Orbital complications of sinusitis in children - Retrospective analysis of an 8.5 year experience.

OBJECTIVE: Orbital complications account for approximately 74-85 % of all complications of acute sinusitis, affect the pediatric population more frequently, and can have devastating consequences. In the years following the COVID-19 pandemic (2022, 2023), a high number of children presented to our clinic with orbital complications. 1)Has there been an increase in orbital complications in the post-covid era? 2)To what extent has the use of MRI reduced radiation in pediatric patients? DESIGN: In our retrospective data analysis, all pediatric patients (age 0-16 years) treated at a university ENT clinic during the period 01/2014-06/2023 who presented with an orbital complication of rhinosinusitis were included. The analysis was descriptive. RESULTS: Forty-four children with orbital complications of rhinosinusitis were treated during the study period, 14 females and 30 males. Most patients (n = 23, 52 %) presented during the years of the waning Covid-19 pandemic (01/2022 to 06/2023). MRI was the initial imaging modality (n = 22,50 %); CT was performed in 17 of 44 cases (39 %) when surgery was indicated. The most common germ detected was of the Streptococcus species, and the predominant antibiotic administered was amipicillin/sulbactam. CONCLUSION: The standard operating procedure (SOP) established at our hospital in 2014 was followed in 42/44 cases. Except for 2 cases, CT was performed exclusively when surgery was indicated. Imaging-related radiation could be avoided in 27 patients (61 %). There was a 30 % increase in orbital complications related to sinus infections postpandemically.

Role of Acute Rhinosinusitis in Periorbital Infections in Children.

OBJECTIVE: Periorbital cellulitis in children are commonly caused by acute rhinosinusitis (ARS). This study investigated the association of ARS and the severity of periorbital cellulitis in children. STUDY DESIGN: Retrospective case-control study of children with periorbital cellulitis with ARS versus periorbital cellulitis without ARS. SETTING: Patients were seen at West Virginia University Children's Hospitals between August 2011 to August 2022. METHODS: Patients were divided into cases and controls based on presence or absence of ARS. ARS was defined based on clinical symptoms with objective presence of disease on CT scan. Patients' characteristics, treatment, hospital length of stay, and readmission were collected. RESULTS: The sample consisted of 118 pediatric patients with orbital cellulitis. Patients with ARS were younger than patients without ARS (6.3 vs 8.5, p = 0.025), however there were no sex differences between two groups (p = 0.540). The ARS group had higher incidence of postseptal cellulitis (51.5% vs 9.6%, p < 0.001). As compared to patients without ARS, patients with ARS were more likely to be admitted (p < 0.001), have a longer length of stay (median of 3.5 days vs 0.5 days, p < 0.001), require IV antibiotics (95.3% vs 54.9%, p < 0.001), and require surgical intervention (23.1% vs 5.8%, p < 0.001). Readmission rate was similar between the two groups. CONCLUSION: Children presenting with acute periorbital cellulitis who have ARS tend to have more severe infection requiring higher level of care. ARS should be assessed and incorporated into the plan of care of pediatric patients with periorbital infections.

Ocular and orbital manifestations of granulomatosis with polyangiitis: a systematic review of published cases.

Objective: Granulomatosis with polyangiitis (GPA) is an autoimmune disorder characterized by necrotizing granulomatous inflammation of small and medium-sized vessels. This systematic review aimed to highlight the most common ophthalmic manifestations and to uncover their associations with antineutrophil cytoplasmic antibody (ANCA) positivity and the presence of granulomas. Methods: A literature search of PubMed, Web of Science, and Scopus electronic databases was performed from journal inception to March 21, 2021, for case reports and a series of ophthalmic GPAs. Cytoplasmic-ANCA (c-ANCA), perinuclear-ANCA (p-ANCA), and granulomas were analyzed against many ophthalmic signs and symptoms. 306 patients with GPA were retrospectively studied. Results: Granulomas were present in 47.7% of our sample, c-ANCA in 59.2%, and p-ANCA in 10.8%. Scleritis was significantly associated with higher odds for c-ANCA positivity. Eye discharge, episcleritis, proptosis, and central nervous system (CNS) involvement were each significantly associated with lower odds for c-ANCA positivity. Orbital mass was significantly associated with lower odds for p-ANCA positivity. CNS involvement was significantly associated with higher odds for p-ANCA positivity (OR:3.08, 95% CI:1.02, 9.36, p=0.047) and orbital mass was significantly associated with lower odds for p-ANCA positivity. Conclusions: We recommend that clinicians should consider ocular or orbital GPA in patients presenting with non-specific eye complaints, such as vision impairment, orbital mass, or proptosis, and obtain further assessments to determine the possible presence of granuloma, c-ANCA, or p-ANCA. Abbreviations: GPA = Granulomatosis with Polyangiitis, ANCA = antineutrophil cytoplasmic antibody, c-ANCA = cytoplasmic-ANCA, p-ANCA = perinuclear-ANCA, CNS = central nervous system, AAVs = ANCA-associated vasculitides, SD = standard deviation, GU = genitourinary, ENT = ear nose and throat, OR = odds ratio, CI = confidence interval.

Revisiting the orbital complications of acute rhinosinusitis.

OBJECTIVE: The present study revisited three classification systems of orbital complications of acute rhinosinusitis (ARS) (Chandler, Mortimore & Wormald, and Velasco e Cruz & Anselmo-Lima) and observed which of them presented the best clinical applicability. METHODS: Clinical data and CT scan findings of patients with orbital infection were retrospectively collected. To compare the three classification systems, we revised and graded all CT images accordingly, and divided the patients into four groups: Eyelid cellulitis (EC), orbital cellulitis (OC), subperiosteal abscess (SA), and orbital abscess (OA). The groups were compared regarding the presence of sinus opacification, the need for hospitalization and/or surgical treatment, and the presence of further complications/sequelae. RESULTS: 143 patients were included. The median number of sinuses involved in patients in the OC, SA, and OA groups was 2.0. ARS was rarely associated with signs of EC (present in both Chandler's and Mortimore & Wormald's classifications. The hospitalization rate was significantly lower in the EC group compared to the other three groups. Surgery was performed in all cases in the OA group, in 58.1% in the SA group, 19.4% in the OC group, and 12.5% in the EC group (p-value < 0.0001). Complications were present at higher rates in the OA group compared to the other three groups. CONCLUSIONS: ARS was rarely associated with Eyelid Cellulitis. The stratification in the other three groups showed to be clinically relevant. Velasco e Cruz & Anselmo-Lima's classification system proved valid, simple, and effective for categorizing orbital complications of ARS.

Case series of central retinal artery occlusion in COVID-19-associated rhino-orbital-cerebral mucormycosis.

Rhino orbital Mucormycosis caused by filamentous fungus of mucoraceae family was considered a rare disease affecting immunocompromised and diabetics with ketoacidosis until the recent COVID 19 pandemic. We are presenting a series of six cases of Rhino orbital cerebral Mucormycosis with central retinal artery occlusion. All six cases had common history of COVID 19 infection in recent past with sinusitis, proptosis and total ophthalmoplegia with central retinal artery occlusion on presentation. MR imaging showed invasive pan sinusitis with orbital and cerebral involvement. Urgent debridement was done and histopathological examination showed broad, filamentous aseptate fungi suggestive of Mucormycosis. All patients inspite of intravenous Amphotericin B with local debridement did not show any improvement and expired within a week of presentation. Hence our study shows poor prognosis of post covid 19 associated Mucormycosis with central retinal artery occlusion.

Frontal osteomyelitis post-COVID-19 associated mucormycosis.

Rhino-orbito-cerebral mucormycosis (ROCM) is the most commonly noted form of mucormycosis, which is the most common secondary fungal infection following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Osteomyelitis is one of the rare sequelae of ROCM, frontal osteomyelitis being the rarest. We present four patients of coronavirus disease 2019 (COVID-19)-associated mucormycosis, who presented with frontal bone osteomyelitis after being treated for ROCM surgically and medically. This is the first case series highlighting this complication in post-COVID-19 mucormycosis patients and needs utmost attention as it can be life-threatening and can cause extreme facial disfiguration. All four patients are alive with salvage of the affected globe and vision being preserved in one patient. If identified early, disfiguration of face and intracranial extension can be avoided.

Factors affecting clinical outcome in COVID-associated rhino-orbito-cerebral mucormycosis (CAROM) patients-An ambispective, single-arm, observational study.

BACKGROUND: COVID-associated Rhino-Orbito-Cerebral Mucormycosis (CAROM) appeared as an epidemic in India during the second wave of the COVID-19 pandemic during the months of March to May 2021. Though many reports have highlighted cross sectional and short-term attributes related to CAROM, long term follow up data is sparse. OBJECTIVE: This report aims to analyze the follow-up outcomes in consecutive patients presenting to us during the epidemic. PATIENTS AND METHODS: This was an ambispective observational analytical study, recruiting the consecutive patients admitted to our tertiary care centre during the period of the CAROM epidemic. The mortality rate during the follow-up and various factors affecting survival were studied using univariable and multivariable statistics with the Stata 14.0 software. RESULTS: Of the 189 patients studied, eight were lost to follow-up. The outcome analysis was performed for the 181 patients. 93.6 % (162/173) of the patients had diabetes. The All-cause mortality was 45 % (81/181), while the ROCM-specific mortality was found to be 24 % (46/181) at a median follow-up of 176 days (IQR: 21-217 days). With univariable analysis, increasing age, higher serum IL-6 levels, presence of additional comorbidities (in addition to Diabetes and hypertension), bilateral disease, skin necrosis, palatal involvement, infratemporal fossa involvement, and impaired vision/ocular movements were found to be associated with increased mortality. However, on multivariable analysis, only 1) increasing age, 2) raised serum IL-6 levels, and 3) bilateral disease were predictive of increased mortality. Surgical debridement (endoscopic, palatal removal, orbital exenteration, neurosurgical intervention) was associated with significantly reduced mortality on both univariable and multivariable analysis. CONCLUSION: Our intermediate-term follow-up data showed advanced age at presentation, raised IL-6 levels, and bilateral sinonasal involvement to be predictive of increased mortality, while surgical debridement is significantly protective from mortality in CAROM patients.

Seasonal variations, acute rhinosinusitis and orbital infections in children.

BACKGROUND: Orbital infections in children are commonly secondary to acute bacterial rhinosinusitis (ABRS). It is unclear whether seasonal variations can predispose to these complications mirroring acute rhinosinusitis incidence. OBJECTIVE: To determine the incidence of ABRS as a cause of orbital infections and whether seasonality is a risk factor. METHODS: A retrospective review of all children who presented to West Virginia University children's hospital between 2012 and 2022 were reviewed. All children with CT evidence of orbital infection were included. Date of occurrence, age, gender, and presence of sinusitis were reviewed. Children with orbital infection secondary to tumors, trauma, or surgery were excluded. RESULTS: 118 patients were identified with mean age of 7.3 years with 65 (55.1 %) males. 66 (55.9 %) children had concomitant sinusitis on CT scan, and the distribution of orbital complications per season showed 37 (31.4 %) cases occurred in the winter season, followed by 42 (35.6 %) cases in spring, 24 (20.3 %) cases in summer, and 15 (12.7 %) in fall. Children with orbital infections during winter & spring had sinusitis in 62 % of children vs. 33 % in other seasons (P = 0.02). Preseptal cellulitis was present in 79 (67 %) children, 39 (33 %) children with orbital cellulitis, and 40 (33.9 %) children with abscesses. 77.6 % children were treated with IV antibiotics and 94 % with oral antibiotics, and 14 (11.9 %) with systemic steroids. Only 18 (15.3 %) children required surgery. CONCLUSIONS: There seems to be a seasonal predisposition for orbital complications mainly in the winter and spring seasons. Rhinosinusitis was present in 55.6 % of children presenting with orbital infections.

[Children's rhinosinusitis orbital complications]. / Orbital'nye oslozhneniya rinosinusita u detei.

The number of cases of children's sinogenic orbital complications does not reduce in spite of the advanced methods of paranasal sinuses visualization, wide use of antibacterial therapy against sinusitis, and preventive vaccination against pneumococcal disease. Orbital complications are more common with children than with adults, the basic reason of their development being ethmoiditis. The prevailing classification of orbital complications proposed by J. Chandler et al. divides these into preceptal and postceptal forms and gives description to 5 development stages of orbital complications in the order of their increasing severity. At an early age preceptal and orbital cellulites prevail, and these commonly need conservative treatment only. In case of orbital cellulitis, the major treatment method is endovenous antibiotic therapy in which the chosen antibiotic is to cover the whole spectrum of aerobic and anaerobic microbes often extracted in such cases. At small subperiostal abscesses (<0.5-1 ml), conservative treatment during 24-48 hours is possible. If there is no positive dynamics, or abscess grows in size, or eye symptoms progress, abscess and affected sinuses drain is recommended. Orbital abscess is to be given surgical treatment; at the same time endoscopic management of paranasal sinuses might by complemented with external surgical approaches (lateral and medial orbitotomy).

Orbital abscess a rare complication after bichectomy surgery.

Bichectomy is the partial removal of the Bichat's fat pad for the aim of smoothing the facial contour. The complications of bichectomy include soft tissue infections, hematoma, facial paralysis (especially buccal branch paralysis), stenon canal injuries and related complications such as sialocele and sialoadenitis, however these are not common complications in clinical practice. Here we report a case of a 29-year-old white female with a right sided orbital abscess following bichectomy. Right sided orbital abscess and orbital cellulitis was managed with endoscopic decompression and drainage. The patient healed completely with no sequela. The frequency of major complications leading to moridity after bichectomy is rare in the literature. This is the first reported intraorbital complication of bichectomy.

Impact of Season on Incidence of Sinusitis-related Orbital Cellulitis.

PURPOSE: To explore the impact of season on the incidence of presentation to emergency departments with sinusitis-related orbital cellulitis in the United States. METHODS: The National Emergency Department Sample was queried to identify cases of patients with sinusitis-related orbital cellulitis. Patient's age, location, and the month of presentation were recorded. Statistical correlations were analyzed via a dedicated software package. RESULTS: A total of 439 patients with sinusitis-related orbital cellulitis were identified. The overall incidence was higher during the winter months ( p < 0.05); while children were more likely to develop this disease during the winter ( p < 0.05), season was not statistically correlated with its incidence among adults ( p = 0.16). The incidence of orbital cellulitis was higher during the winter in the midwest and south regions of the United States ( p < 0.05 for each region), although this correlation did not apply in the northeast and west ( p = 0.60 and 0.99, respectively). CONCLUSIONS: While sinusitis incidence increases during the winter, the relationship between season and orbital cellulitis is complex and varies by age and geographic location. These findings may help to facilitate screening protocols for this disease and to define staffing issues for emergent ophthalmic care.

High risk and low prevalence diseases: Orbital cellulitis.

INTRODUCTION: Orbital cellulitis is an uncommon but serious condition that carries with it a potential for significant morbidity. OBJECTIVE: This review highlights the pearls and pitfalls of orbital cellulitis, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION: Orbital cellulitis refers to infection of the globe and surrounding soft tissues posterior to the orbital septum. Orbital cellulitis is typically caused by local spread from sinusitis but can also be caused by local trauma or dental infection. It is more common in pediatric patients compared to adults. Emergency clinicians should first assess for and manage other critical, sight-threatening complications such as orbital compartment syndrome (OCS). Following this assessment, a focused eye examination is necessary. Though orbital cellulitis is primarily a clinical diagnosis, computed tomography (CT) of the brain and orbits with and without contrast is critical for evaluation of complications such as abscess or intracranial extension. Magnetic resonance imaging (MRI) of the brain and orbits with and without contrast should be performed in cases of suspected orbital cellulitis in which CT is non-diagnostic. While point-of-care ultrasound (POCUS) may be useful in differentiating preseptal from orbital cellulitis, it cannot exclude intracranial extension of infection. Management includes early administration of broad-spectrum antibiotics and ophthalmology consultation. The use of steroids is controversial. In cases of intracranial extension of infection (e.g., cavernous sinus thrombosis, abscess, or meningitis), neurosurgery should be consulted. CONCLUSION: An understanding of orbital cellulitis can assist emergency clinicians in diagnosing and managing this sight-threatening infectious process.