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Management of medial subperiosteal abscess of the orbit in children—a 5 year experience
INTERNATIOW JOURNALOF
International Journal of Pediatric Otorhinolaryngology ELSEVIER
38 (1997)
247-254
Management of medial subperiosteal abscess of the orbit in children-a 5 year experience Kevin D. Pereira*, Ron B. Mitchell, Ramzi T. Younis, Rande H. Lazar Otolaryngology Consultants of’ Memphis, Le Bonheur Childrens Medical Center. 777 Washington Aoenue, P240 Memphis, Tennessee 38105, USA
Received 14 June 1996; revised 23 August 1996; accepted 30 August 1996
Abstract A medial subperiosteal abscess (SPA) of the orbit is the most common serious complication of sinusitis in children. The distinction between SPA and the more benign pre-septal disease is difficult to make especially in a young child in whom an ophthalmological evaluation is often difficult. Computerised tomography (CT) is the investigation of choice in making this distinction. Subperiosteal inflammatory disease of the orbit is initially treated with intravenous antibiotic therapy with surgery reserved for those patients who do not respond to medical treatment and in whom a medial SPA is confirmed by CT. Conventionally, the abscess is drained via an external incision and an ethmoidectomy is performed at the same time. More recently, successful drainage of SPA’s has been accomplished endoscopitally via a intranasal approach with less morbidity and superior cosmesis. We present a 5 year experience of 24 patients with CT scans suggestive of medial SPA who underwent endoscopic exploration of the medial subperiosteal orbital space. We discuss the current management of medial subperiosteal disease of the orbit in children and include a review of the literature. Also included is a clinical staging system which aids the management of orbital complications of sinusitis. Copyright 0 1997 Elsevier Science Ireland Ltd. Keywords:
Complications;
Subperiosteal
abscess; Sinusitis; Children
* Corresponding author. 0165-5876/97/$17.00 Copyright 0 1997 Elsevier Science Ireland Ltd. All rights reserved PIISO165-5876(96)01445-O
248
K.D. Pereira et al. 1 Int. J. Pediatr. Otorhinolaryngol.
38 (1997) 247-2.54
1. Introduction
Orbital complications of sinusitis are infrequently seen in the present antibiotic era [3]. However, paranasal sinusitis remains the most common cause of orbital inflammation and infection [1,9]. Pre-septal inflammation is an acute invariably unilateral condition limited to the tissues of the eyelid and is a well recognized consequence of acute sinusitis in children. It is of vital importance to differentiate this generally benign condition from the more sinister infection of the post-septal tissues, as both can present clinically with periorbital edema and chemosis. Subperiosteal inflammatory disease adjacent to an infected ethmoid sinus is the hallmark of post-septal infection and is a serious condition requiring prompt diagnosis and treatment. The incidence of a sub periosteal abscess (SPA) in orbital infections is about 15%. However despite aggressive management 15-30% of these patients develop various visual sequelae [7]. Computer tomography (CT) scanning is the imaging modality of choice in distinguishing pre-septal cellulitis from post-septal infection of the orbit, and can help in determining initial management. The criteria for performing a CT scan in a child suspected of having this condition are shown in Table 1. Regardless of the edema in the periorbital tissues, a detailed ophthalmological examination is seldom successful in a sick child. In view of this limitation and the aggressive nature of the disease in the pediatric population, it is prudent to obtain a CT scan even in casesof pre-septal inflammation [6]. Traditionally, a medial SPA is drained via an incision halfway between the nasal bridge and medial canthus, with a partial or complete ethmoidectomy performed at the same time. However, successful intranasal drainage using endoscopic techniques is being reported with increasing frequency [1,4,5]. We present 24 cases of post-septal inflammation of the orbit secondary to sinusitis in children and discuss the salient diagnostic and therapeutic issues pertinent to this problem. To the best of our knowledge this is the largest reported series of children with medial SPA’s of the orbit successfully drained by endoscopic sinus surgery.
Table 1 Criteria for performing
a CT scan
Inability to perform a satisfactory opthalmological examination Deterioration of orbital signs despite intravenous antibiotic therapy Diminished visual acuity or restrict& of ocular movement Absence of clinical improvement after 24 h of antibiotic therapy
K.D. Pereira et al. / ht. J. Pediatr. Otorhinoluryngol.
38 (1997) 247-254
249
2. Patients and methods
A review of all children with clinical and CT evidence of medial subperiosteal orbital inflammation, unresponsive to medical treatment, was carried out at the LeBonheur Childrens Medical Center from January 1990 to December 1994. Twenty four patients (15 male, 9 female; age range 2- 14; mean age 5.2) were included in the study. Seventeen patients were admitted via the emergency room and seven patients were referred from other hospitals because of an inadequate response to antibiotic therapy or deterioration in orbital signs. Sixteen patients were started on intravenous (iv.) cefuroxime sodium. The other i.v. antibiotics used were oxacillin, penicillin, chloramphenicol and cefotaxime. Ophthalmologic consultation and CT scans (coronal and axial views) were obtained on all children. Patients with CT evidence of a medial subperiosteal mass lesion in the orbit were treated with endoscopic sinus surgery (ESS). A modified Messerklinger technique was used to perform an endoscopic ethmoidectomy. The lamina papyracea was inspected and if intact, a horizontal cut was made on the inferior surface of the bone using a Freer elevator and extended anteriorly and superiorly. Pus was evacuated by elevating the plate of bone medially. Pus and/or infected tissue was sent for microbiological examination and culture. Entrance into the orbital tissues was meticulously avoided and the procedure completed without using packing or splints. The patients were discharged from hospital on oral broad spectrum antibiotics and a steroid nasal spray which were administered for 2 weeks. The post-operative follow-up was essentially the same as that following an ESS. Endoscopic examination of the operative site was performed on all patients under a general anesthetic 2-3 weeks after surgery in accordance with our protocol for pediatric endoscopic ethmoidectomies. The operative site was inspected, crusts and blood clots were removed, granulations were cleared if present and early synechae were lysed.
3. Results
A complete ophthalmological examination could be performed in 15 of the 24 patients (62%). CT scans were obtained on eight patients immediately after admission; 13 were scanned within the first 24 h and in three the CT was obtained within 48 h of admission. All 24 CT scans showed a medial subperiosteal mass lesion in the orbit adjacent to the lamina papyracea (see Figs. 1 and 2). Sixteen patients had bilateral ethmoidal and maxillary sinusitis. Four had unilateral maxilloethmoiditis and four had only ethmoiditis on the affected side. Pus was encountered in 21 patients (88%) after elevation of the lamina papyracea (Fig. 1). In two patients (8%) only serous fluid was evacuated and one patient (4%) had granulation tissue with inflammatory exudate in the medial subperiosteal
250
K.D. Pereira et al. / Int. J. Pediatr. Otorhinolaryngol.
38~ (1997) 247-254
Fig. 1. The CT scan shows oedema and displacement of the medial rectus. An ill-defined medial extraconal mass is seen in the right orbit. Pus was evacuated at surgery.
space (Fig. 2). Cultures of infected tissue and pus from the operative site were positive in 18 patients, with 11 mixed infections and 7 single organism colonies. Streptococcus pneumonia was the most common organism isolated (lo/l8 patients, 56%).
Fig. 2. The CT scan shows a well defined low density medial extraconal mass in the right orbit displacing the medial rectus. No pus was found at surgery.
K.D. Pereira et al. / Int. J. Pediatr. Otorhinolaryngol.
38 (1997) 247-254
251
Table 2 Stages of orbital involvement in sinusitis 1. Pre-septal inflammation a. Without chemosis-lid edema b. With chemosis-lid and conjunctival edema, pseudo-proptosis II. Post-septal inflammation/infection a. Extraconal-proptosis, chemosis, decreased EOM; Medial subperiosteal abscess-proptosis, lateral deviation of the globe, visual loss (mild to moderate) b. Intraconal-proptosis, ophthalmoplegia, visual loss (moderate to severe) c. Cavernous sinus thrombosis-proptosis, fixed globe, severe visual loss meningitis, bilateral ocular signs
No complications were documented and orbital signs resolved completely within 72 h in all cases.Patients were discharged home from 48 to 96 h (mean 52 h) after the procedure. Post-operative endoscopic examination of the operative site was unremarkable. Permanent visual sequelae either as a result of the disease or treatment were not encountered.
4. Discussion
Acute sinusitis is the predominant cause of orbital infections in children. If treated appropriately and early, approximately 75% resolve completely with medical therapy [7]. A full course of a broad spectrum antibiotic for at least lo-14 days should be prescribed, rather than multiple short courses of antibiotics which are likely to lead to inadequate resolution of infection and the emergence of resistant strains. However, orbital complications may arise despite the use of antibiotics or even before antibiotic therapy is started. The orbital periosteum is an important anatomical barrier preventing the spread of infection from the sinuses into the orbit. It extends anteriorly from the orbital margins into the eye lids where it forms a thin connective tissue membrane known as the orbital septum. This septum separatesthe superficial portion of the lids from the deeper orbital structures and its erosion leads to post-septal orbital disease.We propose a new clinical staging system of orbital involvement in sinusitis based on the orbital septum (Table 2). A medial SPA is the most common post-septal orbital complication of sinusitis [5]. The physical signs of it’s presence include lateral proptosis, decreased adduction and varying degrees of visual loss. However, the most common ophthalmological findings in children with a medial SPA are non-specific and only suggest a post-septal suppurative process [8]. The amount of information that can be obtained from the clinical examination is related to the age and co-operation of the child. This can be very limited in a 2-year old with chemosis or be full and extensive in a co-operative 14-year old child. Although visual acuity is important and should be evaluated in any child with suspected post-septal infection, it is not always an accurate guide to therapy [2]. Moreover, certain objective signs such as diminished pupillary reflexes may not be
252
K.D. Pereira et al. / Int. J. Pediatr. Otorhinolaryngol.
38 (1997) 247-254
seen until irreversible loss of vision has occurred [8]. In our study, a complete ophthalmological examination was only possible in 15 of the 24 patients (62o/o). In the remaining patients the examination was either not possible or incomplete. In a sick child with chemosis, the examination may be restricted to an assessmentof whether the child can or cannot see.In this situation, immediate diagnostic imaging should be considered to confirm and locate the infectious process and guide further management. In the diagnosis of a medial SPA the most useful imaging modality currently available is the CT scan. The orbit is a high contrast area and the infectious process can be easily localized to the pre-septal area, the orbital muscle cone or the subperiosteal space [12]. CT scan findings of a medial SPA are those of a convex mass with an enhancing rim adjacent to the lamina papyracea [5]. Occasionally a gas shadow is seen confirming the diagnosis. The other frequently seen signs are oedema of the medial rectus and displacement of the periosteum away from the medial orbital wall (see Figs. 1 and 2). In a small proportion of patients a serous exudate or granulation tissue may simulate an abscesson the CT scan as was the case in three of our patients (13%). This problem has previously been observed by Towbin et al. [13] who suggested using an orbital ultrasound to help differentiate the two conditions. However, we do not feel that this is of therapeutic benefit, as it would be unwise to delay surgical intervention in a sick proptotic child with sinusitis and with CT evidence of a mass in the medial subperiosteal space of the orbit. Treatment of post-septal inflammation is dependant on the clinical progress of the disease.In the early stages,i.v. antimicrobial therapy is the treatment of choice. Most authors [1,8,10] recommend using the clinical progression of orbital signs while on optimal antibiotic therapy or an obvious abscessdemonstrated by CT scan as criteria for deciding on surgical intervention. Souliere et al. [ll] reported on a series of five patients with CT documented medial SPA’s who were successfully treated with antibiotic therapy and concluded that the presence of a SPA alone should no longer be considered an absolute indication for surgery. Their criteria for surgery for a documented SPA while on antibiotic therapy included worsening of visual acuity and ocular motility or failure to improve clinically after 48 h of medical therapy. However, children can be difficult to evaluate for visual acuity and can progress to more sinister complications rapidly. We feel that in these cases conservative management in the presence of positive radiological findings is difficult to justify. The traditional approach for drainage of SPA’s is through an external ethmoidectomy incision. However, endoscopic drainage of these collections may be contemplated depending on the expertise and experience of the surgeon. In 1991, Lazar and Younis [4], reported the successfulendoscopic drainage of such abscesses in two children. Both recovered rapidly and no complications were encountered. Subsequently, there have been other studies documenting the feasibility, safety and successof this approach [1,5,14]. The advantages of intranasal drainage are the avoidance of a facial scar and rapid resolution of periorbital inflammation [14]. However, the smaller confines of a pediatric nose and the edematous vascular
K.D. Pereira et al. / Int. J. Pediatr. Otorhinolaryngol.
38 (1997) 247-254
253
mucosa of an acute sinusitis can pose technical problems which are compounded by poor visualization. This approach should only be considered when the surgeon is already familiar and comfortable with endoscopic ethmoidectomy in young children, and the CT clearly demonstrates inflammation in the medial orbit adjacent to the lateral ethmoid wall. In the present study, surgery for medial SPA’s was performed by attending pediatric otolaryngologists’ experienced in pediatric sinus surgery. However, one must always be prepared for an external approach if adequate drainage cannot be achieved intranasally or if the orbital swelling fails to resolve 48-72 h after surgery. This problem was not encountered in any of the patient’s in this series. We conclude that an ophthalmological assessment may be incomplete in a sick, chemotic and unattentive child and cannot suggest when exploration of the sub-periosteal space is imperative. A CT scan is the most specific radiological investigation currently available for the diagnosis of a medial SPA and is an Endoscopic intranasal drainage of accurate predictor of surgical intervention. a medial SPA of the orbit is the surgical procedure of choice in experienced hands. It produces little morbidity and is cosmetically superior to conventional techniques.
References [I] Arjmand. E.M., Lusk, R.P. and Muntz, H.R. (1993) Pediatric sinusitis and subperiosteal orbital abscess formation. Diagnosis and treatment. Otolaryngol. Head Neck Surg. 109, 8866894. [2] Hawkins, D.B. and Clark, R.W. (1977) Orbital involvement in acute sinusitis. Clin. Pediatr. 16, 4644471. [3] Hirsch, M. and Lifshitz, T. (1988) Computerized tomography in the diagnosis and treatment of orbital cellulitis. Pediatr. Radio]. 18, 3022305. [4] Lazar, R.H. and Younis, R.T. (1991) The role of FESS in the treatment of sinusitis with complications. Paper presented at the annual meeting of the Southern Medical Association in Atlanta. [5] Manning, SC. (1993) Endoscopic management of medial subperiosteal orbital abscess. Arch. Otolaryngol. Head Neck Surg. 119, 7899791. [6] Oliverio, P.J., Benson, M.L. and Zinreich, S.J. (1995) Update on imaging for functional endoscopic sinus surgery. Otolaryngol. Clin. N. Am. 28, 5855608. [7] Osguthorpe, J.D. and Hochman, M. (1993) Inflammatory sinus diseases affecting the orbit. Otolaryngol. Clin. N. Am. 26, 657-671. [8] Patt, B.S. and Manning, SC. (1991) Blindness resulting from orbital complications of sinusitis. Otolaryngol. Head Neck Surg. 104, 789-795. [9] Schramm. V., Curtin, H. and Kenneerdell, J.S. (1982) Evaluation of orbital cellulitis and results of treatment. Laryngoscope 92. 73228. [IO] Skedros, D.G., Haddad, J., Bluestone, CD. and Curtin, H.D. (1993) Subperiosteal orbital abscess in children: Diagnosis microbiology and management, Laryngoscope 103, 28- 32. [I I] Souliere, CR., Antoine, G.A., Martin, M.P., Blumberg, A.I. and Issaacson, G. (1990) Selective non surgical management of subperiosteal abscess of the orbit. CT and clinical course as indication for surgical drainage. Int. J. Pediatr. Otorhinolaryngol 19, 10991 19. [I21 Spires, J.R. and Smith R.J.H. (1986) Bacterial infections of the orbital and periorbital soft tissues in children. Laryngoscope 96, 763-767.
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38 (1997) 247-254
[13] Towbin, R., Han, B.K., Kaufman, R.A. and Burke, M. (1986) Post-septal cellulitis: CT in diagnosis and management. Head Neck Radio]. 158, 735-737. [14] Younis, R.T. and Lazar, R.H. (1996) Endoscopic drainage of subperiosteal abscessin children: A pilot study. Am. J. Rhinol. 10, 11-15.
International Journal of Pediatric Otorhinolaryngology ELSEVIER
38 (1997)
247-254
Management of medial subperiosteal abscess of the orbit in children-a 5 year experience Kevin D. Pereira*, Ron B. Mitchell, Ramzi T. Younis, Rande H. Lazar Otolaryngology Consultants of’ Memphis, Le Bonheur Childrens Medical Center. 777 Washington Aoenue, P240 Memphis, Tennessee 38105, USA
Received 14 June 1996; revised 23 August 1996; accepted 30 August 1996
Abstract A medial subperiosteal abscess (SPA) of the orbit is the most common serious complication of sinusitis in children. The distinction between SPA and the more benign pre-septal disease is difficult to make especially in a young child in whom an ophthalmological evaluation is often difficult. Computerised tomography (CT) is the investigation of choice in making this distinction. Subperiosteal inflammatory disease of the orbit is initially treated with intravenous antibiotic therapy with surgery reserved for those patients who do not respond to medical treatment and in whom a medial SPA is confirmed by CT. Conventionally, the abscess is drained via an external incision and an ethmoidectomy is performed at the same time. More recently, successful drainage of SPA’s has been accomplished endoscopitally via a intranasal approach with less morbidity and superior cosmesis. We present a 5 year experience of 24 patients with CT scans suggestive of medial SPA who underwent endoscopic exploration of the medial subperiosteal orbital space. We discuss the current management of medial subperiosteal disease of the orbit in children and include a review of the literature. Also included is a clinical staging system which aids the management of orbital complications of sinusitis. Copyright 0 1997 Elsevier Science Ireland Ltd. Keywords:
Complications;
Subperiosteal
abscess; Sinusitis; Children
* Corresponding author. 0165-5876/97/$17.00 Copyright 0 1997 Elsevier Science Ireland Ltd. All rights reserved PIISO165-5876(96)01445-O
248
K.D. Pereira et al. 1 Int. J. Pediatr. Otorhinolaryngol.
38 (1997) 247-2.54
1. Introduction
Orbital complications of sinusitis are infrequently seen in the present antibiotic era [3]. However, paranasal sinusitis remains the most common cause of orbital inflammation and infection [1,9]. Pre-septal inflammation is an acute invariably unilateral condition limited to the tissues of the eyelid and is a well recognized consequence of acute sinusitis in children. It is of vital importance to differentiate this generally benign condition from the more sinister infection of the post-septal tissues, as both can present clinically with periorbital edema and chemosis. Subperiosteal inflammatory disease adjacent to an infected ethmoid sinus is the hallmark of post-septal infection and is a serious condition requiring prompt diagnosis and treatment. The incidence of a sub periosteal abscess (SPA) in orbital infections is about 15%. However despite aggressive management 15-30% of these patients develop various visual sequelae [7]. Computer tomography (CT) scanning is the imaging modality of choice in distinguishing pre-septal cellulitis from post-septal infection of the orbit, and can help in determining initial management. The criteria for performing a CT scan in a child suspected of having this condition are shown in Table 1. Regardless of the edema in the periorbital tissues, a detailed ophthalmological examination is seldom successful in a sick child. In view of this limitation and the aggressive nature of the disease in the pediatric population, it is prudent to obtain a CT scan even in casesof pre-septal inflammation [6]. Traditionally, a medial SPA is drained via an incision halfway between the nasal bridge and medial canthus, with a partial or complete ethmoidectomy performed at the same time. However, successful intranasal drainage using endoscopic techniques is being reported with increasing frequency [1,4,5]. We present 24 cases of post-septal inflammation of the orbit secondary to sinusitis in children and discuss the salient diagnostic and therapeutic issues pertinent to this problem. To the best of our knowledge this is the largest reported series of children with medial SPA’s of the orbit successfully drained by endoscopic sinus surgery.
Table 1 Criteria for performing
a CT scan
Inability to perform a satisfactory opthalmological examination Deterioration of orbital signs despite intravenous antibiotic therapy Diminished visual acuity or restrict& of ocular movement Absence of clinical improvement after 24 h of antibiotic therapy
K.D. Pereira et al. / ht. J. Pediatr. Otorhinoluryngol.
38 (1997) 247-254
249
2. Patients and methods
A review of all children with clinical and CT evidence of medial subperiosteal orbital inflammation, unresponsive to medical treatment, was carried out at the LeBonheur Childrens Medical Center from January 1990 to December 1994. Twenty four patients (15 male, 9 female; age range 2- 14; mean age 5.2) were included in the study. Seventeen patients were admitted via the emergency room and seven patients were referred from other hospitals because of an inadequate response to antibiotic therapy or deterioration in orbital signs. Sixteen patients were started on intravenous (iv.) cefuroxime sodium. The other i.v. antibiotics used were oxacillin, penicillin, chloramphenicol and cefotaxime. Ophthalmologic consultation and CT scans (coronal and axial views) were obtained on all children. Patients with CT evidence of a medial subperiosteal mass lesion in the orbit were treated with endoscopic sinus surgery (ESS). A modified Messerklinger technique was used to perform an endoscopic ethmoidectomy. The lamina papyracea was inspected and if intact, a horizontal cut was made on the inferior surface of the bone using a Freer elevator and extended anteriorly and superiorly. Pus was evacuated by elevating the plate of bone medially. Pus and/or infected tissue was sent for microbiological examination and culture. Entrance into the orbital tissues was meticulously avoided and the procedure completed without using packing or splints. The patients were discharged from hospital on oral broad spectrum antibiotics and a steroid nasal spray which were administered for 2 weeks. The post-operative follow-up was essentially the same as that following an ESS. Endoscopic examination of the operative site was performed on all patients under a general anesthetic 2-3 weeks after surgery in accordance with our protocol for pediatric endoscopic ethmoidectomies. The operative site was inspected, crusts and blood clots were removed, granulations were cleared if present and early synechae were lysed.
3. Results
A complete ophthalmological examination could be performed in 15 of the 24 patients (62%). CT scans were obtained on eight patients immediately after admission; 13 were scanned within the first 24 h and in three the CT was obtained within 48 h of admission. All 24 CT scans showed a medial subperiosteal mass lesion in the orbit adjacent to the lamina papyracea (see Figs. 1 and 2). Sixteen patients had bilateral ethmoidal and maxillary sinusitis. Four had unilateral maxilloethmoiditis and four had only ethmoiditis on the affected side. Pus was encountered in 21 patients (88%) after elevation of the lamina papyracea (Fig. 1). In two patients (8%) only serous fluid was evacuated and one patient (4%) had granulation tissue with inflammatory exudate in the medial subperiosteal
250
K.D. Pereira et al. / Int. J. Pediatr. Otorhinolaryngol.
38~ (1997) 247-254
Fig. 1. The CT scan shows oedema and displacement of the medial rectus. An ill-defined medial extraconal mass is seen in the right orbit. Pus was evacuated at surgery.
space (Fig. 2). Cultures of infected tissue and pus from the operative site were positive in 18 patients, with 11 mixed infections and 7 single organism colonies. Streptococcus pneumonia was the most common organism isolated (lo/l8 patients, 56%).
Fig. 2. The CT scan shows a well defined low density medial extraconal mass in the right orbit displacing the medial rectus. No pus was found at surgery.
K.D. Pereira et al. / Int. J. Pediatr. Otorhinolaryngol.
38 (1997) 247-254
251
Table 2 Stages of orbital involvement in sinusitis 1. Pre-septal inflammation a. Without chemosis-lid edema b. With chemosis-lid and conjunctival edema, pseudo-proptosis II. Post-septal inflammation/infection a. Extraconal-proptosis, chemosis, decreased EOM; Medial subperiosteal abscess-proptosis, lateral deviation of the globe, visual loss (mild to moderate) b. Intraconal-proptosis, ophthalmoplegia, visual loss (moderate to severe) c. Cavernous sinus thrombosis-proptosis, fixed globe, severe visual loss meningitis, bilateral ocular signs
No complications were documented and orbital signs resolved completely within 72 h in all cases.Patients were discharged home from 48 to 96 h (mean 52 h) after the procedure. Post-operative endoscopic examination of the operative site was unremarkable. Permanent visual sequelae either as a result of the disease or treatment were not encountered.
4. Discussion
Acute sinusitis is the predominant cause of orbital infections in children. If treated appropriately and early, approximately 75% resolve completely with medical therapy [7]. A full course of a broad spectrum antibiotic for at least lo-14 days should be prescribed, rather than multiple short courses of antibiotics which are likely to lead to inadequate resolution of infection and the emergence of resistant strains. However, orbital complications may arise despite the use of antibiotics or even before antibiotic therapy is started. The orbital periosteum is an important anatomical barrier preventing the spread of infection from the sinuses into the orbit. It extends anteriorly from the orbital margins into the eye lids where it forms a thin connective tissue membrane known as the orbital septum. This septum separatesthe superficial portion of the lids from the deeper orbital structures and its erosion leads to post-septal orbital disease.We propose a new clinical staging system of orbital involvement in sinusitis based on the orbital septum (Table 2). A medial SPA is the most common post-septal orbital complication of sinusitis [5]. The physical signs of it’s presence include lateral proptosis, decreased adduction and varying degrees of visual loss. However, the most common ophthalmological findings in children with a medial SPA are non-specific and only suggest a post-septal suppurative process [8]. The amount of information that can be obtained from the clinical examination is related to the age and co-operation of the child. This can be very limited in a 2-year old with chemosis or be full and extensive in a co-operative 14-year old child. Although visual acuity is important and should be evaluated in any child with suspected post-septal infection, it is not always an accurate guide to therapy [2]. Moreover, certain objective signs such as diminished pupillary reflexes may not be
252
K.D. Pereira et al. / Int. J. Pediatr. Otorhinolaryngol.
38 (1997) 247-254
seen until irreversible loss of vision has occurred [8]. In our study, a complete ophthalmological examination was only possible in 15 of the 24 patients (62o/o). In the remaining patients the examination was either not possible or incomplete. In a sick child with chemosis, the examination may be restricted to an assessmentof whether the child can or cannot see.In this situation, immediate diagnostic imaging should be considered to confirm and locate the infectious process and guide further management. In the diagnosis of a medial SPA the most useful imaging modality currently available is the CT scan. The orbit is a high contrast area and the infectious process can be easily localized to the pre-septal area, the orbital muscle cone or the subperiosteal space [12]. CT scan findings of a medial SPA are those of a convex mass with an enhancing rim adjacent to the lamina papyracea [5]. Occasionally a gas shadow is seen confirming the diagnosis. The other frequently seen signs are oedema of the medial rectus and displacement of the periosteum away from the medial orbital wall (see Figs. 1 and 2). In a small proportion of patients a serous exudate or granulation tissue may simulate an abscesson the CT scan as was the case in three of our patients (13%). This problem has previously been observed by Towbin et al. [13] who suggested using an orbital ultrasound to help differentiate the two conditions. However, we do not feel that this is of therapeutic benefit, as it would be unwise to delay surgical intervention in a sick proptotic child with sinusitis and with CT evidence of a mass in the medial subperiosteal space of the orbit. Treatment of post-septal inflammation is dependant on the clinical progress of the disease.In the early stages,i.v. antimicrobial therapy is the treatment of choice. Most authors [1,8,10] recommend using the clinical progression of orbital signs while on optimal antibiotic therapy or an obvious abscessdemonstrated by CT scan as criteria for deciding on surgical intervention. Souliere et al. [ll] reported on a series of five patients with CT documented medial SPA’s who were successfully treated with antibiotic therapy and concluded that the presence of a SPA alone should no longer be considered an absolute indication for surgery. Their criteria for surgery for a documented SPA while on antibiotic therapy included worsening of visual acuity and ocular motility or failure to improve clinically after 48 h of medical therapy. However, children can be difficult to evaluate for visual acuity and can progress to more sinister complications rapidly. We feel that in these cases conservative management in the presence of positive radiological findings is difficult to justify. The traditional approach for drainage of SPA’s is through an external ethmoidectomy incision. However, endoscopic drainage of these collections may be contemplated depending on the expertise and experience of the surgeon. In 1991, Lazar and Younis [4], reported the successfulendoscopic drainage of such abscesses in two children. Both recovered rapidly and no complications were encountered. Subsequently, there have been other studies documenting the feasibility, safety and successof this approach [1,5,14]. The advantages of intranasal drainage are the avoidance of a facial scar and rapid resolution of periorbital inflammation [14]. However, the smaller confines of a pediatric nose and the edematous vascular
K.D. Pereira et al. / Int. J. Pediatr. Otorhinolaryngol.
38 (1997) 247-254
253
mucosa of an acute sinusitis can pose technical problems which are compounded by poor visualization. This approach should only be considered when the surgeon is already familiar and comfortable with endoscopic ethmoidectomy in young children, and the CT clearly demonstrates inflammation in the medial orbit adjacent to the lateral ethmoid wall. In the present study, surgery for medial SPA’s was performed by attending pediatric otolaryngologists’ experienced in pediatric sinus surgery. However, one must always be prepared for an external approach if adequate drainage cannot be achieved intranasally or if the orbital swelling fails to resolve 48-72 h after surgery. This problem was not encountered in any of the patient’s in this series. We conclude that an ophthalmological assessment may be incomplete in a sick, chemotic and unattentive child and cannot suggest when exploration of the sub-periosteal space is imperative. A CT scan is the most specific radiological investigation currently available for the diagnosis of a medial SPA and is an Endoscopic intranasal drainage of accurate predictor of surgical intervention. a medial SPA of the orbit is the surgical procedure of choice in experienced hands. It produces little morbidity and is cosmetically superior to conventional techniques.
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