Orbital Cellulitis as a Complication of Acute Rhinosinusitis

Fareed Ahmed

Introduction

Orbital Cellulitis is an uncommon infection involving structures both anterior to the orbital septum, and more importantly structures posterior to the septum. In the current antimicrobial era, most cases of orbital cellulitis can be management medically and complicated cases of infection are uncommon; however surgical management of infection is sometimes needed. The most common cause of orbital cellulitis is secondary to acute rhinosinusitis, however it can also arise due to direct injury, spread from facial/odontogenic infection and rarely haematogenous spread form distant sources (1). Rhinosinusitis is a term used to describe symptomatic inflammation of the mucosa of the nasal sinuses as well as the contiguous nasal passages. It is a common disorder which can affect all age groups, and is a disease which can greatly impair quality of life. Rhinosinusitis can be due to viral, bacterial and fungal infections, and is most commonly categorised as acute or chronic depending duration of symptoms.

Acute Rhinosinusitis and its relation to Orbital Cellulitis

Acute rhinosinusitis is commonly used to define rhinosinusitis with symptom duration of less than 4 weeks (2). It is primarily due to viral infection with pathogens such as rhinovirus, adenovirus, influenza virus and parainfluenza virus (3). The main symptoms experienced include facial pain/pressure, nasal obstruction, nasal discharge which may be purulent, postnasal drip, hyposmia/anosmia and fever.  Up to 90% of individuals with upper respiratory tract infections develop acute concurrent rhinosinusitis (3).  Acute viral sinusitis can uncommonly be complicated by superimposed bacterial infection (suspected if symptoms prolong or worsen after 7 days of onset), with pathogens such as Streptococcus pneumonia, Haemophilus Influenzae and Moraxella Catarrhalis (3). Chronic rhinosinusitis is defined by symptom duration of over 12 weeks, and can be further categorised into chronic rhinosinusitis with polyps (CRSwNP) and without polyps (CRSsNP) (3). Acute rhinosinusitis can be secondary to chronic rhinosinusitis.

Acute Rhinosinusitis is a self-limiting condition, however when bacterial infection is present it can lead to orbital and intracranial complications. These complications arise due to the close anatomical relation of the paranasal sinuses, the orbit, and the skull base. The paranasal sinuses are paired, and include the maxillary, frontal, ethmoid and sphenoid sinuses; their functions include lightening the weight of the head, humidifying inhaled air, and increasing resonance of speech (4). The ethmoid and maxillary sinuses develop early in childhood, and the frontal (age 5) and sphenoid (age 6) sinuses developing later (4). In terms of communication between the paranasal sinuses and the orbit, the lamina papyracea (a component of the ethmoid bone) forms the medial wall of the orbit, whilst forming the lateral wall of the ethmoid sinus. Infection can spread from the sinuses via dehiscence in the lamina papyracea, or via haematological spread through the ophthalmic vein system (4). 

Orbital Cellulitis – Classification, Signs and Symptoms

Orbital complications of rhinosinusitis were first classified in the 1970s by Chandler et al, with 5 groups of orbital cellulitis described all of which follow a progression of infection (5). The groups can be differentiated by their signs and symptoms, and also radiologically via contrast enhanced CT of the sinuses and Orbit (6). Chandler Group 1 includes pre-septal cellulitis which presents with clinical findings of eyelid oedema, erythema and tenderness, and with normal ocular movements and visual acuity. Group 2 includes orbital/post-septal cellulitis which presents with prior mentioned findings as well as conjunctival chemosis and variable degrees of proptosis. Group 3 patients have a subperiosteal abscess, which presents with proptosis and impaired ocular movements. Group 4 patients have an orbital abscess or collection, which presents with significant exophthalmos, chemosis, ophthalmoplegia and visual impairment. Group 5 patients develop cavernous sinus thrombosis which manifest with bilateral orbital pain, chemosis, proptosis and visual impairment (5).

Management

Management of orbital cellulitis as a complication of acute rhinosinusitis includes medical management with nasal decongestants and steroids, along with oral or intravenous antibiotics depending on stage. Antimicrobial therapy should be broad spectrum, and aims to target previously mentioned pathogens commonly associated with acute rhinosinusitis. Contrast enhanced CT Sinuses and Orbit imaging should be conducted for patients who are clinically unwell/not improving, and those who have progressed into chandler stage 2 and beyond (6). Contrast enhanced MRI imaging remains the modality of choice when suspecting intracranial complications (6). The majority of patients with orbital cellulitis groups 1 and 2 can be treated with medical management alone, with surgical options reserved for those systemically unwell, failing to improve, or those with reduced visual acuity and significant ophthalmic impairment (groups 3 to 5) (6).  Surgical intervention to drain infection can be via endoscopic sinonasal approach, via a multitude of direct orbital approaches such as the medial orbitotomy (lynch incision), or via a combined approach (7).

Conclusion

In conclusion, the majority of cases of orbital cellulitis are secondary to acute bacterial rhinosinusitis; this is due to the close relation of the paranasal sinuses and the orbit. Orbital cellulitis should be suspected in individuals with symptoms of rhinosinusitis along with eye involvement. Orbital cellulitis can be classified via chandlers’ classification, with distinct clinical and radiological features separating groups 1 to (5). Contrast enhanced CT Sinuses and Orbit is the imaging modality of choice for these patients. Most cases of orbital cellulitis secondary to acute rhinosinusitis can be medically managed, however in select cases surgical management may be required which requires joint ENT and ophthalmology input. 

References

  1. Ferguson MP, Fraco AA. Current treatment and outcome in Orbital cellulitis. Australian and New Zealand Journal of Ophthalmology. 1999;27(6):375–9. doi:10.1046/j.1440-1606.1999.00242.x
  2. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, Brook I, Ashok Kumar K, Kramper M, et al. Clinical practice guideline (update): Adult sinusitis. Otolaryngology–Head and Neck Surgery. 2015;152(S2). doi:10.1177/0194599815572097
  3. Rosenfeld RM. Acute sinusitis in adults. New England Journal of Medicine. 2016;375(10):962–70. doi:10.1056/nejmcp1601749
  4. Lee S, Fernandez J, Mirjalili SA, Kirkpatrick J. Pediatric paranasal sinuses—development, growth, pathology, & functional endoscopic sinus surgery. Clinical Anatomy. 2022;35(6):745–61. doi:10.1002/ca.23888
  5. Wong SJ, Levi J. Management of Pediatric Orbital Cellulitis: A systematic review. International Journal of Pediatric Otorhinolaryngology. 2018;110:123–9. doi:10.1016/j.ijporl.2018.05.006
  6. Dankbaar JW, van Bemmel AJ, Pameijer FA. Imaging findings of the orbital and intracranial complications of acute bacterial rhinosinusitis. Insights into Imaging. 2015;6(5):509–18. doi:10.1007/s13244-015-0424-y
  7. Abussuud Z, Ahmed S, Paluzzi A. Surgical approaches to the orbit: A neurosurgical perspective. Journal of Neurological Surgery Part B: Skull Base. 2020;81(04):385–408. doi:10.1055/s-0040-1713941

Leave a Reply