Orbital Cellulitis and Subperiosteal Abscess: A 5-year Outcomes Analysis

PURPOSE

Orbital cellulitis and subperiosteal abscess (SPA) are historically associated with poor outcomes. We seek to characterize current associations with abscess formation, surgical failure and vision loss.

METHODS

All cases of orbital cellulitis presenting to an affiliated hospital between April 2008 and 2013 were critically reviewed.

RESULTS

Thirty patients met inclusion criteria. Average age was 28.7 ± 24.4. The male to female ratio was 2:1. Abscesses were identified in 56.7% of patients. Adults were less likely than children to present with abscesses (28.6% vs. 81.3%, p = 0.008). Of the other factors analyzed, only antibiotic use before admission (70.5% vs. 23.1%, p = 0.03) and maximum restriction (-2.5 ± 1.2 vs. -0.9 ± 0.7, p = 0.008) were associated with SPA. Temperature at presentation (37.9 ± 0.9 vs. 37.1 ± 0.4, p = 0.04), relative proptosis (5.8 ± 3.3 mm vs. 2.1 ± 1.1, p = 0.002) and abscess volume (4.3 ± 1.3 mm(3) vs. 0.7 ± 0.5 mm(3), p = 0.0004) were associated with progression to surgery. Reoperation was required in 26.7% of patients. Of these, two-thirds had combined superior/medial abscesses that re-accumulated after isolated endonasal surgery. Two of the 3 patients with profound vision loss had a dental etiology.

CONCLUSIONS

Only young age, prior antibiotics and degree of restriction predicted the presence of an abscess. Re-accumulation was more common than anticipated, and drainage of superior/medial abscesses by endoscopic surgery alone had the strongest association with surgical failure. Patients with odontogenic abscesses must be treated with particular caution.

[Diagnosis and management of the acute attack of sphenoid and ethmoid fungal ball sinusitis]

OBJECTIVE

To improve the diagnosis and treatment of the acute attack of sphenoid and ethmoid fungal ball sinusitis based on the analysis of clinical features.

METHOD

Eighteen patients with sphenoid and ethmoid fungal ball sinusitis were reviewed, and the main symptoms included headache and fever during acute attack. Endoscopy, nasal CT and MRI can provide useful information for diagnosis. Endoscopic sinus surgery was performed on thirteen patients after drug therapy, while the other 5 patients chose conservative therapy.

RESULT

The pathological examination confirmed the fungal lesions and the 13 patients had a good recovery. The result of CT and MRI scanning had a good accordance with the intra-operative findings. One patient receiving conservative treatment had acute attack again 2.5 months later, and antibiotics and topical nasal drugs improved the symptoms.

CONCLUSION

Clinical presentation and radiological imaging contribute to the differential diagnosis of the acute attack of sphenoid and ethmoid fungal ball sinusitis, then the targeted therapy can be taken.

One-year results: Transantral balloon dilation of the ethmoid infundibulum

A prospective, multicenter research study is under way to demonstrate long-term improvement in chronic rhinosinusitis symptoms after transantral balloon dilation of the ethmoid infundibulum. Trial results from an interim analysis of symptomatic status using the Sino-Nasal Outcome Test 20 survey demonstrate significant and sustained improvement through post-procedure 1-year follow-up. Additionally, these data provide evidence that the symptomatic improvements following balloon expansion within the ostiomeatal unit to treat medically refractory inflammation of the maxillary sinuses, either alone or with concomitant anterior ethmoid disease, are similar.

Non-traumatic nasal septal abscess due to acute spheno-ethmoiditis

Non-traumatic nasal septal abscesses (NSAs) are rare and those associated with acute sinusitis are even rarer. We report a case of a 12-year-old female child with NSA and complicating acute spheno-ethmoiditis that was diagnosed by physical examination and computed tomography (CT) scan. The NSA was treated by surgical incision and drainage of the abscess, endoscopic aspiration of pus from the spheno-ethmoidal recess, systemic antibiotic therapy, and nasal cleansing.

Onodi sinusitis presenting with orbital apex syndrome

This article reports the unusual presentation of a patient with an intraconal abscess secondary to sinusitis in an onodi cell in a healthy 63 year old Chinese female. She presented with limited extraocular movements, decreased corneal sensation, rapid drop in visual acuity and signs of optic neuropathy, in the absence of any inflammatory signs in the right eye. MRI scans showed a well-encapsulated mass in the posterior two thirds of the orbit, with the presence of an onodi cell on the right side. She underwent an extended lateral orbitotomy, which revealed frank pus that was positive for Staphylococcus aureus. She was treated with intravenous antibiotics with complete resolution of her presenting signs.

[Acute rhinoethmoiditis with periorbital cellulitis in a newborn]

Rhinoethmoiditis at newborn is rare. Possible complications include orbital abscess, orbital cellulitis, intracranial complications. Inflammation with orbital and periorbital acute onset at newborn present to clinician as therapeutical dilemma. Pathogenic links which involve this process began from cellulitis to orbital abscess, cavernous sinus thrombosis, cerebral abscess, meningitis. We present 2 cases of rhinoethmoiditis at newborn with orbital cellulitis, with the main differential diagnostic problems and therapeutical options.

Arcanobacterium haemolyticum sinusitis and orbital cellulitis

We present a case of sinusitis and orbital cellulitis in a 9-year-old girl caused by the Gram-positive bacillus Arcanobacterium haemolyticum. In addition to antimicrobial chemotherapy, two surgical procedures were required to drain the ethmoid and maxillary sinus cavities and a subperiosteal abscess.

[Complications of rhinosinusitis]

Rhinogenous complications may manifest in the region of the orbits, bone or soft parts of the wall of the frontal sinus, or endocranially. With regard to orbital complications, a differentiation is made between edema, periostitis, subperiosteal abscess and phlegmon--depending on severity and extent. A possible sequela of frontal sinusitis may be osteomyelitis. If the frontal bone is involved, there is a danger that the infection may spread to the endocranium via medullary spaces and blood vessels. The diagnostic basis for deciding appropriate treatment is CT or MRI. While orbital edema and periostitis usually respond to conservative treatment, subperiosteal abscess, orbital phlegmon and abscess of the brain require immediate operative treatment under antibiotic cover. The treatment of choice for osteomyelitis of the frontal bone is the liberal removal of affected bone, also under antibiotic cover.

Neonatal orbital abscess

PURPOSE

To describe two cases of orbital abscess in neonates and to review the literature of orbital cellulitis in neonates.

DESIGN

Two interventional case reports.

METHODS

Photographs, orbital computed tomography scans, and full pediatric examination were obtained in two cases of orbital abscess in neonates.

RESULTS

Acute ethmoiditis with orbital abscess formation was found in both infants. In one of them, Staphylococcus aureus was identified as the source of infection.

CONCLUSIONS

The clinical findings of our cases concur with the literature (eight cases) indicating that orbital abscess caused by Staphylococcal ethmoiditis is the most common form of orbital cellulitis in neonates.

[Treatment of sino-nasal polyposis by Candida albicans immunotherapy: apropos of 4 cases]

The NSP is an inflammatory chronic disease of the mucous of nose and sinuses. None etiological treatment is known up to now. The aim of this study is to consider a model of autoallergy as etiology for NSP proven by specific immunotherapy (STI) to Candida albicans (CA).

METHODS

Four NSP treated by SIT to Candida albicans are reported. The patients are treated either by subcutaneous injections or sublingual drops. The frequency is one injection per week or a few drops per day (absorbed extract on calcium phosphate or aqueous Stallergenes).

RESULTS

The cumulated doses varies from 465 Index of Concentration (IC) to 117500 IC on a period of 3 to 4 years. The results are evaluated according the rhino-sinusal semeiology, the intensity of symptoms, and the stage of polyposis. The SIT is also active on both a late and an immediate components for the symptoms, and the cutaneous tests. The results are significant 60% to 80% of improvement. The viral or bacterial infections reactivate both types of hypersensitivity and they are prevented by SIT. The nasal hyperactivity observed as a more advanced non specific stage of the PNS is also improved by ITS. In two of the clinical cases, the pollenogenic seasonal obstruction is added to the nasal perennial obstruction in a sharp manner. The pollenogenic allergy is also improved after SIT to CA without any other associated SIT.

CONCLUSION

The model of autoallergy already proven as etiology for atopic dermatitis can serve as a base of exploration of PNS. That is showing the presence of IgE antibody corresponding to intracellular proteinic autoallergens having an analogy to environment allergens. The allergy to Candida albicans can thus be considered as an etiology of the PNS.

[Polypous ethmoiditis]

Investigations of etiology, pathogenesis and treatment of polypous ethmoiditis show the role of chronic inflammation, sensitization and autoimmune reactions in mechanisms of nasal polyposis (NP). The development of postoperative recurrences of NP depends on the microflora, defective microcirculation, permeability of the histohematic barriers of the nasal and labyrinthine mucosa and metabolism of glycosaminoglycanes in the above mucosa. Adequate treatment methods are suggested: He-Ne laser radiation, UV blood radiation, cryotherapy, corticosteroids. Promising are also autovaccine, autovaccine with tissue (polypous) antigen, ozone solutions.

[Clinical aspects and treatment of purulent anaerobic non-Clostridium ethmoid sinusitis]

The ethmoidal sinus was punctured for pus samples in 120 patients with purulent ethmoiditis. The sinus of 47.5% of the patients contained non-clostridial anaerobic infection. The species of the microflora and its sensitivity to antibiotics were defined. An effective system of examination and treatment of purulent ethmoiditis caused by anaerobic infection is proposed. The essential elements of this system are: aeration of the paranasal sinuses, immunostimulation and immunomodulation. For non-responders and subjects with frequent recurrences surgical intervention is indicated.

Endoscopic sinus surgery and postoperative intravenous aminoglycosides in the treatment of atrophic rhinitis

A total of 29 atrophic rhinitis patients were treated by endoscopic sinus surgery between 1990 and 1995. After the surgery, a 7 to 10-day course of systematic aminoglycoside was administered. Two cases were excluded, due to later occurrence of nasal lymphoma in one patient and incompleteness of postoperative antibiotic therapy in the other. Among those included, atrophic rhinitis occurred in the absence of prior surgery in 24 patients, and the condition was secondary to a previous intranasal surgery in the other three patients. After a 1 to 6-year follow-up (mean: 63.4 months), seven patients were successfully managed without any characteristic symptom or sign of atrophic rhinitis. Another 18 patients felt improved. Only two patients did not have any improvement. The rate of improvement was 92.6%. Overall, one patient suffered from a left retrobulbar hematoma after operation. Exposed orbital fat was observed in the other patient. The orbital complication rate was therefore 7.4%. No other major complication occurred in this series. The bacteriologic, radiological, antroscopic, and pathologic findings are also included here. It is concluded that endoscopic sinus surgery in combination with adequate postoperative antibiotic therapy can significantly treat atrophic rhinitis.

Report of the first case of invasive fungal sinusitis caused by Scopulariopsis acremonium: review of scopulariopsis infections

Scopulariopsis acremonium is a species of saprophytic fungus not previously reported to cause invasive disease in humans, although invasive infections from other species of Scopulariopsis have been reported and are reviewed. Deep infection with this fungus is associated with a high mortality rate. Invasive fungal sinusitis, in general, is a potentially fatal disease that typically affects immunocompromised patients, such as those receiving intensive chemotherapy or undergoing bone marrow transplantation. We report a case of invasive fungal sinusitis caused by Scopulariopsis acremonium in a patient with leukemia, who was successfully treated with amphotericin B, itraconazole, endoscopic sinus surgery, and granulocyte colony-stimulating factor.

[Low-frequency vibrations in the treatment of patients with acute maxillary sinusitis and ethmoiditis. Non-specific resistance and immunity]

The authors present clinicoroentgenological and immunological evaluation of low-frequency mechanical intermittent biovibromassage used in the treatment of acute maxillary sinusitis alone and in its combination with ethmoiditis. The massage provides simple-in-use and effective impact on inflammation in the cells of the ethmoidal labyrinth. It can be practiced both in hospital and outpatiently.

Orbital complications of sinusitis

The ethmoid and maxillary sinuses are the sinuses most frequently involved with orbital infections. Routes of spread are by direct extension through bone and indirectly through the valveless venous plexuses of the orbit, nose, and sinus. Classification of orbital infections can be thought of as either preseptal or postseptal and then further subdivided from there. The diagnosis has been greatly improved by the use of CT scans; however this should never be the only entity used for diagnosis. The determination of visual acuity (VA) is the single most important finding and will ultimately determine treatment modality. Orbital infections show different and more virulent bacteria than does non-complicated sinusitis and this should be reflected in the choice of medical and surgical therapy. Medical management is well accepted for infections without abscesses, and surgery is generally needed for infections with an abscess.

[Acute ethmoiditis. A review of 38 cases]

OBJECTIVE

The purpose of this study was to assess the usefulness of computerized tomography (CT) scan in the diagnosis and management of the complications of acute ethmoiditis in children.

MATERIALS AND METHODS

A retrospective revision of the records of pediatric patients admitted to Sant Joan de Déu Hospital from January 1985 to June 1994 was performed.

RESULTS

Thirty-eight children (22 males and 16 females) between the ages of 18 months and 15 years (mean age 6.5 years) were studied. All of the patients had eyelid afflictions; 5 (13.2%) with eyelid edema and 33 (86.8%) with periorbital cellulitis. All of them were unilateral without side predominance. The signs and symptoms included fever (37) and orbital pain and headache (24), with 28 patients presenting other forms of sinusitis. CT scan was applied in 24 children (63%). Thirteen of these patients demonstrated complications of the orbit, 6 with orbital cellulitis, 4 subperiosteal abscess and 3 orbital abscesses. Surgery was performed in 3 cases.

CONCLUSIONS

We conclude that the CT scan is a radiological procedure that must be applied when there are signs or symptoms compatible with orbital complications. Patients should also be scanned if their exam is worse or unchanged after 24-48 hours of antibiotic therapy. Early diagnosis and antibiotic treatment can prevent complications subsidiary of surgery.

Functional endoscopic sinus surgery of orbital subperiosteal abscess in children

Subperiosteal abscess of the orbit (SPA) should be considered an important part of the group of orbital complications following acute sinusitis. This situation requires early surgical intervention to avoid visual loss or ophthalmoplegia. Six cases of children with SPA of the orbit treated successfully by Functional Endoscopic Sinus Surgery (FESS) are reviewed. The importance of ophthalmological examination, nasal endoscopy and CT scan is emphasized concerning the management protocol. The major advantage of FESS is the avoidance of external ethmoidectomy with the resultant scar. FESS is demonstrated as a safe and convenient procedure with excellent post operative recovery of the patients.

Diagnosis and treatment of intracranial complications of paranasal sinus infections

Complications and local extension of paranasal sinus infections most often involve the orbit and periorbita. Because of the widespread use of antibiotics since World War II, intracranial extension of maxillofacial sinusitis is rarely seen today. Nevertheless, the clinician must be aware of the potential for these complications, because late recognition of this condition and delays in treatment can increase morbidity and mortality rates. A comprehensive, current review of sinogenic intracranial complications is presented, with illustrative cases of brain abscess, subdural empyema, meningitis, cavernous sinus thrombosis, epidural abscess, and osteomyelitis. The mechanisms and potential for intracranial spread of infection from the frontal, sphenoid, and ethmoid sinuses are discussed in detail. The management of each type of complication is outlined, including the use of computed tomography and magnetic resonance imaging, and the role of surgical drainage.

[Treatment of acute ethmoiditis according to a protocol based on clinical stage]

OBJECTIVE

To describe the results of application of a systematic treatment protocol, meant to reduce the risk of serious complications, when treating acute ethmoiditis.

DESIGN

Prospective study.

SETTING

Academic hospital of the 'Vrije Universiteit (VU)', Amsterdam, The Netherlands.

METHOD

From January 1988 to March 1994, 25 children with acute ethmoiditis were admitted to the VU hospital. Eight of them had Chandler stage I, 8 stage II, 3 stage III, 3 stage IV and 3 stage V. The treatment protocol was stepwise, based on the Chandler stages and focused on intensive antibiotic treatment in combination with surgical drainage of the ethmoid complex and (or) the orbit.

RESULTS

All children with ethmoiditis stages I-III were cured without rest symptoms. One patient with ethmoiditis stage IV and a pre-existent lymphatic leukaemia died of pulmonary complications of a massive fungal infection, 8 months after treatment. One patient with ethmoiditis stage V finally had permanent psychomotor retardation.

CONCLUSION

The used treatment protocol offered the possibility to treat patients with acute ethmoiditis stepwise, depending on stage, with satisfying results. Especially the treatment result in patients with ethmoiditis stage V was good.

Spontaneous cerebrospinal fluid rhinorrhea with associated sinusitis and allergic rhinitis

The entity of spontaneous cerebrospinal fluid rhinorrhea is a rare condition that presents a special challenge to the practicing allergist. Delayed diagnosis can be associated with significant morbidity and mortality. We describe two cases of this condition occurring in association with allergic rhinitis and sinusitis. The presentation and management of these cases is described. A high index of suspicion for this condition should be maintained in all patients who present with profuse and often unilateral rhinorrhea.

Pneumocephalus and exophthalmos secondary to acute sinusitis and nasopharyngeal oxygen catheter

Pneumocephalus is a well-known complication of skull trauma, certain neurosurgical procedures, and sinus neoplasms.1,2 The association between pneumocephalus and infection is very rare, usually occurring in patients with mastoiditis, chronic otitis media, and sinusitis.1,3 In a recent report, pneumocephalus and exophthalmos developed secondary to administration of oxygen by a nasopharyngeal catheter in a patient without sinusitis.4 We describe an infant admitted for treatment of bacterial pneumonia and maxillary and ethmoid sinusitis, in whom pneumocephalus and right-sided severe exophthlalmos developed while the patient was receiving oxygen by a nasopharyngeal catheter.

Temporary nasosinusal drainage and lavage in chronic maxillary sinusitis. Statistical study on 847 maxillary sinuses

We report on 498 patients suffering from chronic maxillary sinusitis verified by sinusoscopy through the inferior meatus and by computed tomography of the sinuses, which permitted also the diagnosis of coexisting chronic ethmoidal sinusitis. The patients were treated by temporary drainage through a polyethylene drain tube left in place at the end of the antroscopy for daily lavage with saline solution and daily instillation in the sinus of thiamphenicol glycinate hydrochloride (similar to chloramphenicol) and N-acetyl-L-cysteine. We followed up 847 maxillary sinuses during the lavages according to 2 parameters: 1) recovery of a clean washout product at the macroscopic examination and 2) recovery of normal ostial patency as measured by sinusomanometry. We concluded that 1) the association with ethmoidal sinusitis does not significantly modify the treatment duration, and 2) fewer than 4% of the maxillary sinuses are likely to recover normal parameters after the 23rd day of lavage, and it is therefore useless to continue this treatment much longer. Of the maxillary sinuses, 36.25% were not submitted to any surgery. The results gained by the lavage technique have to be protected from recurrence by the treatment of general, focal, or local causes.

A case of sinusitis presenting with spheno-cavernous syndrome: discussion of the differential diagnosis

A 60 year old gentleman presented with a left spheno-cavernous syndrome resulting in impaired ocular motility, proptosis and visual loss in an otherwise clinically quiet eye. The history led to a clinical suspicion of posterior ethmoiditis, which was confirmed on C.T. scanning. Surgical drainage and antibiotic treatment resolved the symptoms, but visual impairment persisted. The differential diagnosis and management of spheno-cavernous syndrome is discussed in context with this atypical presentation of orbital cellulitis.

[Ultrasonic ethmoidotomy combined with intracavitary magnetotherapy in chronic polypous ethmoiditis]

The efficacy of ultrasonic ethmoidectomy combined with magnetic therapy was investigated in 90 patients. Ultrasonic ethmoidectomy was applied with the help of a LORA system consisting of a generator and an acoustic unit connected to a waveguide with a spoon-shaped end (44 Hz frequency and 35-40 microns amplitude). Under visual control the ultrasonic spoon was inserted into the meatus nasi medius, and the injured medial, superior and some anterior cells of the ethmoidal bone were opened. Bone trabecules of the cells were removed together with the polypous mucous membrane and polyps, by moving the concave surface forwards and keeping the long axis of the bent portion of the spoon in the vertical position. Follow-up of the treated patients during 6 months to 4 years revealed the absence of polyps in 79.7%. Repeated application of this treatment in the case of severe recurrent forms of polypous ethmoiditis improved the therapeutic efficacy.

[Management of chronic sinusitis in children]

The managements and the results of therapy for children with chronic sinusitis were reported. During the period of 1980 to 1988, 190 patients, aged 3 to 15, were examined at our outpatient clinic. The pathologic conditions of the maxillary sinus were examined by the contrast x-ray study (X-MFT). The mild, moderate and severe lesions in the maxillary sinus evaluated by X-MFT were 22%, 44; and 34%, respectively. Sixty-two per cent of ethmoid sinus was opacified in occipito-frontal view. The degree of patency of the maxillary ostium was evaluated by an application of the constant pressure to the maxillary sinus. Almost all maxillary ostia of these patients were patent. Nasal mucociliary clearance was reduced in 37% of the patients examined after the saccharin method. Antral lavages were performed once in a week for the therapy of 72% of children with chronic sinusitis. The efficacy of this modality was evaluated by the above mentioned items. The maxillary and ethmoid lesions, and nasal mucociliary transit time were significantly improved by the modality after 25 months in average. These results indicate that the antral lavage is an useful therapy for chronic sinusitis in children.

[Therapeutic approach for nasal sinus polyposis]

The multiple etiologies of bilateral naso-ethmoidal polyposis (PNE) make a precise and regulated therapeutic decision difficult. The treatment is chosen after a clinical history, radiology and complete biological investigation. Medical and surgical treatments share the indications. Medical treatment is dominated by local corticotherapy. Its failures and recurrence following its end may suggest general corticotherapy, an efficacious remedy but which carries well known risks. The choice of treatment is guided by whether the characteristics of the polyposis are invalidating or not. The localised forms often respond to local medical treatment. Invalidating polyposis continues to be difficult to treat, especially where there is intolerance to aspirin. Corticotherapy by the general route, even sequential, remains insufficient to be sure of long asymptomatic periods. We suggest for these patients a clear ethmoidal once or twice under local anaesthetic with diazanalgesia. The local treatments associated with corticotherapy and anti histamines help the healing of the operated cavity. Crenotherapy is an useful aid after having obtained clean, permeable nasal fossae. The choice remains empirical and is a function of the group, but it must not include iatrogenic risks greater than those of the illness itself. We report our actual experience.