Types of Orbital Complications and Patient Presentation Orbital complications can be divided into infectious complications that result from direct extension of bacterial or fungal infections into the orbit ( ▶ Table 17.1) or noninfectious complications that result from bony remodeling and anatomic changes due to adjacent sinus pathology causing positive or negative pressure upon the orbit ( ▶ Table 17.2). Acute bacterial rhinosinusitis Acute invasive fungal rhinosinusitis Chronic invasive fungal rhinosinusitis Prevalence of orbital involvement 5% of patients hospitalized for sinusitis 1 50% preseptal cellulitis 35% postseptal cellulitis 15% subperiosteal abscess <1% orbital abscess 9 73.5% of AIFS cases 10 Demographics More common in children 1 Preseptal: 3.9-y old Postseptal: 7.5 y old 12 Diabetes mellitus Hematologic malignancy Systemic chemotherapy Immunosuppressive drugs AIDS Can have no known immunosuppression Diabetes mellitus AIDS Immune status Normal Compromised 11 Normal 11 Common organisms Staphylococcus aureus Streptococcus pneumoniae Haemophilus influenzae Anaerobic species (Peptostreptococcus, Fusobacterium, Bacteroides) 1, 9 Aspergillus spp. Zygomycetes (Rhizopus, Mucor, Rhizomucor) 11 CIFS: Aspergillus fumigatus 4 Granulomatous variant: Aspergillus flavus 11 Location Medial orbital wall 10 Medial orbital wall Orbital apex 4 Medical treatment Preseptal: oral antibiotics Postseptal: IV antibiotics Include anaerobic and MRSA coverage 1, 9 Nasal decongestion Elevation of head of bed Serial examinations 9 IV antifungal Reverse immunocompromised state (i.e., WBC transfusions) Glycemic control in diabetics 4 Discontinuation of steroids 15 Long term oral antifungals 16 Glycemic control in diabetics 4 Discontinuation of steroids 15 Surgical treatment Typically performed if one or more are met 1, 9: Visual impairment Large abscess (>10 mm on CT) Failed trial of appropriate medical treatment Urgent debridement until bleeding, healthy margins 17 May require orbital exenteration 13 Debride to healthy tissue 4 Prognosis Excellent for early cases, but if cavernous sinus involved, mortality as high as 30% 1 Common recurrence 4 Mortality: 50–80% 3 Inversely related to degree of invasion 4 Abbreviations: AIDS, acquired immunodeficiency syndrome; AIFS, acute invasive fungal sinusitis; CIFS, chronic invasive fungal sinusitis; CRS, chronic rhinosinusitis; CT, computed tomography; IV, intravenous; MRSA, methicillin-resistant staph aureus; WBC, white blood cell. Mucocele AFRS Silent sinus Pneumosinus dilatans Prevalence of orbital involvement 20% of paranasal sinus mucoceles 5 Wide variability, 20–93% of AFRS cases 18 Essentially 100% of silent sinus involve the orbit 7 Rare 8 Demographics Elderly (53.1 y old) CRS Younger African American males 20 Regions of high humidity 6 Middle aged (mean 30–50 y) 7 Idiopathic Meningioma Fibro-osseous disease 8 Immune status Normal Atopic 6 Normal Normal Common organisms None Aspergillus spp. (may present without fungal spores) 6 None None Location Frontal sinus 17 Medial and superior orbital wall 5 Medial orbital wall 21 Orbit floor 7 Most common 8: Frontal sinus Sphenoid sinus Maxillary sinus Ethmoid sinus Medical treatment Typically unresponsive 19 Oral and topical steroids Typically unresponsive 7 Typically unresponsive 8 Surgical treatment Decompress mass effect 5 Decompress mass effect 21 Unlikely to need orbital reconstruction as proptosis reverts to normal 2 Endoscopic maxillary antrostomy 7 Relief of ocular symptoms by widening of sinus ostium 8 Prognosis Reduction of symptoms Recurrence rate 25% in patients with orbital complications 5 Able to control with adjuvant medical therapy, regular follow-ups and monitoring for recurrence 6 Excellent if sinus remains patent 7 Reduction of symptoms following surgery 8 Abbreviations: AFRS, allergic fungal rhinosinusitis; CRS, chronic rhinosinusitis. Acute bacterial rhinosinusitis (ABRS) can spread to involve the adjacent orbit and is the most common infectious orbital complication of rhinosinusitis. This occurs most often in pediatric patients without any prior history of sinus problems and normal immune function ( ▶ Fig. 17.1). The onset can be quite rapid and alarming. Chandler has classified the spectrum of acute bacterial complications of rhinosinusitis 1: Preseptal cellulitis: Edema limited to eyelid with normal extraocular motility, painless eye movement, and normal vision. Anatomically, infection is superficial to the fibrous orbital septum and thus excludes the orbital contents. Orbital/postseptal cellulitis: Progressive edema, now involving the globe with chemosis, painful or limited extraocular motility, and in rare instances altered visual acuity. Anatomically, infection is deep to the fibrous orbital septum and thus involves the orbital contents. Subperiosteal abscess: Defined collection of pus between orbital bone (most often lamina papyracea) and periorbita. Patients may have limited motility and proptosis and an overall clinical picture of postseptal cellulitis; thus, imaging is critical to diagnosis. Orbital abscess: Pus within orbit, deep to periorbita, development of ophthalmoplegia. Cavernous sinus thrombosis: Intracranial infection with cranial nerve palsies, fever, headaches. Fig. 17.1 Coronal soft-tissue computed tomography (CT) of a pediatric patient (a) demonstrates subperiosteal abscess in common location along medial orbital wall. Coronal and axial CT of a different child (b,c,d) demonstrates small defect in lamina papyracea (arrow). Patient failed to respond to systemic antibiotics. Endoscopic sinus surgery, with drainage of the abscess resulted in rapid improvement in clinical picture. (These images are provided courtesy of MUSC Rhinology.) Acute invasive fungal rhinosinusitis occurs in patients with suppressed immune systems. This can occur in patients with hematologic malignancies, HIV (human immunodeficiency virus), diabetic ketoacidosis, or those taking immune-modifying medications for transplants or other conditions ( ▶ Fig. 17.2). Clinical presentation can be quite rapid in patients with extremely suppressed immune systems, such as after a bone marrow transplant, or somewhat indolent and mistaken for a routine viral or sinus infection in patients with more subtle immune deficiencies, such as those on long-term immunosuppressive medications Fig. 17.2 A transplant patient who presented with 2 to 3 weeks of sinus symptoms and subsequently developed limited extraocular motility. Symptoms were unresponsive to systemic antibiotics. Coronal soft-tissue CT (computed tomography) demonstrates what began as a fungus ball of the maxillary sinus, but eventually became invasive fungal rhinosinusitis with orbital involvement. Endoscopic sinus surgery, with removal of involved tissue down to periorbita and postoperative antifungals, resulted in rapid improvement. (This image is provided courtesy of MUSC Rhinology.)
17.2.1 Acute Bacterial Rhinosinusitis
17.2.2 Acute Invasive Fungal Rhinosinusitis
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