Iryna Drohobycka, *Lidia Zawadzka-Głos
Ocular compications in ethmoiditis in children treated in a reference laryngological academic center
Powikłania oczodołowe w zapaleniu zatok sitowych u dzieci leczonych w referencyjnym laryngologicznym ośrodku akademickim
Department of Pediatric Otolaryngology, Medical University of Warsaw, Poland
Head of Department: Associate Professor Lidia Zawadzka-Głos, MD, PhD
Streszczenie
Wstęp. Jednym z najczęściej rozpoznawanych schorzeń górnych dróg oddechowych jest zapalenie błony śluzowej nosa i zatok przynosowych. Szczególną postacią zapalenia zatok obocznych nosa u dzieci jest zapalenie sitowia. Z uwagi na umiejscowienie komórek sitowia ich zapalenie stanowi większe zagrożenie dla chorego w porównaniu do zapalenia innych zatok obocznych nosa.
Cel pracy. Celem pracy była ocena występowania, stopnia zaawansowania i sposobu leczenia powikłań oczodołowych zapalenia zatok sitowych u dzieci w materiale akademickiego ośrodka referencyjnego laryngologii dziecięcej.
Materiał i metody. Analizą retrospektywną objęto 41 pacjentów z powikłaniami oczodołowymi w przebiegu zapalenia zatok sitowych, którzy byli hospitalizowani w Klinice Otolaryngologii Dziecięcej Warszawskiego Uniwersytetu Medycznego w latach 2012–2017. Analizie poddano stopień powikłań wg skali Chandlera oraz zastosowane leczenie i patogeny wyizolowane z posiewów materiału uzyskanego podczas zabiegu chirurgicznego.
Wyniki. Do badania włączono 25 chłopców (60%) i 16 dziewcząt (40%) w wieku od 3 miesięcy do 16 lat. Średnia wieku wszystkich dzieci wynosiła 5,34 lat (SD = 3,98). Wg skali Chandlera powikłania zaprzegrodowe stwierdzono u 12 pacjentów (29,27%), a u 29 (70,73%) rozpoznano powikłania przedprzegrodowe. Leczeniu chirurgicznemu poddano 12 (29,27%) pacjentów, z czego u 8 (66,7 %) z nich wykonano ethmoidektomię z dostępu zewnętrznego z drenażem oczodołu, a u 4 pacjentów (33,3%) zastosowano czynnościowo-endoskopową chirurgię zatok przynosowych (FESS – ang. Functional Endoscopic Sinus Surgery). Zgodność obrazu tomografii komputerowej (TK) ze zmianami stwierdzonymi podczas interwencji chirurgicznej stwierdzono u 10 pacjentów (83,3%). Z posiewu materiałów pobranych podczas zabiegu wyizolowano 15 różnych patogenów. W ponad połowie przypadków (53,3%) patogenem był gronkowiec. Wszyscy pacjenci z powikłaniami oczodołowymi zaprzegrodowymi otrzymali terapię skojarzoną obejmującą leczenie chirurgiczne i dwa dożylne antybiotyki według wyniku posiewu. Najczęściej stosowanymi antybiotykami były cefalosporyny trzeciej generacji i klindamycyna.
Wnioski. W zapaleniu zatok sitowych u dzieci leczonych w referencyjnym laryngologicznym ośrodku akademickim powikłania przedprzegrodowe występowały dwukrotnie częściej niż zaprzegrodowe. Większość przypadków nie wymaga interwencji chirurgicznej.
Summary
Introduction. One of the most commonly diagnosed upper respiratory diseases is sinusitis. A particular form of sinusitis in children is ethmoiditis. Due to the location of ethmoidal cells, their inflammation is associated with higher risk of complications compared with inflammation of other sinuses.
Aim. The aim of the study was to assess the prevalence, severity and management of ocular complications of ethmoiditis in the retrospective material of the reference laryngological academic center.
Material and Methods. The retrospective analysis included 41 patients with ocular complications of ethmoid sinusitis who were hospitalized in the Department of Pediatric Otolaryngology in the years 2012–2017. The analysis included the severity of complications on Chandler’s scale, management and results of culture of the material obtained during surgery.
Results. The study included 25 boys (60%) and 16 girls (40%) aged from 3 months to 16 years. Mean age of the patients was 5.34 years (SD = 3.98). According to Chandler’s scale, retroseptal complications were diagnosed in 12 patients (29.27%), and anteroseptal complications – in 29 patients (70.73%). Surgical treatment was performed in 12 patients (29.27%), 8 of whom (66.7%) underwent external ethmoidectomy with orbital drainage, and 4 of whom (33.3%) underwent functional endoscopic sinus surgery (FESS). Consistent findings of CT scan with lesions found during surgical intervention were found in 10 patients (83.3%). Fifteen different pathogens were isolated from the material collected during the procedures. In more than half of the patients (53.3%), the pathogen was a staphylococcus. Al the patients with retroseptal ocular complications underwent combination therapy consisting of surgical management and two intravenous antibiotics targeted for the etiological factor. The most frequently used antibiotics included 3rd generation cephalosporins and clindamycin.
Conclusions. In children with ethmoiditis treated in a reference laryngological academic center, anteroseptal complications occurred twice as often as retroseptal complications. Most cases did not require surgical intervention.
Introduction
One of the most commonly diagnosed upper respiratory diseases is sinusitis. According to the European Position Paper on Rhinosinusitis and Nasal Polyps from 2012 (1), acute sinusitis can be defined as the sudden onset of two or more of the following symptoms: nasal obstruction or nasal discharge, facial pain and pressure and reduction or loss of smell persisting for no more than 12 weeks. To diagnose acute bacterial sinusitis, two of the following symptoms must occur: discoloured discharge with unilateral predominance and purulent secretion in the nasal cavity, severe local pain, fever, elevated ESR/CRP, and deterioration after an initial milder phase of illness (1).
A particular form of sinusitis in children is ethmoid sinusitis, which may occur in very young children, as ethmoid sinuses are developed and separated from nasal cavity as early as after the birth. Due to the location of ethmoidal cells, their acute inflammation is associated with higher risk of complications compared with inflammation of other sinuses, as the inflammation often spreads to orbital tissues. Chandler et al. (2) divided orbital complications into five groups, depending on the location of the process in relation to the orbital septum:
1. Eyelid edema;
2. Orbital cellulitis;
3. Subperiosteal abscess of the orbit;
4. Orbital abscess;
5. Cavernous sinus thrombosis.
Aim
The aim of the study was to assess the prevalence, severity and management of ocular complications of ethmoiditis in the retrospective material of the reference laryngological academic center.
Material and methods
The retrospective analysis included 41 patients with ocular complications of ethmoid sinusitis who were hospitalized in the Department of Pediatric Otolaryngology in the years 2012–2017. In this group, age, sex, severity of complications on Chandler’s scale, culture results from material obtained during surgical procedure, imaging findings in computed tomography, and management were analyzed.
Data were presented as means with standard deviation or average deviation. The differences between continuous data were calculated using Student’s t-test. Variable data were presented as numbers (%, percentage). When using statistical tests, confidence level of 0.05 was assumed - results from p < 0.05 were considered statistically significant.
Results
The study included 25 boys (60%) and 16 girls (40%) aged from 3 months to 16 years (mean age 5.34, SD = 3.98). Table 1 presents demographic parameters of the study group.
Tab. 1. Demographic parameters of the study group
| Sex/age | 0.3–1 | 1–3 | 3–5 | 5–10 | 10–15 | > 15 | Total |
| Boys | 1 (2.4%) | 10 (24.3%) | 4 (9.8%) | 1 (2.4%) | 1 (2.4%) | 1 (2.4%) | 25 (60%) |
| Girls | 1 (2.4%) | 2 (4.9%) | 4 (9.8%) | 3 (7.3%) | 3 (7.3%) | – | 16 (40%) |
| Sum | 2 (4.9%) | 12 (29.2%) | 8 (19,5%) | 4 (9.8%) | 4 (9.8%) | 1 (2.4%) | 41 (100%) |
All children with suspected orbital complications received empiric antibiotic therapy intravenously at admission. In 18 patients with exophtalmia, reduced eyeball mobility, and loss of vision or no response to intravenous antibiotic therapy in 24–48 hours from admission, CT scan of the sinuses was performed. According to Chandler’s scale, retroseptal complications were diagnosed in 12 patients (29.27%), and anteroseptal complications – in 29 patients (70.73%). Mean age of patients with retroseptal complications was 6.7 years (SD = 4.73) and was significantly higher than mean age of patients with anteroseptal complications: 4.8 years (SD = 3.27, p < 0.05). Table 2 presents the incidence of ocular complications according to Chandler’s scale.
Tab. 2. Incidence of ocular complications according to Chandler’s scale.
| Severity of ocular complications according to Chandler’s scale. | Number of patients | Percentage of patients |
| Anteroseptal complications |
| Group 1. Eyelid edema | 29 | 70.73% |
| Retroseptal complications |
| Group 2. Orbital cellulitis | 7 | 17.07% |
| Group 3. Subperiosteal abscess of the orbit | 1 | 2.44% |
| Group 4. Orbital abscess | 4 | 9.76% |
| Group 5. Cavernous sinus thrombosis | – | – |
Indications for surgical intervention included: subperiosteal abscess or orbital abscess in CT scan of sinuses, loss of vision, and lack of improvement or progression of symptoms in 24–48 hours despite intensive conservative treatment. Surgical treatment was performed in 12 patients (29.27%), 8 of whom (66.7%) underwent external ethmoidectomy with orbital drainage, and 4 of whom (33.3%) underwent functional endoscopic sinus surgery (FESS). Consistent findings of CT scan with intrasurgical findings were observed in 10 out of 12 patients (83.3%). In 2 remaining patients (16.7%), CT scan indicated an orbital abscess, which was not confirmed intrasurgically.
Fifteen different pathogens were isolated from the material collected from 11 out of 12 patients during the procedures. In 6 patients (54.5%), one type of pathogen was isolated; in 4 patients (36.4%), several (2 or 3) pathogens were found, and in 1 patient (9.1%), the culture was negative. In more than half of the patients (53.3%), the pathogen was a staphylococcus. In 5 cases (33.3%), the growth of the streptococci was observed. The most frequent pathogen causing purulent orbital lesions (subperiosteal abscess or orbital abscess) was staphylococcus (60%). In 2 patients with orbital abscess (50%) MSSA Staphylococcus aureus was grown. In the patient with subperiosteal abscess, three types of coagulase-negative staphylococci were isolated. Table 3 presents the prevalence of different pathogens.
Tab. 3. Prevalence of different pathogens.
| Isolated pathogen | Number of cases | Percentage |
| MSSA Staphylococcus aureus | 3 | 20% |
| Staphylococcus epidermidis | 2 | 13.3% |
| Staphylococcus hemolyticus | 1 | 6.7% |
| Staphylococcus spp. | 1 | 6.7% |
| Staphylococcus MSCNS | 1 | 6.7% |
| Streptococcus pneumoniae | 2 | 13.3% |
| Streptococcus pyogenes | 2 | 13.3% |
| Streptococcus intermedius | 1 | 6.7% |
| Klebsiella pneumoniae | 1 | 6.7% |
| Actinomyces odontolyticus | 1 | 6.7% |
| No bacterial growth | 1 | 6.7% |
All the patients with retroseptal ocular complications according to Chandler’s scale underwent combination therapy consisting of surgical management and two intravenous antibiotics targeted for the etiological factor. Ceftriaxone was the most commonly used antibiotic (83.3%), followed by cefuroxime (25%). Clindamycin was administered as a second drug in 12 patients (100%). Mean treatment time was 11 days (SD = 2.21) and was significantly longer than in patients with anteroseptal complications, in whom it accounted 8.5 days (SD = 1.96, p < 0.05). In 22 patients (76%) with anteroseptal complications, two antibiotics were used, and in 7 patients (24%), one antibiotic was used. The most commonly used antibiotic in patients with anteroseptal complications was cefuroxime (68%), ceftriaxone (24%), and amoxicillin / clavulanic acid (6.8%). Clindamycin was used as a second drug in 22 (74%) of patients.
Discussion
The incidence of ocular complications in general population in sinusitis varies between very low 0.5–3.9% to high 39% (3-5). In over 60% of patients of the general population, the cause of ocular involvement is ethmoiditis (6, 7). Anatomical localization of ethmoid cells, which are located between the orbit and nasal cavity, as well as thin lamina papyracea that separates ethmoid cells from the orbit (in small children consisting of connective tissue) has a key role in the pathogenesis of spreading of the infection from inflamed ethmoid cells to orbital tissues (2, 8, 9). The main cause of spreading of the infection is congenital dehiscence in lamina papyracea and valveless veins that drain blood from nasal cavity and sinuses into the orbit (2, 8, 9). The involvement of orbits in the inflammatory process is a significant problem in ENT practice, and it requires rapid diagnosis and intensive therapy, as it may be the cause of serious orbital complications leading to vision loss, as well as intracranial complications, such as supra- or subdural empyema, meningitis, dural arteriovenous fistulas with cerebrospinal fluid leak, brain abscess, and cerebral sinus venous thrombosis (2, 8, 9).
Mean age of children in this study was 5.3 years (from 3 months to 15 years) and was similar to mean age reported in other papers (10, 11).
The diagnosis of orbital complications was based on the clinical picture, imaging studies, and ophthalmological consultation. CT scan is considered the most sensitive imaging method of bone structures, including the orbit, paranasal sinuses, and base of skull (12). In our study, it was performed in 18 patients (43%). CT results correlated with intrasurgical findings in 10 patients (83.3%), which is consistent with findings of Clara et al. (13). In the remaining 23 patients (56.1%), in whom CT was not performed, edema and erythema of eyelids was observed, which subsided in 24 to 48 hours after administering intravenous antibiotics.
In determining clinical management, Chandler scale was used (2). In our study, eyelid edema was observed in 29 patients (70.73%), orbital inflammation – in 7 patients (17.09%), subperiosteal abscess of the orbit – in 1 patient (2.44%), and orbital abscess in 4 patients (9.76%). This is consistent with reports from the literature, in which group 1. and 2. of orbital complications are the most prevalent (14, 15). The treatment of complications of the group 1. and 2. is conservative, however, in the absence of clinical improvement within 24–48 hours, surgical intervention is required. In surgical treatment, functional endoscopic sinus surgery and external ethmoidectomy was the most frequently employed. In our study, 8 (66.7%) patients underwent external ethmoidectomy with drainage, and 4 (33.3%) – FESS. Mean age for surgically treated patients was 6.8 years and was higher that mean age of conservatively treated patients (4.8 years), which has been observed previously (16-18). Surgically treated patients required longer hospitalization compared to conservatively treated patients, which is consistent with previous findings (10, 19).
In more than half of our patients (53.3%), the pathogen was a staphylococcus. Other studies also reported streptococcus as the second most common pathogen (20-22). In 83.3%, ceftriaxone was used according to culture results. In empirical treatment, cefuroxime was used as the first-line drug (68%), and clindamycin – as the second-line drug. Other researchers also report using metronidazole (23, 24).
Conclusions
In children with ethmoiditis treated in a reference laryngological academic center, anteroseptal complications occurred twice as often as retroseptal complications. Ocular complications of ethmoiditis in children have a good prognosis when diagnosed early and appropriately treated. Most cases did not require surgical intervention.
Piśmiennictwo
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