of the microbiology of subperiosteal abscesses (SPOA) complicating sinusitis in children and their implications of the antimicrobials administered to treat the infection.

METHODS

Literature search was conducted of the Cochrane Library, EMBASE, TRIP, EMBASE, and MEDLINE databases from their inception.

RESULTS

The most common pathogens isolated from studies of SPOA complicating sinusitis are aerobic (Streptococcus pneumoniae, Streptococcus spp., Haemophilus spp., Eikenella corrodens), anaerobic (Peptostreptococcus, Fusobacterium, Prevotella, Porphyromonas, Bacteroides, and Veillonella spp.), and micoaerophilic streptococci (Streptococcus anginosus/Streptococcus milleri group), all members of the oropharyngeal flora. S. pneumoniae and S. aureus were more frequently recovered in children >7 years old, while polymicrobial aerobic-anaerobic flora were more often isolated from those >15 years. The introduction of pneumococcal vaccine reduced the rate of isolation of S. pneumoniae, and correlated with increase of recovery of S. aureus including methicillin resistant strains, as well as Streptococcus pyogenes and S. anginosus/milleri group.

CONCLUSIONS

The microbiology and consequently the treatment of respiratory infections including sinusitis and its complications has evolved over the past decades. Establishing the microbiology of SPOA by obtaining appropriate cultures for both aerobic and anaerobic bacteria are essential for proper antimicrobial selection.

Hospital cost of pediatric patients with complicated acute sinusitis

OBJECTIVE

Review costs for pediatric patients with complicated acute sinusitis.

METHODS

A retrospective case series of patients in a pediatric hospital was created to determine hospital costs using a standardized activity-based accounting system for inpatient treatment between November 2010 and December 2014. Children less than 18 years of age who were admitted for complicated acute sinusitis were included in the study. Demographics, length of stay, type of complication and cost of care were determined for these patients.

RESULTS

The study included 64 patients with a mean age of 10 years. Orbital cellulitis (orbital/preseptal/postseptal cellulitis) accounted for 32.8% of patients, intracranial complications (epidural/subdural abscess, cavernous sinus thrombosis) for 29.7%, orbital abscesses (subperiosteal/intraorbital abscesses) for 25.0%, potts puffy tumor for 7.8%, and other (including facial abscess and dacryocystitis) for 4.7%. The average length of stay was 5.7 days. The mean cost per patient was $20,748. Inpatient floor costs (31%) and operating room costs (18%) were the two greatest expenditures. The major drivers in variation of cost between types of complications included pediatric intensive care unit stays and pharmacy costs.

CONCLUSION

Although complicated acute sinusitis in the pediatric population is rare, this study demonstrates a significant financial impact on the health care system. Identifying ways to reduce unnecessary costs for these visits would improve the value of care for these patients.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

Radiographic Findings and Clinical Correlates in Pediatric Periorbital Infections

OBJECTIVE

To review radiographic studies of pediatric patients presenting with periorbital infections and to evaluate sinonasal anatomical factors and clinical course related to this disease process.

METHODS

Retrospective study review of computed tomography (CT) scans in 100 patients less than 18 years old, admitted to a tertiary children's hospital with the diagnosis of an orbital infection. CT scans were reviewed for anatomic variants and Lund-Mackay scores were calculated. An independent chart reviews of the treatment course and need for surgical intervention was performed.

RESULTS

Of 100 patients, 67% were male, 60% had left-sided infections, and 30% of patients were treated with surgical drainage. Adenoid hypertrophy (61%), inferior turbinate hypertrophy (80%) and septal deviation (47%) were common, but did not show statistical correlation with the need for surgical intervention. Dehiscence of the lamina papyracea was identified in 21% of patients treated without surgery and in 76% of those requiring surgery (P 0.0048). The average overall Lund-Mackay score was 11.8 and did not correlate with the need for surgical intervention.

CONCLUSIONS

To our knowledge, this is the first study to evaluate the incidence of sinonasal anatomic abnormalities in children presenting with periorbital infections. This study also demonstrated that lamina papyracea dehiscence is a common finding and is associated with higher rates of surgical intervention. Such findings may have an important role in the diagnosis, surveillance and management of sinus disease in the pediatric population.

Subperiosteal orbital abscess: volumetric criteria for surgical drainage

OBJECTIVE

To investigate predictive factors of surgical management of subperiosteal orbital abscess in children.

METHODS

A retrospective monocentric study was conducted between 2000 and 2011 with children hospitalized for acute pediatric orbital cellulitis (APOC). Clinical, biological and radiological data as well as medical and surgical management were collected and analyzed. All patients received intravenous antibiotics and underwent a CT-scan. Orbit and subperiosteal intraorbital abscess dimensions were measured on axial and coronal planes and the abscess volume was calculated using a spheroid model.

RESULTS

Eighty-three children with APOC (mean age: 4.5 years) were included, 53 were boys (63.9%). Thirty-two children (38.6%) presented with a subperiosteal orbital abscess. Mean abscess volume was 570mm(3) and mean exophthalmos was 4.7mm. Twenty patients were treated surgically, 11 of which by an endoscopic approach. A positive correlation was observed between the volume of the abscess or exophthalmos and surgical drainage: 57.9% of patients underwent surgery when exophthalmos was >4mm, 29.4% between 2 and 4mm, and none when <2mm. All patients with an abscess volume >500mm(3) or >5% of orbital volume were operated on whereas only 30% or 39% of patients, respectively, in case of smaller volumes (P<0.05).

CONCLUSION

Surgery for subperiosteal orbital abscess is usually performed in case of visual complications or unfavorable medical outcome. The importance of the exophthalmos and the volume of the abscess measured on the CT-scan are predictive factors of surgery in children with subperiosteal orbital abscess without visual complications.

[Orbital cellulitis complicating acute pansinusitis: report of a case]

Les cellulites orbitaires sont des affections peu fréquentes. Ces infections peuvent être secondaire à une infection oculaire, péri oculaire ou à une septicémie. L'origine sinusienne reste la plus fréquente. Le risque de graves complications mettant en jeu le pronostic fonctionnel et vital nécessite un diagnostic rapide et une prise en charge précoce. Nous rapportons le cas clinique d'une femme de 70 ans connue diabétique, qui a présenté une cellulite orbitaire secondaire à une pansinusite négligée. Le traitement était à la fois médical et chirurgical: antibiothérapie et drainage. L’évolution a été favorable au bout du septième jour. Nous essayons à travers ce cas clinique de souligner la gravité des infections orbitaires et leurs conséquences dramatiques en cas de retard de prise en charge.

[Management of ocular and orbital complications in acute sinusitis]

PURPOSE

Describe the clinical presentations of orbital complications of acute sinusitis and discuss therapeutic approaches.

METHODS

Retrospective study of 29 cases of acute sinusitis with orbital extension hospitalized over a period of 12years (2000 to 2012).

RESULTS

There were 23 men and 6 women. The mean age was 15.75years. The average time until consultation was 7.68 days. Sinusitis was ethmoido-maxillary in 20 cases, ethmoidal in 6 cases, and frontal in 3 cases. Orbital extension was grouped according to the Chandler classification: stage I (3 cases), stage II (3 cases), stage III (15 cases), stage IV (8 cases). Antibiotic therapy was prescribed in all cases. Surgery was performed in 22 cases. Bacterial cultures revealed streptococcus (2 cases), aspergillus fumigatus (1 case) and were negative in 8 cases. The outcome was favorable in 27 cases. In two cases, the outcome was unfavorable with associated intracranial complications.

DISCUSSION

Oculoorbital extension of acute sinusitis is a diagnostic and therapeutic emergency. Paranasal sinus CT is essential to confirm orbital extension and identify the causative sinus. Intravenous antibiotic therapy is the main treatment. The roles of corticosteroid and heparin therapy remain controversial. Surgery is indicated in the case of abscess or high visual risk. Endoscopic endonasal surgery appears to have a double role, in diagnosis and treatment.

Orbital fracture leading to severe multifascial space infection including the parapharyngeal space: a report of a case and review of the literature

Orbital trauma can result in periorbital and orbital infections. Orbital infections have been classified by Chandler et al in 1970 to their anatomic location and boundaries. This case report describes a patient who developed a severe orbital infection following orbital fractures. The infection progressed to the parapharyngeal space. The patient required multiple incision and drainage surgeries and tissue debridements to have clinical resolution. To our knowledge, there has not been a case described in the literature of an orbital infection progressing to the parapharyngeal space. A literature review of orbital trauma leading to infection discusses the pathogenesis of the infections. This case demonstrates that close clinical follow-up and appropriate medical management of comorbidities that put a patient at higher risk of developing an infection is of the utmost importance in the treatment of maxillofacial trauma patients.

Predicting the need for surgical intervention in pediatric orbital cellulitis

PURPOSE

To investigate the predictive value of the complete ophthalmic examination at first presentation in foreseeing the need for surgery in patients with pediatric orbital cellulitis.

DESIGN

Retrospective observational case series.

METHODS

We reviewed 136 cases of radiographically confirmed orbital cellulitis between 2004 and 2012 at Children's Hospital Colorado. The presenting ophthalmic examinations, imaging results, medical and surgical interventions, and clinical complications were recorded. The main outcome measures were ophthalmic examinations on presentation, medical or surgical interventions, and complications.

RESULTS

The median age was 6.5 years. Of the patients, 56 (41%) underwent surgical intervention, and 80 patients (59%) were managed medically. Patients requiring surgery had higher rates of extraocular motility (EOM) restriction (78.6% vs 38.8% P<0.01), proptosis (64.3% vs 21.2%, P<0.01), elevated intraocular pressure (IOP) (35.7% vs 12.5%, P<0.01), and age over 9 years (58.9% vs 20.0%, P<0.01). Using any combination of the above risk factors at presentation, the probability of surgical intervention increases from 7% (95% confidence interval [CI] 1%-13%) with zero risk factors to 95% (95% CI 89%-100%) with 4 risk factors.

CONCLUSIONS

In pediatric orbital cellulitis, the likelihood of surgical intervention can be estimated accurately based on the ophthalmic examination on initial presentation to the hospital. Risk factors for surgery include age older than 9 years, proptosis, EOM restriction, and elevated IOP. These factors may be used to identify patients at high risk for failure of medical management early in the clinical course.

Do you need to operate following recovery from complications of pediatric acute sinusitis?

OBJECTIVES

There are many studies that evaluate the role of surgery in the treatment of complications of pediatric acute sinusitis; however there are few studies, if any that report the incidence of surgery following recovery from acute complicated sinusitis. The goal of this study was to report the incidence and indications for surgical intervention after recovery from complications of pediatric acute sinusitis.

METHODS

We reviewed the records of all children admitted to a tertiary care children's hospital between January 2005 and September 2010 with a diagnosis of sinusitis and an orbital or intracranial complication. Eighty-six patients met inclusion criteria. Charts were reviewed for type of complication, initial treatment (medical or surgical), type of procedure, secondary procedures, age, and comorbidities. Statistical analysis was completed using independent samples student t-tests and Mann-Whitney tests.

RESULTS

A total of 86 patients with a mean age of 6.38 years (2 months to 18 years) were identified. Eighty patients had orbital complications while six presented with intracranial complications. Twenty-seven patients (31%) underwent sinus surgery during the acute phase of their illness whereas 59 patients (69%) were treated medically. After hospitalization and recovery for acute complicated sinusitis, surgery was performed on nine patients (mean age 4.86 years) within 1 month to 2 years post hospitalization. Of the nine patients who required secondary surgery following resolution of the initial complicated sinusitis, four patients were following initial surgical intervention and five patients had initially resolved their complication with medical therapy alone. Indications for subsequent surgery included failure of medical therapy for persistent rhinosinusitis (8 patients) and second complication (1 patient).

CONCLUSIONS

This study suggests that following resolution of complicated pediatric rhinosinusitis, very few patients may need further surgical intervention. Subsequent intervention is best guided by clinical judgment, symptoms during outpatient clinic visits, and failure of medical therapy.

Acute rhinosinusitis in children

Acute rhinosinusitis in children is a common disorder that is characterized by some or all of the following symptoms: fever, rhinorrhea, nasal congestion, cough, postnasal drainage, and facial pain/headache. It often starts as an upper respiratory tract infection that is complicated by a bacterial infection in which the symptoms worsen, persist, or are particularly severe. The accurate diagnosis of acute rhinosinusitis is challenging because of the overlap of symptoms with other common diseases, heavy reliance on subjective reporting of symptoms by the parents, and difficulties related to the physical examination of the child. Antibiotics are the mainstay of treatment. There is no strong evidence for the use of ancillary therapy. Orbital and intracranial complications may occur and are best treated early and aggressively. This article reviews the diagnosis, pathophysiology, bacteriology, treatment, and complications of acute rhinosinusitis in children.

The correlation of microbiology growth between subperiosteal orbital abscess and affected sinuses in young children

BACKGROUND

Subperiosteal orbital abscess (SPOA) typically presents as a collection of pus in the space between the periorbit and the lamina papyracea adjacent to the infected paranasal sinuses. The aim of this study was to investigate the simultaneous microbiological growth from an SPOA and the paranasal sinuses in the same children.

METHODS

A retrospective study was performed on cultures obtained from involved sinuses and surgically drained abscesses in young children with SPOA from January 1992 to March 2009.

RESULTS

Twenty-two children with a mean age of 5.9 years were included. Results of the microbiological studies were available from the sinuses of 17 children (77.2%) and from the SPOA in 18 children (81.8%). High rates of staphylococci bacteria and Streptococcus viridans were observed compared with lower-than-expected upper respiratory tract infection pathogens. Both groups showed scarce anaerobic and polymicrobial growth. In 13 children (59%), both sinus and abscess culture results were available with correlation found in only 4 (30.7%) of these children.

CONCLUSION

In this study we report the results of bacteriological studies of nasal sinuses and SPOAs in young children, with a low rate of correlation between both sites and low rates of anaerobic growth, but high rates of staphylococcal growth in the SPOA cultures. These observations might be related to the trend toward conservative treatment in children.

Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years

OBJECTIVE

To update the American Academy of Pediatrics clinical practice guideline regarding the diagnosis and management of acute bacterial sinusitis in children and adolescents.

METHODS

Analysis of the medical literature published since the last version of the guideline (2001).

RESULTS

The diagnosis of acute bacterial sinusitis is made when a child with an acute upper respiratory tract infection (URI) presents with (1) persistent illness (nasal discharge [of any quality] or daytime cough or both lasting more than 10 days without improvement), (2) a worsening course (worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement), or (3) severe onset (concurrent fever[temperature ≥39°C/102.2°F] and purulent nasal discharge for at least 3 consecutive days). Clinicians should not obtain imaging studies of any kind to distinguish acute bacterial sinusitis from viral URI, because they do not contribute to the diagnosis; however, a contrast-enhanced computed tomography scan of the paranasal sinuses should be obtained whenever a child is suspected of having orbital or central nervous system complications. The clinician should prescribe antibiotic therapy for acute bacterial sinusitis in children with severe onset or worsening course. The clinician should either prescribe antibiotic therapy or offer additional observation for 3 days to children with persistent illness. Amoxicillin with or without clavulanate is the firstline treatment of acute bacterial sinusitis. Clinicians should reassess initial management if there is either a caregiver report of worsening(progression of initial signs/symptoms or appearance of new signs/symptoms) or failure to improve within 72 hours of initial management.If the diagnosis of acute bacterial sinusitis is confirmed in a child with worsening symptoms or failure to improve, then clinicians may change the antibiotic therapy for the child initially managed with antibiotic or initiate antibiotic treatment of the child initially managed with observation.

CONCLUSIONS

Changes in this revision include the addition of a clinical presentation designated as “worsening course,” an option to treat immediately or observe children with persistent symptoms for 3 days before treating, and a review of evidence indicating that imaging is not necessary in children with uncomplicated acute bacterial sinusitis.

Complicated sinusitis in a developing country, a retrospective review

OBJECTIVES

The aim of our study was to assess the incidence rate, mode of presentation, treatment and outcome measures associated with complicated sinusitis in our developing world setting. Additionally we had hope to identify possible patterns or predisposing factors that may assist us in decreasing the significant morbidity and mortality associated with this serious disease.

METHOD

A retrospective chart review was performed on all patients treated for complicated sinusitis at 3 referral hospitals in Durban South Africa between January 2006 and September 2009.

RESULTS

A total of 220 patients were identified including 138 patients with orbital complications only and 82 with intracranial complications with or without orbital manifestations. We report on the demographics, mode of presentation, microbiology, impact on resources, management and mortality of the study group. The incidence rate was found to be 5.83 per million, the most common risk factors associated with intracranial complications, a persistent headache beyond 1 week and referral from a rural rather than urban area (OR 3.24). We found a high mortality rate of 20.7% in those patients with intracranial complications of their sinusitis.

CONCLUSIONS

Complicated sinusitis is still far too common in the developing world with young adolescent males most at risk. A high index of suspicion must be maintained in detecting orbital as well as intracranial extension of disease and appropriate referral for investigation and management swift and aggressive in preventing extensive morbidity and mortality.

Orbital complications of sinusitis

BACKGROUND

Despite the modern antibiotherapies applied in the practice of otorhinolaryngology, the orbital complications of sinusitis are still considered a serious threat to essential functions of the eye, including loss of vision, and at worst, life threatening symptoms.

AIMS

The goal of this study is to consider and analyse patients who were treated for these complications in the last decade in our hospital, which is the only tertiary hospital in our country.

STUDY DESIGN

Retrospective analysis of cases.

METHODS

In our practice, cases treated in the hospital are rhinosinusitis cases where surgical intervention is necessary, or those with a suspicion of complications. Between the years 1999 and 2009 there were 177 cases, the clinical charts of which were reviewed. The cases that are omitted from this study are those involving soft tissues, bone, and intracranial complications. The diagnoses were determined based on anamnesis, anterior rhinoscopy, x-rays of the sinuses with the Water's projection or where there was a suspicion of a complication, and CT scans with coronal and axial projections. In all cases, intensive treatment was initiated with a combination of cefalosporines, aminoglycosides and Proetz manoeuvre. When an improvement in the conditions did not occur within 24-48 hours, we intervened with a surgical procedure, preferably the Lynch-Patterson external frontoethmoidectomy.

RESULTS

In our study, we encountered 35 cases (19.8%) of orbital complications with an average age of 25 (range: 3-75); Palpebral inflammatory oedema (15), orbital cellulitis (10), subperiosteal abscess (6), orbital abscess (3), and cavernous sinus thrombosis (1 patient). The average time that patients remained in hospital was 4.6 days; for those with orbital complications this was 7 days.

CONCLUSION

Orbital complications of sinusitis are considered to be severe pathologies. The appearance of oedema in the corner of the eye should be evaluated immediately and the means to exclude acute sinusitis should be taken under serious consideration. Early diagnosis and aggressive treatment are key to the reduction of these unwanted manifestations.

[Orbital complications of sinusitis]

PURPOSE

Orbital complications of sinusitis are rare but serious, with potential functional and even fatal consequences. The purpose of this work is to study the epidemiological, clinical and paraclinical features of the orbital complications of sinusitis, as well as the various treatment modalities and clinical course.

PATIENTS AND METHODS

We report the results of a retrospective study of 34 cases of orbital complications of sinusitis, collected between 1998 and 2009.

RESULTS

Mean age was 19 years 3 months, with a clear male predominance. No predisposing factors were found. All patients presented with periorbital edema. In addition to periorbital edema, ophthalmological examination also revealed: proptosis in 19 patients, decreased visual acuity in eight patients and ocular motility disturbances in 10 patients. All patients underwent emergent facial CT, two patients underwent orbital ultrasound, and one underwent magnetic resonance imaging. Initial treatment was based on empiric intravenous antibiotic therapy. Orbital drainage was performed in 20 patients. Sinus drainage was performed in 16 patients (14 cases during the acute phase) with a middle meatotomy in all cases. The initial response was favorable in 97.5% of cases. One patient had a recurrence. Mean follow-up was 11 months.

CONCLUSION

Orbital complications of sinusitis are a diagnostic and therapeutic emergency. Imaging helps guide management. Directed treatment and early management can improve mortality and morbidity.

Dimension of Subperiosteal Orbital Abscess as an Indication for Surgical Management in Children

Objective. Eyelid edema in children is one of the signs of orbital complications secondary to acute rhinosinusitis, and identifying abscess formation is crucial for management decision. The objective of this study is to determine whether there are different computed tomography scan abscess dimensions and volumes in children requiring medical versus surgical management for subperiosteal orbital abscess (SPOA).

Study Design. Case series with chart review.

Setting. The study was conducted at Assaf Harofeh Medical Center.

Subjects and Methods. Clinical and radiological parameters of 95 children admitted with eyelid edema between January 2005 and December 2007 were studied.

Results. Of 95 cases of orbital cellulitis, a total of 48 children with sinogenic orbital complications with a mean (SD) age of 4.03 (3.46) years were included. No significant difference was found between the surgically and medically treated SPOA groups regarding the use of preadmission antibiotic and clinical presentation. Statistically significant larger abscesses in the surgically treated group were noted (mean volume 1.389 vs 0.486 mL in the conservatively treated group; P = .013) and a longer mean anterior-posterior and medial-lateral dimension ( P = .001 and .017, respectively).

Conclusion.Children presenting with significant or progressing ocular findings or failure to improve after 48 hours of medical therapy, together with an abscess volume of more than 0.5 mL, a length greater than 17 mm, and a width greater than 4.5 mm, should be strongly considered to have surgical drainage.

Extent of Resection of the Lamina Papyracea in Medial Subperiosteal Abscess

Objective. To compare the surgical outcomes of minimal and wide resections of the lamina papyracea in cases with medial subperiosteal abscess.

Setting. University hospital.

Study Design. Case series and planned collection.

Materials and Methods. Thirteen patients with medial subperiosteal abscess as a complication of sinusitis were included in this study. All patients had reduced visual acuity and ophthalmoplegia. Each patient underwent endoscopic sinus surgery to treat the abscess. Age, sex, extent of lamina resection, postoperative vision status, ophthalmoplegia, and the return of orbit to its normal position were recorded.

Results. Eight (62%) and 5 (38%) patients underwent minimal and wide endoscopic lamina papyracea resection, respectively. Proptosis, visual acuity, and ophthalmoplegia returned to normal within 24 to 48 hours. All patients received medical treatment in the form of intravenous antibiotics and steroids. Neither technique required revision surgery.

Conclusion. Medial subperiosteal abscess is a serious medical condition that can lead to blindness. Endoscopic evacuation of the abscess is currently the treatment of choice. Minimal lamina papyracea resection may be sufficient to drain the abscess. It should be further evaluated as it may have the same result as wide lamina papyracea resection and wide exposure of the periorbit. The aim of the operation is to liberate the pus regardless of the extent of the resection. Revision surgery was not needed with either technique.

Pediatric subperiosteal orbital abscess secondary to acute sinusitis: a 5-year review

OBJECTIVE

Subperiosteal orbital abscesses (SPOAs) secondary to acute sinusitis are rare occurrences in the pediatric age group, more so in the neonatal period. Here, a rare case of SPOA in a 38-day-old newborn later drained via endoscopic sinus surgery is included also. This review describes the demographic data, clinical history, treatment, microbiology results, complications, and outcome.

METHODS

The admission records for all the patients who were admitted to the Pediatric Surgical Ward in Sarawak General Hospital, Kuching, Malaysia, between January 2004 and May 2009 were retrospectively reviewed. Records of patients who presented with preseptal cellulitis, orbital cellulitis, subperiosteal abscess (extraconal), orbital abscess (intraconal), and cavernous sinus thrombosis were closely studied. Ophthalmology consultations were obtained in all these cases. Ultimately, 3 patients having SPOA secondary to acute sinusitis were selected for this review.

RESULTS

All patients were male with rapid onset of periorbital signs, absence of purulent rhinorrhea, and presence of significant thrombocytosis (exceeding 500 × 10(9)/L). The 38-day-old newborn had mixed infection of methicillin-resistant coagulase-negative Staphylococcus bacteremia and local Acinetobacter eye infection with Staphylococcus aureus in the SPOA. All had medially located SPOA that was adequately drained via endoscopic sinus surgery, resulting in full recovery.

CONCLUSION

Newborns with preexisting risk factors and immature immunity are at risk of severe and rare infections. Contrast-enhanced paranasal sinus computed tomographic scan is mandatory and reliable to differentiate preseptal and postseptal orbital infection, as both conditions can present similarly and rapidly deteriorate. In the contrast-enhanced computed tomography-demonstrable SPOA, endoscopic sinus surgery drainage of the abscess proved to be safe and reliable as the main treatment modality. All patients recovered well without complications.

Intraocular pressure change in orbital disease

Intraocular pressure change has been found concurrent with many orbital pathologies, particularly those involving proptosis. The objective of this review is to offer an inclusive classification of orbital disease-related intraocular pressure change, not only for oculoplastics and glaucoma specialists, but also for general ophthalmologists. Various orbital conditions associated with increased intraocular pressure and glaucoma are comprehensively summarized, and pathophysiology, clinical manifestations, and treatment options of these diseases are discussed. Graves disease, arterio-venous shunts, trauma, and orbital neoplasia, and other common conditions are discussed in detail; less frequent syndromes such as orbitocraniofacial deformities, phakomatoses, and mucopolysaccharidoses are included for the sake of comprehensiveness, but discussed less extensively.

Diagnosis and management of acute rhinosinusitis in children

Rhinosinusitis is a common disease in children that is often overlooked. The clinical symptoms of acute rhinosinusitis are nasal blockage or congestion, nasal discharge or postnasal drip (often mucopurulent), facial pain, headache, and reduction in/loss of smell. Direct vision by nasal fibroendoscopy may aid the diagnosis. Regarding imaging criteria, recent consensus documents state that plain sinus x-rays are of limited utility, and CT remains the technique of choice, particularly in children with complications or very persistent or recurrent infections that are unresponsive to medical management. Antibiotics are the primary form of medical treatment for acute bacterial rhinosinusitis, but they should be used when acute bacterial rhinosinusitis presents as persistent or severe disease. This will minimize the number of children with uncomplicated viral upper respiratory tract infections who are treated with antimicrobials. Topical corticosteroids may reduce nasal edema and improve ostial drainage and ventilation of the sinus.

Management of pediatric orbital cellulitis in patients with radiographic findings of subperiosteal abscess

Objective: Controversies remain regarding the management of orbital cellulitis (OC). The objective of this study was to examine the outcomes of patients admitted to our institution for orbital cellulitis during a 7-year period.

Study Design: Case series with chart review.

Setting: Tertiary referral pediatric hospital.

Subjects and Methods: Charts of 465 consecutive OC admissions were reviewed for presentation, imaging, medical and surgical treatment, and outcome.

Results: Of these patients, 189 were treated in the emergency room and 276 were admitted. CT scan was performed on 240 patients. Subperiosteal abscess (SPA) was noted in 68 patients. Of these, 47 were treated medically and 21 had surgery. Surgical patients were older (8.3 vs 6.2 years, P = 0.039), had larger abscesses (>10 mm, P < 0.001), required a longer admission (10.2 vs 6.6 days, P < 0.001), and had higher temperatures on admission (38.0°C vs 37.3°C, P = 0.03).

Conclusion: The majority of small SPAs as diagnosed on CT scans in younger children can be successfully treated medically. Surgery, however, should be considered for a worsening clinical examination. Our findings confirm those of previous reports on this clinical entity.

[Orbital infections in children: clinical signs, imaging, and treatment]

Orbital infections are rare in children. The more posterior the abscess has spread, the more serious it is, with potential intracranial complications. The main etiology is sinusitis, whose location depends on age. The diagnosis is based on clinical examination and CT or MRI. Intravenous antibiotics alone or associated with surgical drainage (for children older than 9 years or those with complications) are performed. Orbital infections in children require good collaboration between ophthalmologists, otolaryngologist, and pediatricians.