Children may have less specific complaints of facial pain and headache associated with acute or chronic sinusitis than adults. Nasal symptoms of purulent discharge, congestion, and associated chronic cough with high fever or if lasting more than 10 days may indicate a sinus infection [4]. The ethmoid and maxillary sinuses are commonly affected in pediatric sinusitis. Infection may spread to the eye from the ethmoid sinus through the thin and permeable lamina papyracea (so named for its paper-thin nature) that separates these two compartments. Once infection breaches this bone, the periosteum and the orbital septum with which it is continuous anteriorly serve as the next barrier in protecting the eye. Additionally, the absence of valves within nasal and ophthalmic veins may permit hematogenous spread of infection within these compartments as well as intracranially. Chandler et al. have described the clinical stages of inflammatory lesions encountered in the orbit [5]. This classification provides a description of the progression of infection to the eye from the ethmoid sinuses (Table 9.1).

Children with facial infections, trauma, and prolonged intubation in the intensive care setting are also at risk for orbital infections [6]. Severe blunt facial trauma with fractures extending into the skull base may expose the contents of the orbit and cranium to sinus mucosa. Penetrating and lacerating injuries from bites or foreign objects around the orbit and maxilla may become infected.

Preseptal cellulitis in children 6–18 months of age usually follows a recent URI. If diagnosed promptly, this condition may be treated with outpatient antibiotics in compliant families. Subperiosteal orbital abscess (SPOA) is less common and requires inpatient admission for medical and possible surgical therapy [7, 8].

The diagnosis of periorbital or orbital infections is based on the practitioner’s index of suspicion and the general condition of the child. Proptosis, chemosis, loss of visual acuity, and restriction of ocular movement may be present with cellulitis, abscess, and cavernous sinus thrombosis. Infectious processes can threaten vision by direct extension, through pressure on the optic nerve and optic chiasm, or by direct extension into the cavernous sinus, which contains cranial nerves 3, 4, 6, and trigeminal V2 and V3 [9]. Figure 9.5 is a magnetic resonance image (MRI) revealing inflammation of the right side of the sphenoid sinus. Despite the lack of lateral extension noted on this scan, the patient experienced loss of sensation along the ipsilateral V2 and V3 branches. Progressive cranial nerve involvement, seizures, mental obtundation, hemiparesis, and meningeal signs may occur in conjunction with orbital infections and signal an ominous intracranial extension.

CT scans may be used as an adjunctive diagnostic procedure in children who present with equivocal symptoms or have had minimal therapeutic benefit from medical therapy. With suspected periorbital abscess or intracranial progression, CT with contrast provides accurate anatomical information for the surgical team by localizing both periorbital and intracranial pathologies. MRI with fat suppression techniques is less desirable than CT because of the lack of bone detail, but it does have some advantage in differentiating cellulitis and abscess. MRI is also superior to CT in detecting cerebritis and dural inflammation (Fig. 9.6) [10].

While many consider the CT scan to be the “gold standard” in diagnosing subperiosteal abscesses, CT findings may be equivocal despite moderate-to-severe clinical findings. The timing of CT scanning may influence these results. An immature abscess may be diagnosed as a subperiosteal phlegmon in the very early course of treatment [11].

The presence of subperiosteal abscess is not in itself an absolute indication for surgery, and multiple studies have reported that some patients with this condition can be successfully treated with medicine alone [12, 13]. The initiation of broad spectrum antibiotics as early as possible is necessary to reduce the morbidity and possible mortality of this condition [14]. Studies of bacteriology of acute pediatric sinusitis show that these infections are often polymicrobial, with Streptococcal species, Haemophilus influenza, Moraxella catarrhalis, and anaerobes frequently cultured [15]. Initiating antibiotics with coverage of β-lactamase-producing or penicillin-resistant bacterial strains, such as ceftriaxone or ampicillin-sulbactam in addition to covering anaerobes with metronidazole or clindamycin, is recommended. Decongestants, both topical oxymetazoline and systemic pseudoephedrine, are sometimes used to promote sinus drainage. Vigilant ophthalmologic and neurologic examinations are essential over the first 24 h of hospitalization in patients to observe for changes in visual acuity or motility [16].

Prompt drainage should be considered if the patient’s condition worsens or is not apparently improved with antibiotic therapy over an observation period of 24–36 h. The indications for immediate surgical management of periorbital abscesses are:

Exploration is, therefore, based on the general condition of the patient and may be recommended in children with equivocal CT scans but who exhibit worsening orbital symptoms (Figs. 9.6 and 9.7). Various authors have reported that patients are more likely to fail a trial of medical management for SPOA if they present with significant proptosis (>2 mm), are older (≥9 years), have large abscesses (width >4 mm), have elevated intraocular pressure (>20 mmHg), chemosis, or gaze restriction [17–19]. In a review article of the available literature, Bedwell and Choi recommended prompt surgery as the primary treatment modality for patients with impaired visual acuity, elevated IOP, ophthalmoplegia, proptosis ≥5 mm, and abscess width >10 mm [13]. Patients with less severe findings may improve with conservative management.

Surgical drainage of SPOA can be accomplished via either an endoscopic or open approach and sometimes necessitates a combination of the two. The majority can be drained via an endoscopic approach. In these procedures, the maxillary sinus is drained via removal of the uncinate process. The anterior and posterior ethmoid sinuses are then opened allowing drainage of what is likely the primary site of infection. If there is an obvious dehiscence in the lamina papyracea in continuity with the infected ethmoid, the procedure can be deemed complete at this point. Otherwise, the lamina can be opened to evacuate the SPOA into the nose. The use of image guidance, which correlates intraoperative surgical landmarks to the patient’s preoperative CT data, can be used to enhance safety and accuracy [20]. Endoscopic drainage may be difficult when the surgeon encounters limitations to surgical exposure secondary to severe intranasal cellulitis, edema, and bleeding brought about by the acute sinusitis. Also, the child’s nasal cavities are smaller, further limiting the visual workspace and increasing the possible risks of intracranial and orbital injury. Pre- or intraoperative use of dexamethasone, reverse Trendelenburg positioning, and meticulous hemostasis through topical vasoconstrictive agents all may aid in facilitating safe endoscopic surgery. Nevertheless, in cases where surgical access is difficult or when the abscess is in a more superior location, an open approach may be necessary. The Lynch incision offers an excellent external approach to the orbit, the ipsilateral ethmoid, and frontal sinuses (Fig. 9.8). During this procedure, the lamina papyracea is opened widely to offer drainage of the abscess into the ethmoid sinuses. The ethmoid and other affected sinuses should be opened and able to drain into the nasal cavity. A rubber band drain is placed in the external incision and removed in 2–3 days. Intracranial, orbital, and sinus infectious processes should be treated during the same setting for optimal recovery [21–23].

Pathological findings associated with tumors and expanding intranasal masses of the upper airway and surrounding structures of the orbit may lead the physician to obtain an otolaryngology consultation. The nasal exam in the office, emergency department, or intensive care unit should begin with observation of alar and midnasal symmetry, dorsum swelling, or a protruding nasal mass. Airflow reduction from a nasopharyngeal or paranasal sinus mass may produce mouth breathing, hyponasal speech, snoring, and sometimes sleep apnea. Nasal endoscopy is advised in the workup of abnormal masses causing obstruction (Fig. 9.10). Signs of serious pathology include reduced visual acuity, trismus, hypesthesia of the cheek, and swelling of the nose, face, and orbital rim [27]. Orbital findings such as chemosis, proptosis, and/or extraocular muscle immobility may occur during the process of extension of tumor from the nose and paranasal sinuses into the orbit [28]. Children may not exhibit orbital symptoms for an extended period of time if the tumor originates in the deeper parts of the skull base or nasal cavities. Unilateral chronic rhinorrhea should be considered to be a sign of nasal tumor or foreign body until proven otherwise.

Pediatric epistaxis may have various causes such as local inflammation and trauma of the normal nasal and sinus vasculature or angioblastic growth and necrosis of various tumors, such as juvenile angiofibromas. Systemic causes may include a blood dyscrasia or hereditary conditions such as hereditary telangiectasia [29].

After careful history and physical examination have been performed, management of the pediatric patient with a suspected orbital or skull base lesion should be directed toward obtaining appropriate radiologic imaging studies. Due to the vascularity associated with certain tumors and the possibility of direct intracranial extension, imaging must be performed prior to any surgical intervention, including biopsy. The combination of both high-resolution CT and MRI is ideal in imaging the bony and soft tissue details of nasal tumors. CT is ideal for evaluating bone erosion, and MRI is the ideal modality to differentiate benign sinus obstruction with inspissated mucus from tumor. Both examinations are useful in identifying tumor type, extension, and vascularity [30].