Aesth.
Plast. Surg.
15:187-190, 1991
Aesthetic _ Plasnc Surgery 9 1991 Springer-VerlagNew York Inc.
Necrotizing Periorbitai Cellulitis Following Septorhinoplasty R. Moscona, M.D., Y. Ullmann, M.D., and I. Peled, M.D. Haifa, Israel Abstract. The complication of infection after a septorhinoplasty is extremely rare. An unusual occurrence of necrotizing periorbital cellulitis after a routine septorhinoplasty in a 30-year-old pediatrician is presented. It consisted of marked swelling and superficial necrosis of the left eyelids and high fever that started one day after surgery. /3 Hemolytic streptococcus was identified as the causative pathogen. The patient responded well to systemic antibiotics and conservative local treatment. After three years of followup the cosmetic appearance is reasonable. Key words: Septorhinoplasty--lnfection--Periorbital cellulitis
Septorhinoplasty is the most c o m m o n aesthetic procedure performed in Israel. Complications following this operation are relatively rare and most of them are caused by failure to achieve the desired aesthetic or physiologic goals. H o w e v e r , disabling and even life-threatening complications do exist but are not usually reported in the plastic surgery literature. Complications may be classified as infectious, traumatic, hemorrhagic, and systemic [7]. The most c o m m o n complication is the infection, estimated to be between 1.7% and 2.8% of all complications [6, 8, I1]. In this article we present an unusual case of necrotizing periorbital cellulitis as a complication of a septorhinoplasty.
Address reprint requests to R. Moscona, M.D., Department of Plastic Surgery, Rambam Medical Center Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
Case Report
A 30-year-old pediatrician who had a humped nose and difficulty breathing was admitted for a septorhinoplasty (Fig. 1A,B). H e r past history revealed recurrent frontal sinusitis which needed drainage, with the last episode occurring six months before surgery. Bacteriologic culture was not obtained. Under local anesthesia with sedation, an ordinary septhorhinoplasty was pertk)rmed. The operation was uneventful and both nostrils were packed. Several hours after surgery she was released. One day later she returned to the hospital with shivering, a lever of 38.6~ severe bilateral periorbital redness, and swelling accompanied by a profound e d e m a of her left cheek. Physical examination revealed no other pathological findings. Both nasal packings were promptly removed. L a b o r a t o r y values were noted to be within normal limits except for marked leukocytosis. X-ray examination disclosed no signs of sinusitis. A direct bacteriologic smear from the nostrils identified gram positive cocci. Blood cultures were negative. The diagnosis of periorbital cellulitis was established and 20,000,000 crystalin penicillin was administered intravenously. During the next day necrosis of the left upper and lower eyelids developed, along with marked e d e m a of the right eyelids (Fig. 2A,B). Conservative local treatment by gauzes soaked with neomycin and streptomycin in 1% solution with meticulous debridement of the necrotic areas was added to the systemic treatment. Fine needle aspirates from the eyelids were cultured and identified as/3 hemolytic streptococcus which was sensitive to penicillin. Repeated blood cultures were all negative. ACT scan showed significant swelling of the eyelids. No pathology of the sinuses and the retrobulbar areas was demonstrated. During subsequent days her body temperature returned to normal
188
Necrotizing Periorbital Cellulitis Following Septorhinoplasty
Fig. I(A,B) Preoperative frontal and lateral views
Fig. 2(A,B) The patient on the fourth postoperative day. Necrosis of the upper and lower left eyelids along with marked edema of the lower right eyelid are seen
levels, complete secondary healing of the necrotic areas was achieved within three weeks, and the edema of the left lower eyelid (Fig. 3) resolved gradually after three months. At present, after three years of followup the cosmetic result is reasonable, except for a small epicanthal web in the left epicanthal area, which the patient does not want corrected (Fig. 4A,B).
Discussion
Pathogenic bacteria such as Staphylococcus aureus and Streptococcus viridans have appeared in over one-third of preoperative nasal cultures in a healthy population undergoing rhinoplasty [9]. Despite the prevalence of many organisms in the nose, plastic surgeons observe very few infections after rhino-
R. Moscona et ai.
189
Fig. 3. Six weeks after surgery, The left lower eyelid is still swollen
Fig. 4(A,B) Three years postoperative there is complete healing. Note the left epicanthal web
plasty because of the excellent blood supply in this area. The addition of a septoplasty to a rhinoplastic procedure does not significantly affect the occurrence of complications or the results [6]. Bacteremia is very uncommon in patients undergoing rhinoplasty [10] but it is found in 3%-12% of the patients undergoing submucous resection of the nasal septum with packing [3]. Local infection in the postoperative period may produce an abscess or cellulitis or it may form a granuloma within the incision lines [7]. This
type of limited infection usually responds well to systemic antibiotic therapy or to local incision and drainage. Bacterial infections of the nasal area are most commonly due to staphylococcus, streptococcus, Hernophylus influenzae, or anaerobic streptococcus of the paranasal sinuses [ll]. Several case reports of postrhinoplasty infections with unusual organisms such as actinomycosis [13] or pseudomonas [5], have also been reported. Intracranial secondary infectious complications follow-
190
ing rhinoplasty such as menengitis, cerebritis, subdural empyema, brain abscess, and cavernous sinus thrombosis are less common in the antibiotic era [11]. Rarely does postrhinoplasty infection become systemic. Some case reports of toxic shock syndrome have been published [1, 14]; they were all associated with nasal packing. The analogy of nasal packing to vaginal tampons as a possible risk factor for toxic shock syndrome development seems likely. The combination of postoperative fever, nausea, vomiting, diarrhea, and erythrodermia should alert the surgeon to the possibility of this syndrome. Nasal packing seems to be the localized source of enterotoxin-producing Staphylococcus aureus. Prompt removal of the nasal packing or other foreign materials should be undertaken when this complication is suspected. The role of perioperative antibiotics in rhinoplasty is controversial [12, 15]. Most authors agree that there is essentially no difference in the infection rate whether prophylactic antibiotics are used or not. H o w e v e r , others [4] believe that the use of prophylactic antibiotics is mandated in certain situations: (1) active infection in the operative site, (2) nasal packing is required for more than 24 hours, (3) in the presence of severe hematoma, (4) alloplastic implants are used, and (5) history of metabolic disease or immunologic deficiency. The patient in our case report demonstrates a dreadful infectious complication postseptorhinoplasty. We were unable to find a similar case in the English-language literature over the past ten years, although many case reports of unusual infectious complications postseptorhinoplasty have been published [1-3, 5, 9-15]. In retrospect, several risk factors could have been detected in our patient. She is a pediatrician with contact with patients with various infectious diseases. She has had several episodes of acute sinusitis in recent years although no signs or symptoms of active sinusitis were present prior to the operation or after it. There is no doubt that the addition of septoplasty with nasal packing enhanced her chances of an infectious complication. We agree with Slavin et al. [10] that the risk of drug toxicity and development of resistant bacterial strains ex-
Necrotizing Periorbital Cellulitis Following Septorhinoplasty
ceeds the incidence of infection in the rhinoplasty patient. However, in view of the risk factors in this particular patient, it seems that preculture from her nasal mucosa and adjusted perioperative antibiotic might have prevented such a scary complication.
References
1. Barbour SD, Shlaes DM, Guertin SR: Toxic-shock syndrome associated with nasal packing: analogy to tampon-associated illness. Pediatrics 73(2): 163, 1984 2. Cabouli JL, Guerrissi JO, Mileto A, Cerisola JA: Local infection following aesthetic rhinoplasty. Ann Plast Surg 17(4):306, 1986 3. Herzon FS: Bacteremia and local infection with nasal packing. Arch Otolaryngol 94"317, 1971 4. Holf GR, Garner ET, McLarey D: Postoperative sequelae and complication of rhinoplasty. Otolaryngol Clin 20(4):854, 1987 5. Kamer FM, Binder WJ: Pseudomonas infection of the nose. Arch Otolaryngol 106:505, 1980 6. Klabunde EH, Falces E: Incidence of complications in cosmetic rhinoplasties. Plast Reconstr Surg 34(2): 192, 1964 7. Lawson W, Kessler S, Biller HF: Unusual and fatal complications of rhinoplasty. Arch Otolaryngol 109:164, 1983 8. Miller T: Immediate postoperative complications of septorhinoplasties. Trans Pac Coast Otoophthalmol Soc Ann Meet 57"201, 1976 9. Slavin SA, Rees TD: Pseudomonas infection in the postoperative nasal septum (discussion). Plast Reconstr Surg 70(1):89, 1982 10. Slavin SA, Rees TD, Guy CL, Goldwyn RM: An investigation of bacteremia during rhinoplasty. Plast Reconstr Surg 71:196, 1983 11. Shikowitz MJ: Nasofrontal abscess following rhinoplasty. Laryngoscope 95:1523, 1985 12. Strong MS: Wound infection in otolaryngologic surgery and the inexpenditure of antibiotic prophylaxis. Laryngoscope 73" 165, 1963 13. Thomas GG, Toohill RJ, Lehman RH: Nasal actinomycosis following heterograft: A case report. Arch Otolaryngol 100:377, 1974 14. Toback A, Fayerman JW: Toxic shock syndrome following septorhinoplasty. Implications for the head and neck surgeon. Arch Otolaryngol 109"627, 1983 15. Weimemert TA, Yod MG: Antibiotics in nasal surgery. Laryngoscope 90"667, 1980
Plast. Surg.
15:187-190, 1991
Aesthetic _ Plasnc Surgery 9 1991 Springer-VerlagNew York Inc.
Necrotizing Periorbitai Cellulitis Following Septorhinoplasty R. Moscona, M.D., Y. Ullmann, M.D., and I. Peled, M.D. Haifa, Israel Abstract. The complication of infection after a septorhinoplasty is extremely rare. An unusual occurrence of necrotizing periorbital cellulitis after a routine septorhinoplasty in a 30-year-old pediatrician is presented. It consisted of marked swelling and superficial necrosis of the left eyelids and high fever that started one day after surgery. /3 Hemolytic streptococcus was identified as the causative pathogen. The patient responded well to systemic antibiotics and conservative local treatment. After three years of followup the cosmetic appearance is reasonable. Key words: Septorhinoplasty--lnfection--Periorbital cellulitis
Septorhinoplasty is the most c o m m o n aesthetic procedure performed in Israel. Complications following this operation are relatively rare and most of them are caused by failure to achieve the desired aesthetic or physiologic goals. H o w e v e r , disabling and even life-threatening complications do exist but are not usually reported in the plastic surgery literature. Complications may be classified as infectious, traumatic, hemorrhagic, and systemic [7]. The most c o m m o n complication is the infection, estimated to be between 1.7% and 2.8% of all complications [6, 8, I1]. In this article we present an unusual case of necrotizing periorbital cellulitis as a complication of a septorhinoplasty.
Address reprint requests to R. Moscona, M.D., Department of Plastic Surgery, Rambam Medical Center Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
Case Report
A 30-year-old pediatrician who had a humped nose and difficulty breathing was admitted for a septorhinoplasty (Fig. 1A,B). H e r past history revealed recurrent frontal sinusitis which needed drainage, with the last episode occurring six months before surgery. Bacteriologic culture was not obtained. Under local anesthesia with sedation, an ordinary septhorhinoplasty was pertk)rmed. The operation was uneventful and both nostrils were packed. Several hours after surgery she was released. One day later she returned to the hospital with shivering, a lever of 38.6~ severe bilateral periorbital redness, and swelling accompanied by a profound e d e m a of her left cheek. Physical examination revealed no other pathological findings. Both nasal packings were promptly removed. L a b o r a t o r y values were noted to be within normal limits except for marked leukocytosis. X-ray examination disclosed no signs of sinusitis. A direct bacteriologic smear from the nostrils identified gram positive cocci. Blood cultures were negative. The diagnosis of periorbital cellulitis was established and 20,000,000 crystalin penicillin was administered intravenously. During the next day necrosis of the left upper and lower eyelids developed, along with marked e d e m a of the right eyelids (Fig. 2A,B). Conservative local treatment by gauzes soaked with neomycin and streptomycin in 1% solution with meticulous debridement of the necrotic areas was added to the systemic treatment. Fine needle aspirates from the eyelids were cultured and identified as/3 hemolytic streptococcus which was sensitive to penicillin. Repeated blood cultures were all negative. ACT scan showed significant swelling of the eyelids. No pathology of the sinuses and the retrobulbar areas was demonstrated. During subsequent days her body temperature returned to normal
188
Necrotizing Periorbital Cellulitis Following Septorhinoplasty
Fig. I(A,B) Preoperative frontal and lateral views
Fig. 2(A,B) The patient on the fourth postoperative day. Necrosis of the upper and lower left eyelids along with marked edema of the lower right eyelid are seen
levels, complete secondary healing of the necrotic areas was achieved within three weeks, and the edema of the left lower eyelid (Fig. 3) resolved gradually after three months. At present, after three years of followup the cosmetic result is reasonable, except for a small epicanthal web in the left epicanthal area, which the patient does not want corrected (Fig. 4A,B).
Discussion
Pathogenic bacteria such as Staphylococcus aureus and Streptococcus viridans have appeared in over one-third of preoperative nasal cultures in a healthy population undergoing rhinoplasty [9]. Despite the prevalence of many organisms in the nose, plastic surgeons observe very few infections after rhino-
R. Moscona et ai.
189
Fig. 3. Six weeks after surgery, The left lower eyelid is still swollen
Fig. 4(A,B) Three years postoperative there is complete healing. Note the left epicanthal web
plasty because of the excellent blood supply in this area. The addition of a septoplasty to a rhinoplastic procedure does not significantly affect the occurrence of complications or the results [6]. Bacteremia is very uncommon in patients undergoing rhinoplasty [10] but it is found in 3%-12% of the patients undergoing submucous resection of the nasal septum with packing [3]. Local infection in the postoperative period may produce an abscess or cellulitis or it may form a granuloma within the incision lines [7]. This
type of limited infection usually responds well to systemic antibiotic therapy or to local incision and drainage. Bacterial infections of the nasal area are most commonly due to staphylococcus, streptococcus, Hernophylus influenzae, or anaerobic streptococcus of the paranasal sinuses [ll]. Several case reports of postrhinoplasty infections with unusual organisms such as actinomycosis [13] or pseudomonas [5], have also been reported. Intracranial secondary infectious complications follow-
190
ing rhinoplasty such as menengitis, cerebritis, subdural empyema, brain abscess, and cavernous sinus thrombosis are less common in the antibiotic era [11]. Rarely does postrhinoplasty infection become systemic. Some case reports of toxic shock syndrome have been published [1, 14]; they were all associated with nasal packing. The analogy of nasal packing to vaginal tampons as a possible risk factor for toxic shock syndrome development seems likely. The combination of postoperative fever, nausea, vomiting, diarrhea, and erythrodermia should alert the surgeon to the possibility of this syndrome. Nasal packing seems to be the localized source of enterotoxin-producing Staphylococcus aureus. Prompt removal of the nasal packing or other foreign materials should be undertaken when this complication is suspected. The role of perioperative antibiotics in rhinoplasty is controversial [12, 15]. Most authors agree that there is essentially no difference in the infection rate whether prophylactic antibiotics are used or not. H o w e v e r , others [4] believe that the use of prophylactic antibiotics is mandated in certain situations: (1) active infection in the operative site, (2) nasal packing is required for more than 24 hours, (3) in the presence of severe hematoma, (4) alloplastic implants are used, and (5) history of metabolic disease or immunologic deficiency. The patient in our case report demonstrates a dreadful infectious complication postseptorhinoplasty. We were unable to find a similar case in the English-language literature over the past ten years, although many case reports of unusual infectious complications postseptorhinoplasty have been published [1-3, 5, 9-15]. In retrospect, several risk factors could have been detected in our patient. She is a pediatrician with contact with patients with various infectious diseases. She has had several episodes of acute sinusitis in recent years although no signs or symptoms of active sinusitis were present prior to the operation or after it. There is no doubt that the addition of septoplasty with nasal packing enhanced her chances of an infectious complication. We agree with Slavin et al. [10] that the risk of drug toxicity and development of resistant bacterial strains ex-
Necrotizing Periorbital Cellulitis Following Septorhinoplasty
ceeds the incidence of infection in the rhinoplasty patient. However, in view of the risk factors in this particular patient, it seems that preculture from her nasal mucosa and adjusted perioperative antibiotic might have prevented such a scary complication.
References
1. Barbour SD, Shlaes DM, Guertin SR: Toxic-shock syndrome associated with nasal packing: analogy to tampon-associated illness. Pediatrics 73(2): 163, 1984 2. Cabouli JL, Guerrissi JO, Mileto A, Cerisola JA: Local infection following aesthetic rhinoplasty. Ann Plast Surg 17(4):306, 1986 3. Herzon FS: Bacteremia and local infection with nasal packing. Arch Otolaryngol 94"317, 1971 4. Holf GR, Garner ET, McLarey D: Postoperative sequelae and complication of rhinoplasty. Otolaryngol Clin 20(4):854, 1987 5. Kamer FM, Binder WJ: Pseudomonas infection of the nose. Arch Otolaryngol 106:505, 1980 6. Klabunde EH, Falces E: Incidence of complications in cosmetic rhinoplasties. Plast Reconstr Surg 34(2): 192, 1964 7. Lawson W, Kessler S, Biller HF: Unusual and fatal complications of rhinoplasty. Arch Otolaryngol 109:164, 1983 8. Miller T: Immediate postoperative complications of septorhinoplasties. Trans Pac Coast Otoophthalmol Soc Ann Meet 57"201, 1976 9. Slavin SA, Rees TD: Pseudomonas infection in the postoperative nasal septum (discussion). Plast Reconstr Surg 70(1):89, 1982 10. Slavin SA, Rees TD, Guy CL, Goldwyn RM: An investigation of bacteremia during rhinoplasty. Plast Reconstr Surg 71:196, 1983 11. Shikowitz MJ: Nasofrontal abscess following rhinoplasty. Laryngoscope 95:1523, 1985 12. Strong MS: Wound infection in otolaryngologic surgery and the inexpenditure of antibiotic prophylaxis. Laryngoscope 73" 165, 1963 13. Thomas GG, Toohill RJ, Lehman RH: Nasal actinomycosis following heterograft: A case report. Arch Otolaryngol 100:377, 1974 14. Toback A, Fayerman JW: Toxic shock syndrome following septorhinoplasty. Implications for the head and neck surgeon. Arch Otolaryngol 109"627, 1983 15. Weimemert TA, Yod MG: Antibiotics in nasal surgery. Laryngoscope 90"667, 1980
