ORBITALNE KOMPLIKACIJE ZAPALJENJA NOSNIH SINUSA

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1 Professional article Stručni rad UDK :617.7 Medicus 2007; 8(2): ORBITAL COMPLICATIONS OF RHINOSINUS INFLAMMATORY ORIGIN Jasmina Stojanovic, Branislav Belic, Ljiljana Tadic and Snezana Arsenijevic Otorhinolaryngology Clinic, Clinical Center, Kragujevac, Serbia ORBITALNE KOMPLIKACIJE ZAPALJENJA NOSNIH SINUSA Jasmina Stojanović, Branislav Belić, Ljiljana Tadić i Snežana Arsenijević Klinika za otorinolaringologiju, Klinički centar, Kragujevac, Srbija Received/Primljen: Accepted/Prihvaćen: ABSTRACT Orbital infections most frequently occur in the form of bacterial complications of the paranasal sinus inflammation. In adult patients with inflammatory sinus illness approximately 3 5% are subject to the occurrence and development of orbital complications, while with the percentage averages between 0.5 8%. By means of retrospective observation a group of 32 patients treated at the Otorhinolaryngological Clinic, Clinical Center, Kragujevac, within the period from 1990 to 2002, was subject of our analysis. The group of 32 patients with orbital complications of rhinosinus origin consisted of 18 (56.25%) and 14 (43.75%). Inflammatory processes in the orbit of rhinosinus origin most commonly occur between 7 and 15 years of age. With the most common complication was orbital cellulitis (n=10/18), while with the it was the retrobulbar neuritis (n=8/14). Orbital complications with in 88.89% of the cases were resulted to their acute sinusitis, while chronic sinusitis preceded complications with the total of the adult patients. There were differences in the clinical picture with and. With fifteen (83.33%), out of the total of 18, the X-ray find was a homogeneous intensive shadowing. Streptococcus pneumoniae (n=10/12) bacteria was most frequently isolated with the using the middle nasal corridor swab, while with it was Moraxella catarrhalis in 8 cases (47.06%). If in the course of 48 hours of conservative otorhinolaryngological treatment no signs of the clinical improvement were observed, surgical treatment would be applied. Complications prevention is based on an adequate and opportune acute sinusitis treatment with, as well as chronic process rehabilitation (allergies, polyp, cysts) with. Key words: sinusitis, complications, orbital diseases SAŽETAK Orbitalne infekcije se najčešće javljaju kao bakterijska komplikacija zapaljenja paranazalnih sinusa. Prosečno kod 3 5% odraslih bolesnika sa zapaljenjskim oboljenjem sinusa, mogu se razviti komplikacije u orbiti, dok se kod dece taj procenat kreće od 0.5 8%. Retrospektivnim praćenjem obuhvaćena je grupa od 32 pacijenta lečenih na Klinici za uvo, grlo i nos, Kliničkog centra u Kragujevcu, u periodu od 1990 do godine. Grupu od 32 pacijenta sa orbitalnim komplikacijama rinosinusnog porekla činilo je 18-oro dece (56.25%) i 14 oro odraslih (43.75%). Zapaljenski procesi u orbiti rinosinusnog porekla javljaju se najčešće u uzrastu od 7 do 15 godina. U dečijem uzrastu najčešća komplikacija bio je celulitis orbite (n=10/18), dok je kod odraslih to bio retrobulbarni neuritis (n=8/14). U dece orbitalne komplikacije bile su u 88,89 % (n= 6/18) posledica akutnih sinuzitisa, dok su hronični sinuzitisi prethodili komplikacijama kod svih odraslih pacijenata. Postoje razlike u kliničkoj slici kod dece i odraslih. Kod petnaestoro (83.33%), od ukupno 18-oro dece, nalaz na RTG bio je homogeno intenzivno zasenčenje. Iz brisa srednjeg nosnog hodnika u odraslih najčešće izolovana bakterija je bila Streptococcus pneumoniae (n=10/12), dok je kod dece to bila Moraxella catarrhalis u 8 slučajeva (47.06 %). Ukoliko se u toku 48 h konzervativnog lečenja ne uoče znaci poboljšanja kliničkog otorinolaringološkog nalaza, pristupa se hirurškom lečenju. Prevencija komplikacija zasnovana je na adekvatnom i pravovremenom lečenjenju akutnih sinusitisa kod dece, kao i saniranju hroničnih procesa (alergija, polipi, ciste) kod odraslih. Ključne reči : sinuzitis, komplikacije, bolesti orbite INTRODUCTION Orbital infections most frequently occur in the form of bacterial complications with the inflamed paranasal sinuses, though certain other etiological factors such as injuries, foreign body penetration, bacteremia or skin infection should be taken into consideration as well (1). According to Friedman bacterial infections of the orbit caused by paranasal sinus inflammation occur with approximately 75% of the patients (2). Orbital complications of rhinosinus inflammatory origin occur due to inflammatory process progression towards periost, thereof towards the orbital tissue and the tissue of the eye itself or due to mucous membrane trombophlebitis and paranasal sinuses and orbitare. They are most frequently formed peracutely thus requiring urgent diagnostics and polyvalent treatment approach. It is widely accepted that, even in the era of antibiotic treatment, there is a probability of orbital complications with the patients with inflammatory sinus illness averaging between 3 5%, while with the percentage averages between 0,5 8% (3-5). Orbital complications of rhinosinus orbital origin belong to the group of exocranial complications (3, 6, 7). We categorize them as following: Periorbital (preseptal) Correspondence: Jasmina Stojanović Phone: Street: Miodraga Stefanovića No Kragujevac, Serbia 67 cellulitis is the early stage of orbital complications. It is characterized by a mild form of edema and the redness of the upper eye lid. Orbital periostitis presents inflammatory process limited to the orbit brim. Subperiostal abscess presents a pus collection localized below the periost. Orbital cellulitis occurs when inflammatory process penetrates the periost. With the progression of the process we may thereof assume orbital phlegmone, and if localization of the inflammatory process occurs as well, we assume orbital abscess. Retrobulbar neuritis is the inflammation localized in the optic nerve behind the bulbus. Upper orbital fissure syndrome occurs as a complication of the rear ethmoid cells inflammation or sphenoid sinus inflammation. PATIENTS AND METHODS This paper has been written with the aim of conducting the analysis of the clinical picture and inflammatory processes within the orbit of sinus origin with and. Retrospective observance was oriented towards a group of 32 patients who were subject to treatment at the Otorhinolaryngolocical Clinic, Clinical Center, Kragujevac, in the period from 1990 till 2002.

2 Medical history charts of 32 patients with diagnosed orbital complications of rhinosinus origin were used. The overall clinical material has been analyzed by applying objective mathematical and statistical methods. RESULTS The group of 32 patients with orbital complications of rhinosinus origin was comprised of 18 (56.25%) and 14 (43.75%) (figure 1). Inflammatory processes in the orbit of rhinosinus origin most frequently occur in the period between 7 and 15 years of age (43.75%), while in the oldest age group (46 55 years) the latter were diagnosed in none of the cases (table 1). Table 1. Distribution of the patients according to age. Age Patient number % , , , , , total The sample of 32 patients with orbital complications consisted of rhinosinus origin of 18 (56.25%) and 14 (43.75%) (figure 1). 44% 56% Figure 1. Illness tendency ratio with and. Inflammatory processes in the orbit of rhinosinus origin most frequently occur in the period between 7 and 15 years of age, while in the oldest group (46 55 years of age) none of the patients suffered from these complications. Distribution of orbital complications in relation to the gender bears neither statistically significant diversities nor season characteristics. With the most common complication occurring was orbital cellulitis (n=10/18), while with it was the case of retrobulbar neuritis (n=8/14) (table 2). Orbital complications of sinus origin that emanate from the maxillary sinus inflammation, and more commonly from the ethmoidal labyrinth inflammation, can be encountered with patients in the first year of life. These complications are characterized by extremely intense symptomatology and prograding clinical picture. Depending on the location and penetration depth of the infection, they can be manifested as orbital cellulites, orbital phlegmone, retrobulbar neuritis or subperiostal abscess (11). With the most common complication was orbital cellulites (n=10/18), while with it was the retrobulbar neuritis (n=8/14) (table 2). Table 2. Types of orbital complications. Preseptal cellulitis Orbital cellulitis Orbital phlegmone Retrobulbar neuritis Total Children Adults Total Orbital complications with were 88.89% (n=16/18) due to the acute sinusitis, while chronic sinusitis preceded the complications occurring with the total number of the adult patients (table 3). According to the data obtained from the personal anamnesis and based on the character of primary illness, patients were divided into two groups. The first group consisted of patients who had never suffered from sinusitis previous to the occurrence of orbital complications. 16 patients belonged to this group (48.5%), and all of them were not older than 15 years of age. The second group consisted of patients who had suffered from chronic sinusitis, and, in one of the stages of chronic inflammatory process exacerbation in paranasal sinuses, there occurred the manifestation of one of the forms of orbital complications. 17 patients belonged to this group (51.5%), 15 of which were and 2 of which were, aged 13 and 14 (table 3). Table 3. Acute and chronic sinusitis (exacerbation) ratio as the cause of orbital complications. Children Adults Total Acute sinusitis Chronic sinusitis Total Symptom s and complication s diversity between the and the is presented in the table 4. Table 4. Clinical picture and diagnostic parameters of orbital complications with and. Features Children (n) Adults (n) Anamneses Clinical findings High temperature... (13) Pain... (14) Both eye lids swelling onesidedly... ( 9) Anxiety...(11), Lacrimation... (2) Pain accompanied by the irradiation into the nasal root (Valeix points)... (8) Swelling and cheek redness (14) Edema and hyperemia of both eye lids one-sidedly (15) High temperature... (15) Vision deterioration... ( 9 ) Nasal secretion drip (12) Headache... (14) Pain accompanied by irradiation into the orbit. (Valeix points)...8) Edema and hyperemia of both eye lids one-sidedly (10) Puss secretion from middle nasal cavity... (12) Ptosis... (4) Limited bulbus mobility... (10) Leukocytes High (over )... (16) High (over )...(12) Sedimentation Rate / h Elevated... (8) elevated Highly elevated... (7) > 50/ h highly elevated X-ray findings Maxillary sinusitis and ethmoids Elevated... (7) Highly elevated... (6) Maxillary sinusitis and polysinusitis 68

3 While examining the clinical picture of synoorbital complications with and in this paper, a difference in symtomatology and form of orbital complication was observed (table 4). In the X-ray image we observed the homogeneous intensive shadow in 83.33% of the cases, while with the both homogeneous intensive and homogeneous non-intensive shadows were observed in the X-ray image. With fifteen (83.33%) out of the total of 18, the X-ray finding was the homogeneous intensive shadowing, the homogeneous non-intensive shadowing occurred with two patients, and the level shadow in the maxillary sinus with one patient. With 7 (50%) out of the total of 14 adult patients, there occurred the homogeneous intensive shadowing, while homogeneous non-intensive shadowing occurred with 6 patients, and the level-shadow in the frontal sinus with 1 patient (figure 2) Figure 2. Comparative analysis of shadow intensity on X-ray images of paranasal. In 29 cases out of the total of 32 patients (90%) the swab pathogen was isolated from the middle nasal corridor. The most frequently isolated bacteria with the were Streptococcus catarrhalis, 8 cases (47.06%), Hemophilus influence, 6 cases (35.29%) and Streptococcus pneumoniae, 3 cases (17.65%), respectively (figure 3) unhomogeneous homogeneous 0 pneumococus hemophilus moraxella Figure 3. Isolated bacteria in middle nasal corridor swab. With all of the patients pathogenic germs were isolated, monoflora was found in the middle nasal corridor swab whereby the most common pathogen was Streptococcus pneumoniae (13 patients), while Haemofilus influence and Moraxella catarrhalis were equally presented (8 patients each). With Moraxella catarrhalis was most frequently isolated bacterium (in 8 cases or 47.06%), then Haemofilus influence in 6 cases (35.29%), while with Streptococcus pneumoniae was by far the most frequently isolated one (in 10 cases or 83.33%) (figure 3). Isolated bacteria were significant in the antibiotic treatment with orbital complications approach. High percentage findings of Moraxella catarrhalis with was the probable cause for the complication occurrence (8/18), since Moraxella produces resistence towards beta lactam antibiotics (penicillin antibiotics and cephalosporine antibiotics). DISCUSSION Inflammatory processes in the orbit of rhinosinus origin, occur with somewhat different clinical picture with persons belonging to different age groups, as well as with altered courses of propagation and infection spreading from paranasal cavities depending on patient s age. Diversities encountered upon in clinical observations of the same complications which occur with and are based on overall and local physiopathological characteristics of patient s age, whereby it is to be noted that with the evolution of all paranasal sinuses is terminated. With the illness is of a peracute form, which is explained by the instability of humoral and cellular defense mechanism and poor resistance to viral and bacterial infections, so that the occurrence of synoorbital complications is usually preceded by some viral infection of upper respiratory tract, and orbital complications usually occur within the period of approximately 5 8 days after the acute sinusitis outset (3). With the occurrence of orbital complications is most frequently the consequence of chronic inflammatory process exacerbation in sinuses, or the latter were the consequence of recurrent acute sinusitis, and the inflammatory process progression is always direct and accompanied by bone wall microdestruction, whereas with the inflammatory process almost always spreads from sinuses to orbit veinally and lymphatically (8-10). Synoorbital complications with in 88.89% of the cases occured due to the acute sinusitis (n=16/18) (table 3), which concurs with scientific literature data. Complications were preceded by some of the viral infections: morbilli, influenza, viral infections of upper respiratory tract, as well as allergies. The occurrence of inflammatory process in the orbit with bore season characteristics, while with synoorbital complications were not seasonal (3, 10). Each of these complications was of a different degree and severity, but their common characteristic was highly uncertain prognosis. In making the diagnosis, close cooperation with ophthalmologists and pediatricians (with ) was established, which facilitated the most adequate treatment procedure. The basis for making the diagnosis was anamnesis, clinical picture, clinical otorhinolaryngological examination, biochemical blood test and X-ray occipitomental imaging of paranasal cavities. The number of affected sinuses was not in relation with the type of the complication, but it made the clinical picture more severe. Generally speaking (18), the 69

4 younger the child was, the more intense the clinical picture became. The overall state was more serious in than in. Febrility or high febrility was presented in all, and the inflammatory process was firstly manifested in nasalorbital corner, and then it was spread to lower or upper eye lid. The inflammatory process rapidly spreads from the orbit tissue to other eye structures (8). With adult patients (14) headache was the most frequent symptom. Localization of headache depended on the number of inflamed sinuses, as well as on the type of the inflamed sinus. With 12 patients a mixed type of headache was presented. Pain was presented in the nape region and in the inner corner of the eye with 8 patients suffering from retrobulbar neuritis, and with 4 patients suffering from orbital phlegmone in the forehead region and the inner corner of the eye. With 2 patients suffering from preseptal cellulites the pain was presented above the inflamed maxillary sinus. With all patients (32) X-ray occipitomental open-mouth scanning was conducted (Waters cliché), as well as tomography of maxillary sinus in certain cases. In the X-ray image we observed the homogenous intensive shadowing in 83.33% of the, while with the homogenous intensive and homogenous non-intensive shadowing were presented in equal ratio. With paranasal cavities walls were proportionately thicker when compared to their volume so it is possible to conclude that chronic inflammation was presented, mucous membrane of paranasal cavities with being significantly thicker than with, that is to say, the physiological hypertrophy of mucous membrane was developed. In order to be able to maintain with certainty that there exists the mucous membrane inflammation of the maxillary sinus, the mucous membrane thickness on the X-ray image should amount to at least 6 mm (so called unhomogenous edge shadowing), or that there exists the level shadow in the maxillary sinus or the shadowing of the latter (9). Paranasal cavities X-ray finding with due to the existence of physiological hypertrophy of the paranasal cavity mucous membrane, bears no clinical significance, thus representing a mere auxiliary diagnostic means in the orbital complications diagnostic algorithm of rhinosinus origin. Retrobulbar neuritis, in the material used, occurred as the most frequent complication; it was mostly brought about as the consequence of sphenoiditis and rear ethmoid cells inflammation. Since X-ray occipitomental image was insufficient, conducting of CT or MRI diagnostic was necessary. In contemporary approach with orbital complications of synonasal origin, it also necessary, besides the paranasal sinus status, to have in depth insight into the process spread within the orbit, where, unlike the rentgenography, CT and MRI provide us with precious data (12-19). Therapeutic approach with implies administering high dosage of antibiotics, corticosteroid treatment, local administering of decongestives, and with, if subjective and objective improvement did not occur within the course of the first hours after administering of high dosage of antibiotics, surgical approach in treating synoorbital complications is to be applied. In conclusion, orbital complications of rhinosinus inflammatory origin, although rare, occupy special place in otorhinolaryngology both from diagnostic and therapeutic aspect. They occur as the consequence of acute sinusitis with and chronic sinusitis exacerbation with. 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