Complicación orbitaria recurrente por rinosinusitis. Reporte de un caso / Recurrent orbital complication by rhinosinusitis. A case report

El compromiso orbitario es la complicación más frecuente de la rinosinusitis aguda en pediatría, y el etmoides es el seno más afectado. La recurrencia es infrecuente. Existen solo tres casos publicados en la literatura. Una anomalía anatómica del proceso unciforme o un mucocele podrían ser factores predisponentes, que pueden obstruir el drenaje normal de los senos junto con la presencia de etmoiditis.La tomografía computada y la resonancia magnética orientan el diagnóstico. El tratamiento quirúrgico está indicado ante la falta de respuesta al tratamiento instaurado luego de 48 horas o disminución de la agudeza visual o recurrencias sin patología tumoral de base.Se presenta a un paciente de 4 años de edad que consultó por un cuadro compatible con etmoiditis complicada recurrente. Presentó celulitis preseptal en seis oportunidades y un episodio de absceso subperióstico, desde los 3 meses de edad. Evolucionó favorablemente luego de la operación quirúrgica.

Orbital infection is the most frequent complication of ethmoiditis. Recurrent periorbital cellulitis is a very rare complication of rhinosinusitis with only three reports in the literature describing this pathological process.This complication can be favored by an anatomical abnormality of the uncinate process or mucocele obstructing the normal drainage pathway, in addition to ethmoidal sinusitis.Computed tomography and magnetic resonance guide the diagnosis. The treatment is based on antibiotics, corticosteroids and local decongestants. Surgical treatment is indicated in the absence of response to treatment established after 48 hours or decrease in visual acuity or recurrent orbital complications without underlying tumor pathology. In this report, we present a case of orbital complication of rhinosinusitis in a 4 year-old-child with six episodes of unilateral periorbital cellulitis and one episode of subperiosteal orbital abscess since the age of 3 months. There was a complete resolution with no recurrence after the surgical intervention

Woakes' syndrome.

Woakes' syndrome is a rare entity defined as recurrent sinonasal polyposis with a consequent nasal pyramid deformity. Only a few cases are reported in the literature. The goal of this study is to present the features of Woakes' syndrome through a clinical case. A 42-year-old man presented with a history of ASA triad. He started self-medication for 5 years. He returned to the otorhinolaryngology department for the aggravation and persistence of symptoms. CT scans showed the deformity and thinning of the nasal bones. A functional endoscopic sinus surgery and correction of nasal pyramid deformity were performed. At 6 months' follow-up, good functional and aesthetic outcomes were observed. Woakes' syndrome was described more than 130 years ago. Treatment includes endoscopic sinonasal surgery and local treatment. Adequate management and good adherence to the therapeutic protocol could be factors to prevent this syndrome.

Nocardia asteroides sinusitis in a pediatric patient: Case report with 20 year follow-up and review of the literature.

Nocardia Asteroides infection in a non-immunocompromised pediatric patient is extremely rare. We present a case of ethmoid sinusitis and orbital subperiosteal abscess caused by N. asteroides with a 20 year follow up and a review of the literature. N. asteroides was grown from intraoperative cultures for mycobacteria following surgical incision and drainage of the abscess. Postoperatively, the patient received a seven month course of trimethoprim-sulfamethozaxole and had no subsequent sequelae. Nocardia infections are common in immunocompromised patients. We present what we believe to be the first case of pediatric Nocardia sinusitis with 20-year follow up.

[The 'black turbinate sign' in a case of rhinocerebral mucormycosis]. / Signo del cornete negro en un caso de mucormicosis rinocerebral.

TITLE: Signo del cornete negro en un caso de mucormicosis rinocerebral.

[Septic cavernous sinus thrombosis following ethmoiditis: a case report]. / Thrombose du sinus caverneux compliquant une ethmoïdite aiguë

Acute ethmoiditis is a rare infection of ethmoidal cells. The pathognomonic sign is an edema of the internal corner of the eye. Imaging may be necessary to verify the absence of orbital or endocranial complications. Thrombophlebitis of the cavernous sinus is a serious complication of this infectious process. We report the case of an 11-year-old boy who presented with ethmoiditis complicated with thrombophlebitis of the cavernous sinus, with right hemiplegia and left Bell palsy sequelae. Early diagnosis of this disorder and urgent therapy are essential. Treatment is based on the antibiotic therapy.

A case of Schizophyllum commune sinusitis following unrelated cord blood transplantation for acute lymphoblastic leukemia.

Schizophyllum commune is a globally distributed basidiomycete fungus that is known as a rare cause of sinusitis, for which no prompt treatment has been established. We describe the first report of S. commune sinusitis following unrelated cord blood transplantation for acute lymphoblastic leukemia. Thirteen days after transplantation, a 23-year-old female developed maxillary and ethmoid sinusitis. The sinusitis was antimicrobial-resistant, and the sinus aspirate culture revealed white wooly mold, which was identified as S. commune by nucleotide sequencing. The patient was successfully treated with intravenous administration of liposomal amphotericin B for 2 months, followed by oral voriconazole. This report suggests the effectiveness of liposomal amphotericin B and voriconazole for S. commune infection in immunocompromised patients. Given the difficulty in distinguishing S. commune infection from aspergillosis by standard culture methods, the incidence of S. commune infection following allogeneic hematopoietic stem cell transplantation may be underestimated. Nucleotide sequencing may be useful in the diagnosis of S. commune infection.

Steroid-independent upregulation of matrix metalloproteinase 9 in chronic rhinosinusitis patients with radiographic evidence of osteitis.

BACKGROUND: Chronic sinonasal inflammation is associated with tissue remodeling, such as osteitis, which may be a marker of refractory disease; however, the pathophysiology of osteitis in chronic rhinosinusitis (CRS) is insufficiently understood. METHODS: Ethmoid mucosa and bone samples were obtained from 35 medically refractory CRS patients and 9 control subjects. Quantitative real-time polymerase chain reaction (RT-PCR) was performed separately on bone and mucosa for matrix metalloproteinase 2 and 9 (MMP2, MMP9) and tissue inhibitor of matrix metalloproteinase 1 (TIMP1). Osteitis was classified as mild, moderate, or severe by measuring bone thickness of the maxillary, sphenoid, and ethmoid sinuses on multiplanar computed tomography (CT). Patients were classified based on severity of osteitis and compared to controls. RESULTS: Nine patients demonstrated radiographic evidence of osteitis (mild = 3, moderate/severe = 6). Bone PCR revealed biologically significant upregulation of MMP9 in all patients with CRS, but the magnitude of the upregulation decreased with severity of osteitis. Mucosa PCR showed upregulation of MMP9 in moderate/severe osteitis only. No significant changes were seen in MMP2 or TIMP1 regulation. CONCLUSION: This is the first study to evaluate the role of MMP in the bone and mucosa of patients with sinonasal osteitis. The pattern of expression suggests there may be a time- and tissue-dependent role for MMP9 in the pathophysiology of osteitis. In addition, MMP9 overexpression is seen despite preoperative oral and intranasal steroid use, suggesting that if MMP9 is an important factor in the development of osteitis then steroids may not be the best treatment in prevention of osteitis.

Oral levofloxacin-induced optic neuritis progressing in loss of vision.

This case report highlights a rare adverse drug reaction caused by levofloxacin, resulting in optic neuritis progressing into unilateral loss of vision. A 49-year-old male patient was diagnosed to suffer from left maxillary and ethmoid sinusitis and was only prescribed oral levofloxacin 500 mg tablets once daily for 5 days. Within a few minutes after taking the first dose of the drug, the patient experienced respiratory distress, dizziness, confusion with pain, and loss of color vision, followed by almost complete loss of vision in the right eye. The left eye was normal. After ophthalmologic examinations and investigations, he was diagnosed to suffer from optic neuritis, probably (according to Naranjo adverse drug reaction probability scale) induced by levofloxacin.

Advance II: a prospective, randomized study assessing safety and efficacy of bioabsorbable steroid-releasing sinus implants.

OBJECTIVE: Endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) may be compromised by postoperative inflammation, polyposis, and adhesions, often requiring subsequent intervention. To address this issue, the authors investigated the safety and effectiveness of controlled delivery of mometasone furoate to the sinus mucosa via bioabsorbable implants deployed at the time of ESS. STUDY DESIGN: Prospective, multicenter, randomized, controlled, double-blind trial using an intrapatient control design. SETTING: Otolaryngology-head and neck surgery centers; both academic and private practices. SUBJECTS AND METHODS: The study enrolled 105 patients with CRS undergoing bilateral ethmoidectomy to compare the effect of drug-releasing to non-drug-releasing implants using an intrapatient control design. Postoperative interventions, polyposis, and adhesions were assessed postoperatively. Efficacy was determined through independent analysis of randomized video-endoscopies by 3 blinded sinus surgeons. Safety assessments included ocular examinations. RESULTS: Implants were successfully deployed in all 210 ethmoid sinuses. Compared with control sinuses with non-drug-releasing implants, the drug-releasing implant provided a 29.0% relative reduction in postoperative interventions (P = .028) and a 52% (P = .005) decrease in lysis of adhesions. The relative reduction in frank polyposis was 44.9% (P = .002). Similar reductions were observed in real-time grading performed by the clinical investigators. No clinically significant changes from baseline in intraocular pressure or cataracts were observed. CONCLUSION: This study provides a high level of evidence that use of steroid-releasing implants that apply a sustained release of corticosteroid improves surgical outcomes by reducing synechiae formation, polyposis, and the need for postoperative interventions, with no observable ocular safety risk.

ADVANCE: a multisite trial of bioabsorbable steroid-eluting sinus implants.

OBJECTIVES/HYPOTHESIS: Disease recurrence and adverse wound healing in the form of inflammation, polyposis, adhesions, and middle turbinate lateralization may induce suboptimal outcomes following sinus surgery. The study objective was to assess the safety and effectiveness of a bioabsorbable, steroid-eluting implant used following functional endoscopic sinus surgery in patients with chronic rhinosinusitis (CRS). STUDY DESIGN: Prospective, multicenter, single-cohort trial enrolling 50 patients. METHODS: The study allowed bilateral or unilateral steroid-eluting implant placement. Oral and topical steroids were withheld for 60 days postoperatively. Endoscopic follow-up was performed to 60 days. Patient-reported outcomes (Sino-Nasal Outcome Test-22 Questionnaire, Rhinosinusitis Disability Index) were collected to 6 months. Efficacy was assessed by grading inflammation, polyp formation, adhesions, and middle turbinate position. Safety assessment included ocular exams at baseline and 30 days. RESULTS: Implants were successfully placed in all 90 sinuses. Mean inflammation scores were minimal at all time points. At 1 month, the prevalence of polypoid edema was 10.0%, significant adhesions 1.1%, and middle turbinate lateralization 4.4%. Changes from baseline in patient-reported outcomes were statistically significant (P < .0001). No clinically significant changes from baseline in intraocular pressure occurred. CONCLUSIONS: This consecutive case series provides clinical evidence of the safety, effectiveness, and clinical utility of a bioabsorbable steroid-eluting implant for use in CRS patients. The implant was associated with favorable rates of sinus patency. At 1 month, minimal degrees of inflammation and adhesions were observed, suggesting a positive clinical impact of local steroid delivery without evidence of ocular risk.

Unilateral proptosis in a 60-year-old man.

A 60-year-old immunocompromised patient developed rapidly progressive proptosis that was secondary to mucormycosis. This life-threatening fungal infection usually is associated with chemosis, proptosis, ophthalmoplegia, and visual loss. The fungus may invade ocular structures, sinuses, and extend into the brain. The standard of care includes correction of the underlying condition, administration of liposomal amphotericin B with posaconazole, and surgical debridement of infected and necrotic tissue. We present a case of unilateral proptosis due to mucormycosis in an immunocompromised patient. The patient was successfully managed medically without exenteration. The indications for exenteration are currently unclear, and no clinical guidelines exist.

[Blindness due to acute ethmoiditis]. / Akut etmoiditis kan medføre blindhed.

Orbital complications of ethmoiditis are well-described. This case presents a healthy ten-year-old boy who was admitted under the diagnosis of acute ethmoiditis. A computed tomography (CT) showed orbital cellulitis, but no definite abscess. The patient improved during intravenous antibiotic treatment, but suddenly complained about loss of vision. The clinical signs were central scotoma and visual impairment to 0.05. Both repeat CT, magnetic resonance imaging and ethmoidectomy were performed without signs of abscess. Blindness due to ethmoiditis without abscess in orbita is rare and probably results from neuritis in the nervus opticus.

[Complications of bacterial rhino-sinusitis in children: a case report and a review of the literature]. / Complications des sinusites bactériennes du grand enfant. A propos d'un cas et revue de la littérature.

Acute sinusitis in children is a controversial issue in terms of its diagnostic criteria, classification and therapeutic management. A therapeutic delay can lead to complications if the cause is bacterial. Guidelines have been set, but they are not consensual in pediatrics. Complications of acute bacterial sinusitis are uncommon in children, but they can be extremely severe and cause high morbidity and mortality. Because of their rarity, they often are not identified early, exposing the patient to an unfavorable outcome. We report on a case of acute bacterial pan-sinusitis complicated with thrombophlebitis of the cavernous sinuses and meningitis in a 9-year-old child, in spite of early and adapted antibiotic therapy. The bacterial agent was Staphylococcus aureus, which had no resistance or toxin profile. The progression was favorable under intravenous antibiotic therapy and after bilateral sphenoidectomy. This case raises the question of the best therapy for acute bacterial sinusitis in pediatrics and the management of complications.

Safety of ethmoid sinus drug-eluting catheter insertion.

OBJECTIVES: We sought to evaluate an instrument that allows a drug-eluting catheter to be inserted into the ethmoid sinuses and to demonstrate its safety and reproducibility in a cadaver model. METHODS: A drug-eluting catheter was placed into 12 cadaveric anterior and posterior ethmoid sinuses by use of a trocar-based insertion device. The device's position was analyzed with computed tomographic scans, and postprocedural dissection was performed. RESULTS: The drug-eluting catheter system was successfully inserted in all ethmoid sinuses without injury to the medial orbital wall, skull base, or sphenoid face. The final position of the distal tip of the catheter averaged 8.1 mm (root mean square [RMS], 3.3 mm) from the skull base, 5.6 mm (RMS, 3.5 mm) from the sphenoid face, and 5.0 mm (RMS, 3.5 mm) from the lamina papyracea; the proximal tip was at the face of the ethmoid bulla and 17.1 mm (RMS, 3.5 mm) below the skull base. CONCLUSIONS: A trocar-based instrument can relatively safely and reproducibly introduce a drug-eluting catheter into the ethmoid sinuses without injuring the skull base, lamina papyracea, or sphenoid face. This device may allow safe topical drug delivery into the ethmoid sinuses and serve as a vehicle to treat chronic ethmoid sinusitis with direct and sustained topical therapy.

Ethmoidal pneumocele following drainage of an ethmoidal mucocele.

Ethmoidal pneumocele is a rare condition with little known about its etiology. We report a 5-year-old boy who had recurrent right orbital cellulitis, non-axial proptosis, and inferolateral globe displacement. Initial radiological investigations demonstrated an ethmoidal mucocele. There was complete resolution of inflammatory signs with endoscopic drainage of the mucocele; however, repeat CT revealed a residual pneumocele with continued proptosis and lateral displacement of the globe. This case illustrates the potential for chronic sinusitis and iatrogenic drainage of an ethmoidal mucocele to progress to a pneumocele.