Adverse Events in Endoscopic Sinus Surgery for Infectious Orbital Complications of Sinusitis: 30-Day NSQIP Pediatric Outcomes

Orbital Subperiosteal Abscess Drainage: Transorbital vs. Endonasal Approach

Background: This study aims to compare the surgical outcomes of transorbital versus endonasal endoscopic approaches for orbital subperiosteal abscess drainage. Methods: A retrospective review was conducted at a single institution of patients who underwent orbital subperiosteal abscess drainage from November 2009 to April 2023. Results: Of 64 patients, 44 (68.8%) underwent abscess drainage via an orbital approach, while 20 (31.3%) underwent endonasal endoscopic drainage. No significant difference in operative time or visual acuity improvement was found between the two groups. Abscess drainage via orbitotomy was associated with a longer total (average 8.1 days) and postoperative (average 7.3 days) hospitalization time compared to the endoscopic group (average 5.4 days and 4.2 days, respectively), though this difference was not statistically significant (p = 0.197, 0.136, respectively). For medial orbital abscesses, the average length of total and postoperative hospitalization was greater after orbitotomy (p = 0.028 and 0.019, respectively). At discharge, patients who underwent orbitotomy more commonly reported periorbital swelling (p = 0.0003), while postoperative pain was more common in the endoscopic drainage group (p = 0.009). Reoperation rate was higher after orbitotomy (34.1%) compared to the endoscopic drainage group (15.0%), though this was not statistically significant (p = 0.115). Conclusions: Transorbital and endoscopic surgical approaches for orbital abscess drainage have similar surgical outcomes, with no statistically significant differences noted in terms of visual acuity change or reoperation rate. Longer hospital stays were found for patients with medial orbital abscesses drained via orbitotomy.

Systemic Outcomes in Adults Undergoing Emergent Repair of Orbital Blowout Fractures

Purpose

To analyze the association between emergent surgery status and systemic adverse outcomes in patients undergoing open orbital floor blowout fracture repair.

Methods

This retrospective cohort analysis utilized the 2005-2018 National Surgery Quality Improvement Program (NSQIP) database. Current Procedural Terminology (CPT) codes were used to identify cases with open treatment of orbital floor blowout fractures (21385, 21386, 21387, 21390, 21395). Demographics, comorbidities, and complication incidences were compared between patients undergoing emergent surgery and those undergoing non-emergent orbital blowout fracture repair using chi-square analyses. The independent effect of preoperative emergent status on adverse outcomes was analyzed using binary logistic regression.

Results

1,146 (96.0%) non-emergent and 48 (4.0%) emergent orbital blowout fracture repairs were identified from 2005 to 2018. Chi-square analysis indicated patients undergoing emergent repairs had higher incidences of preoperative wound infection (8.3% vs. 2.3%; p = 0.029) and systemic sepsis (8.3% vs. 0.6%; p = 0.001). The emergent cohort had a higher proportion of patients with Hispanic ethnicity (p = 0.011). Unadjusted chi-square analysis indicated the emergent cohort had a higher incidence of prolonged length of stay (50.1% vs. 10.1%; p < 0.001). After adjusting for confounders, logistic regression analysis indicated emergent status was an independent risk factor for prolonged length of stay (OR 13.05; 95% CI 5.26-32.37; p < 0.001).

Conclusion

Emergent surgery status is an important factor associated with increased odds of prolonged length of stay in patients undergoing open orbital blowout fracture repair.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-024-04681-0.

Visual outcomes following orbital decompression for orbital infections

OBJECTIVE

To analyze the visual outcomes and sequelae of endonasal intervention for orbital infections.

INTRODUCTION

Orbital infections pose a serious threat to vision in the pediatric population and can result in complications such as blindness, diplopia, intracranial involvement, and death. [1] Orbital decompression by endonasal intervention is a common treatment to address a variety of orbital infections including orbital cellulitis, orbital abscesses, and subperiosteal abscesses. [2] The outcomes of visual sequelae such as loss or limitation of visual acuity, extraocular movements, and increased intraocular pressure following orbital decompression via endonasal intervention have not been sufficiently investigated in the current literature.

METHODS

This retrospective cohort study was performed at our tertiary care pediatric hospital using data from 69 patients aged 0-18 years who were admitted between 2008 and 2018. Data was extracted from the electronic medical record system.

RESULTS

Following endoscopic sinus surgery, symptoms of orbital infection improved throughout the cohort. Improvement in visual acuity is demonstrated by a statistically significant decrease in the average logMAR value in both the right and left eye (P = 0.002 and P = 0.028 respectively). There was also a significant improvement to normal values postoperatively for patients who initially presented with abnormal tonometry, extraocular movement, and the appearance of eyelids and eyelashes.

CONCLUSION

There is no decline or loss of vision with otolaryngology surgical intervention for orbital cellulitis in our cohort. This retrospective chart review demonstrates the efficacy of surgical intervention on overall visual outcomes following endonasal intervention for orbital infections such as orbital cellulitis, orbital abscesses, and subperiosteal abscesses.

Cost-effectiveness of Endoscopic Polypectomy in Clinic compared to Endoscopic Sinus Surgery: A modelling study

OBJECTIVE

To compare costs and quality-adjusted life years of patients receiving endoscopic polypectomy in the clinic those receiving endoscopic sinus surgery from the perspective of Canada's health system.

METHOD

We developed a Markov model to simulate costs and quality-adjusted life years among a cohort of patients with chronic rhinosinusitis with polyps who received endoscopic polypectomy in clinic or endoscopic sinus surgery, over a patient's lifetime. Our study focused on patients with chronic rhinosinusitis with polyps who have the predominant symptom of bilateral nasal obstruction. Cost data were obtained from Canadian sources. Health utility values were derived from Sino-nasal Outcome Test (SNOT-22) scores reported in the published literature. A cycle length of six months was used. Both costs and quality-adjusted life years were discounted using an annual rate of 1.5%. We conducted one-way and probabilistic sensitivity analyses to assess the robustness of the study findings.

RESULTS

Endoscopic polypectomy in clinic was a cost-saving option as it had a lower cost (C$736 vs. C$6,728) and produced more quality-adjusted life years (13.85 vs 13.06) compared to endoscopic sinus surgery. Our findings were, however, highly sensitive to health utility values. Results from probabilistic sensitivity analysis showed that endoscopic polypectomy in clinic had a lower cost and was more effective compared to endoscopic sinus surgery in 99.86% of iterations.

CONCLUSION

From the perspective of the publicly funded healthcare system, endoscopic polypectomy in clinic was economically attractive compared to endoscopic sinus surgery for chronic rhinosinusitis with polyps patients who have a primary symptom of bilateral nasal obstruction. The cost-effectiveness results are, however, highly dependent on the relative impact of endoscopic polypectomy in the clinic and endoscopic sinus surgery on post-surgery health utility values.

Effectiveness of endoscopic versus external surgical approaches in the treatment of orbital complications of rhinosinusitis: a systematic review protocol

OBJECTIVE

This review aims to investigate and compare the effectiveness of endoscopic drainage techniques against external drainage techniques for the treatment of orbital and subperiosteal abscesses as a complication of rhinosinusitis.

INTRODUCTION

Transnasal endoscopic drainage and external drainage techniques have been used in the management of subperiosteal orbital abscesses secondary to rhinosinusitis. Each of these approaches has its own advantages and disadvantages, with extensive literature describing each technique separately. However, there is a lack of guidance in the studies on assessing and comparing the safety, effectiveness and suitability of these techniques. This review aims to compare the effectiveness of these techniques based on measuring outcomes in the literature such as: length of postoperative hospital stay, rate of revision surgery and complication rates.

INCLUSION CRITERIA

Eligible studies will include people of all ages diagnosed with subperiosteal abscess, orbital abscess or cavernous sinus thrombosis (Chandler stages III-V) secondary to rhinosinusitis disease, who have also undergone drainage via either an endoscopic approach, external approach or combined surgical approach.

METHODS

A comprehensive search of both published and unpublished literature will be performed to uncover studies meeting the inclusion criteria. Reference lists of studies included in final analyses will also be manually searched and subject matter experts contacted to investigate other sources of literature. Two reviewers will screen studies and a third reviewer will resolve disagreements. Studies will, where possible, be pooled in statistical meta-analysis with heterogeneity of data being assessed using the standard Chi-squared and I tests.

Innovations in Endonasal Sinus Surgery in Children

Although there have been many advances in new tools and procedures for endonasal sinus surgery in children, the management and care for pediatric chronic rhinosinusitis has remained relatively unchanged. However, there have been advances in skull base surgery and tumor removal and new knowledge about perioperative concerns in children. This article discusses the role and risks of endoscopic sinus surgery, the use of balloon sinuplasty in children, management of complicated rhinosinusitis, and advances in skull base tumors and choanal atresia repair.

Perioperative Risk Factors Associated With Morbidity and Mortality Following Pediatric Inpatient Sinus Surgery

OBJECTIVES:

Pediatric sinus surgery is indicated for a wide range of sinonasal and skull base pathologies, but it is most commonly performed for recalcitrant chronic rhinosinusitis or complicated acute sinusitis. The authors aim to report medical risk factors of morbidity and mortality following inpatient sinus surgery in the pediatric population.

METHODS:

Using data from the Kids' Inpatient Database from 2003 to 2012, patients with International Classification of Diseases, Ninth Revision, procedure codes for primary sinus surgery were identified. Mixed-effect multivariable logistic regression was used to identify risk factors of inpatient postoperative morbidity and mortality.

RESULTS:

The final sample included a weighted estimate of 4965 pediatric patients. The rates of inpatient morbidity and mortality were 6% and 1%, respectively. Respiratory complications (2.5%) were the most prevalent postoperative adverse events. The most prevalent comorbidities were chronic sinusitis (59.8%), acute sinusitis (27.8%), and cystic fibrosis (26.4%). Compared with patients who did not experience any morbidity, patients with inpatient morbidity had higher rates of pneumonia, mycoses, and nasal or paranasal benign neoplasm ( P < .05). The odds of inpatient morbidity and mortality were highest for patients with leukemia (odds ratio, 2.74; 95% confidence interval, 1.59-4.72; P < .001) and mycoses (odds ratio, 15.84; 95% confidence interval, 6.45-38.89; P < .001), respectively.

CONCLUSIONS:

This study is the first to report the national comorbidity burden and risk factors for postoperative adverse events following inpatient sinus surgery. Knowledge of the comorbidities and independent factors associated with morbidity and mortality will help in directing preoperative optimization and counseling.

LEVEL OF EVIDENCE:

2c.

Surgical Treatment of Rhinosinusitis-Related Orbital Complications: Factors Affecting Irreversible Blindness

If left untreated, rhinosinusitis can rarely cause a devastating complication irreversible blindness (IB). Despite new technologies in endoscopic sinus surgery and use of new broad-spectrum antibiotics, IB outcome is still a problem for surgically treated orbital complication of paranasal sinus infection (OCPSI) patients, and factors leading to IB outcome are not actually known. The aim of this study was to assess the factors leading to the IB outcome for surgically treated OCPSI patients. Results of 25 surgically treated OCPSI patients in our clinic were combined with surgically treated OCPSI patients reported through the PubMed database search from the year 2007. Patients were divided into 2 groups: IB group and recovery group. Patients having at least 1 immune status-related additional risk factor (ARF) were more common in the IB group, having an at least 1 ARF had 1.683 risk value of IB outcome (RR: 1.683, P = 0.006). IB patients had statistically significant higher mean (21.87 ± 40.35, P = 0.005) time interval (days) (TI) between onset of ophthalmological symptoms and surgical intervention compared to recovery group patients (2.92 ± 2.53). ROC curve analysis for an estimation of IB outcome according to the TI value demonstrated that a cut-off value of ≥2.5 days had the ideal sensitivity (87.5%) and specificity (71.9%) that resulted in IB outcome. (80.5% power, P = 0.008) IB and recovery group patients did not differ according to orbital complication type according to Chandler's classification (P = 0.492) and white blood cell count status (P = 0.584). In conclusion, OCPSI patients with ARFs and delayed admission after onset of orbital symptoms have a higher risk of IB outcome. These patients deserve prompt evaluation and early surgical intervention to prevent blindness. With future studies, new surgical criteria, including the ARF status and onset of ophthalmological symptoms (≥2.5 days) may be added to classical surgical criteria to prevent IB for OCPSI cases.