ORBITAL COMPLICATIONS

OF SINUSITIS- N. ARAVINTHO

Epidemiology• 80 – 90% of cases.• Peak incidence between 5 - 10 years• 80% of patients <18 Y/O ( Younis et al 2002)• Sinus infections are the most common cause of

unilateral proptosis in children and the 3rd most common cause in adults following Graves’ orbitopathy and pseudotumor

• Ethmoid sinusitis is most common cause , followed by Maxillary

Orbital Complications Of Sinusitis

Etiology• Direct extension of ethmoid sinusitis through thin

lamina papyracea• Retrograde bacterial phlebitis with intact lamina

papyracea via:1. The anterior & posterior ethmoidal neurovascular

foramina2. The ophthalmic venous system, the superior and inferior

ophthalmic veins, are valveless, allowing for free-flowing communication of infection from the nose and ethmoid sinus to the orbit.(Chandler et al., 1970)

RELATION OF SINUSES TO ORBIT

Anatomy• Orbital septum is a thin fibrous tissue continuation of orbital rim

periostium which extends to the tarsal plates• Deep to posterior orbicularis fascia• Anterior extent of orbit & Posterior extent of eyelid• A Fascial barrier against the spread of periorbital infections into the

orbit proper

GRADING OF ORBITAL CELLULITIS

• G 1 : PRE SEPTAL CELLULITIS• G 2: POST SEPTAL CELLULITIS• G 3: SUBPERIOSTEAL ABSCESS• G 4: ORBITAL ABSCESS• G 5: CAVERNOUS SINUS THROMBOSIS• SUPERIOR ORBITAL FISSURE SYNDROME • ORBITAL APEX SYNDROME

Optic globe and septum divides the orbit into anterior and Optic globe and septum divides the orbit into anterior and posterior compartmentsposterior compartments

Localizing orbital disease to compartment helps generate a Localizing orbital disease to compartment helps generate a differential diagnosis.differential diagnosis.

Orbital CompartmentsOrbital Compartments

PRE SEPTAL CELLULITIS• NO MARKED ERYTHEMA AND

TENDERNESS OF THE LIDS• ONLY OEDEMA OF THE LIDS• OCCULAR MOVEMENTS AND VISION NOT

AFFECTED• UPPER LID INVOLVED IN FRONTAL ,

LOWER IN MAXILLARY AND BOTH IN ETHMOIDAL CELLULITIS

Orbital Cellulitis Pre-septal cellulitis

9

Orbital Cellulitis Post-septal (Orbital) Cellulitis

10

. Axial CE fat-suppressed T1-W MRI obtained in a 40-. Axial CE fat-suppressed T1-W MRI obtained in a 40-Y/O man demonstrates right exophthalmos and Y/O man demonstrates right exophthalmos and heterogeneous enhancement of orbital (arrows) and heterogeneous enhancement of orbital (arrows) and periorbital (arrowhead) fat.periorbital (arrowhead) fat.

Christina A. LeBedis, Osamu Sakai. Christina A. LeBedis, Osamu Sakai. RSNA, 2008 RSNA, 2008 •• radiographics.rsnajnls.orgradiographics.rsnajnls.org

SUBPERIOSTEAL ABSCESS• ETHMOID SINUSES- UNDER PERIOSTEUM

OF LAMINAPAPYRACEA• PUSHES THE EYEBALL OUTWARD,

LATERALLY, AND DOWNWARDS• FRONTAL SINUSE- DOWNWARDS AND

LATERALLY• MAXILLARY SINUSES- UPWARD AND

FORWARDS

Subperiosteal AbcessSubperiosteal Abcess

Subperiosteal abscess due to ethmoid sinusitis. Axial Subperiosteal abscess due to ethmoid sinusitis. Axial (a) (a) and coronal and coronal (b) (b) nonenhanced CT images obtained in a 24-year-old man depict a subperiosteal nonenhanced CT images obtained in a 24-year-old man depict a subperiosteal abscess (arrow) along the medial wall of the right orbit,adjacent to the opacified abscess (arrow) along the medial wall of the right orbit,adjacent to the opacified ethmoid air cells, with resultant lateral displacement of the medial rectus ethmoid air cells, with resultant lateral displacement of the medial rectus muscle.muscle.. .

Christina A. LeBedis, Osamu Sakai. Christina A. LeBedis, Osamu Sakai. RSNA, 2008 RSNA, 2008 •• radiographics.rsnajnls.orgradiographics.rsnajnls.org

ORBITAL ABSCESS• SUBPERIOSTEAL ABSCESS BURSTS INTO

ORBIT CAUSING ORBITAL ABSCESS• HIGH FEVER• OEDEMA OF THE LIDS • PROPTOSIS • CHEMOSIS OF CONJUNTIVA• EYEBALL MOVEMENTS RESTRICTED• VISION AFFECTED

Orbital Abscess

Post-Septal Orbital AbscessChild with an intraorbital abscess Child with an intraorbital abscess 2ry to ethmoid sinusitis2ry to ethmoid sinusitis

SUPERIOR ORBITAL FISSURE SYNDROME

• INFECTION OF SPHENOID SINUSES • DEEP ORBITAL PAIN, FRONTAL

HEADACHE• PROGRESSIVE PARALYSIS OF

CRANIAL N 4, 3 AND 6 IN THAT ORDER

ORBITAL APEX SYNDROME

SUP ORBITAL FISSURE SYNDROME + INVOLEMENT OF OPTIC NERVE AND MAXILLARY DIVISION OF TRIGEMINAL NERVE

1.1. Periorbital (Pre-Septal) cellulitisPeriorbital (Pre-Septal) cellulitis2.2. Orbital (Post-Septal) cellulitisOrbital (Post-Septal) cellulitis3.3. Subperiosteal AbscessSubperiosteal Abscess4.4. Orbital abscessOrbital abscess5.5. Cavernous Sinus ThrombophlebitisCavernous Sinus Thrombophlebitis

Orbital Complications Of SinusitisOrbital Complications Of SinusitisClassificationClassification

Pre-Septal• More common• Anterior to the septum• Erythema/Edema eyelids• No proptosis• No Pain• Normal vision • No restriction of ocular

movements/Painless• No aff. Pupillary defect• No abscess• ±Fever

Post-Septal• Less frequent <5y• Posterior to the septum• Massive eyelid swelling • Proptosis• Severe Pain• Diminution of vision • Restriction of ocular

movements/Painful • Afferent pupillary defect• An abscess may form • ‡Fever

CLINICAL PRESENTATION• CHILDREN AND YOUNG ADULT COMONLY

INVOLVED• ORBITAL COMPLICATION MOSTLY ARISE AS

COMPLICATION OF ACUTE ETHMOIDAL SINUSITIS OR RARELY ACUTE EXACERBATION OF CHRONIC SINUSITIS

• SWELLING AROUND EYE WITH H\O UPP. RESPIRATORY INFECTION

• EYEBALL MOVEMENTS AND VISION DEPENDS ON THE GRADING (G 3 ONWARDS)

• VISUAL ACUITY AND COLOUR VISION – MEASURE OF OPTIC NERVE

EXAMINATION• DIAGNOSTIC NASAL ENDOSCOPY• FULL RANGE OF EYE MOVEMENTS• DEGREE OF PROPTOSIS• LIGHT REFLEX• VISUAL ACUITY• COLOUR VISION• FUNDUS EXAMINATION

INVESTIGATION• TO DEFINE THE EXTENT AND SITE OF THE

DISEASE• CT SCAN OF ORBIT, PNS AXIAL AND

CORONAL VIEW• HEMATOLOGY : TC , DC , RBC COUNT , Hb • URINE ANALYSIS : DIABETES MELLITUS

TREATMENT MEDICAL MANAGEMENTFIRST LINE OF TREATMENT

IV ANTIBIOTICS- BROAD SPECTRUM Like 3rd GENERATION CEPHALOSPORIN,

CEFOTAXIME CEFTRIAXONE

SURGICAL MANAGEMENT AIM IS TO TREAT COMPLICATION AND SINUSITIS

• SURGERY FOR ALL CASES WITH PROPTOSIS IRRELAVENT OF EYEBALL MOVEMENTS AND VISUAL ACUITY

• ENDOSCOPIC APPROCH: • EXTERNAL APPROCH: LYNCH HOWARTH

SURGERY

LYNCH HOWARTH SURGERY

DRAINAGE OF ABSCESS DRAINAGE TUBE EITHER INTO

NASAL CAVITY OR DRAINED EXTERNALLY

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