Grand Round

DMCENT department

Hussain AlsheefENT resident

History

8 years old girl medically free CC : Lt. eye swelling X 4days URTI 6 days prior presentation

odynophagia , fever , rhinorrhea and coughHeadache

Not started on antibiotics Lt.eye swelling 4 days prior presentation

seen in eye specialist hospital CT sinuses done and referred to ENT.

LAMA as no more fever and headache Admitted 2nd day.

Examination

Vitally stable , afebrile Conscious oriented , not on pain or distress Nose : congested mucosa , no purulent

discharge , patent Throat : not congested , no PND Ears : intact TM B/L Eyes : Lt.eye swelling and erythema .

Can’t open her eyes bcz pain. Tense on palpationvision and EOM intact

Plan

Admission Ophthalmology consultation Blood inv. CT sinuses IV Antibiotics plan for surgery as not improved

CT findings

Left lateral orbit collection (2 x 1.2 x 0.6 cm) with mass effect on the left globe manifested by medial rotation of the globe.

Peripheral enhancement post IV contrast suggests orbital Abscess .

Orbital cellulitis. The left maxillary sinus shows opacification with

a relatively central hyperdensity suggestive of early pyogenic sinusitis .

the left anterior ethmoid and left frontal sinuses show complete opacification.

Lacrimal gland is diffusely enlarged suggestive of inflammation.

Conclusion:left orbital cellulitis with left lacrimal gland involvement possibly due to adjacent sinus disease with preseptal and supraorbital abscess.

OR

Ophtha : I&D on most prominent area and packing with povidone gauze

Lt. FESS done : Findings : severly inflammed nasal mucosa and

turbinates with DNS to Lt.large adenoid obstructing 75% choana

M.T medialization , widening maxillary osteum and cleaning maxillary sinus with irrigation.

Bulla ethmoidalis removed reaching ant.ethmoids cleaned and irrigation was full of pus

Frontal sinus osteum identified&cleaned with irrigation with saline

Pack inserted in middle meatus

Sinusitis with orbital complications

Orbital complications

Results from a thrombophlebitis and interference with the venous drainage of the orbital contents.

superior and inferior ophthalmic veins are valveless, allowing direct communication between the nose, ethmoid sinuses, face, orbit, and cavernous sinus

congenital or other dehiscences in the lamina papyracea expose the orbital contents to direct extension of sinusitis

Orbital periosteum is important structure because it is the only soft tissue barrier between the sinuses and the orbital contents.

Chandler classification

Preseptal cellulitis

Preseptal abscess

Subperiosteal abscess

Orbital cellulitis

Indications for surgical intervention

CT evidence of abscess formation 20/60 or worse visual acuity is

observed on initial evaluation progression of orbital signs and

symptoms occurs despite medical treatment

or lack of improvement is seen within 48 hours despite aggressive medical treatment

Subperiosteal abscess

A useful framework for assessing patients outlined by Oxford and McClay :

medial subperiosteal abscess with normal vision (better than 20/40)

No ophthalmoplegia, intraocular pressure less than 20 mm Hg, proptosis less than 5 mm, and width of abscess less than 4 mm on CT

can be considered for possible medical management. These objective criteria were shown retrospectively to

predict successful medical management with good outcomes, even in older children.

Thank you,,