David Tunkel, M.D.
The adolescent showed up in the ED complaining of sharp pains and blurry vision in his left eye for three days. Indeed, his eye was both bulging out of the socket and swollen shut.
“He had periorbital edema to the point that his eye was completely closed, and the only way we could open it was to forcefully push it open with our fingers,” first-year resident Jana Mohassel reported at a recent Hopkins Children’s case conference. “We did a lot of probing to see if he had suffered any kind of bug bites or trauma to the eye, but we couldn’t come up with anything.”
Then Mohassel and the team saw the patient’s CT scan from his local hospital showing inflammation in the ethmoid and maxillary sinuses that had extended into his orbit. The initial concern was an abscess that had also extended into the cranium, prompting an order for an MRI, which confirmed an abscess in the orbit but not an epidural mass or involvement with the brain. Now they were faced with how best to treat this severe sinusitis and orbital cellulitis. Additional imaging? Inpatient or outpatient medical therapy? Surgery? And if surgery, when and what kind of approach?
Pediatric otolaryngologist David Tunkel, consulting on the case, said the immediate concern in such cases is potential vision loss from ischemic or toxic optic neuropathy and increased intraorbital pressure. If there is gaze limitation and bulging of the eye – proptosis – it’s an orbital infection that is unlikely manageable with antibiotics alone. “And if there’s a change in visual acuity,” he said, “it becomes more of a fire drill and you have to move more quickly” to relieve the pressure.
Surgery to decompress the orbit, drain an abscess or open an infected sinus is indicated when vision is compromised, imaging shows an orbital or large subperiosteal abscess, or when the infection does not resolve with antibiotics. The degree of proptosis, Tunkel said, usually predicts who will need surgery.
Examination, he noted, is usually more helpful than imaging in these cases. Problems tend to surface when physicians wait for CT scans to make decisions, make a suboptimal antibiotic choice or dose, or lack understanding about the contraindications for medical management. Staphyloccocus aureus and strep species are the usual pathogenic culprits, Tunkel added. Orbital complications are uncommon but serious, and most often best treated through a combination of medical management and surgery.
“Get everyone involved early and often,” Tunkel said.
In this case the abscess was drained in the OR using an external approach. In some cases, Tunkel noted, drainage can be achieved using an endoscopic approach through the nose, avoiding a scar and resulting in a quicker recovery for the patient.
So, how can pediatricians distinguish early on the severe sinusitis with potential orbital complications from your run-of-the-mill sinusitis case? Should they change their practice?
“You can’t tell, and there’s no practice change you can make. It’s not unlike complications of otitis media. We just need to recognize the signs of such orbital complications when they occur,” Tunkel said. “The patient I really worry about is the 14-year-old male child who comes into the ED with a bad headache and low grade fever, and who is diagnosed with frontal sinusitis and sent home. That’s the patient who should have a CT scan of the brain and sinuses, probably with contrast, because he may have an unrecognized intracranial infection.”
“The take-home message is recognizing the signs and symptoms of orbital cellulitis early so that patients can be referred for timely surgical or medical intervention,” added Mohassel. “Then you can avoid the serious associated morbidities such as blindness.”