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Superolateral subperiosteal orbital abscess complicating sinusitis in a child
International Journal of Pediatric Otorhinolaryngology 48 (1999) 255 – 258
Case report
Superolateral subperiosteal orbital abscess complicating sinusitis in a child Franklin Pond *, Robert G. Berkowitz Department of Otolaryngology, The Royal Children’s Hospital Melbourne, Victoria 3052, Australia Received 20 September 1998; received in revised form 13 January 1999; accepted 14 January 1999
Abstract Orbital complications of sinusitis in children generally occur as a consequence of ethmoid sinusitis due to preferential spread across the lamina papyracea. A case is presented of a subperiosteal abscess (SPA) in the superolateral orbital wall complicating frontal sinusitis in a 6-year-old female. Congenital bony dehiscences exist in the lateral floor of the frontal sinus, which may allow direct spread of infection through to that region. While the general principles of managing orbital complications of sinusitis are applicable, the surgical approach for a SPA complicating frontal sinusitis differs from that of the typical medial SPA, and the clinician should be mindful of this variation when planning surgical treatment. © 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Sinusitis; Frontal sinusitis; Orbit; Abscess
1. Introduction Subperiosteal abscess (SPA) complicating sinusitis typically occurs due to ethmoid sinus disease because the thin lamina papyracea is a * Corresponding author. Present address: Franklin Pond. 22 Grandview Terrace Kew, Victoria 3101, Australia..
poor barrier to the spread of infection. A case of a 6-year-old child with a SPA in the superolateral orbital wall complicating frontal sinusitis is reported. The location of the SPA and the apparent origin from the frontal sinus is uncommon, particularly in young children. Recognition of this variation is important in order to identify the sinus responsible and to instigate appropriate surgical management.
0165-5876/99/$ - see front matter © 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 5 - 5 8 7 6 ( 9 9 ) 0 0 0 1 9 - 1
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F. Pond, R.G. Berkowitz / Int. J. Pediatr. Otorhinolaryngol. 48 (1999) 255–258
2. Case report A 6-year-old girl presented with a 3 day history of frontal headache and progressive painful left eye swelling. There was a background of an upper respiratory tract infection in the preceding 2 weeks which had been treated with two doses of oral penicillin. No previous history of significant sinonasal tract symptomatology was noted. Initial examination revealed a temperature of 40.7°C. There was extensive cellulitis involving the left upper eyelid with left proptosis and ophthalmoplegia on upward gaze. Percussion tenderness localized to the left frontal sinus, and a formal ophthalmologic assessment demonstrated 6/6 visual acuity. Computer tomography (CT) revealed pansinusitis and a large SPA in the roof of the left orbit as shown in Figs. 1 – 3. Hematological evaluation was essentially normal. After one intravenous dose of cefotaxime and flucloxacillin, the patient was placed under general anesthetic and, via a lateral supraorbital incision, the periosteum was elevated and the superolateral orbital wall abscess drained. Elevation of the periosteum was extended medially to expose the lamina papyracea which was intact. A
Fig. 1. Contrast enhancement coronal image of the orbit showing a large extra-conal collection in the orbital roof with a locule of gas (black arrow). It causes downward displacement of the superior rectus muscle and globe.
Fig. 2. Marked preseptal swelling is seen with concurrent ethmoid and sphenoid disease.
Penrose drain tube was inserted into the abscess cavity and brought out through the wound. Bilateral antral washouts were performed but no pus was obtained. A penicillin-sensitive Group A Streptococcus was cultured from the abscess cavity, and the intravenous antibiotics changed to oral penicillin and flucloxacillin for a total of 7 days. The oph-
Fig. 3. Bony window image showing a small defect in the floor of the left frontal sinus (white arrow) and adjacent gas outlining the orbital roof.
F. Pond, R.G. Berkowitz / Int. J. Pediatr. Otorhinolaryngol. 48 (1999) 255–258
thalmoplegia slowly resolved over that period and the drain tube was removed on day 6. On discharge at day 8, the patient received a further week of oral penicillin and flucloxacillin. She was well at post-operative review 3 weeks later.
3. Discussion Orbital infections typically occur as a complication of acute sinusitis, particularly in children 3 years of age or older. Schramm et al. [7] estimated this prevalence in children to be 74 – 85%. Another 10% of these orbital complications had foci from cutaneous infections such as impetigo or infected facial lacerations, and the remaining 5% were related to dacryocystitis, facial fracture, orbital surgery, penetrating injuries, otitis media, and dental infections. The frontal sinus is the only sinus absent at birth. By the age of 3 years, the cupola of the sinus appears above the level of the nasion, but very little growth occurs until the ages of 7 and 8. From then on, rapid enlargement of the frontal sinus occurs to reach its mature size at puberty [2]. Consequently, frontal sinusitis is rare until the latter half of the first decade, and, even then, the incidence is relatively low. A study examining the CT scans of 196 children with rhinosinusitis between the ages of 3 and 14 years found frontal sinus involvement at 7% for the 7 – 8 age group, increasing to 15% for 11 – 12 years of age [9]. The reasons for the low incidence even in older children is unclear but may reflect the relatively low frequency of underlying structural anomalies. Duvoisin et al. [6] found frontal sinusitis in 85% of cases with computer tomographic evidence of frontonasal duct stenosis or obstruction, and noted a correlation between frontal sinusitis and frontonasal duct abnormalities. The prevalence of SPA is approximately 12 – 17% of all orbital infections requiring hospital admission [3,5]. However, this figure must be seen in the light that many cases of orbital infection present as mild periorbital cellulitis which does not require hospitalisation. SPA is most commonly due to ethmoid sinusitis alone or in association with maxillary sinus disease. Frontal sinus
257
involvement is uncommon but, when present, it occurs as part of a pansinusitis or extremely rarely in isolation [8]. The superolaterally located SPA due to frontal sinusitis has not been commonly reported in children. A 7 year review of 30 patients with SPA in the Children’s Hospital of Pittsburgh revealed a purely medial location for SPA [4]. Williams et al. [3] found 16 children with SPA over an 11 year period, one of whom presumably had a SPA associated with frontal bone osteomyelitis and intracranial absceses. The mode of disease spread from sinus to orbit is by bacterial thrombophlebitis through valveless veins, direct extension from bony erosion, or via congenital or acquired bony dehiscences. The frontal sinus displays three common sites of dehiscences in the floor, which were described by Williamson-Noble [1]: 1. behind the trochlear fossa; 2. behind the supraorbital notch; 3. at the junction of the middle and outer thirds of the sinus floor. The presence of these congenital dehiscences may predispose to the development of a superolateral SPA following frontal sinusitis. The radiographs of this patient display a partially opacified frontal sinus, a dehiscence in the sinus wall and a SPA in the vicinity of the dehiscence. It appears likely that the inflammatory process in the frontal sinus discharged through the dehiscence and into the orbit. Spontaneous drainage of the frontal sinus collection into the orbit may explain why there is partial aeration of the frontal sinus. Although the central area of abscess formation does not coincide with the point of dehiscence, this may be due to the preferential spread of pus laterally in the orbit. Alternatively, the superolateral SPA may have arisen from retrograde extension of infection through venous channels. Management of SPA requires good quality CT scanning, ophthalmological assessment, intravenous antibiotics, and surgical drainage. Surgical treatment involves aspiration of the abscess cavity and a provision for ongoing drainage. Complete exenteration of the ethmoid air cells is not generally necessary for SPA occurring as a complica-
258
F. Pond, R.G. Berkowitz / Int. J. Pediatr. Otorhinolaryngol. 48 (1999) 255–258
tion of ethmoid sinusitis as antibiotic therapy is relied upon to treat the ethmoid disease. However, anterior ethmoidectomy is necessary to allow intranasal drainage of the SPA. Where SPA occurs in a superolateral site, the frontal sinus is assumed to be the source of suppuration. While not specifically drained in this case, management of complicated frontal sinusitis should include frontal sinus trephine and external drainage of the frontal sinus. The position of the surgical incision should also allow access to both the frontal sinus floor and orbital collection. Management by endoscopic surgery is not appropriate. In conclusion, frontal sinusitis which generally occurs in the setting of pansinusitis can result in a superolaterally placed collection. This is presumably due to disease extension through congenital bony dehiscences in the frontal sinus floor. Clinicians should be aware of this variation of SPA as a different operative approach is required, and surgical attention to the frontal sinus itself is recommended.
Acknowledgements The authors thank Dr Michelle Fink for her contributions to the computed tomography images.
References [1] F.A. Williamson-Noble, Disease of the orbit and its contents secondary to pathological conditions of the nose and paranasal sinuses, Ann. R. Coll. Surg. Engl. 15 (1954) 46 – 64. [2] C.D. Bluestone, S.E. Stool, S.K. Arjona. Pediatr. Otolaryngol. (1983) 675 – 676. [3] B.J. Williams, H.C. Harrison, Subperiosteal abscess of the orbit due to sinusitis in childhood, Aust. NZ J. Ophthalmol. 19 (1) (1991) 29 – 36. [4] D.G. Skedros, J. Haddad Jr., C.D. Bluestone, H.D. Curtin, Subperiosteal orbital abscess in children: diagnosis, microbiology, and management, Laryngoscope 103 (1993) 28 – 32. [5] I. Samad, K. Riding, Orbital complications of ethmoiditis: B.C. Children’s Hospital experience, J. Otolaryngol. 20 (6) (1991) 400 – 403. [6] B. Duvoisin, P. Schnyder, Do abnormalities of the frontonasal duct cause frontal sinusitis? A CT study in 198 patients, Am. J. Roentgenol. 159 (6) (1992) 1295 – 1298. [7] V.L. Schramm, H.D. Curtin, J.S. Kennerdell, Evaluation of orbital cellulitis and results of treatment, Laryngoscope 92 (1982) 732 – 738. [8] V.L. Schramm, E.N. Myers, J.S. Kennerdell, Orbital complications of acute sinusitis: evaluation, management, and outcome, Otolaryngology 86 (1977) 221 – 230. [9] P.J. Van Der Veken, P.A. Clement, T. Buisseret, B. Desprechins, L. Kaufman, M.P. Derde, CT scan study of the incidence of sinus involvement and nasal anatomic variations in 196 children, Rhinology 28 (3) (1990) 177 – 184.
. .
Case report
Superolateral subperiosteal orbital abscess complicating sinusitis in a child Franklin Pond *, Robert G. Berkowitz Department of Otolaryngology, The Royal Children’s Hospital Melbourne, Victoria 3052, Australia Received 20 September 1998; received in revised form 13 January 1999; accepted 14 January 1999
Abstract Orbital complications of sinusitis in children generally occur as a consequence of ethmoid sinusitis due to preferential spread across the lamina papyracea. A case is presented of a subperiosteal abscess (SPA) in the superolateral orbital wall complicating frontal sinusitis in a 6-year-old female. Congenital bony dehiscences exist in the lateral floor of the frontal sinus, which may allow direct spread of infection through to that region. While the general principles of managing orbital complications of sinusitis are applicable, the surgical approach for a SPA complicating frontal sinusitis differs from that of the typical medial SPA, and the clinician should be mindful of this variation when planning surgical treatment. © 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Sinusitis; Frontal sinusitis; Orbit; Abscess
1. Introduction Subperiosteal abscess (SPA) complicating sinusitis typically occurs due to ethmoid sinus disease because the thin lamina papyracea is a * Corresponding author. Present address: Franklin Pond. 22 Grandview Terrace Kew, Victoria 3101, Australia..
poor barrier to the spread of infection. A case of a 6-year-old child with a SPA in the superolateral orbital wall complicating frontal sinusitis is reported. The location of the SPA and the apparent origin from the frontal sinus is uncommon, particularly in young children. Recognition of this variation is important in order to identify the sinus responsible and to instigate appropriate surgical management.
0165-5876/99/$ - see front matter © 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 5 - 5 8 7 6 ( 9 9 ) 0 0 0 1 9 - 1
256
F. Pond, R.G. Berkowitz / Int. J. Pediatr. Otorhinolaryngol. 48 (1999) 255–258
2. Case report A 6-year-old girl presented with a 3 day history of frontal headache and progressive painful left eye swelling. There was a background of an upper respiratory tract infection in the preceding 2 weeks which had been treated with two doses of oral penicillin. No previous history of significant sinonasal tract symptomatology was noted. Initial examination revealed a temperature of 40.7°C. There was extensive cellulitis involving the left upper eyelid with left proptosis and ophthalmoplegia on upward gaze. Percussion tenderness localized to the left frontal sinus, and a formal ophthalmologic assessment demonstrated 6/6 visual acuity. Computer tomography (CT) revealed pansinusitis and a large SPA in the roof of the left orbit as shown in Figs. 1 – 3. Hematological evaluation was essentially normal. After one intravenous dose of cefotaxime and flucloxacillin, the patient was placed under general anesthetic and, via a lateral supraorbital incision, the periosteum was elevated and the superolateral orbital wall abscess drained. Elevation of the periosteum was extended medially to expose the lamina papyracea which was intact. A
Fig. 1. Contrast enhancement coronal image of the orbit showing a large extra-conal collection in the orbital roof with a locule of gas (black arrow). It causes downward displacement of the superior rectus muscle and globe.
Fig. 2. Marked preseptal swelling is seen with concurrent ethmoid and sphenoid disease.
Penrose drain tube was inserted into the abscess cavity and brought out through the wound. Bilateral antral washouts were performed but no pus was obtained. A penicillin-sensitive Group A Streptococcus was cultured from the abscess cavity, and the intravenous antibiotics changed to oral penicillin and flucloxacillin for a total of 7 days. The oph-
Fig. 3. Bony window image showing a small defect in the floor of the left frontal sinus (white arrow) and adjacent gas outlining the orbital roof.
F. Pond, R.G. Berkowitz / Int. J. Pediatr. Otorhinolaryngol. 48 (1999) 255–258
thalmoplegia slowly resolved over that period and the drain tube was removed on day 6. On discharge at day 8, the patient received a further week of oral penicillin and flucloxacillin. She was well at post-operative review 3 weeks later.
3. Discussion Orbital infections typically occur as a complication of acute sinusitis, particularly in children 3 years of age or older. Schramm et al. [7] estimated this prevalence in children to be 74 – 85%. Another 10% of these orbital complications had foci from cutaneous infections such as impetigo or infected facial lacerations, and the remaining 5% were related to dacryocystitis, facial fracture, orbital surgery, penetrating injuries, otitis media, and dental infections. The frontal sinus is the only sinus absent at birth. By the age of 3 years, the cupola of the sinus appears above the level of the nasion, but very little growth occurs until the ages of 7 and 8. From then on, rapid enlargement of the frontal sinus occurs to reach its mature size at puberty [2]. Consequently, frontal sinusitis is rare until the latter half of the first decade, and, even then, the incidence is relatively low. A study examining the CT scans of 196 children with rhinosinusitis between the ages of 3 and 14 years found frontal sinus involvement at 7% for the 7 – 8 age group, increasing to 15% for 11 – 12 years of age [9]. The reasons for the low incidence even in older children is unclear but may reflect the relatively low frequency of underlying structural anomalies. Duvoisin et al. [6] found frontal sinusitis in 85% of cases with computer tomographic evidence of frontonasal duct stenosis or obstruction, and noted a correlation between frontal sinusitis and frontonasal duct abnormalities. The prevalence of SPA is approximately 12 – 17% of all orbital infections requiring hospital admission [3,5]. However, this figure must be seen in the light that many cases of orbital infection present as mild periorbital cellulitis which does not require hospitalisation. SPA is most commonly due to ethmoid sinusitis alone or in association with maxillary sinus disease. Frontal sinus
257
involvement is uncommon but, when present, it occurs as part of a pansinusitis or extremely rarely in isolation [8]. The superolaterally located SPA due to frontal sinusitis has not been commonly reported in children. A 7 year review of 30 patients with SPA in the Children’s Hospital of Pittsburgh revealed a purely medial location for SPA [4]. Williams et al. [3] found 16 children with SPA over an 11 year period, one of whom presumably had a SPA associated with frontal bone osteomyelitis and intracranial absceses. The mode of disease spread from sinus to orbit is by bacterial thrombophlebitis through valveless veins, direct extension from bony erosion, or via congenital or acquired bony dehiscences. The frontal sinus displays three common sites of dehiscences in the floor, which were described by Williamson-Noble [1]: 1. behind the trochlear fossa; 2. behind the supraorbital notch; 3. at the junction of the middle and outer thirds of the sinus floor. The presence of these congenital dehiscences may predispose to the development of a superolateral SPA following frontal sinusitis. The radiographs of this patient display a partially opacified frontal sinus, a dehiscence in the sinus wall and a SPA in the vicinity of the dehiscence. It appears likely that the inflammatory process in the frontal sinus discharged through the dehiscence and into the orbit. Spontaneous drainage of the frontal sinus collection into the orbit may explain why there is partial aeration of the frontal sinus. Although the central area of abscess formation does not coincide with the point of dehiscence, this may be due to the preferential spread of pus laterally in the orbit. Alternatively, the superolateral SPA may have arisen from retrograde extension of infection through venous channels. Management of SPA requires good quality CT scanning, ophthalmological assessment, intravenous antibiotics, and surgical drainage. Surgical treatment involves aspiration of the abscess cavity and a provision for ongoing drainage. Complete exenteration of the ethmoid air cells is not generally necessary for SPA occurring as a complica-
258
F. Pond, R.G. Berkowitz / Int. J. Pediatr. Otorhinolaryngol. 48 (1999) 255–258
tion of ethmoid sinusitis as antibiotic therapy is relied upon to treat the ethmoid disease. However, anterior ethmoidectomy is necessary to allow intranasal drainage of the SPA. Where SPA occurs in a superolateral site, the frontal sinus is assumed to be the source of suppuration. While not specifically drained in this case, management of complicated frontal sinusitis should include frontal sinus trephine and external drainage of the frontal sinus. The position of the surgical incision should also allow access to both the frontal sinus floor and orbital collection. Management by endoscopic surgery is not appropriate. In conclusion, frontal sinusitis which generally occurs in the setting of pansinusitis can result in a superolaterally placed collection. This is presumably due to disease extension through congenital bony dehiscences in the frontal sinus floor. Clinicians should be aware of this variation of SPA as a different operative approach is required, and surgical attention to the frontal sinus itself is recommended.
Acknowledgements The authors thank Dr Michelle Fink for her contributions to the computed tomography images.
References [1] F.A. Williamson-Noble, Disease of the orbit and its contents secondary to pathological conditions of the nose and paranasal sinuses, Ann. R. Coll. Surg. Engl. 15 (1954) 46 – 64. [2] C.D. Bluestone, S.E. Stool, S.K. Arjona. Pediatr. Otolaryngol. (1983) 675 – 676. [3] B.J. Williams, H.C. Harrison, Subperiosteal abscess of the orbit due to sinusitis in childhood, Aust. NZ J. Ophthalmol. 19 (1) (1991) 29 – 36. [4] D.G. Skedros, J. Haddad Jr., C.D. Bluestone, H.D. Curtin, Subperiosteal orbital abscess in children: diagnosis, microbiology, and management, Laryngoscope 103 (1993) 28 – 32. [5] I. Samad, K. Riding, Orbital complications of ethmoiditis: B.C. Children’s Hospital experience, J. Otolaryngol. 20 (6) (1991) 400 – 403. [6] B. Duvoisin, P. Schnyder, Do abnormalities of the frontonasal duct cause frontal sinusitis? A CT study in 198 patients, Am. J. Roentgenol. 159 (6) (1992) 1295 – 1298. [7] V.L. Schramm, H.D. Curtin, J.S. Kennerdell, Evaluation of orbital cellulitis and results of treatment, Laryngoscope 92 (1982) 732 – 738. [8] V.L. Schramm, E.N. Myers, J.S. Kennerdell, Orbital complications of acute sinusitis: evaluation, management, and outcome, Otolaryngology 86 (1977) 221 – 230. [9] P.J. Van Der Veken, P.A. Clement, T. Buisseret, B. Desprechins, L. Kaufman, M.P. Derde, CT scan study of the incidence of sinus involvement and nasal anatomic variations in 196 children, Rhinology 28 (3) (1990) 177 – 184.
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