Abstract
Background
Orbital compartment syndrome is a rare ocular emergency requiring immediate intervention to prevent vision loss. It can arise due to a variety of causes including trauma, neoplasms and retrobulbar hemorrhage during endoscopic sinus surgery. Lateral canthotomy and inferior cantholysis is a well-known therapeutic procedure to rapidly relieve raised intraocular pressures.
Case report
We report a case of a subperiosteal orbital abscess due to acute maxillary sinusitis that underwent endoscopic drainage. Intraoperatively, he developed raised intraocular pressure following irrigation of the maxillary sinus and manual pressure on the malar abscess, necessitating emergent lateral canthotomy and inferior cantholysis.
Conclusion
To our knowledge, this is the first reported case of orbital compartment syndrome following sinonasal irrigation and malar pressure in the English literature. This case will serve as a reminder to the sinus surgeon of the potential danger of transmitted pressure from the paranasal sinus or malar soft tissue into the orbital compartment.
1
Introduction
Subperiosteal orbital abscess is an infective post-septal orbital complication seen in acute rhinosinusitis. While patients with milder symptoms may improve with conservative management, refractory cases of subperiosteal orbital abscess usually require drainage. Surgical approaches include external, endoscopic or a combination of both. We report a case of a subperiosteal orbital abscess due to acute maxillary sinusitis that underwent endoscopic drainage. Intraoperatively, he developed raised intraocular pressure following irrigation of the maxillary sinus and manual pressure on the malar abscess, necessitating emergent lateral canthotomy and inferior cantholysis. An extensive search on PubMed revealed no prior reported cases of orbital compartment syndrome arising following sinonasal irrigation. To the best of our knowledge, this is the first-ever reported case of such an occurrence in the English literature.
2
Case report
A 56-year old Chinese gentleman with a history of suboptimally controlled type II diabetes mellitus presented in September 2014 with two weeks of right orbital pain and ipsilateral hemifacial swelling. While this was associated with intermittent purulent rhinorrhea, the patient denied any visual blurring or excessive tearing. Examination revealed right periorbital swelling and erythema with exquisite tenderness on palpation ( Fig. 1 ). There was no proptosis or chemosis and the range of extra-ocular muscle movements was full. Testing for relative afferent pupillary defect was negative and visual acuity testing was normal. Nasoendoscopy revealed a congested right middle meatus with otherwise no frank mucopus or secretions.
The patient underwent computed tomography (CT) scan of the paranasal sinuses and orbits. Together with elevated inflammatory markers (white cell count of 15,100 cells per microliter, and C-reactive protein level of 45.9 milligrams per liter), the CT scan showed right maxillary sinusitis with concomitant right ethmoidal and frontal sinus opacification. Erosion of the anterosuperomedial wall of the right maxillary sinus with a resultant inferomedial subperiosteal orbital abscess was seen. Additionally, an adjoining right malar soft tissue abscess was also noted ( Fig. 2 ). The right orbit was otherwise intact with no intraconal collection.
When his condition failed to improve after 24 hours of intravenous amoxicillin-clavulanic acid and strict diabetic control, ophthalmology input was sought again with a view for external drainage of the malar abscess combined with endoscopic drainage of the diseased maxillary sinus. However, the ophthalmologist opined that a percutaneous incision could be avoided by applying digital pressure to the area to channel its contents into the maxillary sinus during endoscopic drainage. Thus, a decision was made for endoscopic drainage of the subperiosteal orbital abscess.
Intraoperatively, the patient was noted to have right maxillary, ethmoidal and frontal sinusitis with abundant mucopus. An inferomedial subperiosteal abscess coursing along the floor of orbit which communicated with the maxillary sinus via a dehiscence in its roof was noted. After drainage of the abscess and ventilation of the maxillary sinus, digital pressure at the right malar area was applied to facilitate drainage of the soft tissue abscess. The anterior ethmoid artery was preserved during surgery. Subsequently, the right maxillary sinus cavity was flushed copiously with normal saline. During this, a sudden increase in orbital swelling was noted with a tense and bulging orbit ( Fig. 3 ). An urgent ophthalmology review was sought and tonometry confirmed orbital compartment syndrome with raised intraocular pressures of 40 mmHg on rapid sequential testing. A decision was made for emergent lateral canthotomy and inferior cantholysis. Exploration was then attempted but no bleeding source could be identified post-release. Repeat tonometry now showed a marked reduction to 22 mmHg on repeated testing. Gradual resolution of the orbital swelling ensued.
