Orbital Complications of Rhinosinusitis in the Adult Population: Analysis of Cases Presenting to a Tertiary Medical Center Over a 13-Year Period

Complicated Odontogenic Sinusitis: Extrasinus Infectious Spread

Odontogenic sinusitis (ODS) is a common cause of orbital, intracranial, and osseous infectious extrasinus complications. Dental infections can spread to the orbital or intracranial spaces though the sinuses via thrombophlebitis or direct extension, or from the dentition or oral cavity via vascular channels in the maxillary alveolar bone. ODS typically presents with unilateral involvement both clinically and radiographically. Any suspicion for extrasinus spread based on history and physical examination should be followed by appropriate imaging, formal dental evaluation, and, when appropriate, ophthalmology and neurosurgery consultations. This multidisciplinary approach ensures appropriate management of both the acute orbital and intracranial complications.

Subperiosteal and Orbital Abscesses: A Comparison of Clinical Features, Management, and Outcomes

PURPOSE

To compare the clinical features, management, and outcomes between orbital cellulitis patients with subperiosteal abscess (SPA) and those with orbital abscess (OA).

METHODS

A retrospective study was conducted at a tertiary care center through medical record search to identify patients with orbital cellulitis from January 1, 2000 to December 31, 2022. Charts were screened for those with radiographic evidence of SPA or OA. Demographic data and presenting clinical features were compared between the 2 cohorts. Primary outcomes compared included rates of surgical intervention, reoperation, and readmission; and length of hospital stay and final vision.

RESULTS

A total of 189 patients, 162 with SPA and 27 with OA, met the criteria. The OA group (mean 46.5 ± 18.6 years) was older than the SPA group (mean 19.1 ± 21.4 years). Comorbid sinusitis was significantly more common in the SPA cohort (95.7% SPA; 70.4% OA; p < 0.001), while OA was more likely to occur with orbital trauma (29.6% vs. 8.0%; p = 0.003), implanted hardware (11.1% vs. 0.6%; p = 0.005), and comorbid diabetes (22.2% vs. 4.3%; p = 0.001). OA patients more often presented with a relative afferent pupillary defect (21.7% vs. 3.9%; p = 0.005), vision worse than 20 of 50 (42.3% vs. 16.2%; p = 0.005), and methicillin-resistant Staphylococcus aureus infection (20.8% vs. 5.8%; p = 0.036). OA was associated with a higher reoperation rate (47.8% vs. 21.3%; p = 0.019), readmission rate (18.5% vs. 5.6%, p = 0.047), and limited extraocular motility at follow-up (4.3% vs. 25%; p = 0.013); while mean length of hospital stay and final visual acuity were similar.

CONCLUSION

OA may affect an older population with a divergent risk factor profile compared with SPA. OA may cause more severe functional impairment on presentation, warranting more aggressive management to achieve visual outcomes similar to SPA.

Orbital Cellulitis and Frontal Epicranial Empyema Secondary to Pansinusitis: A Case Report

Orbital cellulitis is a relatively uncommon complication of sinusitis. Its association with intracranial complications is rare. We present the case of a 36-year-old patient with no associated risk factors who presented with a four-day history of headache, periorbital inflammation, suppuration, and necrosis. A computed tomography (CT) scan revealed a frontal epidural abscess and signs of chronic pansinusitis. This case highlights the importance of maintaining a high index of suspicion for complications of this condition and the necessity of a multidisciplinary approach in managing this rare complication.

Incidence Rates and Risk Ratios of Normal Tension Glaucoma in Patients with Chronic Rhinosinusitis: A Population-Based Longitudinal Follow-Up Study

Several studies have investigated the association between chronic rhinosinusitis (CRS) and ophthalmological complications. However, it remains uncertain whether CRS is independently associated with the development of normal tension glaucoma (NTG). Therefore, this retrospective cohort study aimed to investigate the prospective association between CRS and the increased incidence and risk of NTG using a representative population-based dataset. The selection of both the CRS and comparison groups was meticulously conducted through the propensity scoring method. The incidence and risk ratios of NTG were measured using person-years at risk and a weighted Cox proportional hazards model. We enrolled 30,284 individuals without CRS (comparison group) and 15,142 individuals with CRS. The NTG incidence rates were 1.19 and 0.81 in the CRS and comparison groups, respectively. The CRS group showed a significantly increased risk of subsequent development for NTG (adjusted hazard ratio = 1.41, 95% confidence interval = 1.16-1.72), regardless of the CRS subtype. Additionally, the risk of developing NTG was relatively higher in the first 2 years after CRS diagnosis. Moreover, a subgroup analysis revealed a higher risk of NTG in elderly female individuals with CRS. The present findings underscore the importance of monitoring and managing NTG risk in individuals with CRS, especially in elderly female patients.

Recovery From Visual Loss After Endoscopic Endonasal Decompression of Iatrogenic Orbital Abscess

Orbital complications are the second most common complications of endoscopic sinus surgery (ESS), and orbital hematoma is the most frequent orbital complication. An orbital abscess is usually associated with rhinosinusitis, and a few cases of orbital abscesses occurring after orbital trauma have been reported. However, orbital abscess occurring after ESS is rare. Herein, we present a case of a right orbital abscess that developed after bilateral ESS, performed at an outside facility, and decreased vision in the right eye to light perception only. The visual loss persisted for 3 days, after which the patient was referred to our hospital for urgent management. The cause of abscess formation might have been an infected stagnant orbital venous hematoma that occurred as a complication of ESS. A defect in the right lamina papyracea and emphysema were confirmed on computed tomography. Orbital symptoms started immediately after ESS, and vision deteriorated to light perception only and lasted for 3 days, which was considered a high-grade risk factor for irreversible blindness by the ophthalmology team. Urgent endoscopic endonasal orbital decompression was performed to drain the orbital abscess, and maximal medical treatment was initiated, which included intravenous corticosteroids, intravenous broad-spectrum antibiotics, topical intranasal corticosteroids, irrigation, and topical antibiotic eye drops. Close follow-up assessments were performed by the infectious diseases team, and the ophthalmology team performed frequent orbital assessments. The patient recovered from blindness, which was an unexpected outcome.

Hospitalizations and severe complications following acute sinusitis in general practice: a registry-based cohort study

OBJECTIVES

To investigate complication rates of acute sinusitis in general practice, and whether antibiotic prescribing had an impact on complication rate.

METHODS

All adult patients diagnosed with sinusitis in Norwegian general practice between 1 July 2012 and 30 June 2019 were included. GP consultation data from the Norwegian Control and Payment for Health Reimbursements Database were linked with antibiotic prescriptions (Norwegian Prescription Database) and hospital admissions (Norwegian Patient Registry). Main outcomes were sinusitis-related hospitalizations and severe complications within 30 days. Logistic regression was used to estimate associations between antibiotic prescriptions, prespecified risk factors, individual GP prescribing quintile, and outcomes.

RESULTS

A total of 711 069 episodes of acute sinusitis in 415 781 patients were identified. During the study period, both annual episode rate (from 30.2 to 21.2 per 1000 inhabitants) and antibiotic prescription rate (63.3% to 46.5%; P < 0.001) decreased. Yearly hospitalization rate was stable at 10.0 cases per 10 000 sinusitis episodes and the corresponding rate of severe complications was 3.2, with no yearly change (P = 0.765). Antibiotic prescribing was associated with increased risk of hospitalization [adjusted OR 1.8 (95% CI 1.5-2.1)] but not with severe complications. Individual GP prescribing quintile was not associated with any of the outcomes, whereas risk factors such as previous drug abuse, or head injury, skull surgery or malformations, and being immunocompromised were significantly associated with increased risk of both outcomes.

CONCLUSIONS

Severe complications of acute sinusitis were rare and no protective effect of high prescribing practice among GPs was found. Recommendations to further reduce antibiotic prescribing are generally encouraged, except for high-risk groups.

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

Bacterial orbital cellulitis - A review

Infections of orbit and periorbita are frequent, leading to significant morbidity. Orbital cellulitis is more common in children and young adults. At any age, infection from the neighboring ethmoid sinuses is a likely cause and is thought to result from anatomical characteristics like thin medial wall, lack of lymphatics, orbital foramina, and septic thrombophlebitis of the valveless veins between the two. Other causes are trauma, orbital foreign bodies, preexisting dental infections, dental procedures, maxillofacial surgeries, Open Reduction and Internal Fixation (ORIF), and retinal buckling procedures. The septum is a natural barrier to the passage of microorganisms. Orbital infections are caused by Gram-positive, Gram-negative organisms and anaerobes in adults and in children, usually by Staphylococcus aureus or Streptococcus species. Individuals older than 15 years of age are more likely to harbor polymicrobial infections. Signs include diffuse lid edema with or without erythema, chemosis, proptosis, and ophthalmoplegia. It is an ocular emergency requiring admission, intravenous antibiotics, and sometimes surgical intervention. Computed tomography (CT) and magnetic resonance imaging (MRI) are the main modalities to identify the extent, route of spread from adjacent structures, and poor response to intravenous antibiotics and to confirm the presence of complications. If orbital cellulitis is secondary to sinus infection, drainage of pus and establishment of ventilation to the sinus are imperative. Loss of vision can occur due to orbital abscess, cavernous sinus thrombosis, optic neuritis, central retinal artery occlusion, and exposure keratopathy, and possible systemic sequelae include meningitis, intracranial abscess, osteomyelitis, and death. The article was written by authors after a thorough literature search in the PubMed-indexed journals.

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.

Orbital Subperiosteal Abscess: The Role of Nonsurgical Management Among Adolescents and Adults

PURPOSE

To investigate the role of nonsurgical management in the treatment of orbital cellulitis complicated by subperiosteal abscess (SPA) in adolescent and adult populations.

METHODS

A retrospective cohort study to assess the demographic, clinical, and outcome profiles of adolescent and adult patients with orbital SPA treated nonsurgically versus those who received surgical intervention. Primary outcome measures included hospitalization length and best-corrected visual acuity (BCVA) in the final evaluation.

RESULTS

The study comprised 76 patients diagnosed with SPA in the setting of orbital cellulitis. Twelve were stratified into the nonsurgical cohort, while 64 represented the surgical group. Sinusitis was the most prevalent risk factor among both populations, and the rate did not differ significantly. SPA was located medially at a significantly higher rate in the nonsurgical cohort compared with the surgical. No patients in the nonsurgical population had a relative afferent pupillary defect (RAPD) on presentation. The proportion of patients who received adjunctive systemic corticosteroid therapy was comparable in both groups. Hospitalization length was significantly higher in the surgery cohort. BCVA in the final evaluation was favourable in both groups. Sinusitis subgroup analysis including eight nonsurgical patients produced overall consistent results.

CONCLUSIONS

Findings from the largest study of orbital cellulitis complicated by SPA to date demonstrate a role for nonsurgical management in adolescent and adult patients who present with a medial SPA and/or ophthalmic examination without an RAPD. Among these populations, visual prognosis is favourable whether management includes surgical debridement or not, and surgical intervention may not predict a shorter duration of hospitalization.

Odontogenic Sinusitis is a Common Cause of Operative Extra-Sinus Infectious Complications

BACKGROUND

Orbital, intracranial, and osseous extra-sinus complications can arise from bacterial or fungal sinusitis. Odontogenic sinusitis (ODS) can cause extra-sinus complications, but its prevalence remains poorly characterized.

OBJECTIVE

To determine the frequency of ODS as a cause of operative extra-sinus infectious complications and describe clinical features of all complicated sinusitis cases.

METHODS

A multi-institutional retrospective review was performed on all operative sinusitis-related extra-sinus complications from 2011 to 2020. ODS was diagnosed by sinus computed tomography (CT) and dental evaluations when available. Demographics, complication types, sinusitis etiologies, and various clinical features were analyzed.

RESULTS

Forty-five patients were included (mean age 55.5 years, 56% male). Of the extra-sinus complications, 40% were orbital only, 22% intracranial only, 13% osseous only, and 25% involved combined complications. The 2 most common causes of extra-sinus complications were ODS (40%) and mucopyocele (27%). When invasive fungal etiologies were excluded, and only unilateral maxillary opacification on CT was considered, nearly 60% of extra-sinus complications were due to ODS. Unilateral maxillary sinus opacification on CT was present in 100% of complicated ODS compared to 44% of nonodontogenic cases, and oral anaerobes were only identified in ODS cases. No complicated ODS patients underwent dental interventions during hospitalization.

CONCLUSION

ODS was the most common cause of operative extra-sinus infectious complications. Clinicians should consider ODS high on the differential diagnosis of all patients presenting with complicated sinusitis, especially when sinusitis is unilateral and invasive fungal infection is not suspected.

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.

Extrasinus Complications From Odontogenic Sinusitis: A Systematic Review

OBJECTIVE

Odontogenic sinusitis (ODS) can cause infectious orbital, intracranial, and osseous complications. Diagnosis and management of complicated ODS have not been discussed in recent sinusitis guidelines. The purpose of this systematic review was to describe epidemiological and clinical features, as well as management strategies of complicated ODS.

DATA SOURCES

PubMed, EMBASE, and Cochrane Library.

REVIEW METHODS

A systematic review was performed to describe various features of complicated ODS. All complicated ODS studies were included in qualitative analysis, but studies were only included in quantitative analysis if they reported specific patient-level data.

RESULTS

Of 1126 studies identified, 75 studies with 110 complicated ODS cases were included in qualitative analysis, and 47 studies with 62 orbital and intracranial complications were included in quantitative analyses. About 70% of complicated ODS cases were orbital complications. Only 23% of complicated ODS studies were published in otolaryngology journals. Regarding ODS-related orbital and intracranial complications, about 80% occurred in adults, and 75% were male. Complicated ODS occurred most commonly from apical periodontitis of maxillary molars. There were no relationships between sinusitis extent and orbital or intracranial complications. High rates of anaerobic and α-hemolytic streptococcal bacteria were identified in complicated ODS. Management generally included systemic antibiotics covering aerobic and anaerobic bacteria, and surgical interventions were generally performed to address both the complications (orbital and/or intracranial) and possible infectious sources (dentition and sinuses).

CONCLUSION

ODS should be considered in all patients with infectious extrasinus complications. Multidisciplinary management between otolaryngologists, dental specialists, ophthalmologists, and neurosurgeons should be considered to optimize outcomes.

Intracranial thrombosis associated with MSSA bacteraemia in the setting of influenza A

The authors present a case of a 42-year-old previously healthy man who presented in sepsis, with right lateral gaze palsy. He was found to have bilateral cavernous sinus thrombosis (CST) and bilateral internal jugular thrombosis in the setting of Staphylococcus aureus bacteraemia. The patient was successfully treated and recovered from his illness after a protracted stay in the medical intensive care unit. We go over the treatment course and follow-up of this patient and discuss the need to have a high degree of clinical suspicion for CST and suppurative thrombophlebitis of the internal jugular veins. We also discuss the possible role of the Panton-Valentine leukocidin in causing thrombotic complications of S. aureus bacteraemia.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Common Cold and Acute Rhinosinusitis: Up-to-Date Management in 2020

PURPOSE OF REVIEW

The purposes of the review are as follows: (1) to define acute rhinosinusitis (ARS) and their phenotypes, (2) to highlight the ARS management according to international guidelines, (3) to compare the physicians' management with the ARS guideline recommendations, and (4) to report ARS socioeconomic burden.

RECENT FINDINGS

Bacterial and non-bacterial ARS have similar symptoms, although they can be discriminated by using a combination of specific signs and symptoms. The prescription of antibiotics should be limited to clearly suspected bacterial ARS. There is an overuse of diagnosis tools and treatment prescriptions. The total cost per ARS episode in Europe is over €1000. ARS is mainly an inflammatory disease triggered by viral infection, and few cases end up developing bacterial infection. In most of the cases, it is a self-resolving disease which diagnosis is mainly clinical and the treatment symptomatic. The incidence of complications is low and independent of antibiotic use. There is a high socioeconomic burden associated to ARS.

To What Extent Can Orbital Cellulitis Emergency Aspect Influence the Diagnosis of Maxillary Sinus Lymphoma?

We present a case of a 46-year-old woman admitted to the emergency department for acute swelling and erythema of the right eyelid for 3 days. Ophthalmological examination was notable for 10/10, P2 best visual acuity, and inflammatory periorbital edema, without exophthalmia nor extraocular motility disturbance. Intraocular pressure was 14 mmHg and fundoscopic examination was not notable for any abnormality. Preseptal cellulitis diagnosis was made, and oral antibiotherapy was immediately started; after 72 hours, the patient did not improve and started complaining of pain on ocular movements. Brain and orbit MRI scan revealed right retroseptal cellulitis associated with homolateral pansinusitis. Intravenous antibiotherapy with oral corticosteroid was started simultaneously leading to full remission but with steroid dependency; 5 days after finishing prednisone, orbital cellulitis symptoms reappeared. The same treatment protocol was given but with corticosteroid tapering over weeks. Nevertheless, steroid dependency persisted. Except for the inflammatory syndrome, complete biological examinations did not disclose any abnormalities. The patient underwent maxillary sinus and fat orbital biopsy; however, histopathological examination was not contributory. Persistence of steroid dependency, chronic atypical rhinosinusitis, normal paraclinical investigations, and age of patient let us suspect lymphoma origin hidden by chronic corticosteroid. We carried out for the second time a maxillary sinus biopsy after stopping steroids, which disclosed primitive non-Hodgkin lymphoma of the maxillary sinus. The aim of this observation is firstly to evoke though it is exceptional the diagnosis of maxillary lymphoma in case of atypical orbital cellulitis and secondly to incite clinicians to be more vigilant in prescribing corticosteroid even if there is an emergency character of orbital cellulitis.

The Development of Glaucoma after Surgery-Indicated Chronic Rhinosinusitis: A Population-Based Cohort Study

This study investigates the development of glaucoma in subjects with surgery-indicated chronic rhinosinusitis (CRS) by the use of the National Health Insurance Research Database in Taiwan. Individuals that received the functional endoscopic sinus surgery (FESS) with a diagnostic code of CRS were regarded as surgery-indicated CRS and enrolled in the study group. Four non-CRS patients were age- and gender-matched to each patient in the study group. The exclusion criteria included legal blindness, ocular tumor, history of eyeball removal, and previous glaucoma. The outcome was regarded as the development of glaucoma, and conditional logistic regression was used for the statistical analysis, which involved multiple potential risk factors in the multivariate model. A total of 6506 patients with surgery-indicated CRS that received FESS and another 26,024 non-CRS individuals were enrolled after exclusion. The age and gender distributions were identical between the two groups due to matching. There were 108 and 294 glaucoma events in the study group and control group, respectively, during the follow-up period, and the study group had a significantly higher adjusted hazard ratio (1.291, 95% confidential interval: 1.031–1.615). The cumulative probability analysis also revealed a correlation between the occurrence of glaucoma and the CRS disease interval. In the subgroup analysis, the chance of developing open-angle glaucoma and normal-tension glaucoma was significantly higher in the study group than in the control group. In conclusion, the existence of surgery-indicated CRS is a significant risk factor for the development of glaucoma, which correlated with the disease interval.