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

[Acute rhinosinusitis in children requiring hospitalization between 2016 and 2022 - retrospective analysis]

Bevezetés: A rhinosinusitis az orr- és orrmelléküregek nyálkahártyájának váladékképződéssel és ödémás duzzanattal járó gyulladása. Az akut bakteriális rhinosinusitis főként szövődményes eseteiben gyakran szükséges fekvőbeteg-intézménybe való felvétel. Célkitűzés: A Szegedi Tudományegyetem Fül-Orr-Gégészeti és Fej-Nyaksebészeti Klinikájának fekvőbetegosztályára 2016 és 2022 között akut rhinosinusitis miatt felvett gyermekek anyagának retrospektív elemzése, illetve annak megállapítása, hogy a COVID–19-járvány befolyással volt-e a felvételt igénylő esetek arányára. Módszer: Demográfiai és klinikai adatok gyűjtése, az eredmények összehasonlítása hazai és nemzetközi irodalmi adatokkal. Eredmények: 497 gyermekből 471 beteg kezelése kizárólag ambulánsan történt. 26 gyermek, 17 fiú és 9 lány került felvételre (1 fő 2 alkalommal). Az átlagéletkor 7,65 év volt. A felvételek 52%-a a három téli hónapban, az összes felvétel 89%-a a novembertől áprilisig terjedő időszakban történt. 19 esetben akut ethmoiditis, 5 esetben akut sinusitis maxillaris, 2 esetben akut pansinusitis, 1 alkalommal akut sphenoiditis volt a felvételi diagnózis. A felvétel oka 19 gyermeknél a következményes szemhéjödéma, 7 esetben az alkalmazott terápia melletti progresszió volt, 1 betegnél intracranialis szövődmény igazolódott. Az átlagos hospitalizáció 4,2 nap volt. 16 esetben amoxicillin-klavulánsav, 11 esetben cefuroxim parenteralis adása történt. 9 esetben (8 orbitalis, 1 intracranialis szövődmény) elkerülhetetlen volt a műtét. Minden betegnél funkcionális endoszkópos beavatkozás történt. 2 alkalommal, orbitatályog miatt, külső megnyitásra is szükség volt, az intracranialis szövődménynél idegsebészeti műtét is történt. Megbeszélés: A vizsgált paraméterek korrelálnak az irodalmi adatokkal, a COVID–19-járványnak tulajdonítható esetszámváltozást nem tapasztaltunk. Következtetés: Az akut rhinosinusitis konzervatív terápiával általában gyógyítható, de előfordulhatnak súlyos, életet veszélyeztető szövődmények. Bár a kórházi felvételt igénylő esetek száma csökkent, a szövődmények aránya nem változott, ezért nagyon fontos azok gyors felismerése és hatékony kezelés. Orv Hetil. 2024; 165(19): 747–753.

Role of Acute Rhinosinusitis in Periorbital Infections in Children

OBJECTIVE

Periorbital cellulitis in children are commonly caused by acute rhinosinusitis (ARS). This study investigated the association of ARS and the severity of periorbital cellulitis in children.

STUDY DESIGN

Retrospective case-control study of children with periorbital cellulitis with ARS versus periorbital cellulitis without ARS.

SETTING

Patients were seen at West Virginia University Children's Hospitals between August 2011 to August 2022.

METHODS

Patients were divided into cases and controls based on presence or absence of ARS. ARS was defined based on clinical symptoms with objective presence of disease on CT scan. Patients' characteristics, treatment, hospital length of stay, and readmission were collected.

RESULTS

The sample consisted of 118 pediatric patients with orbital cellulitis. Patients with ARS were younger than patients without ARS (6.3 vs 8.5, p = 0.025), however there were no sex differences between two groups (p = 0.540). The ARS group had higher incidence of postseptal cellulitis (51.5% vs 9.6%, p < 0.001). As compared to patients without ARS, patients with ARS were more likely to be admitted (p < 0.001), have a longer length of stay (median of 3.5 days vs 0.5 days, p < 0.001), require IV antibiotics (95.3% vs 54.9%, p < 0.001), and require surgical intervention (23.1% vs 5.8%, p < 0.001). Readmission rate was similar between the two groups.

CONCLUSION

Children presenting with acute periorbital cellulitis who have ARS tend to have more severe infection requiring higher level of care. ARS should be assessed and incorporated into the plan of care of pediatric patients with periorbital infections.

Revisiting the orbital complications of acute rhinosinusitis

OBJECTIVE

The present study revisited three classification systems of orbital complications of acute rhinosinusitis (ARS) (Chandler, Mortimore & Wormald, and Velasco e Cruz & Anselmo-Lima) and observed which of them presented the best clinical applicability.

METHODS

Clinical data and CT scan findings of patients with orbital infection were retrospectively collected. To compare the three classification systems, we revised and graded all CT images accordingly, and divided the patients into four groups: Eyelid cellulitis (EC), orbital cellulitis (OC), subperiosteal abscess (SA), and orbital abscess (OA). The groups were compared regarding the presence of sinus opacification, the need for hospitalization and/or surgical treatment, and the presence of further complications/sequelae.

RESULTS

143 patients were included. The median number of sinuses involved in patients in the OC, SA, and OA groups was 2.0. ARS was rarely associated with signs of EC (present in both Chandler's and Mortimore & Wormald's classifications. The hospitalization rate was significantly lower in the EC group compared to the other three groups. Surgery was performed in all cases in the OA group, in 58.1% in the SA group, 19.4% in the OC group, and 12.5% in the EC group (p-value < 0.0001). Complications were present at higher rates in the OA group compared to the other three groups.

CONCLUSIONS

ARS was rarely associated with Eyelid Cellulitis. The stratification in the other three groups showed to be clinically relevant. Velasco e Cruz & Anselmo-Lima's classification system proved valid, simple, and effective for categorizing orbital complications of ARS.

LEVEL OF EVIDENCE: 3

Complications of Acute Bacterial Rhinosinusitis in Contemporary Practice: Lessons Learnt and the Way Ahead

There are variable presentations of complications of rhinosinusitis, which may be subtle especially due to use of antibiotics. Thus the classical picture as described by Chandler is rarely seen and threshold for diagnosing and treating a complication should be low. To identify possible risk factors for development of complications in acute bacterial rhinosinusitis (ABRS) and suggest a new method of reporting/classifying the complications. We conducted a retrospective study and observed the clinical presentation and risk factors of 9 patients who presented with complications of ABRS in our OPD during a period of 6 years, and then tried to formulate a reporting method based on the risk factors. We identified certain risk factors which include age, gender, sinus involved, extension beyond sinus, history of trauma, anatomical variations, and duration of symptoms. There are possible risk factors for development of complications. These factors can be studied in further details to ascertain their causal relationship in causing these complications. We also suggest a new method of reporting the complications. Such a reporting system would help in accurately identifying the exact severity of the disease, prognosticating the disease and guide treatment.

Management options for orbital complications of acute rhinosinusitis in pediatric patients

OBJECTIVES

Acute bacterial rhinosinusitis (ABRS) is a common pediatric condition. Despite its tendency to heal without complications, orbital complications (OC) are seen in 6% of patients and can cause vision impairment and put life at risk. Current treatment of this complications involves systemic antibiotics with or without surgical drainage, remaining controversial the use of corticosteroids. The aim of this study is to describe our results in the management of this complication both through medical and surgical treatment, with the inclusion of corticosteroids on it.

METHODS

A retrospective cross-sectional study was conducted in a tertiary hospital over pediatric patients with this complication.

RESULTS

23 patients were included with a mean age of 7.4 years. Ten of them (43.5%) presented ophthalmoplegia on admission and 2 of those also impaired visual acuity. A computerized tomography was performed in all patients and all of them received intravenous antibiotics and corticosteroids achieving that 60% did not require surgical treatment. The mean length of hospital stay was 6.2 days.

CONCLUSIONS

The treatment of OC of ABRS with intravenous antibiotics and corticosteroids is safe, remaining surgical treatment available when necessary. When evolution is favorable, a reduced hospital stay must be sought.

Sex Disparities in Pediatric Acute Rhinosinusitis: A National Perspective

OBJECTIVE

This study aims to provide an age-stratified analysis of associations with patient sex in pediatric inpatients with acute rhinosinusitis (ARS).

STUDY DESIGN

Retrospective cohort study.

SETTING

National administrative database.

METHODS

The 2016 Kids' Inpatient Database was queried for pediatric inpatients (<21 years old) with ARS (ICD-10 J01). Orbital and intracranial sequelae were selected via ICD-10 codes. Statistical associations by sex were determined via univariate and multivariable analyses. Weighted measures are reported to provide national estimates.

RESULTS

Of the 5882 patients identified with ARS, 2404 (40.9%) were female and 3478 (59.1%) were male. Male patients were younger than female patients (mean, 9.3 vs 9.9 years; P < .001). Multivariable analysis indicated that males and females had similar total charges ($71,094 vs $66,892, P = .464) and length of stay (5.8 vs 6.1 days, P = .263). However, male patients underwent more procedures (1.8 vs 1.5, P < .001). Mortality was similar between male and female patients (odds ratio [OR], 0.91; P = .664). Male patients also had increased odds for having orbital (OR, 1.58; P < .001) and intracranial (OR, 1.99; P < .001) complications. Differences in sex-dependent sequela risk were starkest in patients aged 14 to 20 years, with male patients being more likely to have orbital (OR, 2.91; P < .001) and intracranial (OR, 3.86; P < .001) complications.

CONCLUSION

In a cohort of pediatric inpatients with ARS, males have increased odds for orbital and intracranial sequelae and undergo more procedures than females. However, males and females have similar charges and length of stay. Our study highlights age-stratified differences in ARS across patient sex.

Sinogenic Orbital Complications

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Preseptal Versus Orbital Cellulitis in Children: An Observational Study

BACKGROUND

Preseptal and orbital cellulitis are two types of infection surrounding the orbital septum with very different potential outcomes. Our aim was to describe key differential features of both conditions, laying special emphasis on diagnostic and therapeutic tools.

METHODS

A retrospective review of patients admitted to a tertiary hospital over a 15-year period (January 2004-October 2019) was conducted. We included 198 patients with preseptal and 45 with orbital cellulitis. Descriptive statistics were performed to examine the available information.

RESULTS

Statistically significant differences were found between patients with preseptal and orbital cellulitis regarding age (3.9 ± 2.14 vs. 7.5 ± 4.24 years), presence of fever (51.5% vs. 82.2%), and preexisting sinusitis (2% vs. 77.8%) (all P < 0.001). Diplopia, ophthalmoplegia and proptosis were only present in orbital cellulitis (P < 0.001). Median values of C-reactive protein were significantly higher among children with orbital involvement [136.35 mg/L (IQR 74.08-168.98) vs. 17.85 (IQR 6.33-50.10), P < 0.0001]. A CRP>120 mg/L cut-off point for orbital cellulitis was obtained. Early CT scans were performed in 75.6% of suspected orbital cellulitis and helped detecting complications at an early stage. Abscesses were revealed in 70.6% of cases, especially medial subperiosteal abscesses (58.8%). All patients received intravenous antibiotics, whereas corticosteroids were preferred in patients with orbital implication (8.6% vs. 73.3%, P < 0.001). Only 26.7% of patients required additional surgery.

CONCLUSIONS

Clinical presentation and CRP are extremely sensitive for differential diagnosis of preseptal and orbital cellulitis. Prompt initiation of intravenous antibiotics is mandatory and can prevent surgical procedures even in cases with incipient abscesses.

The role of adjuvant systemic steroids in the management of periorbital cellulitis secondary to sinusitis: a systematic review and meta-analysis

PURPOSE

The role of adjuvant systemic corticosteroids in the management of periorbital cellulitis and subperiosteal/orbital abscesses secondary to sinonasal infections is not well understood. Our objective was to systematically review the current evidence on the efficacy and side effects of systemic steroids when used in the management of periorbital cellulitis.

METHODOLOGY

A systematic review of literature was conducted in accordance with PRISMA guidance. A systematic search of MEDLINE, Embase and Cochrane databases, MetaRegister and ISI conference proceedings was conducted. The outcomes of interest were duration of inpatient stay, requirement for surgical intervention, adverse effects and recurrent/residual symptoms.

RESULTS

Four studies were identified involving 118 patients. Of these, 78 underwent treatment with systemic corticosteroids and 40 were controls. Meta-analysis demonstrated that the mean duration of inpatient stay was significantly shorter in the steroid group (WMD - 2.90 days; 95% CI - 3.07, - 2.73; p < 0.00001). There were no significant differences in requirement for surgical intervention (RR 0.93; 95% CI 0.50, 1.75; p = 0.83). Side effects were reported in 6/78 patients (7.7%), with 5 patients showing signs of hyperactivity and 1 patient with insomnia. These were mild except in one case, which required early cessation of corticosteroids. There was one case of recurrence of symptoms in each cohort (steroid vs. non-steroid) following discharge.

CONCLUSIONS

The evidence suggests that systemic corticosteroids may offer some benefit in the management of periorbital cellulitis secondary to sinonasal infections. However, there is significant heterogeneity and risk of bias. A well-designed randomised controlled trial may provide a better insight into the efficacy of systemic steroids for this condition.