Orbital Complications of Sinusitis

Orbital Complications of Sinogenic Origin: A Case Study of 20 Patients

Authors: Shrinivas Shripatrao Chavan*, Sunil D.Deshmukh**, Vasant G. Pawar***, Vaibhav G. Kirpan****, Smita W Khobragade****, Kaustubh Sarvade****, Dasharath M Kothule*****

*Assistant Professor ENT, **Professor & Head ENT, ***Senior Resident, ****Resident, *****Professor & Head Opththalmology

Institution: Department of Otorhinolaryngology and Head and Neck Surgery, Govt. Medical College, Aurangabadn (Maharashtra), India.

Corresponding Author:

Shrinivas Shripatrao Chavan
Department of ENT and Head and Neck Surgery
Government Medical College
Aurangabad ( M.S.)
E mail shrinivasc77@hotmail.com

Abstract:

Sinusitis with orbital complication is a potentially fatal disease that has been known since the days of Hippocrates. Primary sinus infection is the most common cause of orbital cellulitis and if not diagnosed early and managed aggressively it poses life-threatening complications such as meningitis, cavernous sinus thrombosis and brain abscess. The purpose of our study is to evaluate the clinical presentation, diagnosis, management and surgical outcome of orbital complication due to sinusitis.

Patient and Method : We retrospectively reviewed 20 patients with orbital complication of sinogenic origin admitted to the Otorhinolaryngology and Ophthalmology ward of the Government Medical College of Aurangabad from Jan. 2007 to Sept. 2010. The clinical presentation, laboratory examination, radiological finding, bacteriological report and treatment method were analyzed.

Results : 20 patients with orbital complication of sinogenic origin were treated. The mean age was 40-60 years. There was male preponderance. CT scan showed subperiosteal abscess in 7 (35%) and orbital abscess in 5 (25%). The most common infection was of the ethmoid sinus. It was involved, unilaterally, in 6 (30%) patients and bilaterally in 14(70%). Considering the extent and severity suggested by clinical features and radiological finding, 7 cases were treated conservatively and 13 cases needed surgical intervention. Out of 13 cases, 2 cases were approached externally and 11 cases were approached endonasally. The culture report of the excudate showed Staphycoccus aureus in 16 (80%) as the most common pathogen followed by B Hemolytic Streptococci, mycobacterium tuberculosis, and aspergillus species. None of our patients showed cavernous sinus thrombosis, or brain abscess during the course of management and follow up after 1 to 2 months.

Introduction:

The paranasal sinus is a group of air-filled spaces in the skull that surround the nasal cavity extending superiorly to the skull base and laterally to encompass the medial wall and floor of the orbit.¹ Paranasal sinus infection is most frequently encountered in the medical practice and with higher, broad spectrum, and newer antibiotics the majority of cases are managed without any complication. Orbital complication of sinogenic origin is an age old disease that has been described even during the days of Hippocrates.² Due to the close proximity of the orbit with the ethmoid, maxillary, frontal and sphenoid sinuses any sinonasal infection, if not diagnosed early and treated adequately, can lead to the spread of infection through the neurovascular foramina via congenital and acquired bony dehiscence and indirectly through the valveless ophthalmic veins draining the sinuses and orbit as a result of thrombophlebitis and embolism.^2,3,4 The erosion and destruction of the lamina papyracea, a paper-thin bone separating the ethmoid sinus and orbit, provides the most common pathway for the contagious spread of sinus infection to the orbit.² Orbital complications of sinusitis include edema, orbital cellulitis, subperiosteal abscess, orbital abscess, cavernous sinus thrombosis and in advanced stage intracranial complications such as meningitis and brain abscess.³ Orbital complication of sinogenic origin should always be treated as an emergency and treated aggressively as it poses life-threatening intracranial complications and blindness. Prompt recognition, correct diagnosis and appropriate treatment is necessary to avoid orbital complications of sinogenic origin. The aim of our retrospective study is to evaluate the clinical features, radiological finding, bacteriology, treatment and outcome of the disease.

Methods:

A retrospective study was conducted by the Otorhinolaryngology and Ophthalmology Department of the Government Medical College, Aurangabad, of all cases of clinically and radiologically diagnosed orbital cellulitis of sinogenic origin admitted to our institute from the period of Jan. 2007 to Sept. 2010. The inclusion criteria of our study were orbital complications of sinogenic origin. While exclusion criteria was any orbital pathology other than sinogenic origin. A series of 20 patients were included in our study among which 12 were males and 8 were females. The inclusion criteria were entirely based on clinical signs and symptoms, laboratory test and radiological investigation. The sinusitis was defined as presence of opacification or air fluid level on CT scan. All cases had undergone ophthalmic and medical examination. Based on Chandler’s Classification, we categorized our cases into 4 groups. All patients were kept on IV antibiotics and steriods for 48 hours. Seven cases that had preseptal or orbital cellulitis were classified into Chandler's groups I and II. These cases responded well to antibiotics and steroids. The other 12 cases with more severe disease were categorized into Chandler's groups III, IV and V. These cases required surgical intervention.² However, our surgical intervention was entirely based on CT scan showing subperiosteal abscess, orbital abscess and failure to improve clinically within 48 hours. In 2 cases, we utilized an external approach and in 11 cases we performed endonasal drainage using a 0 degree and 30 degree endoscope.

Surgical management:

External approach: Osteoplastic bone flap procedure:
A bitemporal coronal incision was used to elevate a scalp flap to the level of the supraorbital rim. The borders of the frontal sinus are determined and marked, by visual inspection or if necessary by using transillumination or a x-ray template. The sinus is then opened with a chisel and its contents exposed. The diseased contents are removed. The walls of the frontal sinus are polished with a drill and the mucosa is completely removed. The nasal mucosa is inverted towards the nose. The frontonatal duct is sealed with cartilage and a layer of connective tissue. The sinus cavity is filled with freshly harvested abdominal fat and the bony flap is replaced and secured with periosteal suturing .

The above patient is a 55 year old male with a 4 month history of proptosis and a one month history of diplopia and headaches.. The above FLASH presentation shows the large left frontal mucocele eroding through the anterior wall of the sinus and displacing the globe laterally and inferiorly. The patient's MRI Scans and intraoperative pictures are also shown.

Endoscopic approach:⁷ With the 0 degree endoscope, diagnostic nasal endoscopy was performed to inspect the status of the sinuses and lamina papyracea. Uncinectomy was performed. The anterior and posterior ethmoid sinuses were cleared, respectively. In four cases, maxillary sinus clearance was accomplished by widening the maxillary ostium. In cases where lamina papyracea was intact, a vertical cut was made on the anterior aspect using a Freer‘s elevator. The bony plate was elevated, medially, and the purulent contents were evacuated. In four cases, the frontal sinus was opened using Giraffe forceps. The purulent material and granulation tissue was sent for microbiological examination and culture.

Results:

Of the 20 patients included in our study, 12 (60%) were males and 8 (40%) were females. The age range was between 8 to 65 years with 25% belonging to the 4th decade and 25% belonging to the 5th decade.

Figure 1: Age & sex distribution of patients with orbital complications of sinogenic origin.

Orbital complication of sinogenic origin was encountered more commonly on the right side compared to the left side. The most common symptoms, on the day of admission, was lid edema and erythema in 20 (100%) patients followed by proptosis in 14 (70%), purulent rhinorrhea in 8 (40%), restricted extraocular mobility in 8 (40%) and diplopia in 5 (25%) along with constitutional symptoms like fever and headache.

Table 1: Clinical features on presentation

Clinical Features	Number	Percent
Lid edema and lid erythema	20	100
Proptosis	14	70
Purulent rhinorrhea	8	40
Restricted extraocular mobility	8	40
Vision loss	5	25
	0	0

Figure 2: Percentage of Types of Orbital Complications

All the cases were kept on broad spectrum antibiotics (Amoxicillin, clavanate and metronidizole) and steriods (Dexamethasone 8 mg) for 48 hours.¹⁴

All of the patients underwent CT scan of the perinasal and sinus area (PNS) which showed a solitary ethmoid sinusitis in 30, followed by Ethmoid, Frontal and Maxilary Sinuses in 20%, Maxillary Sinus in 15%, Frontal Sinus in l5%, Ethmoid and Frontal Sinuses in 10%, Ethmoid and Maxillary Sinuses 10%.

Table 2: Distribution of involvement of sinuses

Sinuses Involved with Disease	Number	Percent
Ethmoid	6	30
Maxillary	3	15
Frontal	3	15
Ethmoid & Frontal & Maxillary	4	20
Ethmoid & Frontal	2	10
Ethmoid & Maxillary	2	10
Sphenoid	0	0

Out of eight cases which were grouped into Grades I and II, seven cases responded well to antibiotics and steroids and one case deteriorated clinically and was taken for surgery. Twelve cases which showed evidence of subperiosteal and orbital abscess were taken to surgery after 48 hours of antibiotics and steroids. Two cases were performed by external approach and 11 cases were done by endonasal approach.

Table 3: Management of preseptal and postseptal orbital complications

	Conservative	Surgical Treatment (N=12) 60%
	Treatment (N=8) 40%	External Approach	Endoscopic Approach
Preseptal/Orbital Cellulitis	7 (35%)	0	1 (5%)
Subperiosteal abscess	0	0	7 (35%)
Orbital abscess	0	1 (5%)	3 (15%)
Frontal pyocele	0	1 (5%)	0

The pus culture report showed staphylococcus aureus (80%) most common pathogen followed by beta hemolytic streptococci (5%), H influenza (5% ), mycobacterium T B (5%), Aspergillus species (5%).

Table 4: Distribution of causative organisms.

Organism	Number	Percent
Staph. aureus	16	80
Beta Hemolytic Strep	1	5
H. Influenza	1	5
Mycobacterium T.B.	1	5
Invasive Aspergillus	1	5
Anaerobic micro-organisms	0	0

In the immediate postoperative period, all cases showed dramatic improvement in proptosis and restricted ocular mobility and gradual resolution of lid edema and erythema over a period of 4-5 days, postoperatively. Seven cases which were managed conservatively were discharged on oral broad- spectrum antibiotics and local steroid spray. Patients were to follow up after 1 month with repeat CT scan of the perinasal and sinus area (PNS) to evaluate for any evidence of persistent sinusitis.

Case 1: The patient is a 12 year old male who had a four day history of fever and painful swelling around the left eye. He had headaches for two days and a purulent drainage from the left eye. CT scan showed a maxillary and ethmoid sinusitis with a defect in the lamina papyracea and a subperiosteal abscess. The patient did not respond to IV antibiotics and underwent endoscopic sinus surgery with an ethmoidectomy, opening of the frontal recess and drainage of the subperiosteal abscess.


Pre Operative Appearance	Post Operative Appearance	Post Operative Appearance

Case 2: The patient is a 42 year old male with a three month history of swelling over his right eye. He has a one month history of proptosis, diplopia and headaches. CT scan showed a 4.5 by 4 cm expansile cystic lesion of the right frontal sinus with extension into the orbit. The patient was treated by an endoscopic anterior ethmoidectomy, drainage of the frontal sinus and removal of the lamina papyracea for orbital decompression.


Pre Operative Appearance	Pre Operative CT Scan	Post Operative Appearance

Case 3: The patient is a 52 year old female who complained of painful swelling around the left eye and purulent left nasal drainage for five days. She had a frontal headache and an intermittent fever. She also had a past history of repeated episodes of rhinitis. CT scan showed a left maxilllary and ethmoid sinusitis. Cultures were positive for Aspergillus. She was treated with endoscopic drainage of the maxillary, ethmoid and frontal sinus and post-operatively was given Amphotericin B.


Pre Operative Appearance	Pre Operative CT Scan	Post Operative Appearance

Case 4: The patient is a 64 year old female who presented with a chief complaint of proptosis and decrease in vision in the right eye for the past 15 days. She also complained of headaches for 10 days. She had no history of trauma or nasal drainage. CT Scan showed a large right frontal mucocele with intraorbital extension. An endoscopic anterior ethmoidectomy with drainage of the frontal sinus and removal of the lamina papyracea for orbital decompression was performed.


Pre Operative Appearance	Pre Operative CT Scan	Intraoperative Transillumination Immediately After Endoscopic Frontal Sinus Drainage

Case 5: The patient is a 70 year old male who presented with a two month of gradual swelling of his right ey and a one month history of diplopia and proptosis with painful restriction of extraocular movement. The CT scan showed a 4 by 5 cm cystic lesion originating in the right frontal sinus. The patient underwent Functional Endoscopic Sinus Surgery under general anesthesia. An anterior and posterior ethmoidectomy with maxillary sinus osteotomy was performed. The right frontal sinsu osteum was opened and thick fluid was drained. External pressure further decompressed and drained the cystic cavity. The right lamina papyracea was removed to decompress the orbit and aid in drainage.


Pre Operative Appearance	Pre Operative CT Scan	Post Operative Appearance

Discussion:

Orbital infection has long been the most common complication of sinusitis. In developing countries, sinusitis is under treated and is one of the leading causes of orbital complications.^1,5 In the pre-antibiotic era, the morbidity and mortality in patients with orbital complications secondary to sinusitis were 20.5% and 17%, respectively.^12,13 With the advent of stronger antibiotics and newer surgical modalities, rates of morbidity and mortality have declined to 3-11% and 1-2.5%, respectively.^8,9

In 1937, Hubert, was the first to classifiy orbital complications of sinusitis into five groups.¹ This classification was refined by Smith and Spencer.⁴ The latest classification was introduced by Chandler in 1970 and is well accepted today.⁶

Chandler’s classification of orbital complications of sinusitis:

Group 1 (preseptal cellulitis)	Inflammatory edema due to restricted venous drainage	Edematous nontender eyelid
Group 2 (orbital cellulitis )	Pronounced edema and inflammation without abscess formation	Edematous eyelid with signs of proptosis and reduced ocular mobility and chemosis
Group 3 (subperiosteal abscess)	Pus collection in space between bone and periosteum	Marked edema and proptosis
Group 4 (orbital abscess)	Pus collection within orbital contents	Severe proptosis; complete ophthalmoplegia with loss of vision
Group 5 (cavernous sinus thrombosis)		Fever, headache, ophthalmoplegia, loss of vision, cranial nerve palsy

Shramm and Molony did further modification in Chandler’s classification.⁶

Acute sinusitis is most commonly seen in the pediatric age group and so are the complications.² But in our study, the highest incidence is seen in the fourth and fifth decade each with a 25% incidence with male preponderance. Incidentally, the right eye has consistently been shown to be more frequently affected. The Ethmoid sinus (70%) is most commonly seen to be involved in orbital complications of sinusitis followed by Frontal (45%) and Maxillary (45%) with the most common pattern of sinus involvement with the combination of Ethmoid, Maxillary & Frontal Sinuses (20%).

In our study, all of the 20 patients were having lid edema and erythema (100%), 14 cases (70%) had proptosis, 8 cases (40%) had purulent rhinorrhea, 8 cases (40%) had restricted extraocular mobility and 5 cases (25%) had diplopia as the presenting complaint.

A CT scan showed subperiosteal abscess in 7 cases (35%) followed by periorbital cellulitis in 5 cases (25%), orbital abscess in 5 cases (25%) and 3 cases (15%) showed orbital cellulitis. Not a single case of cavernous sinus thrombosis, meningitis and brain abscess was reported.

Due to the improvement in socioeconomic status and hygiene, the rate of morbidity and mortality of orbital complications has decreased. In addition to this increased awareness of possible complications and the introduction of advanced diagnostic tools, new broad spectrum antibiotics and innovative surgical technique have improved the management of infection.
The first line of treatment suggested in all these cases was IV antibiotics and steroids. Patients were considered for surgical management on the basis of CT findings and deterioration of their condition despite receiving IV antibiotics. CT scans were 90% accurate in determining appropriate initial management. CT scans helped to differentiate orbital cellulitis and orbital abscess.

Patients who were having orbital abscess and subperiosteal abscess were considered for surgical intervention. Seven (35%) of patients belonging to group I and group II (Chandler) improved with IV antibiotics and steroids without any surgical intervention. 72% of the cases in Schramm’s series and 73% of the cases in Gan’s series improved with antibiotics alone.^10,11 The adjunct use of steroids with antibiotics improves the healing process in experimentally induced rhinosinusitis.¹⁴ Surgical interventions were indicated in patients belonging to group III, IV, and V(Chandler). Out of 13(65%) patients in which surgical interventions were used, 11 (84.61%) cases underwent endoscopic drainage by an ENT surgeon, by the first author of this case study. The frequency of surgical intervention was 21% in Schramm’s series and 27% in Gan’s series.

Microbiological results of the excudate and culture showed staphylococcus aureus (80%) as a leading pathogenic organism. One case each of tuberculous (5%) and fungal (5%) sinusitis was found to cause orbital complications.⁵ In the immediate postoperative period, patients showed dramatic resolution of proptosis and improvement in extraocular mobility and resolution of lid edema and chemosis by the fifth postoperative day. All patients were followed up with antibiotics and nasal steroid spray. After one month a CT scan of the perinasal sinuses was performed to detect any residual sinusitis.

Orbital complications, secondary to sinusitis, in the new millennium still poses a serious threat to patients and can lead to irreversible damage if not treated aggressively. The clinical manifestations and CT findings provide the mean for making diagnostic and therapeutic decisions. Standard surgery still plays an important role especially in treating orbital abscess. The trend has shifted from using the external open technique to endoscopic sinus surgery; as a safe and effective measure of surgical drainage for subperiosteal and orbital abscess.

Conclusion:

1) In our study, patients belonging to group I and group II (Chandler’s classification) were treated successfully with IV antibiotics, and the rest of the patients were managed surgically .
2) Endoscopic approach is preferred approach over external.
3) In our study, orbital complications secondary to sinusitis are common during the fourth and fifth decade with male preponderance.
4) The right eye is commonly seen to be involved.
5) The ethmoid sinus is the most commonly affected area with 70% of the cases with the common pattern of pansinusitis (Ethmoid, Frontal and Maxillary Sinuses) in 20%.
6) Staphylococcus aureus (80%) is the most common causative organism in our study.
7) Two, not so common cases of tubercular sinusitis and fungal sinusitis, were found to cause orbital complication and were treated surgically followed by antitubercular and antifungal therapy, respectively.
8) In this era of stronger antibiotics, vision loss, meningitis and brain abscess are the rarest complications of sinusitis and were absent in the patients in our study.

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