Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Orbital and Periorbital Complications of Sinusitis Many anatomic factors account for the incidence of orbital complications of paranasal sinus disease. Once the sinuses are fully developed, over half the circumference of the orbit consists of bony sinus walls. Of greatest clinical significance is the relationship between the ethmoid sinus and the orbit: the lamina papyracea contains several fissures, and the anterior and posterior ethmoidal foraminae. In addition, the ophthalmic venous system contains no valves, resulting in open, two-way venous communication between the face, nasal cavity, sinuses, orbit, cavernous sinus and pterygoid plexus. In 1937, Hubert proposed a classification system for orbital inflammation. Chandler et al, in 1970, proposed a modification of Hubert's classification system, based on the pathogenesis of the disease. Stage 1 is preseptal cellulitis, which affects the eyelid only, typically the upper lid first. Stage 2 is orbital cellulitis, characterized by orbital pain, proptosis, chemosis and decrease in extraocular motility. As the inflammation progresses, visual acuity can worsen. Stage 3 is subperiosteal abscess, in which an abscess forms in the potential space between the orbital periosteum and the bony sinus wall. The globe is proptotic, typically deviated downward and laterally, with decreased ocular motility, and often some degree of visual loss. Stage 4 is orbital abscess. This is characterized by complete ophthalmoplegia, axial (rather than lateral) proptosis, chemosis, visual loss and often an afferent pupillary defect. Stage 5 is cavernous sinus thrombosis. The clinical picture is similar to orbital abscess, except that prostration and meningeal signs are often present and the opposite orbit may develop proptosis, ophthalmoplegia, and visual loss. Of the five stages of periorbital and orbital inflammation, preseptal cellulitis is by far the most common. Next most common is subperiosteal abscess. Orbital abscess and cavernous sinus thrombosis are very rare. Orbital and periorbital complications of sinusitis are primarily noted in children, although they do occur in adults. However, older patients have a higher incidence of orbital cellulitis. Younger patients typically have preseptal cellulitis only. Sinusitis is the most common etiology of orbital and periorbital inflammation, although cutaneous trauma or infection, dacryocystitis, conjunctivitis, periorbital surgery, and orbital fractures are other causes. Fearon et al (1979), in Toronto, reviewed 6,770 patients admitted with sinusitis over a 25-year period, and noted 156 cases of orbital or periorbital complications, or 2.3% of children admitted with sinusitis. There are several reports on the bacteriology of orbital and periorbital inflammation, and the most common organisms found consistently are H flu, Staph, and Strep. H flu is seen only in young children. Most authors agree that swabs of the nose or the conjunctiva are not helpful since they rarely correlate with the organism grown from the abscess or cellulitis. The CT scanner has revolutionized the diagnosis of orbital and periorbital complications of sinusitis. CT scanning is the gold standard for evaluation of the status of the orbit, and it allows evaluation of the paranasal sinuses as well. Orbital ultrasound has also been used with some success. But ultrasound is not adequate to evaluate the apex or the posterolateral roof of the orbit, and does not allow evaluation of the adjacent sinuses. However, in selected patients, ultrasound may be helpful. The indications for immediate CT scan include: clinical evidence of orbital inflammation, decreased visual acuity, and lack of clinical improvement on medical therapy. All patients admitted with periorbital or orbital inflammation should have blood cultures drawn, and intravenous antibiotics should be initiated immediately. Antibiotics should cover Strep, Staph, and anaerobes. B-lactamase-producing H flu should be considered in children less than six. Ampicillin and chloramphenicol are the classic recommendations for children, but many recent authors use agents such as cefuroxime or Unasyn alone. In older children where H. flu is not suspected, other authors report good success with penicillin G and Nafcillin together. In addition, topical or systemic decongestants, or both, are important to promote drainage of the infected sinus. Emergency CT scan or ultrasound should be considered. Even if CT scanning is not performed immediately, it should be considered at some point for several reasons: to define the presence of sinusitis as the etiology; to identify any bony defects or other anatomic abnormalities which predispose the patient to orbital complications; and to rule out late complications such as brain abscess. If the CT scan reveals subperiosteal or orbital abscess, it should be drained surgically. The approach for orbital exploration depends on the location of the abscess. Subperiosteal abscesses are best drained using an external ethmoidectomy approach, with elevation of the orbital periosteum until the abscess is encountered. Some controversy exists as to whether or not to perform a sinusectomy procedure at the time of abscess drainage, but even those authors who advocate simultaneous sinus surgery recommend limited drainage procedures only. A few authors have reported success with medical treatment and close observation of patients with subperiosteal abscess. While on maximal medical management, patients were examined every two hours. The decision as to whether or not to operate was made using the following criteria: worsening of visual acuity or ocular motility, or failure to improve clinically in 48 hours. Fifty percent came to complete resolution with medical management only. All patients should be followed to confirm resolution of their sinusitis, and some may require further sinus surgery in the future. Case Presentation A 12-year-old white male, previously in good health, developed a low-grade fever and malaise 3 days prior to admission. One day prior to admission he developed some swelling in the right eyelid. He was seen by a pediatrician who prescribed Augmentin. The patient vomited 4 of 6 doses of Augmentin. The next morning the eye was swollen shut, the patient spiked a fever to 102 degrees, and he presented to the Emergency Room. His past medical history was entirely unremarkable. In particular, the patient denied any history of nasal congestion or sinusitis. On physical examination, the temperature was 102.5o F. The right eyelid edema had completely covered the globe, and the eye was markedly proptotic. He had complete ophthalmoplegia, but normal visual acuity. Intranasal exam revealed some mucopurulent material draining from the right middle meatus, and the left side of the nose was normal. Laboratory evaluation was remarkable for a WBC of 19,000 with a left shift. He underwent emergency CT scan of the paranasal sinuses and orbits, which revealed a subperiosteal abscess of the right orbit. The CT also demonstrated soft tissue opacification of the right ethmoid sinus with secondary fluid collections present in the right maxillary, sphenoid and frontal sinuses. He underwent emergency drainage of the subperiosteal abscess through an external ethmoidectomy-type incision, and was placed on IV antibiotics (Unasyn). Post-operatively, he did well. A follow-up CT scan on post-operative day two revealed resolution of the abscess with some continued orbital cellulitis. His vision remained normal, and the proptosis and ophthalmoplegia improved dramatically beginning post-operative day two. Intra-operative cultures grew only Hemophilus parainfluenzae. The patient was discharged on post-operative day five, and completed a three-week course of IV Ceftriaxone at home. 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