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ORIGINAL ARTICLE
Year : 2009  |  Volume : 11  |  Issue : 1  |  Page : 16-20

Intravenous corticosteroids in the management of orbital cellulitis


Consultant ORL Surgeon, Department of Ororhinolaryngology, Erfan-Bagedo General Hospital; Emeritus Professor of Otorhinolaryngology, King Abdulaziz University, Jeddah, Saudi Arabia

Date of Web Publication7-Jan-2020

Correspondence Address:
Kamal J Daghistani
P.O. Box 11217, Jeddah 21453
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-8491.275320

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  Abstract 


Objective: Orbital complications of acute sinusitis are common. If not treated promptly and properly, they lead to serious consequences. This study aimed at delineating the clinical , bacteriological and radiological findings and the outcome of management of orbital cellulitis.
Materials and Methods: This was a review of 17 cases of orbital cellulitis seen over the period April 2000-November 2007. Al cases received full clinical examination, laboratory testing and CT scanning of the sinuses. All cases were treated conservatively and follow up period was up to 2 years.
Results: Seventeen cases were reviewed. The age range was 7 months to 26 years and there were more males than females. The most common presenting feature was proptosis. Treatment consisted of I.V. antibiotics with I.V. Steroids. Local decongestant and steroid were also used.
No cases needed surgical interventions except for the incision and drainage of a lid abscess.
Conclusions: The addition of I.V. steroids to the management of orbital cellulitis is valuable and with no added morbidity.

Keywords: orbital cellulitis, I.V corticosteroids, rhinosinusitis,


How to cite this article:
Daghistani KJ. Intravenous corticosteroids in the management of orbital cellulitis. Saudi J Otorhinolaryngol Head Neck Surg 2009;11:16-20

How to cite this URL:
Daghistani KJ. Intravenous corticosteroids in the management of orbital cellulitis. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2009 [cited 2022 Dec 4];11:16-20. Available from: https://www.sjohns.org/text.asp?2009/11/1/16/275320




  Introduction Top


Bacterial infection in the paranasal sinuses is one of the most frequent diseases both in adults and children. Almost always secondary to a viral infection of the upper airways, sinusitis usually brings about rhinorrhea, nasal obstruction, headache and fever, among other signs and symptoms.

Among sinusitis complications, the ones that involve the orbit region are the most frequent and are usually associated with ethmoid sinuses involvement in younger patients [1]. The disease starts in the ethmoid sinus and the infection spreads into the subperiosteal lining of the orbit through the ethmoid bone. The lamina papyracea is so called because of its thinness and because it is perforated by several blood vessels. This combination allows ready spread of inflammation from the ethmoid sinus. The orbital septum is an extension of the periosteum of the frontal bone and extends into the eyelid. The orbital septum forms a sturdy barrier to spread of orbital infection from posteriorly to anteriorly or anteriorly to posteriorly. Because of its firm attachment to the upper edge of the frontal bone, infection beginning posteriorly is limited by the orbital septum and this can be used clinically where a sharp demarcation line is visible just below the brow. Even in severe orbital cellulitis a sharp the demarcation line, corresponding to the periosteal attach ment of the frontal bone is clearly visible.

It is estimated that sinusitis complications before the of antibiotics era occurred for 1 in every 5 patients, and the rates of both morbidity and mortality related to orbital cellulites were very high; from 17 to 20% of these patients died because of meningitis or ended up with some permanent visual impairment in the affected eye [2]. Currently, these sequels do not reach 5% of the cases [3].

Although today orbital complications of sinusitis are less common, especially because of the availability of CT scans and MRI that allow for accurate localization of the disease and early diagnosis, and the presence of broad spectrum antibiotic agents that aid in the proper treatment of the infectious processes, these situations keep on occurring and bear the same severity if not properly diagnosed and treated.

In 1948 Smith and Spencer [4] introduced a classification for sinusitis complications used in a series of adult patients, emphasizing that the categories would simply mean an artificial division of a continuous process. Chandler et al., in 1970, [5] modified this classification, and since then it has been used internationally. In all classifications proposed, proptosis seems to be the finding that differentiates the most severe stages of the complication [3]. In general, the larger the proptosis, more severe is the inflammation or the abscess size. In those patients who developed orbital cellulitis, 10% have temporary visual loss in the affected eye [5]. Other complications may occur less frequently and include meningitis, frontal osteomyelitis, and intracranial abscess.

The treatment of these complications requires the cooperation of different disciplines; the otorhinolaryn- gologist , the ophthalmologist , the pediatrician and the microbiologist[6],[7]. Clinical treatment is based on the use of high doses of intravenous antibiotics capable of crossing the blood-brain barrier, and by monitoring the response through systemic and visual signs and symptoms [8].

Infection is rarely due to a single organisms and Streptococcus, Staphylococcus, Bacteriodes, Haemophilus and anaeorbic Streptococcus are commonly found . Organisms responsible for causing pediatric orbital cellulitis are evolving, with Staphylococcus followed by Streptococcus species being the most common pathogens. The occurrence of MRSA in pediatric orbital cellulitis is increasing [8]. Periorbital cellulitis is often difficult to distinguish from orbital cellulitis. Preseptal and orbital cellulitis range in severity from minor to potentially severe complications.

This study aimed at delineating the clinical , bacteriological and radiological findings and the outcome of management of orbital cellulitis


  Materials and Methods Top


From April 2000 to November 2007 all cases with proptosis and signs and symptoms of sinusitis admitted to the Department of ENT, Erfan-Bagedo Hospital or Department of ORL King Abdulaziz Hospital, Jeddah, Saudi Arabia ( patients with other causes of proptosis were excluded from this study) and subjected to the following protocol:

  1. History and Clinical examinations ( the assistance of an ophthalmologists, paediatrician and microbiologist was always sought).
  2. Complete blood test including C-reactive protein (CRP) and blood culture.
  3. Pus for culture and sensitivity whenever found on examination of the middle meatus.
  4. CT scan of sinuses ( coronal and axial views ).


Patients with other causes of proptosis were excluded from this study.

Once orbital cellulitis was provisionally diagnosed the following was given:

IV antibiotics and continue on oral antibiotics once there is significant clinical improvement for 14 days.

IV dexamethaone for 48 hours.

Local decongestant for one week.

Local corticosteroids spray.

Oral decongestants when not contra-indicated.

Analgesics.

All patients were re-examined after 8 hours and 24 hours.

The modified Chandler [5] classificatio was used.


  Results Top


Seventeen patients were enrolled in this study with 11 ( 64.7% ) males and 6 ( 35.2%) females with a male to female ratio of 2.75:1.5. Age was 7 months to 26 years with a mean age of 6.8 years [Table 2] Sinusitis and URTI were the contributing factors. Seven of these patients were referred to us from the department by the ophthalmologist, three form the emergency room, three by pediatri cian and four attended the ENT outpatients clinic.
Table 1:

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Table 2:

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Radiologically confirmed sinusitis was found in 14 (77.7%) of patients and 12 ( 70.5%) had multiple sinuses involved. Six cases ( 35.2%) had a history of recent common cold.

Clinical presentation: All presented with proptosis. The majority presented with pain, fever and redness of the involved eye [Table 2]. Fundal examination was normal in all patients. Results of laboratory investigations are shown in [Table 3].

Average duration of symptoms before admission was 2 days (range 1-5 days) and average hospital stay was four days ( range 4-10 days). Follow up period was 4 month to two years.

Conservative treatment was successful in all patients. All patients received I.V. antibiotics followed by the oral route when their conditions stabilized and showed significant clinical improvement. This was continued for two weeks. Amoxicillin-Clavulanic acid in a dose of 30mg/kg body weight 8 hourly for children 7 month to 12 years old was given. The adult dose of 1.2 g every 12 hours was followed for children above 12 years. Adult patient received a combination of ciprofloxacin 200mg I.V. every 12 hours and metronidazole 500mg every 12 hours. Dexametrhasone : Children were given 200-500mcg I.V. in divided doses and adults 10-20mg I.V. in divided doses. Oral pseudoephedrine HCL tablets were given twice a day when not contraindicated to adults and older children while the syrup form was used for younger children. Xylometazoline HCL 1% drops was used locally in adults patients and 0.5% drops was used in children. One patient developed a lid abscess which was incised and drained [Figure 1].
Figure 1: left lid abscess before and after incision and drainage.

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Another patient developed a second attack of orbital cellulitis in the same eye five month later. This patient was a known case of nasopharyngeal carcinoma without recurrence for more than 10 years. She developed severe trismus as a complication of radiotherapy. Hence in this particular case medical treatment was of paramount importance. Fortunately she recovered completely with no recurrence of the disease at 2 years follow up [Figure 2].
Figure 2: Left orbital abscess

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  Discussion Top


Complications of acute rhinosinusitis seem to occur more frequently in children than in adults, and are directly linked to the intimate anatomical relations of the paranasal sinuses with structures of the head, neck . Orbital cellulitis may occur after trauma or intra-orbital surgery, however, it is more frequently found in children as a complication of sinusitis, especially of ethmoidal sinusitis [8],[9],[10].

In our series the majority ( 58.8%)of patients were less than 16 years of age with 10 children and seven adults. There were 11 males and 6 females in this series. Male patients also predominate in other series [3],[11].

The clinical features of orbital cellulitis are diffuse oedema of the orbital contents without abscess formation. Chemosis, proptosis and ophthalamoplegia may be present. All of our patients presented with proptosis ( 100%). Fever and chemosis were present in 76.4% while pain was present in 64.7% of patients. Four ( 23.5%) patients showed a decreased extraocular movements, Fundal examination was normal in all patients. Chemosis, proptosis, pain and limitation of extraocular muscle movements and decreased vision usually indicate post-septal involvement [3].

The amount of information that can be obtained from clinical examination is age-related and depends on the cooperation of the child . The assessment of vision can be difficult in young children with pronounced oedema.

Laboratory investigations can be of help but not necessarily reliable. Leucocytosis was present in 6 ( 35%) and CRP in 11 (64%) of patients. Chen-Fang Ho et al [13], report and elevated CRP in 70% of their cases with 31% rise of WBC. Staphylococcus aureus Scientific Name Search  was obtained from three ( 17.6%) of our patients. Our culture material was obtained from the middle nasal meatus. Staphyloccocus aureus is also reported by other workers [11].

The organisms most commonly responsible for orbital cellulitis are Staphylococcus aureus, Streptococcus pnuemoniae,Haemophilus influenzae and anaerobe . However, organisms responsible for causing pediatric orbital cellulitis are evolving, with Staphylococcus followed by Streptococcus species being the most common pathogens. The occurrence of MRSA in pediatric orbital cellulitis is increasing and empiric antimicrobial therapy should be directed against these organisms if they are prevalent in the community [9].

All blood cultures ( 100%) were negative in our patients. Chaudary et al report that blood cultures were positive in two of the 34 patients while Liu et al , report extremely low positive rate from blood culture in their series [14]. Positive blood culture yield was 3 out of 73 of patients in Chen-Fang Ho et al series [12].

CT scanning of the sinuses and orbits allows accurate localization of the sinus infection and usually enables an accurate grading of the orbital inflammation [6]. If any degree of displacement of the globe, ophthalamo-plegia or visual impairment is present an urgent C.T. scan is mandatory [9]. CT provides detailed information of bone and soft tissue with images in coronal and axial planes. MRI provides superior soft tissue resolution when compared with CT scan. It is the method of choice in evaluating soft tissue masses and suspicion of intracranial extension. Recently, ultrasound examination of the orbit is becoming popular. It is inexpensive, non-invasive and can be used at bedside. It can differentiate between orbital abscess and orbital cellulitis. Ultrasound can demonstrate different parts of the orbit including fat, muscles, optic nerve and masses. The early use of CT scan to assess the extent of the disease is important in establishing prognosis and in assessing the need for surgical intervention [6]. CT scan of the sinuses was employed in 17 of our patients. Radiologically confirmed sinusitis was found in 14 (77.7%) of the cases, 12 (70.5%) of whom had multiple sinuses involved. The ethmoid was the most commonly involved sinus followed by the maxillary sinus. This is in agreement with other reports in the literature [2],[13].

Although Chandler’s classification is the most commonly used, it has two drawbacks; One is that it does not cover other complications of sinusitis; Two cavernous sinus thrombosis is actually an intracranial complication. The existing classifications of orbital complications, as Chandlers, do not consider the orbit’s anatomical characteristics and became obsolete after the development of the CT scan [13]. All patients in our study received I.V. antibiotics, I.V dexamthesone for 48 hours, local corticosteroids and decongestants as well as oral decongestants, in addition to analgesics. We found that I.V amoxicillin + calvulanate was effective in children. Our adult patients received I.V ciprofloxacin and metronidazole. None of our patients developed further complication and none needed surgical intervention.

The use of corticosteroids in active infection goes against the classical teaching. Some authors do not recommend the use of corticosteroids in the presence of infection [14],[15]. However others recommend the use of corticosteroids and they do not report any complications [16],[17]. We administered IV corticosteroids for 48 hours in all of our patients without any untoward effects. Liu et [18] believe that early diagnosis and appropriate medical treatment and / or surgical intervention can achieve good results. Botting et al [7]recommend that in the absence of acute visual compromise or other signs of disease progression, initial management with intravenous antibiotics for 48 hours is advised . Caversacccio et al [1] believe that orbital cellulitis should be treated primarily with surgery. Uy and Tuano [19] consider ampicillin and flucloxacillin as a suitable regime in cases of children. Ferran et [20] treated 69% of their patients with a single antibiotic. In another report 2 out of 25 patients did not respond to medical treatment and needed surgery [2].

It is controversial whether medical management is adequate for orbital infection [21],[22]. Garcia and Harris [19] suggest a balance between securing adequate time for clinical response to I.V antibiotics and minimizing the risk of progression to complications .


  Conclusion Top


Orbital cellulitis is a dangerous disease that requires prompt and effective therapy. Conservative medical management plays a great role in the treatment and avoidance of surgical intervention. The addition of I.V corticosteroids at the very onset of treatment has a role to play.



 
  References Top

1.
Caversaccio M, Heimgartner S, Aebi C. Orbital complications of acute pediatric rhinosinusitis: medical treatment versus surgery and analysis of the computer tomogram. Laryngorhinootologie. 2005;84(11):817-21.  Back to cited text no. 1
    
2.
Lusk R, Tychsen L, Park TS. Complications of sinusitis. Pediatric Sinusitis edited by R Lusk, New York: Raven Press; 1992, pp.127-46.  Back to cited text no. 2
    
3.
Mekhitarian Neto L, Pignatari S, Mitsuda S, Fava AS, Stamm A. Acute sinusitis in children: a retrospective study of orbital complications. Braz J Otorhinolaryngol. 2007;73(1):75-9.  Back to cited text no. 3
    
4.
Smith AT, Spencer JT. Orbital complications resulting from lesions of the sinuses. Ann Otol Rhinol Laryngol 1948;57:5-27.  Back to cited text no. 4
    
5.
Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of orbital complications In acute sinusitis. Laryngoscope. 1970; 80:1414-28.  Back to cited text no. 5
    
6.
Beech T, Robinson A, McDermott AL, Sinha A. Paediatric periorbital cellulitis and its management. Rhinology. 2007 Mar;45(1):47-9.)  Back to cited text no. 6
    
7.
Botting AM, McIntosh D, Mahadevan M. Paediatric pre- and post-septal peri-orbital infections are different diseases. A retrospective review of 262 cases. Int J Pediatr Otorhinolaryngol. 2008;72(3):377-83.  Back to cited text no. 7
    
8.
Gurucharri MJ, Lazar RH, Younis RT. Current management and treatment of complications of sinusitis in children. Ear Nose Throat J. 1991;70(2):112.  Back to cited text no. 8
    
9.
Pignatari S, Mitsuda S, Sérgio A F, Stamm A. Rev. Bras. Otorhinolaringol. vol.73 no.1 São Paulo Jan./Feb. 2007.  Back to cited text no. 9
    
10.
Ho CF,Huang YC,Wang CJ,Chiu CH,Lin TY. Clinical analysis of computed tomography-staged orbital cellulitis in children. J Miceobiol Immunol Infect.2007;40(6):516-24.  Back to cited text no. 10
    
11.
Chaudhry IA, Shamsi FA, Elzaridi E, Al-Rashed W, Al-Amri A, Arat YO. Inpatient preseptal cellulitis: experience from a tertiary eye care centre. Br J Ophthalmol. 2008;92(10):1337-41.  Back to cited text no. 11
    
12.
Chen-Fang Ho, Yhu-Chering Huang , Chao-Jen Wang , Cheng-Hsun Chiu1, Tzou-Yien Lin . Clinical analysis of computed tomography-staged orbital cellulitis in children. J Microbiol Immunol Infect. 2007;40:518-524.  Back to cited text no. 12
    
13.
Velasco e Cruz AA, Demarco RC, Valera FC, dos Santos AC, Anselmo-Lima WT, Marquezini RM. Orbital complications of acute rhinosinusitis: a new classification. Braz J Otorhinolaryngol. 2007 Sep-Oct;73(5):684-8.  Back to cited text no. 13
    
14.
Maniglia AJ, Kronberg FG, Culbertson W. Visual loss associated with orbital and sinus disease. Laryngoscope.1984;94:1050-9.  Back to cited text no. 14
    
15.
Lane AP, Kennedy DW. In: Sinusitis and Polyposis. Ballemger’s Otorhinolaryngology Head and Neck Surgery, 6th Ed. Eds John B. Snow jr and John Jacob Ballaenger. BC Decker Inc. Hamilton, Ontario. Pp. 760-787,2003.  Back to cited text no. 15
    
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Shovlin JP. Orbital infections and inflammations. Curr Opin Ophthalmol. 1998;9(5):41-8  Back to cited text no. 16
    
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Wane AM,Ndoye-Roth PA, Demedeiros ME, Ndiaye MR,Ndiaye PA, Ben Nasr S,Wade A. Senegalese experience of orbital cellulitis. J Fr Ophthalmol. 2005;28(10):1098-94.  Back to cited text no. 17
    
18.
Liu IT, Kao SC, Wang AG, Tsai CC, Liang CK, Hsu WM. Preseptal and orbital cellulitis: a 10-year review of hospitalized patients. J Chinese Med Associat.2006; 69(9) 415-422.  Back to cited text no. 18
    
19.
Uy HS, Tuano PM. Preseptal and orbital cellulitis in a developing country: Orbit. 2007; 26(1):33-7.  Back to cited text no. 19
    
20.
Ferran LR,Vallhonrat RP, Youssef WF, Aristazábal JLR, Cubells CL, FernándezJP. Celulitis orbitaria y perior-bitaria. Revisión de 107casos. An Esp Pediatr. 2000;53:567-572.  Back to cited text no. 20
    
21.
Starkey CR, Steele RW. Medical management of orbital cellulitis. Pediatr Infect Dis J. 2001;20:1002-5.  Back to cited text no. 21
    
22.
Garcia GH, Harris GJ. Criteria for nonsurgical management of subperiosteal abscess of orbit: analysis of outcomes 1988-1998. Ophthalmology. 2000;107:1454-6.  Back to cited text no. 22
    


    Figures

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    Tables

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