Predictors of surgical management for paediatric orbital subperiosteal abscesses

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.

Pediatric preseptal and orbital cellulitis - a 6 year experience from a London tertiary centre

PURPOSE

This study reports the experience of pediatric preseptal and orbital cellulitis at a London tertiary centre during a 6-year period and highlights the role of orbital surgeons in the management of subperiosteal abscess (SPA).

METHODS

A retrospective review was conducted of all pediatric patients hospitalised for preseptal and orbital cellulitis.

RESULTS

A total of 201 children including 152 cases of preseptal cellulitis and 49 cases of orbital cellulitis were admitted at a London tertiary centre over the study period. Patients with orbital cellulitis and especially those managed surgically had higher rates of fever, higher presenting white cell count and C-reactive protein level compared to cases of preseptal cellulitis. 77.6% of patients with orbital cellulitis had SPA. 81.6% of SPA had a medial component, while 28.9% had superior component. 61.2% of orbital cellulitis cases were managed surgically. Surgical intervention was carried out by otorhinolaryngologists (ENT) in 76.7% of cases, jointly between ENT and orbital surgeons in 16.7% of cases and by orbital surgeons alone in 6.7% of cases. Of the 11 SPA involving the orbital roof, all were surgically managed and orbital surgeons were involved in 54.5% of cases. When SPA involved the medial wall, orbital surgeons were only involved in 6.5% of cases.

CONCLUSIONS

We recommend all patients with superior SPA be treated at a centre with both ENT and orbital surgeons as these may not be amenable to drainage by ENT alone.

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.

Clinical Characteristics and Risk Factors for Evisceration in Trauma-Dominant Orbital Cellulitis: A 10-Year Review

Purpose

To analyze the clinical characteristics of trauma-dominant orbital cellulitis (OC) and evaluate the risk factors associated with evisceration.

Methods

This retrospective study included inpatients diagnosed with orbital cellulitis at the Zhongshan Ophthalmic Center between January 2010 and December 2020. The demographic features, etiology, clinical characteristics, microbiological isolates, and risk factors associated with evisceration were analyzed.

Results

Among 148 consecutive subjects (n = 148, 148 eyes), the mean age was 42.07 ± 20.35 years and 70.27% were male. Penetrating globe injuries were the most common (52.03%). No light perception (NLP) was recorded in 50% of patients on admission. Endophthalmitis was observed in 103 cases (69.59%), intraocular foreign bodies (IOFB) were detected in 43 cases (29.05%), and total corneal melting was observed in 31 cases (20.95%). Sixty patients (40.54%) underwent evisceration. Logistic regression analysis showed that total corneal dissolution [odds ratio (OR) = 83.019, P = 0.000], IOFB (OR = 3.402, P = 0.016), and NLP (OR = 0.185, P = 0.001) were risk factors for evisceration. Microorganism detection showed that Pseudomonas aeruginosa and Bacillus cereus were the leading pathogens.

Conclusion

Among hospitalized trauma-dominant OC patients, middle-aged men were the major subjects and penetrating globe injury was the major cause. Significant complications such as complete visual loss and evisceration were unavoidable in many patients with OC in the current study. NLP, IOFB, and total corneal melting were the risk factors for evisceration.

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.

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.