Sinusitis with orbital complication case review classifications indications for surgical interventions

1. DMC
ENT department

2.  8 years old girl medically free
 CC : Lt. eye swelling X 4days
 URTI 6 days prior presentation
odynophagia , fever , rhinorrhea and cough
Headache
 Not started on antibiotics
 Lt.eye swelling  4 days prior presentation
seen in eye specialist hospital CT sinuses done
and referred to ENT.
 LAMA as no more fever and headache
 Admitted 2nd day.

3.  Vitally stable , afebrile
 Conscious oriented , not on pain or distress
 Nose : congested mucosa , no purulent
discharge , patent
 Throat : not congested , no PND
 Ears : intact TM B/L
 Eyes : Lt.eye swelling and erythema .
Can’t open her eyes bcz pain.
Tense on palpation
vision and EOM  intact

4.  Admission
 Ophthalmology consultation
 Blood inv.
 CT sinuses
 IV Antibiotics
 plan for surgery as not improved

17.  Left lateral orbit collection (2 x 1.2 x 0.6 cm) with mass effect
on the left globe manifested by medial rotation of the globe.
 Peripheral enhancement post IV contrast suggests orbital
Abscess .
 Orbital cellulitis.
 The left maxillary sinus shows opacification with a relatively
central hyperdensity suggestive of early pyogenic sinusitis .
 the left anterior ethmoid and left frontal sinuses show
complete opacification.
 Lacrimal gland is diffusely enlarged suggestive of
inflammation.
 Conclusion:left orbital cellulitis with left lacrimal gland
involvement possibly due to adjacent sinus disease with
preseptal and supraorbital abscess.

18.  Ophtha : I&D on most prominent area and packing
with povidone gauze
 Lt. FESS done :
 Findings : severly inflammed nasal mucosa and turbinates
with DNS to Lt.
large adenoid obstructing 75% choana
 M.T medialization , widening maxillary osteumand
cleaning maxillary sinus with irrigation.
 Bulla ethmoidalis removed reaching ant.ethmoids cleaned
and irrigation was full of pus
 Frontal sinus osteumidentified&cleaned with irrigation
with saline
 Pack inserted in middle meatus

20.  Results from a thrombophlebitis and
interference with the venous drainage of the
orbital contents.
 superior and inferior ophthalmic veins are
valveless, allowing direct communication
between the nose, ethmoid sinuses, face, orbit,
and cavernous sinus
 congenital or other dehiscences in the lamina
papyracea expose the orbital contents to direct
extension of sinusitis

21.  Orbital periosteum is important structure
because it is the only soft tissue barrier
between the sinuses and the orbital contents.

28.  CT evidence of abscess formation
 20/60 or worse visual acuity is observed on
initial evaluation
 progression of orbital signs and symptoms
occurs despite medical treatment
 or lack of improvement is seen within 48
hours despite aggressive medical treatment

29.  A useful framework for assessing patients outlined by
Oxford and McClay :
 medial subperiosteal abscess with normal vision
(better than 20/40)
 No ophthalmoplegia,
 intraocular pressure less than 20 mm Hg,
 proptosis less than 5 mm,
 and width of abscess less than 4 mm on CT
 can be considered for possible medical management.
 These objective criteria were shown retrospectively to
predict successful medical management with good
outcomes, even in older children.