Orbital infection as a complication of sinusitis: are diagnostic and treatment trends changing?

Abstract

Orbital infection has long been the most common complication of sinusitis. In light of our increased knowledge of sinusitis, improved diagnostic tools, and new pharmacologic and surgical treatments, we investigated whether trends in diagnosis and treatment are changing. We reviewed the charts of all 43 patients who had been referred to our institution with orbital complications of sinusitis between Jan. 1, 1985, and Dec. 31, 1999. Nine of the 43 patients had been diagnosed between Jan. 1, 1985, and Dec. 31, 1990 (mean: 1.5 patients/yr) and 34 had been diagnosed between Jan. 1, 1991, and Dec. 31, 1999 (mean: 3.8 patients/yr). Of the 43 patients, 27 had cellulitis and 16 had an abscess (one of the 16 had two abscesses--one subperiosteal and one supraorbital). All 17 abscesses were treated surgically. Five of the 7 abscesses operated on from 1985 through 1990 were treated via an open external approach, whereas 7 of the 10 abscesses that were operated on later were treated via an endoscopic approach. We conclude that orbital complications of sinonasal origin are being recognized more frequently than they were in the past and that endoscopy has supplanted the open external approach as the preferred method of drainage.

Introduction

Orbital infections can still pose a serious threat to a patient's vision and even his life. During the preantibiotic era, the rates of blindness and mortality in patients with orbital infections secondary to sinusitis were 20.5 and 17%, respectively. (1,2) Overtime, both rates have declined; the incidence of vision loss since then has been reported to be 3 to 11%, and mortality stands at 1 to 2.5%.(3,4)

Orbital infection can occur whenever a sinus infection spreads beyond the sinus cavity and into the orbit. The orbit shares anatomic walls with the ethmoid, maxillary, frontal, and sphenoid sinuses. These infections can spread directly through the neurovascular foramina or via congenital or acquired bony dehiscences. They can also spread indirectly through the valveless veins of the sinuses and orbit as a result of a thrombophlebitic or embolic condition. Sinusitis-related orbital infection is the most common cause of unilateral proptosis in children and the third leading cause in adults, behind Graves' orbitopathy and pseudotumor.(1,5,6)

Diagnosis of orbital infections requires a thorough history and physical examination, including an ophthalmologic evaluation. Computed tomography (CT) is frequently required as an adjunct in assessing the clinical manifestations of advanced disease, and it can assist the physician in surgical planning if required. Management of orbital infection depends on its stage. Medical therapy alone is usually sufficient in most cases. The surgical armamentarium includes a spectrum of procedures, ranging from external ethmoidectomy and Caldwell-Luc surgery to endoscopic sinus surgery. Surgical drainage involves drainage of both the infected sinuses and any existing orbital abscesses.

In this article, we describe our experience with the diagnosis, management, and surgical treatment of orbital infections. We address the role of various radiologic modalities, and we discuss the importance of immediate intervention and the evolving role of endoscopic sinus surgery in these patients.

We reviewed the charts of 43 patients--33 males and 10 females, aged 8 months to 41 years--who had been referred to the University of Mississippi Medical Center in Jackson, a tertiary care and academic center, with sinusitis and an orbital infection between Jan. 1, 1985, and Dec. 31, 1999. Thirty-three patients (76.7%) were younger than 18 years of age.

Patients and methods

Of this group, there were 27 cases of cellulitis (21 periorbital and six orbital) and 17 abscesses (12 subperiosteal [including one case of supraorbital abscess] and five orbital). Three of the 43 patients also had other associated complications: one patient with periorbital cellulitis had meningitis, one patient with a subperiosteal abscess had an associated epidural abscess, and one patient with an orbital abscess was blind.

Results

Follow-up ranged from 8 months to 8 years. We found that the number of cases referred to our institution increased over time. Nine of the 43 patients had been diagnosed between Jan. 1, 1985, and Dec. 31, 1990 (mean: 1.5 patients/yr) and 34 had been diagnosed between Jan. 1, 1991, and Dec. 31, 1999 (mean: 3.8 patients/yr).

All 27 patients with cellulitis were successfully treated with medical therapy only. For those patients who required abscess drainage, an external open surgical procedure was the most common approach used from 1985 through 1990 (5 of 7 patients). From 1991 through 1999, the most common approach was endoscopic surgery (7 of 10 patients) (table 1). The most common finding overall on CT was that disease was present in the ipsilateral ethmoid sinus (table 2).

Discussion

Sinusitis has become the most common chronic illness in the United States, surpassing arthritis and hypertension. (7) Acute sinusitis is the most common cause of orbital infections in children, and acute exacerbation of chronic sinusitis is often the cause of serious orbital complications in adults. (1) Most orbital infections respond to medical management. (1,8) Our approach to treating serious complications of sinusitis has evolved over the past 2 decades. Increased awareness of possible complications and the introduction of advanced diagnostic tools, new broadspectrum antibiotics, and innovative surgical techniques have improved the management of these infections. Surgical intervention to drain the sinuses and abscesses is reserved for patients who have more advanced disease and for those who do not respond to medical therapy.

Classification of infections. The classification of orbital infections was introduced by Hubert (9) and refined by Smith and Spencer. (10) The most recent system was introduced in the 1970s by Chandler et al and is widely used today (figure 1). (11) Their system classifies orbital infections into five stages: periorbital cellulitis (stage I), orbital cellulitis (stage II), subperiosteal abscess (stage III), orbital abscess (stage IV), and cavernous sinus thrombosis (stage V).

Another classification approach categorizes orbital infections as either preseptal (superficial) or postseptal (deep). (1) The dividing line that designates an infection as either pre- or postseptal is the orbital septum and the tarsal plate that is contiguous with the periosteum of facial bone. Because no lymphatic or venous connection exists between these two compartments, the orbital septum acts as a barrier to the spread of infection from the face to the deep orbit.

Preseptal infections usually arise from a skin infection, laceration, or a foreign body, and they can manifest as eyelid swelling, erythema, and tenderness. Treatment includes antibiotics, head elevation, warm packs, and management of the underlying cause. Rarely are incision and drainage of an eyelid abscess required. In contrast, postseptal infections are confined to the orbital walls, and they usually manifest as chemosis, proptosis, conjunctival erythema, limited extraocular movement, and/or visual changes. They are most often sinonasal in origin. The ethmoid sinus is by far the most common site (84% of patients), although studies have shown that postseptal infections usually involve more than one sinus; the most common combination involves the ethmoid and maxillary sinuses. (1, 12)

Clinical manifestations. The clinical manifestations of orbital infection are the primary determining factors in making a provisional diagnosis, and CT is the gold standard for diagnosing an orbital abscess associated with sinusitis. However, CT is merely an adjunct to the clinical findings; it does not replace them. Clinical manifestations vary according to the stage of the infection, as delineated by Chandler et al (11):

* The most common preseptal infection is periorbital cellulitis (stage I), which usually manifests as upper eyelid swelling; there are no extraocular or visual changes.

* Orbital cellulitis (stage II) manifests as eyelid swelling, proptosis, and chemosis, with limited or no impairment of extraocular movement.

* Subperiosteal abscess (stage III) is characterized by a collection of pus at the medial aspect of the orbit between the orbital periosteum and the lamina papyracea (figure 2). The globe is usually displaced downward and laterally. Extraocular movement is impaired, and visual acuity might be impaired at a later stage.

* Orbital abscess (stage IV) is associated with severe proptosis and complete ophthalmoplegia (figure 3). Visual acuity is usually impaired and can progress to irreversible blindness.

* Cavernous sinus thrombosis (stage V) is characterized by orbital pain, chemosis, proptosis, sepsis, and ophthalmoplegia (figure 4). It characteristically progresses to the other eye.

When orbital infection is suspected, ophthalmologic consultation and follow-up should be obtained immediately. Any worsening of the condition detected during the ophthalmologic examination calls for further intervention. These ophthalmologic signs include color vision changes, optic disc pallor, papilledema, and a decrease in venous pulsations. Associated manifestations such as lethargy, neck rigidity, and headache might indicate the presence of a concurrent intracranial complication.

Imaging studies. CT facilitates the diagnostic and management decision-making process by providing excellent resolution of the globe, the retro-orbital tissue, the sinuses, and the cranium. CT delineation of an abscess formation can help determine the need for surgical drainage. (12) Abscess formation is suggested on CT by a low-density mass effect, with or without enhancement. However, CT is limited in its ability to differentiate soft-tissue density, especially in acute infections. (4,12,13) The detection of an air-fluid level within a mass is more specific, and other findings (e.g., lateral displacement of the medial rectus) are also suggestive.

CT is usually unnecessary in patients with preseptal infections (i.e., periorbital or orbital cellulitis). Most investigators agree that CT is indicated only when a postseptal infection is suspected clinically, based on findings of proptosis, gaze restriction, or changes in visual acuity. (12) CT is mandatory when intracranial complications are suspected or when signs or symptoms of postseptal inflammation progress in 24 to 48 hours despite therapy. (1,3,14)

Magnetic resonance imaging (MRI) can be obtained when the physician suspects an intracranial complication (e.g., a fungal infection or an intracranial extension of sinus disease) or when tumor extension is suspected. Ultrasonography is rarely used as a diagnostic tool for orbital infections, but it can be used when nonapical disease exists. More often, it is used for monitoring the response to therapy after the presence of disease has already been documented by CT or MRI.

Treatment. Most orbital infections respond to medical therapy. The cornerstone of medical treatment is a broad-spectrum antibiotic, which can be started intravenously and later taken orally. A local nasal decongestant might also be useful. Surgical intervention is required in certain cases. We recommend surgical drainage when one of five circumstances is present: (1) CT evidence of abscess formation, (2) 20/60 (or worse) visual acuity on initial evaluation, (3) severe orbital complications (e.g., blindness or an afferent pupillary reflex) on initial evaluation, (4) progression of orbital signs and symptoms despite therapy, or (5) a lack of improvement within 48 hours despite medical therapy.

In the past, the mainstay of treatment for sinusitis with complications has been standard open operations, such as external ethmoidectomy and the Caldwell-Luc procedure. Nowadays, functional endoscopic sinus surgery has gained ground as the surgical modality of choice for chronic sinusitis in adults and children. It is being used for more indications, and we have observed its benefits with regard to surgical drainage in most patients who have sinusitis and subperiosteal abscess.

In our study, we found that a higher average number of orbital infections had been referred to our institution during the latter 9 years (mean: 3.8 patients/yr) than during the first 6 years (mean: 1.5 patients/yr). Most of the patients referred during the latter years were children who had stage I preseptal infections, and all responded to medical therapy without the need for CT or surgical intervention. This finding is in accordance with findings and recommendations published by others. (3,7,8) Our study also revealed an increase in the use of endoscopic sinus surgery (7 of 10 patients) to drain sinuses and subperiosteal abscesses during the latter 9 years. We believe that in the hands of an experienced surgeon, the endoscopic approach offers several advantages to the patient. This technique avoids external scarring, produces less edema and allows for faster recovery and thus a shorter hospital stay. Open sinus surgery--primarily external ethmoidectomy and the Caldwell-Luc procedure--was widely used up unti l the early 1990s, and it is still considered the procedure of choice for most patients with severe complications of sinusitis or orbital abscess formation. In our study, all five patients who had orbital abscesses (stage IV)--whether in the first (1985 through 1990) or second (1991 through 1999) periods--were treated with drainage via external sinus surgery.

In conclusion, orbital infections in the new millennium still pose a serious threat to patients, and they can lead to irreversible damage if they are not treated promptly and adequately. The clinical manifestations and CT findings provide the means for making diagnostic and therapeutic decisions. Standard surgery still plays an important role, especially in treating orbital abscesses, but the trend has shifted from using the external open technique to endoscopic sinus surgery. The latter is a safe and effective means of surgical drainage of the sinuses and subperiosteal abscesses.

We believe that the increase in the ratio of orbital complications of sinonasal origin that were referred to our institution reflects an increased awareness among physicians, the widespread use of CT, and the possibly skewed sample of patients who are seen at an academic, tertiary care referral center. Further research might clarify the picture, and other multilevel studies are encouraged.

Table 1. Sex and type of treatment

                                 Medical    Endoscopic  Open surgical
Infection                 M  F  management   surgery      procedure

Periorbital cellulitis   15  6     All          0             0
(n = 21)

Orbital cellulitis        4  2     All          0             0
(n = 6)

Subperiosteal abscess *   9  2     All          7             5
(n = 12)

Orbital abscess           5  0     All          0             5
(n =5)

* One of these patients also had a supraorbital abscess.

Table 2. CT findings in the different sinuses

                         Ethmoid   Maxillary  Frontal  Sphenoid
Infection                I *  B *   I     B    I    B   I     B

Periorbital cellulitis   18    3    8     3    6    0   0     0
(n = 21)

Orbital cellulitis        5    1    4     1    2    0   0     1
(n = 6)

Subperiosteal abscess +   8    4    8     4    6    2   8     2
(n = 12)

Orbital abscess           2    3    2     3    2    3   2     3
(n = 5)

* I = ipsilateral sinus disease; B = bilateral sinus disease.

+ Includes one patient who also had a supraorbital abscess.

References

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(2.) Goodwin WJ, Jr. Orbital complications of ethmoiditis. Otolaryngol Clin North Am 1985;18:139-47.

(3.) Patt BS, Manning SC. Blindness resulting from orbital complications of sinusitis. Otolaryngol Head Neck Surg 1991;104:789-95.

(4.) Schramm VL, Jr., Curtin HD, Kennerdell JS. Evaluation of orbital cellulitis and results of treatment. Laryngoscope 1982;92:732-8.

(5.) Jackson K, Baker SR. Clinical implications of orbital cellulitis. Laryngoscope 1986;96:568-74.

(6.) Quick CA, Payne E. Complicated acute sinusitis. Laryngoscope 1972;82:1248-63.

(7.) Lazar RH, Younis RT. Management of the complications of acute and chronic sinusitis. In: Cummings CW, ed. Otolaryngology-Head and Neck Surgery. Vol. 1. St. Louis: Mosby, 1992:149-58.

(8.) Souliere CR, Jr., Antoine GA, Martin MP, et al. Selective non-surgical management of subperiosteal abscess of the orbit: Computerized tomography and clinical course as indication for surgical drainage. Int J Pediatr Otorhinolaryngol 1990;19:109-19.

(9.) Hubert L. Orbital infections due to nasal sinusitis. NY State J Med 1937;37:1559-64.

(10.) Smith AF, Spencer JF. Orbital complications resulting from lesions of the sinuses. Ann Otol Rhinol Laryngol 1948;57:5-27.

(11.) Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of orbital complications in acute sinusitis. Laryngoscope 1970;80:1414-28.

(12.) Weber AL, Mikulis DK. Inflammatory disorders of the paraorbital sinuses and their complications. Radiol Clin North Am 1987;25:615.30.

(13.) Towbin R, Han BK, Kaufmann RA, Burke M. Postseptal cellulitis: CT in diagnosis and management. Radiology 1986;158:735-7.

(14.) Zimmerman RA, Bilaniuk LT. CT of orbital infection and its cerebral complications. AJR Am J Roentgenol 1980;134:45-50.

From the Department of Otolaryngology, University of Miami, Miami, Fla. (Dr. Younis and Dr. Bustillo); the LeBonheur Children's Medical Center, Memphis, Tenn. (Dr. Lazar); and the Division of Otolaryngology, Department of Surgery, University of Mississippi, Jackson (Dr. Anand).

Reprint requests: Ramzi T. Younis, MD, Chief, Pediatric Ear, Nose, and Throat Section. Department of Otolaryngology, University of Miami School of Medicine, 900 N. W. 17th St., Room 509, Miami, FL 33136. Phone: [phone]; fax: [phone]; e-mail: [e-mail]

Originally presented at the International Rhinology Congress; Washington, D.C.; Sept. 21,2000.