|Year : 2003 | Volume
| Issue : 1 | Page : 5-9
Orbital complications of rhinosinusitis
Ali Al Zarae, Awad Al-Serhani
Department of Otorhinolaryngology - Head & Neck Surgery, King Abdul Aziz University Hospital, College of Medicine - King Saud University Riyadh, Saudi Arabia
|Date of Web Publication||11-Jul-2020|
M.D Awad Al-Serhani
Dept. of ORL-H & NS, KAUH P.O. Box 245, Riyadh 11411
Source of Support: None, Conflict of Interest: None
Objective: This study was performed to determine the common features of orbital complications of rhinosinusitis.
Material and Method: This was a retrospective study of 21 patients’ charts who were diagnosed and treated for orbital complications of rhinosinusitis in King Abdul Aziz University Hospital (Riyadh, Saudi Arabia) over 10 years period (from 1992 to 2001).
Results: The most common presentations of orbital complications of rhinosinusitis were swollen upper eyelid (95.2%) followed by redness of the eyes (90.5%), pain and inability to open the involved eye (71.4%). Other less common features included diplopia (14.5%), proptosis (9.5%), and lower eyelid involvement (5%). The most common orbital complications was preseptal cellulitis (52.4%), followed by orbital cellulitis (33.3%) and subperiosteal abscess (14.3%). Features of Rhinosinusitis in patients with orbital suppuration were uncommon (23.8%). The most commonly affected sinuses were the ethmoids (43%) followed by the ethmoids in association with the maxillary sinus (24%), the frontal sinus (19%) and the sphenoid sinus (14%). The most common causative organisms were Staph, aureus (55%) followed by Streptococcus and H. influenza(15% each) and Moraxilla catarrhales (10%).
Conclusion: We conclude from this study that the most commonly involved single sinus related to orbital disease is the ethmoid sinuses followed by ethmoids in association with maxillary, frontal and sphenoid sinuses, while Staph, aureus as the commonest causative organism. The majority were diagnosed as cellulitis. Orbital abscess as well as cavernous sinus thrombosis were not found. All patient with orbital suppuration should be evaluated clinically and radiologically for sinus disease even if they do not have stigma of rhinosinusitis.
Keywords: Sinusitis, Orbital complications, Orbital cellulitis, Preseptal cellulitis
|How to cite this article:|
Zarae AA, Al-Serhani A. Orbital complications of rhinosinusitis. Saudi J Otorhinolaryngol Head Neck Surg 2003;5:5-9
| Introduction|| |
Orbital complications of paranasal sinusitis have been recognized for at least 50 years. , The most commonly used classification divides the stages of such complications into inflammatory edema (preseptal cellulitis), orbital (post septal) cellulitis, subperiosteal abscess, orbital abscess and cavernous sinus thrombosis.
These complications can occur in adults and children but are more common in children. , Rapid diagnosis and management is essential to prevent potentially serious outcome such as optic neuritis, endophthalmitis, meningitis and brain abscess.  Pathogenesis of orbital complications of rhinosinusitis depends on specific structural elements such as neurovascular foramina, congenital and acquired bony openings and valveless venous pathways anastomosis, which allow direct extension of bacteria into the subperiosteal space.
A patient with acute complication of rhinosinusitis whether a child or an adult has to be hospitalized, and treated without delay. Vision must be assessed by the ophthalmologist in all patients and high resolution CT scan should be obtained.Bacterial pathogens are usually the same that cause sinusitis although complication is common with some organism than the others. Beta-lactamase, resistant antibiotics are the mainstay of medical treatment.
The purpose of this study wasto examine the experience of King Abdulaziz University Hospital (Riyadh, Saudi Arabia) between 1992-2001 and determine accordingly the common features of orbital complications of rhinosinusitis.
| Materials and Methods|| |
All charts of patients with orbital infection seen in King Abdulaziz University Hospital (Riyadh, Saudi Arabia) during the period 1992 - 2001 were traced. A retrospective review of 21 patients’ charts who were diagnosed and treated for orbital complications of rhinosinusitis were studied.
Patients withother orbital suppuration not associated with documented rhinosinusitis were excluded from this study. We excluded also patients with other non orbital complications of rhinosinusitis like qsteomyelitis or intracranial complications.
The patients age, sex, presentation, duration of symptoms and diagnosticprocedures such as CT scan of paranasal sinus, brain, and orbit, B scan and ultrasound of the orbit and assessment of proptosis and visual acuity were noted. The involved sinuses and causative organisms were determined. The data were analysed and statistically studied by applying Z test.
| Results|| |
The study group consisted of 21 patients, 14 (66.7%) males and 7 (33.3%) females. The age range was from 1-75 years with the mean age being 17 years.
Majority of patients presented with history of swollen upper eyelid (95.2%), eye redness (90.4%), pain and inability to open the involved eye (71.4%). Other presentations included diplopia (14.2%) and proptosis (9.5%). Five patients (23.8%) had history of flue like symptoms few days before eye swelling and redness appeared. Presence of typical features of sinusitis were uncommon (23.8%) in patients with orbital suppuration.
Four patients (19.0%) who had stigma of acute rhi- nosinusitis developed subperiosteal abscess.
The only involved single sinus leading to orbital disease was the ethmoid sinus (43%), followed by ethmoid and maxillary (24%), ethmoid and frontal (19%), and ethmoid and sphenoid (14%) as illustrated in [Figure 1].
Duration of eye involvement ranged from 2-4 days prior to presentation.. The disease progressed rapidly in patients who did not receive antibiotics for sinus infection. Although some patients (33.3%) received antibiotics, the selection, the dose, or compliance were not proper and some were changed before presentation to the hospital. All patients with orbital complications were admit ted to the hospital and had radiological evaluation in the form of CT scan of paranasal sinuses. Five patients (23.8%) did not respond to intravenous antibiotics [Table 1] and CT scan showed abscess formation so they underwent surgical drainage [Figure 2],[Figure 3]. Three patients (14.2%) had endoscopic abscess drainage and two (9.5%) had combined external and endoscopic approach.
|Figure 2: CT scan finding showing Lt subperiosteal abscess and ethmoiditis|
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|Table 1: Distribution of antibiotic used for complicated rhinosinusitis in our series|
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Staphylococcus aureus was found to be the most common causative organism (55%) followed by Streptococcus pneumonae and, H. influenza (15%) each, and moraxella catarrhalis (10%). Non invasive Aspergillus flavus was found in one patient who had chronic rhinosinusitis and nasal polyposis for many years. The complication was due to secondary bacterial infection [Figure 4].
Orbital complications of rhinosinusitis were found to be more common in children (66.6%) than adults (33.3%). However, there was no significant difference in the sex distribution.
All patients, who were treated surgically (14.3%), were found to have pus collection intraoperative. After surgery intravenous antibiotic therapy was continued for about 7 days, then the patients were discharged on oral antibiotics, [Table 1]
The most common orbital complication was preseptal cellulitis (52.4%) followed by orbital cellulitis (33.3%) and subperiosteal abscess (14.3%)[Figure 5]. Orbital abscess and cavernous sinus thrombosis were not found in our series. There was no evidence of other serious complications such as intracranial extension or osteomyelitis.
| Discussion|| |
It is well known that the commonest complication of rhinosinusitis in all age groups is orbital complications. However, rhinosinusitis is more recognized as a common cause of orbital inflammation in children .
Although the incidence of serious complications of rhinosinusitis has decreased in the era of antibiotics, the risk of orbital involvement remains relatively high.
The incidence of orbital complications being secondary to rhinosinusitis is between 21-96%, the exact incidence of orbital complications due to sinusitis in children is unknown.
In the diagnosis of orbital complication of rhinosinusitis, the patient’s history, signs and symptoms are crucial. Proptosis of different degrees, visual disturbance such as diplopia or decreased visual acuity and/or impaired eye motility can occur. For the precise diagnosis the optimal assessment of vision is of utmost importance.
Some orbital complications can cause permanent or reversible visual loss. ,, This can be due to compression by the abscess or cellulitis resulting in elevated intraorbital pressure. Other possible mechanisms include septic optic neuritis, or embolic lesions in the vascular supply of theoptic nerve, retina or choroid. It is notable that the retina and optic nerve tolerate ischaemia for only a short time (2-3 hours). 
Although imaging can improve the diagnostic accuracy of acute sinusitis in some cases, many issues are still unresolved. For example, common colds, often include radiological evidence of sinus involvement. , However, diagnostic imaging is always indicated when a complication of sinusitis is suspected. 
Computerized topography, ultrasound and B scanning are helpful in detecting abscess formation. Magnetic Resonance Imaging is also helpful to distinguish between an abscess and cellulitis in the orbit.
Patients with a complication of sinusitis have to be hospitalized, and intravenous antimicrobial therapy has to be started without delay. The choice of antibiotics is based on the probability of the pathogens. Broad-spectrum antibiotics effective against aerobic and anaerobic bacteria is started till the organism can be cultured and the sensitivity is established.
It was reported in literature that acute diseases of ethmoid sinus in children and frontal sinus in adults are the frequent sinuses leading to orbital complications. In our study we have shown that involvement of the ethmoids either by acute or chronic infection was present in all cases of orbital diseases. This was involving the ethmoid alone in 43% followed by ethmoid and maxillary 24%, ethmoid and frontal 19% and ethmoid and sphenoid 14%.
Other observations were that 4 out of 5 patients with acute rhinosinusitis developed subperiosteal abscess (14.3%) as confirmed by radiological examination and operative finding forming (14.3%) of the series. All patients with subperiosteal abscess underwent surgical exploration while the others treated conservatively. In the literature, the criteria for surgical intervention include one or more of the following:
- Progression of disease for more than 24 hours despite appropriate antibiotic therapy.
- Lack of clear improvement after 48 to 72 hours of antibiotic therapy.
- Decrease in visual acuity or extraocular mobility as demonstrated by repeated ophthalmologic examinations, Obvious abscess demonstrated by CT scan.
- Immunocompromized patient and/or presence of other complications.
In our series the most common orbital complications of rhinosinusitis were preseptal cellulits (52.4%) followed by orbital cellulits (33.3%) and subperiosteal abscess (14.3%).
Patients with preseptal cellulitis and orbital cellulitis were hospitalized and received intravenous antimicrobial therapy. Orbital abscess and cavernous sinus thrombosis were not reported in our study. This may have been due to the early intervention as the hospital is an otolaryngology and ophthalmology center.
Although the most common organism causing sinusitis are Streptococcus pneumonia, H. influenza and Moraxilla catarrhalis, we found the most common organism cultured was Staph, aureus 55% while Streptococcus pneumonia and H. influenza were 15% for each and moraxilla was 10% as there is similarity of causative organism in acute otitis media and acute sinusitis the same is expected also for the organism causing complications; orbital complication of sinusitis is commonly caused by Staph, aureus simulating mastoid abscess (complication of acute otitis media); commonly caused by Staph, aureus .
Fungal elements in the form of aspergillus flavus was found in only one case (5%) along with bacterial infection. This patient had chronic rhinosinusitis complicating allergic rhinitis and had previous nasal surgeries. Orbital complication in his case may have been due to secondary bacterial infection.
We have found that incidence of symptoms and signs for rhinosinusitis are uncommon in this series (only 23.8%). From such finding, we strongly recommend full evaluation of the sinuses in patient presenting with orbital suppuration to exclude sinus disease even if he/she is not having any stigma of rhinosinusitis. Radiological evaluation in the form of CT scan is of utmost importance.
| Conclusions|| |
In our series the most common orbital complication of sinusitis was preseptal cellulitis followed by orbital cellulitis and subperiosteal abscess. The most commonly involved sinus was the ethmoid sinus followed by ethmoid in combination with the maxillary, frontal and finally sphenoid sinus. Staph, aureus was the commonest causative organism.
Any patient with suppurative orbital disease should be evaluated for sinus disease even if there is no stigma of rhino-sinusitis. Nasal endoscopy and radiological investigation are mandatory.
Impirical treatment should consider antibiotic coverage of Staph, aureus till culture and sensitivity is established. Close observation of vision is very important. Patient should be treated surgically if not improved by medical therapy or if there is evidence of abscess formation or visual impairment.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]