Ann Otol Rhind LaryTllfollOl:1992
ORBITAL COMPLICATIONS OF ACUTE SINUSITIS: COMPARISON OF COMPUTED TOMOGRAPHY SCAN AND SURGICAL FINDINGS RANDALL A. CLARY, MD
MICHAEL J. CUNNINGHAM, MD
ROLAND D. EAVEY, MD BOSTON, MASSACHUSETTS
The accuracy of computed tomography (CT) in distinguishing an abscess from cellulitis in children who present with orbital manifestations ofparanasal sinus infection remains in question. In this 1O-year retrospective study, cr results are compared with surgical findings in 19 patients with orbital complications who underwent surgical exploration within 24 hours of their cr scans. Fifteen of the 19 CT scan interpretations indicated abscesses that were verified intraoperatively. Two patients had negative surgical explorations despite cr interpretations predicting abscesses. An abscess was also surgically documented in 1 of 2 patients whose preoperative scans indicated cellulitis alone. We conclude that the correlation between radiologic and operative findings in 16 of these 19 cases, although not absolute, does substantiate the use of cr scanning as a therapeutic guide in children presenting with orbital disease secondary to paranasal sinusitis. KEY WORDS -
computed tomography, orbital abscess, orbital cellulitis, paranasal sinusitis.
Orbital complications of paranasal sinusitis have been recognized for at least 50 years. 1,2 The most commonly used classification divides such complications into inflammatory edema (preseptal cellulitis), orbital (postseptal) cellulitis, subperiosteal abscess, orbital abscess, and cavernous sinus thrombosis.' The literature demonstrates a variety of management approaches for children with such complications.V
ing for critical decision-making in children with orbital sequelae of paranasal sinus infection. METHODS
We reviewed the medical records of 78 pediatric patients less than 18 years of age who received diagnoses of orbital or periorbital infections at the Massachusetts Eye and Ear Infirmary and Massachusetts General Hospital between 1980 and 1990. These records were examined to identify patients whose hospital course met the following criteria: 1) an or-
Progressive proptosis and chemosis with ophthalmoplegia and visual impairment are the clinical findings that typically prompt consideration of surgery. Ophthalmologic examination, particularly the assessment of visual acuity, can be difficult in children. Radiologic assessment of the orbit by means of plain radiographs, ultrasonography, and especially computed tomography (CT) is very much relied on in this age group." Although CT scanning has been increasingly accepted as the preferred radiologic modality for differentiating the orbital complications of paranasal sinusitis, there are reports in isolated cases of disparities in results between CT and surgical findings.?:? Since an abscess within the confines of the bony orbit requires treatment by surgical exploration and drainage, distinguishing between cellulitis and abscess in children is critical. The impetus for this study was an index child in whom a preoperative CT scan predicted a subperiosteal abscess that was not verified at the time of immediate surgical exploration (see Figure). Our working hypothesis was that CT findings could be mislead-
Axial image with contrast enhancement interpreted as left subperiosteal abscess. No abscess was found at surgical exploration.
From the Department of Otology and Laryngology, Harvard Medical School, and the Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts. Presented at the meeting of the Society for Ear, Nose and Throat Advances in Children, Washington, DC, December 7-9, 1990. REPRINTS - Michael J. Cunningham, MD, Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA 02114.
598
Downloaded from aor.sagepub.com at MCMASTER UNIV LIBRARY on February 12, 2015
599
Clary et al, Orbital Complications ofAcute Sinusitis
COMPARISON OF SURGICAL AND
cr sca« Subject
1 2 3
4 5 6 7 8 9 10 11
12 13 14 15 16 17 18 19
cr -
cr SCAN FINDINGS
Report
Surgical Findings
Contrast (+/-)
Imaging Plane(s) (Axial/Coronal)
SPA SPA SPA OA SPA SPA SPA SPA SPA OA SPA SPA OA SPA SPA SPA SPA Cellulitis Cellulitis
SPA SPA SPA OA SPA SPA SPA SPA SPA OA SPA SPA OA SPA SPA Cellulitis Cellulitis SPA Cellulitis
+ + + + + + + + +
NC NC NC NC NC NC NC NC NC NC NC
+ + + + + +
A A A C
computed tomography, SPA -
NC A
NC NC
+
Adjacent Sinus
Ethmoid Ethmoid Frontal Ethmoid Ethmoid Ethmoid Ethmoid Frontal Ethmoid Ethmoid Frontal Ethmoid Frontal Ethmoid Frontal Ethmoid Ethmoid Ethmoid Ethmoid
subperiosteal abscess, OA - orbital abscess.
bital infection of paranasal sinus origin, 2) a formal written radiologic interpretation for a CT scan performed at these institutions, and 3) written documentation of surgical findings at orbital exploration done within 24 hours of the CT scan. The operative findings were compared with the CT scan interpretations. RESULTS
Nineteen of the 78 patients satisfied the above criteria (see Table). Of these 19, 15 were children in whom the CT scan indicated an abscess and the surgical exploration verified the presence of purulent fluid. The CT scan in 2 other patients suggested abscess formation that was not identified during surgery. In the 2 remaining patients, the CT findings were interpreted as cellulitis with no evidence of abscess. Both patients were explored for failure to respond to medical therapy. In 1 child, an abscess was found; no abscess was identified in the other child. In summary, in 16 of the 19 children (84%) the operative findings correlated with the preoperative CT interpretations. The patients were also categorized by orbital disease location relative to the periorbita and apparent sinus of origin (see Table). Sixteen of the 19 CT scans indicated subperiosteal involvement, including the 2 scans read as cellulitis. The remaining 3 scans revealed extraconal orbital abscesses. Fourteen CT scans showed the inflammatory process to be adjacent to the ethmoid sinuses; the other 5 scans indicated the abscess to be centered near the unilateral frontal sinus.
Additional information was obtained from the records in an attempt to identify the optimum scanning protocol. Primarily two types of CT scanners were used over the course of this study. Thirteen of the patients were imaged with a Siemens Somotron scanner; in 4 cases a GE 9800 scanner was used; the medical records did not identify the exact scanner used to assess the remaining 2 patients. Intravenous contrast media was used in 16 of the 19 cases. Both axial and coronal projections were used in 12 studies. Seven radiologists were involved in the interpretations. DISCUSSION
Strict entrance criteria were used to enhance the validity of this retrospective study. Many of the original 78 children were transferred to our institutions with CT scans completed at the referring hospitals. By including only those children whose CT scans were performed at our institutions, we attempted to minimize differences in imaging technique and radiologic interpretation. The 24-hour time span between CT scan performance and surgical exploration was invoked so that progression or improvement of disease would not adversely influence the outcome of our comparisons. This study was performed from a surgical perspective. Radiologic consultation for CT assessment was requested, with no attempt to control imaging parameters. The use ofcontrast enhancement and coronal as well as axial projections in CT imaging of children with orbital complications is not a uniform practice. Towbin et al 10reported accurate imaging of subperios-
Downloaded from aor.sagepub.com at MCMASTER UNIV LIBRARY on February 12, 2015
600
Clary et al, Orbital Complications ofAcute Sinusitis
teal and orbital abscesses without contrast enhancement using axial projections; others have argued that the use of both intravenous contrast and coronal projections markedly improves imaging accuracy .11 It is noteworthy that our false-positive (subjects 16 and 17) and false-negative (subject 18) cases occurred both with and without the use of contrast enhancement and coronal views (see Table), so that no optimal scanning protocol could be retrospectively defined. The vast majority of the cases were subperiosteal processes adjacent to the ethmoidal sinuses, reflecting the well-established common spread of infection through bony dehiscences in the lamina papyracea or along vascular and neural ethmoidal foramina. Retrograde hematogenous spread through valveless veins of the superior and inferior venous plexus and, less commonly, systemic hematogenous seeding are alternative routes of orbital infection. The radiologic documentation of abscesses in proximity to the fron-
tal sinuses in five children is particularly important in this regard. The CT scans in these five cases directed surgical management to include drainage of the frontal sinuses in addition to ethmoidectomy. CONCLUSION
The evaluation of children with orbital complications from paranasal sinusitis can be challenging. Prompt decision-making may help preserve vision or prevent additional ophthamologic complications. Our study further supports the use of CT scanning in the preoperative orbital assessment of such children, with the understanding that the radiologic documentation of the presence or absence of a subperiosteal or orbital abscess may be inexact. Surgical exploration, regardless of CT findings, is recommended in children who initially present with decreased visual acuity or who demonstrate progression of orbital manifestations despite medical therapy.
REFERENCES 1. Blodi FC. Field Marshall Radetzky's orbital abscess. Doc OphthalmoI1989;71:205-19.
sound in the evaluation oforbital cellulitis. Laryngoscope 1982;92: 728-31.
2. Gamble RC. Acute inflammation of the orbit in children. Arch OphthalmoI1933;10:483-97.
7. Catalano RA, Smoot CN. Subperiosteal orbital masses in children with orbital cellulitis: time for a reevaluation? J Pediatr Ophthalmol Strabismus 1990;27:141-2.
3. Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of orbital complications in acute sinusitis. Laryngoscope 1970;80:1414-28. 4. Souliere CR, Antoine GA, Martin MP, Blumberg AI, Isaacson G. Selective nonsurgical management of subperiosteal abscess of the orbit: computerized tomography and clinical course as indication for surgical drainage. Int J Pediatr OtorhinolaryngoI1990;19:109-19. 5. Rubin SE, Rubin LG, Zito J, Goldstein MN, Eng C. Medical management of orbital subperiosteal abscess in children. J Pediatr Ophthalmol Strabismus 1989;26:21-6. 6. Goodwin WJ Jr, Weinshall M, Chandler JR. The role of high resolution computerized tomography and standardized ultra-
8. Gold SC, Arrigg PG, Hedges TRill. Computerized tomography in the management of acute orbital cellulitis. Ophthalmic Surg 1987;18:753-6. 9. Patt BS, Manning SC. Blindness resulting from orbital complications of sinusitis. Otolaryngol Head Neck Surg 1991; 104:789-95. 10. Towbin R, Bokyung KH, KaufmanRA, BurkeM. Postseptal cellulitis: CT in diagnosis and management. Radiology 1986; 158:735-7. 11. Langham-Brown JJ. Rhy-Williams S. Computed tomography of the acute orbital infection: the importance of coronal sections. Clin RadioI1989;40:471-4.
Downloaded from aor.sagepub.com at MCMASTER UNIV LIBRARY on February 12, 2015
ORBITAL COMPLICATIONS OF ACUTE SINUSITIS: COMPARISON OF COMPUTED TOMOGRAPHY SCAN AND SURGICAL FINDINGS RANDALL A. CLARY, MD
MICHAEL J. CUNNINGHAM, MD
ROLAND D. EAVEY, MD BOSTON, MASSACHUSETTS
The accuracy of computed tomography (CT) in distinguishing an abscess from cellulitis in children who present with orbital manifestations ofparanasal sinus infection remains in question. In this 1O-year retrospective study, cr results are compared with surgical findings in 19 patients with orbital complications who underwent surgical exploration within 24 hours of their cr scans. Fifteen of the 19 CT scan interpretations indicated abscesses that were verified intraoperatively. Two patients had negative surgical explorations despite cr interpretations predicting abscesses. An abscess was also surgically documented in 1 of 2 patients whose preoperative scans indicated cellulitis alone. We conclude that the correlation between radiologic and operative findings in 16 of these 19 cases, although not absolute, does substantiate the use of cr scanning as a therapeutic guide in children presenting with orbital disease secondary to paranasal sinusitis. KEY WORDS -
computed tomography, orbital abscess, orbital cellulitis, paranasal sinusitis.
Orbital complications of paranasal sinusitis have been recognized for at least 50 years. 1,2 The most commonly used classification divides such complications into inflammatory edema (preseptal cellulitis), orbital (postseptal) cellulitis, subperiosteal abscess, orbital abscess, and cavernous sinus thrombosis.' The literature demonstrates a variety of management approaches for children with such complications.V
ing for critical decision-making in children with orbital sequelae of paranasal sinus infection. METHODS
We reviewed the medical records of 78 pediatric patients less than 18 years of age who received diagnoses of orbital or periorbital infections at the Massachusetts Eye and Ear Infirmary and Massachusetts General Hospital between 1980 and 1990. These records were examined to identify patients whose hospital course met the following criteria: 1) an or-
Progressive proptosis and chemosis with ophthalmoplegia and visual impairment are the clinical findings that typically prompt consideration of surgery. Ophthalmologic examination, particularly the assessment of visual acuity, can be difficult in children. Radiologic assessment of the orbit by means of plain radiographs, ultrasonography, and especially computed tomography (CT) is very much relied on in this age group." Although CT scanning has been increasingly accepted as the preferred radiologic modality for differentiating the orbital complications of paranasal sinusitis, there are reports in isolated cases of disparities in results between CT and surgical findings.?:? Since an abscess within the confines of the bony orbit requires treatment by surgical exploration and drainage, distinguishing between cellulitis and abscess in children is critical. The impetus for this study was an index child in whom a preoperative CT scan predicted a subperiosteal abscess that was not verified at the time of immediate surgical exploration (see Figure). Our working hypothesis was that CT findings could be mislead-
Axial image with contrast enhancement interpreted as left subperiosteal abscess. No abscess was found at surgical exploration.
From the Department of Otology and Laryngology, Harvard Medical School, and the Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts. Presented at the meeting of the Society for Ear, Nose and Throat Advances in Children, Washington, DC, December 7-9, 1990. REPRINTS - Michael J. Cunningham, MD, Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA 02114.
598
Downloaded from aor.sagepub.com at MCMASTER UNIV LIBRARY on February 12, 2015
599
Clary et al, Orbital Complications ofAcute Sinusitis
COMPARISON OF SURGICAL AND
cr sca« Subject
1 2 3
4 5 6 7 8 9 10 11
12 13 14 15 16 17 18 19
cr -
cr SCAN FINDINGS
Report
Surgical Findings
Contrast (+/-)
Imaging Plane(s) (Axial/Coronal)
SPA SPA SPA OA SPA SPA SPA SPA SPA OA SPA SPA OA SPA SPA SPA SPA Cellulitis Cellulitis
SPA SPA SPA OA SPA SPA SPA SPA SPA OA SPA SPA OA SPA SPA Cellulitis Cellulitis SPA Cellulitis
+ + + + + + + + +
NC NC NC NC NC NC NC NC NC NC NC
+ + + + + +
A A A C
computed tomography, SPA -
NC A
NC NC
+
Adjacent Sinus
Ethmoid Ethmoid Frontal Ethmoid Ethmoid Ethmoid Ethmoid Frontal Ethmoid Ethmoid Frontal Ethmoid Frontal Ethmoid Frontal Ethmoid Ethmoid Ethmoid Ethmoid
subperiosteal abscess, OA - orbital abscess.
bital infection of paranasal sinus origin, 2) a formal written radiologic interpretation for a CT scan performed at these institutions, and 3) written documentation of surgical findings at orbital exploration done within 24 hours of the CT scan. The operative findings were compared with the CT scan interpretations. RESULTS
Nineteen of the 78 patients satisfied the above criteria (see Table). Of these 19, 15 were children in whom the CT scan indicated an abscess and the surgical exploration verified the presence of purulent fluid. The CT scan in 2 other patients suggested abscess formation that was not identified during surgery. In the 2 remaining patients, the CT findings were interpreted as cellulitis with no evidence of abscess. Both patients were explored for failure to respond to medical therapy. In 1 child, an abscess was found; no abscess was identified in the other child. In summary, in 16 of the 19 children (84%) the operative findings correlated with the preoperative CT interpretations. The patients were also categorized by orbital disease location relative to the periorbita and apparent sinus of origin (see Table). Sixteen of the 19 CT scans indicated subperiosteal involvement, including the 2 scans read as cellulitis. The remaining 3 scans revealed extraconal orbital abscesses. Fourteen CT scans showed the inflammatory process to be adjacent to the ethmoid sinuses; the other 5 scans indicated the abscess to be centered near the unilateral frontal sinus.
Additional information was obtained from the records in an attempt to identify the optimum scanning protocol. Primarily two types of CT scanners were used over the course of this study. Thirteen of the patients were imaged with a Siemens Somotron scanner; in 4 cases a GE 9800 scanner was used; the medical records did not identify the exact scanner used to assess the remaining 2 patients. Intravenous contrast media was used in 16 of the 19 cases. Both axial and coronal projections were used in 12 studies. Seven radiologists were involved in the interpretations. DISCUSSION
Strict entrance criteria were used to enhance the validity of this retrospective study. Many of the original 78 children were transferred to our institutions with CT scans completed at the referring hospitals. By including only those children whose CT scans were performed at our institutions, we attempted to minimize differences in imaging technique and radiologic interpretation. The 24-hour time span between CT scan performance and surgical exploration was invoked so that progression or improvement of disease would not adversely influence the outcome of our comparisons. This study was performed from a surgical perspective. Radiologic consultation for CT assessment was requested, with no attempt to control imaging parameters. The use ofcontrast enhancement and coronal as well as axial projections in CT imaging of children with orbital complications is not a uniform practice. Towbin et al 10reported accurate imaging of subperios-
Downloaded from aor.sagepub.com at MCMASTER UNIV LIBRARY on February 12, 2015
600
Clary et al, Orbital Complications ofAcute Sinusitis
teal and orbital abscesses without contrast enhancement using axial projections; others have argued that the use of both intravenous contrast and coronal projections markedly improves imaging accuracy .11 It is noteworthy that our false-positive (subjects 16 and 17) and false-negative (subject 18) cases occurred both with and without the use of contrast enhancement and coronal views (see Table), so that no optimal scanning protocol could be retrospectively defined. The vast majority of the cases were subperiosteal processes adjacent to the ethmoidal sinuses, reflecting the well-established common spread of infection through bony dehiscences in the lamina papyracea or along vascular and neural ethmoidal foramina. Retrograde hematogenous spread through valveless veins of the superior and inferior venous plexus and, less commonly, systemic hematogenous seeding are alternative routes of orbital infection. The radiologic documentation of abscesses in proximity to the fron-
tal sinuses in five children is particularly important in this regard. The CT scans in these five cases directed surgical management to include drainage of the frontal sinuses in addition to ethmoidectomy. CONCLUSION
The evaluation of children with orbital complications from paranasal sinusitis can be challenging. Prompt decision-making may help preserve vision or prevent additional ophthamologic complications. Our study further supports the use of CT scanning in the preoperative orbital assessment of such children, with the understanding that the radiologic documentation of the presence or absence of a subperiosteal or orbital abscess may be inexact. Surgical exploration, regardless of CT findings, is recommended in children who initially present with decreased visual acuity or who demonstrate progression of orbital manifestations despite medical therapy.
REFERENCES 1. Blodi FC. Field Marshall Radetzky's orbital abscess. Doc OphthalmoI1989;71:205-19.
sound in the evaluation oforbital cellulitis. Laryngoscope 1982;92: 728-31.
2. Gamble RC. Acute inflammation of the orbit in children. Arch OphthalmoI1933;10:483-97.
7. Catalano RA, Smoot CN. Subperiosteal orbital masses in children with orbital cellulitis: time for a reevaluation? J Pediatr Ophthalmol Strabismus 1990;27:141-2.
3. Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of orbital complications in acute sinusitis. Laryngoscope 1970;80:1414-28. 4. Souliere CR, Antoine GA, Martin MP, Blumberg AI, Isaacson G. Selective nonsurgical management of subperiosteal abscess of the orbit: computerized tomography and clinical course as indication for surgical drainage. Int J Pediatr OtorhinolaryngoI1990;19:109-19. 5. Rubin SE, Rubin LG, Zito J, Goldstein MN, Eng C. Medical management of orbital subperiosteal abscess in children. J Pediatr Ophthalmol Strabismus 1989;26:21-6. 6. Goodwin WJ Jr, Weinshall M, Chandler JR. The role of high resolution computerized tomography and standardized ultra-
8. Gold SC, Arrigg PG, Hedges TRill. Computerized tomography in the management of acute orbital cellulitis. Ophthalmic Surg 1987;18:753-6. 9. Patt BS, Manning SC. Blindness resulting from orbital complications of sinusitis. Otolaryngol Head Neck Surg 1991; 104:789-95. 10. Towbin R, Bokyung KH, KaufmanRA, BurkeM. Postseptal cellulitis: CT in diagnosis and management. Radiology 1986; 158:735-7. 11. Langham-Brown JJ. Rhy-Williams S. Computed tomography of the acute orbital infection: the importance of coronal sections. Clin RadioI1989;40:471-4.
Downloaded from aor.sagepub.com at MCMASTER UNIV LIBRARY on February 12, 2015
