Orbital Complications of Sinusitis and Management

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).

























































Table 17.1 Infectious orbital complications of rhinosinusitis


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


89.9% of CIFS and granulomatous invasive fungal CRS 10,​ 11


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


Chronic steroid use 3,​ 11,​ 13


Can have no known immunosuppression


Diabetes mellitus


AIDS


Chronic steroid use 3,​ 11,​ 13


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 or superior orbital wall 9,​ 14


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.



































































Table 17.2 Noninfectious orbital complications of sinusitis


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


Previous sinonasal trauma 5,​ 19


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.



17.2.1 Acute Bacterial 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.)


    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,



17.2.2 Acute Invasive Fungal Rhinosinusitis


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



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


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.)

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Feb 25, 2020 | Posted by in OTOLARYNGOLOGY | Comments Off on Orbital Complications of Sinusitis and Management
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