Clinical Review & Education
Review
Orbital Complications of Acute Sinusitis in Infants A Systematic Review and Report of a Case Saurabh Sharma, MD; Gary D. Josephson, MD, MBA
IMPORTANCE Orbital infections from acute sinusitis are rare in neonates and infants and can
lead to devastating complications. To our knowledge, no prior dedicated review exists for evaluation, treatment, and outcomes of orbital complications in this age group. OBJECTIVE To perform a systematic review over the past 50 years on the diagnosis and treatment of orbital complications secondary to acute sinusitis in neonates and infants and report a case. EVIDENCE AND ACQUISITION A systematic review of the literature was performed searching PubMed to collect all the pertinent case reports and series in the English language with subperiosteal orbital abscess (SPOA) or orbital abscess in neonates or infants (date range, 1959-2012). RESULTS Eleven cases of SPOA in infants were identified, including our current case. Ages ranged from 10 to 74 days. There were 6 female and 5 male infants. The right eye was affected in 5 cases, the left in 5, and both in 1. There was 1 mortality in this series for which surgical drainage was not performed. Staphylococcus aureus was the most common organism isolated in 9 of 11 cases. Seven of the cases had open surgical drainage, 2 had endoscopic procedures (including our case), and 1 had spontaneous rupture of the abscess. CONCLUSIONS AND RELEVANCE An orbital complication due to acute sinusitis is rare in infants and neonates. Drainage in this patient population appears to be paramount, since the only infant in this series who did not receive drainage had died. Modern telescopes and equipment have allowed endoscopic drainage to be a safe and effective surgical treatment in this age group. JAMA Otolaryngol Head Neck Surg. 2014;140(11):1070-1073. doi:10.1001/jamaoto.2014.2326 Published online October 9, 2014.
A
cute sinusitis is the predominant cause of orbital infections in children. It is not uncommon for acute ethmoiditis to lead to orbital complications in children aged 2 to 10 years.1 In neonates, defined by the American Academy of Pediatrics as age up to 30 days, and infants, 31 days to 12 months, acute ethmoiditis leading to orbital complications is rare. Neonates and infants present unique challenges in the diagnosis and treatment of these potentially dangerous infections. They have a developing immune system and still depend on remaining circulating antibodies obtained in utero from their mother. This makes them more vulnerable to infection, especially in the very early months. In addition, the sinuses are smaller and evolving, challenging the surgeon in decision making for adequate drainage through an endoscopic approach if surgical drainage is desired. Clinical symptoms of infection may also be subtle or absent. Patients may present with redness and swelling of the orbital region with or without systemic symptoms. An untreated abscess can lead to blindness, intracranial spread, cavernous sinus thrombosis, cerebral abscess, or sepsis.2 1070
Author Affiliations: Department of Otolaryngology–Head and Neck Surgery, University of South Florida, Tampa (Sharma); Pediatric Otolaryngology–Head and Neck Surgery, Nemours Children’s Clinic, Jacksonville, Florida (Josephson). Corresponding Author: Gary D. Josephson, MD, MBA, Division of Pediatric Otolaryngology–Head and Neck Surgery, Nemours Children’s Clinic Jacksonville, 807 Children’s Way, Jacksonville, FL 32207 ([email protected]).
Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the typical offending organisms in the pediatric population that cause acute sinusitis.1 Treatment for complicated infections with orbital involvement includes intravenous antibiotics directed at the typical organisms with or without drainage. When surgical drainage is performed, open drainage using an external incision in this age group has been preferred in the past owing to the smaller size of the sinuses making access to the abscess cavity in the orbit more difficult. We present the results of a systematic review over the past 50 years on the diagnosis and treatment of orbital complications in neonates and infants. We include our case involving a 74-dayold infant who presented with a left orbital abscess that was successfully drained through an endoscopic approach. To our knowledge, this is the first report dedicated to the treatment of orbital abscess or subperiosteal orbital abscess (SPOA) in this age group, and our case is the second reported case of successful endoscopic drainage.
JAMA Otolaryngology–Head & Neck Surgery November 2014 Volume 140, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a Purdue University User on 05/23/2015
jamaotolaryngology.com
Orbital Complications of Acute Sinusitis in Infants
Review Clinical Review & Education
Figure. Preoperative CT and Intraoperative Images B
A
A, Axial view of the computed tomographic (CT) scan of the sinus with contrast delineating the subperiosteal abscess in the left orbit. B, Intraoperative image showing total ethmoidectomy performed on the left with purulent drainage noted after removal of the medial orbital wall.
Report of a Case A 74-day-old female infant presented with fever, erythema, and edema of the left eye. Her white blood cell count was 15.7 × 103/ mL. The patient was admitted to the hospital and empirically started on therapy with intravenous ceftriaxone sodium and clindamycin hydrochloride. A computed tomographic (CT) scan of the sinuses with contrast was obtained and showed opacification of the left maxillary and ethmoid sinuses as well as a subperiosteal fluid collection consistent with acute maxillary and ethmoid sinusitis with an SPOA (Figure, A). The patient was taken to the operating room, and a transnasal endoscopic approach was used to perform an uncinectomy, maxillary antrostomy, total ethmoidectomy, and orbital decompression to drain the abscess (Figure, B). Cultures were obtained intraoperatively that grew oxacillinresistant Staphylococcus aureus sensitive to the clindamycin. Therapy with ceftriaxone was stopped. The infant continued to improve and was discharged home 3 days later on a 2-week course of oral clindamycin. Office follow-up 3 weeks after discharge revealed complete resolution of the infection.
Methods This study was approved by the institutional review board of Nemours Children’s Clinic. A PubMed database search was performed for all cases of orbital abscess and SPOA (date range, 19592012). The search was performed using combinations of the following terms: orbital abscess, subperiosteal abscess, and orbital complications with infants, neonates, pediatrics, and children. The search results were narrowed by limiting the age range of patients to neonates ( L)
No
NR
3/M/30
Maruszcak et al,4 1979
L
Yes
Unable to determine
WBC Count, ×103/mL
Antibiotics Used
Drainage Type
Outcome
S aureus
Penicillin and streptomycin
Open
Cure
3.5
S aureus
Penicillin and streptomycin
Not performed
Death
Normal
S aureus
Methicillin and streptomycin
Open
Cure
D pneumoniae
NR
Open
Cure
S aureus
Flucloxacillin, gentamicin, and ceftazidime
Open
Cure
S aureus + Aspergillus
Cloxacillin and amikacin
Open
Cure
24
4/F/35
Maruszcak et al,4 1979
L
No
NR
5/F/15
Saunders et al,5 1993
L
Yes
Ethmoiditis
NR
6/M/10
Reddy et al,2 1999
L
Yes
Ethmoiditis
26.1
6
19.2
Cultures
7/F/21
Cruz et al, 2001
R
Yes
Ethmoiditis
Normal
None
Cephalothin
Open
Cure
8/F/17
Cruz et al,6 2001
R
Yes
Ethmoiditis
3.3
S aureus
Oxacillin and amikacin
Spontaneous
Cure
9/M/28
Anari et al,7 2005
R
Yes
Ethmoiditis
8.49
MRSA
Vancomycin and rifampicin
Open
Cure
10/M/38
Soon et al,1 2009
R
Yes
Ethmoiditis
17.4
S aureus
Ceftazidime, cloxacillin, and metronidazole
Endoscopic
Cure
11/F/74
Present case, 2012
L
Yes
Ethmoid and Maxillary
15.7
ORSA
Clindamycin
Endoscopic
Cure
Abbreviations: CT, computed tomography; D, Diplococcus; L, left; MRSA, methicillin-resistant Saureus; NR, not reported; ORSA, oxacillin-resistant S aureus; R, right; S, Staphylococcus; WBC, white blood cell.
Discussion Orbital infections, though very rare in infants, can start even after a single episode of acute sinusitis. The first case of orbital sepsis that likely resulted from an abscess was reported in 1959 by Burnard in 2 patients aged 14 days.3 One of the infants was treated with external surgical drainage and recovered after a few days of antibiotic administration. The second infant was treated only with antibiotics, developed septicemia, and died within 48 hours of presentation. Since then, there have been 9 additional cases identified in babies younger than 1 year, including our case report presented in this review.1-7 In addition to antibiotic therapy, the abscesses were drained in the last 9 patients, and all recovered well. Paranasal sinusitis is responsible for 66% to 75% of cases of orbital infections, and the most common source of orbital cellulitis in children is ethmoidal sinusitis.1 Anatomically, there is an intimate relationship between the orbit and its contents and the paranasal sinuses. Only a paper-thin bony plate of the ethmoid separates the orbit from the ethmoid cells. Moreover, there are anterior and posterior ethmoidal foramina that allow the passage of nerves and vessels that can provide a route for infection to spread from the sinuses to the orbit. In some patients, congenital dehiscences that provide an additional route of transmission are present. There are several other factors that make this particular age group unique. Neonates and infants have limited antigen exposure, and an adaptive immune system is still relatively early in maturation.8 They rely heavily on innate immune response as well as immunoglobulin passed on by the mother. Anatomically, the sinuses are small, allowing the infection to spread more quickly to surrounding tissues and making the endoscopic surgical approach 1072
for drainage more challenging. When surgical drainage is required, an open drainage approach has been traditionally favored. The offending organisms in sinus infections in the pediatric population generally consist of H influenzae, S pneumoniae, and M catarrhalis. With orbital involvement, these bacteria predominate along with Streptococcus pyogenes, S aureus, and Staphylococcus epidermidis.1 With more widespread use of the H influenzae type b and pneumococcal vaccine, the incidence of different pathogenic bacteria is changing.9 A recent study showed the significant impact of 7-valent pneumococcal conjugate vaccine in reducing invasive S pneumoniae acute complicated sinusitis and associated orbital infections.10 Similar results were also reported from the Texas Children’s Hospital group that showed S aureus and more recently methicillin-resistant S aureus has become the dominant pathogen isolated from these infections in children.10,11 Interestingly, our review showed that in infants and neonates with orbital abscess or SPOA, S aureus has been the predominant offending organisms even in cases reviewed as early as 1959. We believe when empirical antibiotic coverage is begun, consideration should be made to include coverage for methicillin-resistant S aureus because of its increasing incidence. The current recommendations by the American Academy of Ophthalmology favor medical treatment without the need for surgical drainage for orbital and SPOA in children younger than 9 years.12,13 Oxford and Mcclay14 report one of the largest review series of management of subperiosteal abscess and recommend medical management of SPOA smaller than 4 mm in width. Garcia et al15 performed a prospective cohort study with nonsurgical management of SPOA in 29 patients younger than 9 years, with 27 patients successfully treated without surgical drainage. Because orbital abscess or SPOA are very rare in neonates and
JAMA Otolaryngology–Head & Neck Surgery November 2014 Volume 140, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a Purdue University User on 05/23/2015
jamaotolaryngology.com
Orbital Complications of Acute Sinusitis in Infants
Review Clinical Review & Education
infants, the majority of the recommendations were extrapolated from data collected in children older than 1 year and generalized to this patient population. Our systematic review showed that all reported abscesses in this age group required drainage, and the only mortality was in the one patient without surgical intervention. We believe that this age group presents unique challenges not present in older pediatric patients, and a low threshold to early surgical intervention is warranted. When surgical drainage is desired, multiple approaches have been described in the literature with the goal of draining the abscess and releasing the pressure off the orbit. Traditionally, an external approach with a lynch incision or modified lateral rhinotomy has been used. This has been particularly true in the pediatric population younger than 1 year, possibly because of the concern of the inability to adequately access and drain the abscess through the endoscopic approach owing to the smaller nose and sinuses. Soon1 reported the first case of a 38-day-old newborn with a right SPOA that was successfully drained endoscopically. In our case, the endoscopic approach offered an excellent method of adequately decompressing the orbit and draining the abscess while addressing the nidus of infection from the ethmoid sinus. We believe that with the advancements of endoscopic equipment and techniques, the endoscopic approach by experienced surgeons is an excellent option in this age group. ARTICLE INFORMATION Submitted for Publication: April 30, 2014; final revision received July 23, 2014; accepted August 21, 2014. Published Online: October 9, 2014. doi:10.1001/jamaoto.2014.2326. Author Contributions: Drs Sharma and Josephson had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Josephson. Acquisition, analysis, or interpretation of data: Sharma, Josephson. Drafting of the manuscript: Sharma, Josephson. Critical revision of the manuscript for important intellectual content: Sharma, Josephson. Statistical analysis: Sharma. Administrative, technical, or material support: Josephson. Study supervision: Josephson. Conflict of Interest Disclosures: Dr Josephson is a consultant for Medtronic Corporation and has been a consultant for Acclarent Corporation in 2012, unrelated to any content in this article. No other disclosures are reported. REFERENCES 1. Soon VT. Pediatric subperiosteal orbital abscess secondary to acute sinusitis: a 5-year review. Am J Otolaryngol. 2011;32(1):62-68.
jamaotolaryngology.com
Conclusions Although very rare in the newborn and infant population, acute sinusitis can lead to orbital infections with devastating consequences if not treated expeditiously and appropriately. Our review showed that although medical therapy alone may be adequate to treat orbital complications from sinusitis in the pediatric population, more aggressive early surgical management is warranted in the neonatal and infant age group. Based on our review, our opinion is that infants should be classified separately from children older than 1 year in the decision-making process. Empirical antibiotics should offer broad coverage to include typical pathogens as well as coverage for S aureus. With the increasing incidence noted of resistant strains of Staphylococcus, clindamycin appears to be a good choice, along with a cephalosporin, which covers the more common pediatric sinus pathogens, until culture sensitivities are available. In addition, surgical drainage should be considered early in this population, since our systematic review and case report revealed that surgical intervention was essential in resolving the infection. With the latest endoscopic technologies and equipment available, the transnasal endoscopic approach is a safe and effective surgical technique in this patient population.
2. Reddy SC, Sharma HS, Mazidah AS, Darnal HK, Mahayidin M. Orbital abscess due to acute ethmoiditis in a neonate. Int J Pediatr Otorhinolaryngol. 1999;49(1):81-86.
10. Peña MT, Preciado D, Orestes M, Choi S. Orbital complications of acute sinusitis: changes in the post-pneumococcal vaccine era. JAMA Otolaryngol Head Neck Surg. 2013;139(3):223-227.
3. Burnard ED. Proptosis as the first sign of orbital sepsis in the newborn. Br J Ophthalmol. 1959;43(1): 9-12.
11. McKinley SH, Yen MT, Miller AM, Yen KG. Microbiology of pediatric orbital cellulitis. Am J Ophthalmol. 2007;144(4):497-501.
4. Maruszczak D, Krarup JC, Fledelius HC. Orbital abscess in two neonates, deriving from conjunctival malformations. Acta Ophthalmol (Copenh). 1979;57 (4):643-648.
12. Greenberg MF, Pollard ZF. Medical treatment of pediatric subperiosteal orbital abscess secondary to sinusitis. J AAPOS. 1998;2(6):351-355.
5. Saunders MW, Jones NS. Periorbital abscess due to ethmoiditis in a neonate. J Laryngol Otol. 1993; 107(11):1043-1044. 6. Cruz AA, Mussi-Pinhata MM, Akaishi PM, Cattebeke L, Torrano da Silva J, Elia J Jr. Neonatal orbital abscess. Ophthalmology. 2001;108(12): 2316-2320. 7. Anari S, Karagama YG, Fulton B, Wilson JA. Neonatal disseminated methicillin-resistant Staphylococcus aureus presenting as orbital cellulitis. J Laryngol Otol. 2005;119(1):64-67. 8. Levy O, Wynn JL. A prime time for trained immunity: innate immune memory in newborns and infants. Neonatology. 2014;105(2):136-141.
13. Baharestani S, Zoumalan CI, Lisman RD. Evaluation and management of orbital subperiosteal abscess. July/August 2009. EyeNet Magazine. http://www.aao.org/publications/eyenet /200907/upload/July-2009-Pearl.pdf. Accessed August 27, 2014. 14. Oxford LE, McClay J. Medical and surgical management of subperiosteal orbital abscess secondary to acute sinusitis in children. Int J Pediatr Otorhinolaryngol. 2006;70(11):1853-1861. 15. Garcia GH, Harris GJ. Criteria for nonsurgical management of subperiosteal abscess of the orbit: analysis of outcomes 1988-1998. Ophthalmology. 2000;107(8):1454-1458.
9. Barone SR, Aiuto LT. Periorbital and orbital cellulitis in the Haemophilus influenzae vaccine era. J Pediatr Ophthalmol Strabismus. 1997;34(5):293296.
JAMA Otolaryngology–Head & Neck Surgery November 2014 Volume 140, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a Purdue University User on 05/23/2015
1073
Review
Orbital Complications of Acute Sinusitis in Infants A Systematic Review and Report of a Case Saurabh Sharma, MD; Gary D. Josephson, MD, MBA
IMPORTANCE Orbital infections from acute sinusitis are rare in neonates and infants and can
lead to devastating complications. To our knowledge, no prior dedicated review exists for evaluation, treatment, and outcomes of orbital complications in this age group. OBJECTIVE To perform a systematic review over the past 50 years on the diagnosis and treatment of orbital complications secondary to acute sinusitis in neonates and infants and report a case. EVIDENCE AND ACQUISITION A systematic review of the literature was performed searching PubMed to collect all the pertinent case reports and series in the English language with subperiosteal orbital abscess (SPOA) or orbital abscess in neonates or infants (date range, 1959-2012). RESULTS Eleven cases of SPOA in infants were identified, including our current case. Ages ranged from 10 to 74 days. There were 6 female and 5 male infants. The right eye was affected in 5 cases, the left in 5, and both in 1. There was 1 mortality in this series for which surgical drainage was not performed. Staphylococcus aureus was the most common organism isolated in 9 of 11 cases. Seven of the cases had open surgical drainage, 2 had endoscopic procedures (including our case), and 1 had spontaneous rupture of the abscess. CONCLUSIONS AND RELEVANCE An orbital complication due to acute sinusitis is rare in infants and neonates. Drainage in this patient population appears to be paramount, since the only infant in this series who did not receive drainage had died. Modern telescopes and equipment have allowed endoscopic drainage to be a safe and effective surgical treatment in this age group. JAMA Otolaryngol Head Neck Surg. 2014;140(11):1070-1073. doi:10.1001/jamaoto.2014.2326 Published online October 9, 2014.
A
cute sinusitis is the predominant cause of orbital infections in children. It is not uncommon for acute ethmoiditis to lead to orbital complications in children aged 2 to 10 years.1 In neonates, defined by the American Academy of Pediatrics as age up to 30 days, and infants, 31 days to 12 months, acute ethmoiditis leading to orbital complications is rare. Neonates and infants present unique challenges in the diagnosis and treatment of these potentially dangerous infections. They have a developing immune system and still depend on remaining circulating antibodies obtained in utero from their mother. This makes them more vulnerable to infection, especially in the very early months. In addition, the sinuses are smaller and evolving, challenging the surgeon in decision making for adequate drainage through an endoscopic approach if surgical drainage is desired. Clinical symptoms of infection may also be subtle or absent. Patients may present with redness and swelling of the orbital region with or without systemic symptoms. An untreated abscess can lead to blindness, intracranial spread, cavernous sinus thrombosis, cerebral abscess, or sepsis.2 1070
Author Affiliations: Department of Otolaryngology–Head and Neck Surgery, University of South Florida, Tampa (Sharma); Pediatric Otolaryngology–Head and Neck Surgery, Nemours Children’s Clinic, Jacksonville, Florida (Josephson). Corresponding Author: Gary D. Josephson, MD, MBA, Division of Pediatric Otolaryngology–Head and Neck Surgery, Nemours Children’s Clinic Jacksonville, 807 Children’s Way, Jacksonville, FL 32207 ([email protected]).
Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the typical offending organisms in the pediatric population that cause acute sinusitis.1 Treatment for complicated infections with orbital involvement includes intravenous antibiotics directed at the typical organisms with or without drainage. When surgical drainage is performed, open drainage using an external incision in this age group has been preferred in the past owing to the smaller size of the sinuses making access to the abscess cavity in the orbit more difficult. We present the results of a systematic review over the past 50 years on the diagnosis and treatment of orbital complications in neonates and infants. We include our case involving a 74-dayold infant who presented with a left orbital abscess that was successfully drained through an endoscopic approach. To our knowledge, this is the first report dedicated to the treatment of orbital abscess or subperiosteal orbital abscess (SPOA) in this age group, and our case is the second reported case of successful endoscopic drainage.
JAMA Otolaryngology–Head & Neck Surgery November 2014 Volume 140, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a Purdue University User on 05/23/2015
jamaotolaryngology.com
Orbital Complications of Acute Sinusitis in Infants
Review Clinical Review & Education
Figure. Preoperative CT and Intraoperative Images B
A
A, Axial view of the computed tomographic (CT) scan of the sinus with contrast delineating the subperiosteal abscess in the left orbit. B, Intraoperative image showing total ethmoidectomy performed on the left with purulent drainage noted after removal of the medial orbital wall.
Report of a Case A 74-day-old female infant presented with fever, erythema, and edema of the left eye. Her white blood cell count was 15.7 × 103/ mL. The patient was admitted to the hospital and empirically started on therapy with intravenous ceftriaxone sodium and clindamycin hydrochloride. A computed tomographic (CT) scan of the sinuses with contrast was obtained and showed opacification of the left maxillary and ethmoid sinuses as well as a subperiosteal fluid collection consistent with acute maxillary and ethmoid sinusitis with an SPOA (Figure, A). The patient was taken to the operating room, and a transnasal endoscopic approach was used to perform an uncinectomy, maxillary antrostomy, total ethmoidectomy, and orbital decompression to drain the abscess (Figure, B). Cultures were obtained intraoperatively that grew oxacillinresistant Staphylococcus aureus sensitive to the clindamycin. Therapy with ceftriaxone was stopped. The infant continued to improve and was discharged home 3 days later on a 2-week course of oral clindamycin. Office follow-up 3 weeks after discharge revealed complete resolution of the infection.
Methods This study was approved by the institutional review board of Nemours Children’s Clinic. A PubMed database search was performed for all cases of orbital abscess and SPOA (date range, 19592012). The search was performed using combinations of the following terms: orbital abscess, subperiosteal abscess, and orbital complications with infants, neonates, pediatrics, and children. The search results were narrowed by limiting the age range of patients to neonates ( L)
No
NR
3/M/30
Maruszcak et al,4 1979
L
Yes
Unable to determine
WBC Count, ×103/mL
Antibiotics Used
Drainage Type
Outcome
S aureus
Penicillin and streptomycin
Open
Cure
3.5
S aureus
Penicillin and streptomycin
Not performed
Death
Normal
S aureus
Methicillin and streptomycin
Open
Cure
D pneumoniae
NR
Open
Cure
S aureus
Flucloxacillin, gentamicin, and ceftazidime
Open
Cure
S aureus + Aspergillus
Cloxacillin and amikacin
Open
Cure
24
4/F/35
Maruszcak et al,4 1979
L
No
NR
5/F/15
Saunders et al,5 1993
L
Yes
Ethmoiditis
NR
6/M/10
Reddy et al,2 1999
L
Yes
Ethmoiditis
26.1
6
19.2
Cultures
7/F/21
Cruz et al, 2001
R
Yes
Ethmoiditis
Normal
None
Cephalothin
Open
Cure
8/F/17
Cruz et al,6 2001
R
Yes
Ethmoiditis
3.3
S aureus
Oxacillin and amikacin
Spontaneous
Cure
9/M/28
Anari et al,7 2005
R
Yes
Ethmoiditis
8.49
MRSA
Vancomycin and rifampicin
Open
Cure
10/M/38
Soon et al,1 2009
R
Yes
Ethmoiditis
17.4
S aureus
Ceftazidime, cloxacillin, and metronidazole
Endoscopic
Cure
11/F/74
Present case, 2012
L
Yes
Ethmoid and Maxillary
15.7
ORSA
Clindamycin
Endoscopic
Cure
Abbreviations: CT, computed tomography; D, Diplococcus; L, left; MRSA, methicillin-resistant Saureus; NR, not reported; ORSA, oxacillin-resistant S aureus; R, right; S, Staphylococcus; WBC, white blood cell.
Discussion Orbital infections, though very rare in infants, can start even after a single episode of acute sinusitis. The first case of orbital sepsis that likely resulted from an abscess was reported in 1959 by Burnard in 2 patients aged 14 days.3 One of the infants was treated with external surgical drainage and recovered after a few days of antibiotic administration. The second infant was treated only with antibiotics, developed septicemia, and died within 48 hours of presentation. Since then, there have been 9 additional cases identified in babies younger than 1 year, including our case report presented in this review.1-7 In addition to antibiotic therapy, the abscesses were drained in the last 9 patients, and all recovered well. Paranasal sinusitis is responsible for 66% to 75% of cases of orbital infections, and the most common source of orbital cellulitis in children is ethmoidal sinusitis.1 Anatomically, there is an intimate relationship between the orbit and its contents and the paranasal sinuses. Only a paper-thin bony plate of the ethmoid separates the orbit from the ethmoid cells. Moreover, there are anterior and posterior ethmoidal foramina that allow the passage of nerves and vessels that can provide a route for infection to spread from the sinuses to the orbit. In some patients, congenital dehiscences that provide an additional route of transmission are present. There are several other factors that make this particular age group unique. Neonates and infants have limited antigen exposure, and an adaptive immune system is still relatively early in maturation.8 They rely heavily on innate immune response as well as immunoglobulin passed on by the mother. Anatomically, the sinuses are small, allowing the infection to spread more quickly to surrounding tissues and making the endoscopic surgical approach 1072
for drainage more challenging. When surgical drainage is required, an open drainage approach has been traditionally favored. The offending organisms in sinus infections in the pediatric population generally consist of H influenzae, S pneumoniae, and M catarrhalis. With orbital involvement, these bacteria predominate along with Streptococcus pyogenes, S aureus, and Staphylococcus epidermidis.1 With more widespread use of the H influenzae type b and pneumococcal vaccine, the incidence of different pathogenic bacteria is changing.9 A recent study showed the significant impact of 7-valent pneumococcal conjugate vaccine in reducing invasive S pneumoniae acute complicated sinusitis and associated orbital infections.10 Similar results were also reported from the Texas Children’s Hospital group that showed S aureus and more recently methicillin-resistant S aureus has become the dominant pathogen isolated from these infections in children.10,11 Interestingly, our review showed that in infants and neonates with orbital abscess or SPOA, S aureus has been the predominant offending organisms even in cases reviewed as early as 1959. We believe when empirical antibiotic coverage is begun, consideration should be made to include coverage for methicillin-resistant S aureus because of its increasing incidence. The current recommendations by the American Academy of Ophthalmology favor medical treatment without the need for surgical drainage for orbital and SPOA in children younger than 9 years.12,13 Oxford and Mcclay14 report one of the largest review series of management of subperiosteal abscess and recommend medical management of SPOA smaller than 4 mm in width. Garcia et al15 performed a prospective cohort study with nonsurgical management of SPOA in 29 patients younger than 9 years, with 27 patients successfully treated without surgical drainage. Because orbital abscess or SPOA are very rare in neonates and
JAMA Otolaryngology–Head & Neck Surgery November 2014 Volume 140, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a Purdue University User on 05/23/2015
jamaotolaryngology.com
Orbital Complications of Acute Sinusitis in Infants
Review Clinical Review & Education
infants, the majority of the recommendations were extrapolated from data collected in children older than 1 year and generalized to this patient population. Our systematic review showed that all reported abscesses in this age group required drainage, and the only mortality was in the one patient without surgical intervention. We believe that this age group presents unique challenges not present in older pediatric patients, and a low threshold to early surgical intervention is warranted. When surgical drainage is desired, multiple approaches have been described in the literature with the goal of draining the abscess and releasing the pressure off the orbit. Traditionally, an external approach with a lynch incision or modified lateral rhinotomy has been used. This has been particularly true in the pediatric population younger than 1 year, possibly because of the concern of the inability to adequately access and drain the abscess through the endoscopic approach owing to the smaller nose and sinuses. Soon1 reported the first case of a 38-day-old newborn with a right SPOA that was successfully drained endoscopically. In our case, the endoscopic approach offered an excellent method of adequately decompressing the orbit and draining the abscess while addressing the nidus of infection from the ethmoid sinus. We believe that with the advancements of endoscopic equipment and techniques, the endoscopic approach by experienced surgeons is an excellent option in this age group. ARTICLE INFORMATION Submitted for Publication: April 30, 2014; final revision received July 23, 2014; accepted August 21, 2014. Published Online: October 9, 2014. doi:10.1001/jamaoto.2014.2326. Author Contributions: Drs Sharma and Josephson had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Josephson. Acquisition, analysis, or interpretation of data: Sharma, Josephson. Drafting of the manuscript: Sharma, Josephson. Critical revision of the manuscript for important intellectual content: Sharma, Josephson. Statistical analysis: Sharma. Administrative, technical, or material support: Josephson. Study supervision: Josephson. Conflict of Interest Disclosures: Dr Josephson is a consultant for Medtronic Corporation and has been a consultant for Acclarent Corporation in 2012, unrelated to any content in this article. No other disclosures are reported. REFERENCES 1. Soon VT. Pediatric subperiosteal orbital abscess secondary to acute sinusitis: a 5-year review. Am J Otolaryngol. 2011;32(1):62-68.
jamaotolaryngology.com
Conclusions Although very rare in the newborn and infant population, acute sinusitis can lead to orbital infections with devastating consequences if not treated expeditiously and appropriately. Our review showed that although medical therapy alone may be adequate to treat orbital complications from sinusitis in the pediatric population, more aggressive early surgical management is warranted in the neonatal and infant age group. Based on our review, our opinion is that infants should be classified separately from children older than 1 year in the decision-making process. Empirical antibiotics should offer broad coverage to include typical pathogens as well as coverage for S aureus. With the increasing incidence noted of resistant strains of Staphylococcus, clindamycin appears to be a good choice, along with a cephalosporin, which covers the more common pediatric sinus pathogens, until culture sensitivities are available. In addition, surgical drainage should be considered early in this population, since our systematic review and case report revealed that surgical intervention was essential in resolving the infection. With the latest endoscopic technologies and equipment available, the transnasal endoscopic approach is a safe and effective surgical technique in this patient population.
2. Reddy SC, Sharma HS, Mazidah AS, Darnal HK, Mahayidin M. Orbital abscess due to acute ethmoiditis in a neonate. Int J Pediatr Otorhinolaryngol. 1999;49(1):81-86.
10. Peña MT, Preciado D, Orestes M, Choi S. Orbital complications of acute sinusitis: changes in the post-pneumococcal vaccine era. JAMA Otolaryngol Head Neck Surg. 2013;139(3):223-227.
3. Burnard ED. Proptosis as the first sign of orbital sepsis in the newborn. Br J Ophthalmol. 1959;43(1): 9-12.
11. McKinley SH, Yen MT, Miller AM, Yen KG. Microbiology of pediatric orbital cellulitis. Am J Ophthalmol. 2007;144(4):497-501.
4. Maruszczak D, Krarup JC, Fledelius HC. Orbital abscess in two neonates, deriving from conjunctival malformations. Acta Ophthalmol (Copenh). 1979;57 (4):643-648.
12. Greenberg MF, Pollard ZF. Medical treatment of pediatric subperiosteal orbital abscess secondary to sinusitis. J AAPOS. 1998;2(6):351-355.
5. Saunders MW, Jones NS. Periorbital abscess due to ethmoiditis in a neonate. J Laryngol Otol. 1993; 107(11):1043-1044. 6. Cruz AA, Mussi-Pinhata MM, Akaishi PM, Cattebeke L, Torrano da Silva J, Elia J Jr. Neonatal orbital abscess. Ophthalmology. 2001;108(12): 2316-2320. 7. Anari S, Karagama YG, Fulton B, Wilson JA. Neonatal disseminated methicillin-resistant Staphylococcus aureus presenting as orbital cellulitis. J Laryngol Otol. 2005;119(1):64-67. 8. Levy O, Wynn JL. A prime time for trained immunity: innate immune memory in newborns and infants. Neonatology. 2014;105(2):136-141.
13. Baharestani S, Zoumalan CI, Lisman RD. Evaluation and management of orbital subperiosteal abscess. July/August 2009. EyeNet Magazine. http://www.aao.org/publications/eyenet /200907/upload/July-2009-Pearl.pdf. Accessed August 27, 2014. 14. Oxford LE, McClay J. Medical and surgical management of subperiosteal orbital abscess secondary to acute sinusitis in children. Int J Pediatr Otorhinolaryngol. 2006;70(11):1853-1861. 15. Garcia GH, Harris GJ. Criteria for nonsurgical management of subperiosteal abscess of the orbit: analysis of outcomes 1988-1998. Ophthalmology. 2000;107(8):1454-1458.
9. Barone SR, Aiuto LT. Periorbital and orbital cellulitis in the Haemophilus influenzae vaccine era. J Pediatr Ophthalmol Strabismus. 1997;34(5):293296.
JAMA Otolaryngology–Head & Neck Surgery November 2014 Volume 140, Number 11
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a Purdue University User on 05/23/2015
1073
