대한비과학회

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KISEP Original Articles J Rhinol 7((((2)))), 2000

Orbital Complications of Rhinosinusitis：：：： Characteristics in Pediatric Patients*

Yong-Jae Kim, M.D.

¹

and Yang-Gi Min, M.D.

²

ABSTRACT

To evaluate the differences in clinical features of rhinosinogenic orbital complications between the pediatric and adult groups, a multicenter survey was made on 79 cases of rhinogenic orbital complications (from January 1985 through October 1999).

The patients ranged in age between 8 months and 79 years with a mean of 28 years. Thirty-five patients were under 15 years of age (pediatric group), and 44 patients were over 15 years of age (adult group). Twenty-three of 35 pediatric patients (65.7%) had postseptal orbital inflammation, whereas 30 of 44 adult patients (68.2%) had postseptal orbital inflammation. The pediatric group had shorter symptom duration than the adult group. Pediatric OCRS also developed as various forms-inflammatory edema, orbital cellulitis, orbital abscess and subperiosteal abscess. Sixteen of 35 pediatric patients (45.7%) underwent surgical interventions. The cure rate by surgical interventions in the pediatric group (14/16, 87.4%) was higher than that in the adult group (21/26, 80.8%). The cure rate by medical treatment in the pediatric group (18/19, 94.7%) was also higher than that in the adult group (11/16, 68.7%).

KEY WORDS：Orbital complication·Pediatric rhinosinusitis.

INTRODUCTION

More than 60% of orbital inflammatory processes originate from the acutely inflammed paranasal sinuses.¹⁾ Since endoscopic sinus surgery (ESS) became one of the popular surgical tools along with the deve- lopment of computerized tomography (CT), a wider variety of nasal diseases has been indicated for surgical treatment. Furthermore with the advent of the markedly enhanced resolution power and magnification of rece- ntly developed surgical endoscopes, the deep operative fields with surgical risks are now a commonplace for

surgery.²⁾³⁾ Enhanced endoscopic surgical technique can bring about more surgical risks. On the other hand, it can be a helpful measure to manage the rhinogenic orbital complications.

The most commonly used classification of orbital complications is；I. inflammatory (preseptal) edema, II.

orbital (postseptal) cellulitis, III. subperiosteal abscess (SPA), IV. orbital abscess, and V. cavernous sinus thrombosis (CST).⁴⁾

To investigate the differences in clinical features of orbital complications accompanying rhinosinusitis between the pediatric (age®15 years) and adult (age>15 years) groups, we conducted a multicenter questionnaire survey from 16 tirtiary care hospitals in Korea.

MATERIALS AND METHODS

We sent a questionnaire on orbital complications associated with rhinosinusitis (OCRS) to 68 tirtiary care hospitals with otolaryngology training program in Korea.

Sixteen general hospitals replied to the questionnaire with 79 cases that occurred from January 1985 through October 1999. Each center has reported one to fifteen cases individually. Medical history, ophthalmologic and otolaryngologic findings including clinical features

*The authors agree to transfer the copyright of the manuscript

‘Oribital complications of rhinosinusitis：Characteristics in pediatric patients’ to the ‘Journal of Rhinology’.

1Department of Otolaryngology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea

2Department of Otolaryngology, College of Medicine, Seoul National University, Seoul, Korea

Address correspondence and reprint requests to Yong-Jae Kim, M.D., Department of Otolaryngology, University of Ulsan Co- llege of Medicine, Asan Medical Center 388-1 Poongnapdong, Songpagu, Seoul 138-736 Korea

Tel：82-2-2224-3712, Fax：82-2-489-2773 E-mail：[email protected]

Accepted for publication on October 17, 2000

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110 / J Rhinol 7(2), 2000

and hospital courses were reviewed. About the clinical data, radiologic findings (including CT scan) were also required. Appropriate CT scan was requested for the evaluation of the involved sinuses in OCRS, but was available only in 29 pediatric patients and 39 adult patients. The informations about their hospital courses, antibiotic treatment measure, microbiologic study result for ordinary bacteria and fungus, applied surgical modalities, and final outcomes were included within the questionnaire.‘Cure’as a treatment result was defined, when the patient was recovered from OCRS without permanent disabilities, or deteriorating to intracranial complications or even to death. The follow-up period ranged between 4 weeks and 3 years with a mean of 12 weeks.

RESULTS Clinical features of OCRS

Thirty-five pediatric patients ranged in age between 8 months and 15 years with a mean of 7 years. OCRS commonly occured in the patients under the age of 15 (35/79, 44.3%)(Table 1). Forty-four patients were in the adult group, but incidence was low in their 20s, 30s and 40s. A relatively small number of patients (17.2%) were between the ages of 20 and 40. Twenty-five (70%) of 35 pediatric patients and 24 (54.6%) of 44 adult patients were male.

Although 8 (22.9%) of 35 pediatric patients and 3 (6.8%) of 44 adult patients had bilateral sinusitis, no case with bilateral orbital complication was noted.

The affected paranasal sinuses underlying OCRS, both in the pediatric and adult patients were summarized in Table 2.

Incidence of orbital complications

In the pediatric patients, the incidence of inflammatory edema was 68.6% (24/35 cases), that of orbital cellulitis was 51.4% (18/35 cases), that of orbital abscess was 14.3% (5/35 cases), and that of SPA was 14.3% (5/35 cases). In the adults, 65.9% (29/44 cases) had inflammatory edema, 45.5% (20/44 cases) had orbital cellulitis, 11.4% (5/44 cases) had orbital abscess, 9.1% (4/44 cases) had SPA (Fig. 1), and 18.2% (8/44 cases) had CST (Table 1, 3). Two cases of brain abscess were found in this series.

Their chief complaints were shown in Table 4. Fifty- five patients presented with the chief complaints of periorbital swelling, exophthalmos, or proptosis. The other complaints were periorbital pain, hyperrhinorrhea, postnasal drip, nasal block, headache and diplopia in order of frequency. Twenty-nine (96.7%) of 30 pediatric patients characteristically had relatively shorter duration (less than 7 days) of symptoms pertaining to orbital complications, compared with 28 (73.6%) of 38 patients in the adult group (Table 5).

Bacteriologic culture was done with nasal swab from the middle meatus (Table 6). In the pediatric patients, Staphylococci were most frequently identified (10/20, 50.0%), whereas two strains of Streptococcus were

Table 1. Incidence of orbital complications

Children (N＝35) Adults (N＝44) Inflammatory edema 24 29 Orbital cellulitis 18 20 Orbital abscess 5 5 Subperiosteal abscess 5 4

CST* - 8

*：Cavernous sinus thrombosis

Table 2. Affected sinuses in the pediatric and adult patients Affected sinus Children (N＝29) Adults (N＝39) Maxillo-ethmoidal sinuses 17 12 Ethmoidal sinus alone 4 6

Maxillo-ethmoido-frontal - 4 Maxillary sinus alone 7 4

Sphenoid sinus alone - 3

Pansinusitis 1 4

Misc. 0 6

Fig. 1. Axial computerized tomography of a 3-year-old child with subperiosteal abscess on the left side (arrow).

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Kim et al：Rhinogenic Orbital Complications / 111

identified, and 45% (9 of 20) of the swabs were sterile.

In the adults, Streptococci were the most frequent or- ganism identified (7/26 cases, 26.9%), but 57.7 % (15 of 26 cases) of the samples were sterile in the patients with orbital complications of rhinosinusitis.

Treatment results of OCRS

The cure rate by surgical treatment in the pediatric patients (14/16, 87.4%) was higher than in the adult patients (21/26, 80.8%). The surgical treatment modalities were shown in the Table 7. The cure rate by medical treatment in the pediatric patients (18/19, 94.7%) was also higher than in the adult patients (11/16, 68.7%).

Failure cases include 2 cases of progressive intracranial infection spread and 2 cases of mortality due to underlying malignant lymphoma and complication of diabe- tes mellitus for each case.

DISCUSSIONS

The orbital complications of rhinosinusitis are usually first seen by pediatricians, ophthalmologists, and other physicians rendering primary patient care. Consequently, the diagnosis of OCRS, when referred to otolaryngo- logists, is often delayed, and subsequent permanent sequelae such as loss of vision can also combined with OCRS.⁴⁾ Inflammatory or pre-septal edema is the most common and mildest form of orbital complications.

Spires et al. reported that inflammatory edema occurred in young children, mostly under 2 years of age and that 226 of 242 patients (93%) were diagnosed with preseptal edema.⁵⁾ In this series, the incidence of inflammatory or pre-septal edema was statistically equivalent in the pediatric group (24/35, 68.5%) with that (29/44, 65.

8%) in the adult patients (Table 1). Many patients with inflammatory edema in the pediatric group may have been successfully treated by primary physicians.

Preseptal edema in infants with a preceding upper res- piratory infection, is usually secondary to H influenzae type B bacteremia and not a complication of sinusitis.

This process does not usually lead to the serious orbital sequelae associated with acute sinusitis, and responds quickly to appropriate antibiotic therapy.⁶⁾

It is considered that the frontal and sphenoid sinuses may become clinically significant after 6 years of age.

Accordingly, sinusitis in children under 6 years of age is confined to the maxillary and ethmoid sinuses.⁷⁾ In this series, the majority of pediatric patients (28/29, 96.

6%) had maxillary and ethmoid sinusitis, but a various combinations of the paranasal sinuses were affected in the adult group (Table 2).

The symptom duration of less than 7 days reflects rapid progression of inflammatory process in the pedia-

Table 3. Age distribution of preseptal and postseptal orbital complications*

Ages Preseptal Postseptal Total 8 months - 4 years 4 7 11

5 - 9 years 4 8 12

10 - 5 years 4 8 12

*：In the adult group, postseptal complications were noted in 68.1% (30/44)

Table 4. Chief complaints of orbital complications Symptom Children

(N＝35)

Adults

(N＝44) Total Periorbital swelling 24 28 52

Local pain 2 8 10

Nasal obstruction 1 3 4 Hyperrhinorrhea 3 1 4

Exophthalmos 3 - 3

Diplopia - 2 2

Headache - 2 2

Fever 2 - 2

Table 5. Symptom duration of orbital complications Duration of disease Children (N＝30) Adults (N＝38)

Within 1 week 29 28

1 - 3 weeks 1 6

3 weeks - 3 months - 1

More than 3 months - 3

*：Cavernous sinus thrombosis

Table 6. Bacteria identified from the middle meatus Children (N＝20) Adults (N＝26) Staphylococci spp. 10 3 Streptococci spp. 2 7

Proteus mirabilis - 1

No growth 9 15

Table 7. Applied surgical modalities for the treatment of or- bital complications

Children (N＝16) Adults (N＝26) Intranasal ethmoidectomy 7 20 Orbital abscess drainage 5 2 External ethmoidectomy 4 3 Transantral procedure 2 7 Combined procedures 5 9

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112 / J Rhinol 7(2), 2000

tric group. Twenty-nine (96.7%) of 30 pediatric patients had relatively shorter duration (less than 7 days) of symptoms pertaining to orbital complications, compared to 28 (73.7%) of 38 patients in the adult group (Table 5). The common chief complaints were periorbital swelling (52/79, 65.8%) and pain (10/79, 12.7%) in the total patient group (Table 4).

Radiologic assessment of the orbit by means of plain radiography, ultrasonography, and especially CT is of value in pediatric group for the diagnosis of underlying sinusitis and classification of rhinosinogenic orbital complications.⁸⁾⁹⁾ Coronal CT with enhancement is useful in improving imaging accuracy.¹⁰⁾¹¹⁾ Ultrasonography is not so helpful to evaluate the presence of an abscess, but may be useful in monitoring the amount of periorbital edema and displacement.¹²⁾ In this series, the most frequently affected sinus was the maxillary-ethmoid sinuses both in the pediatric (17/29, 58.6%) and the adult (12/39, 30.8%) groups.

Gram staining and culture for conjunctiva, nose and throat may be helpful, but are not always representative of the offending organisms.⁸⁾¹³⁾ Blood culture needs 3 or more days of cultivation to yield the pathogen, and is frequently negative especially if the patients received antibiotic therapy.¹²⁾ In this series, Staphylococci were the commonest pathogen identified (10/20, 50.0%) from nasal swabs in the pediatric group, whereas Streptoco- cci were in the adult group (7/26, 26.9%).

The indications for surgical drainage include abscess formation demonstrated on CT scan, progression of symptoms (ophthalmoplegia, decreased vision) for more than 48 to 72 hours.¹⁴⁾ Blindness or rapidly deteriorating vision is generally considered as an ophthalmologic emergency.¹²⁾ Surgical exploration is also recommended, regardless of CT findings, for children who initially present with decreased visual acuity or demonstrate progression of orbital manifestation despite medical therapy.¹⁵⁾ Recovery of visual acuity is believed better in cases of infectious processes secondary to nonspeci- fic inflammations or mucoceles compared with fungal diseases.¹⁶⁾ In this series, the cure rate in the pediatric group by surgical and by medical treatment was higher than that in the adult group. It can be explained by the fact that preseptal edema with a preceding upper respi- ratory infection is not a complication of sinusitis, but usually is secondary to H influenzae bacteremia⁶⁾ and

can easily resolved without serious sequelae as in the adult group.

CONCLUSION

Orbital complications in the pediatric rhinosinusitis patients have short duration of symptoms and develop as various forms-inflammatory edema, orbital cellulitis, orbital abscess and subperiosteal abscess. How-ever, early diagnosis and appropriate management usually result in better outcome in the pediatric patients than in the adult patients.

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