Professional Documents
Culture Documents
39 (2006) 1037–1047
Endoscopic Management
of Orbital Abscesses
Samer Fakhri, MD, FRCSC*,
Kevin Pereira, MD, MS(ORL)
Department of Otolaryngology-Head and Neck Surgery, University of Texas Medical School
at Houston, 6410 Fannin Street, Suite 1200, Houston, TX 77030, USA
Clinical presentation
The clinical signs of a postseptal infection include chemosis, proptosis,
restriction of extraocular muscle movements, and, if untreated, progressive
visual loss, which may be temporary or permanent. Damage to vision is
caused by increased intraorbital pressure, optic neuritis, traction on the op-
tic nerve, or retinal artery thrombosis. Residual visual sequelae are more
* Corresponding author.
E-mail address: samer.fakhri@uth.tmc.edu (S. Fakhri).
0030-6665/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.otc.2006.06.001 oto.theclinics.com
1038 FAKHRI & PEREIRA
likely in patients who had a visual acuity of 20/60 or worse when treatment
was initiated or those who did not undergo, or had delayed, surgery [4].
Hence, the management of these patients requires close cooperation between
an otolaryngologist, ophthalmologist, and infectious disease specialist who
is aware of the resistance patterns of the causative organisms in the area.
The amount of information that can be obtained from an ophthalmologic
examination varies from very limited in a febrile 2-year-old who has chemo-
sis and proptosis, to detailed in a 14-year-old who has limited periorbital
edema. Two pediatric studies of medial subperiosteal abscesses (SPA) in
children reported that complete clinical examinations were possible in
57% and 62% of their subjects [5,6]. Diminished pupillary reflexes may
not be seen until significant visual loss has occurred [7]. Being able to distin-
guish colors may be used as a guide to disease progression. Increasing intra-
orbital pressure causes loss of red/green perception before visual acuity
deteriorates [1]. A recent study recommended visual acuity checks every
2 hours for 24 hours when awake, and every 4 hours when asleep. As clinical
signs improve, acuity checks may be decreased to every 4 hours [6]. The ease
of examination and certainty of objective clinical findings play a major role
in guiding management.
Radiologic evaluation
CT scanning is the diagnostic imaging modality of choice in the manage-
ment of patients who have postseptal complications of sinusitis. It is fast,
widely available, and allows accurate assessment of both soft tissue and
bony changes. In addition, it can be performed in children without the
need for sedation, especially when using the spiral CT technique. Imaging
may be repeated after 48 hours if the patient’s condition does not improve.
The paranasal sinuses and orbit present an area of highly contrasting den-
sities with air, fat, and soft tissue, which increases the accuracy of the exam-
ination. Axial and coronal views of the orbits and sinuses with contrast
should be obtained in both soft tissue and bone windows. Axial views better
demonstrate the displacement of the medial rectus muscle and the abscess
within the orbit, whereas coronals cuts are useful to delineate orbital and
sinus anatomy. A medial subperiosteal abscess is seen on CT scans as a
rim-enhancing mass within the orbit, next to the lamina papyracea displac-
ing the medial rectus laterally. Edema and thickening of the medial rectus
are also evident, when compared with the opposite side (Fig. 1). A recent
study used lateral displacement of the medial rectus muscle of at least
2 mm as a diagnostic criterion for a subperiosteal abscess [6]. Intraconal
involvement is not as well-defined and appears as a diffuse infiltration of
orbital fat with a lack of clear visualization of the optic nerve and extraoc-
ular muscles. However, CT scans have their limitations in the diagnosis of
sinonasal disease, especially in children. Mucosal changes tend to persist,
despite the resolution of clinical disease, with one study reporting incidental
ENDOSCOPIC MANAGEMENT OF ORBITAL ABSCESSES 1039
Fig. 1. Axial (A) and coronal (B) CT scans, soft tissue window with intravenous contrast, dem-
onstrating a right subperiosteal abscess. Note ipsilateral ethmoid (A,B) and maxillary sinus opa-
cification (B). Also note reactive thickening of the right medial rectus muscle.
soft tissue changes in up to 50% of subjects without sinus disease [8,9]. Ad-
ditionally, CT scans have been found to correlate with surgical findings in
only 84% of orbital complications of sinusitis, and can miss up to 50% of
IC complications [3,10]. Using contrast while scanning the sinuses and brain
enhances the ability to identify these complications.
MRI is the diagnostic study of choice for evaluating IC complications of
sinusitis including cavernous sinus thrombophlebitis. MRI is superior to CT
in identifying marrow space abnormalities such as edema or osteomyelitis,
inflammation of the meninges, extra-axial empyemas, and early cerebritis
[11]. It also provides superior soft tissue detail and does not expose the
patient to radiation. However, an MRI study takes a lot longer than CT
scanning, is sensitive to motion artifact, requires general anesthesia in youn-
ger children and sedation in older children. In patients who have orbital
complications of sinusitis, MRI should be performed if fever recurs after
an appropriate initial response to the antibiotic; if there are changes in
the patient’s mental status; or when CT findings suggest, but cannot con-
firm, IC spread of disease. Standardized orbital ultrasound has also been
used in the diagnosis of intraocular pathology. It has the advantage of
low cost and no radiation, and may be repeated at short intervals. It can
be done at the bedside, and may be useful in monitoring the progress of
an orbital infection. Its main disadvantage is its inability to detect a suppu-
rative process in the posterior orbit [12].
Preoperative planning
A number of factors must be evaluated thoroughly, once the decision is
made to proceed with drainage of a subperiosteal or intraorbital abscess.
Clear communication between the ophthalmologist and the otolaryngologist
(ENT) surgeon regarding the results of serial ophthalmologic examinations
and their significance is critical and often time-sensitive. All relevant param-
eters of the ophthalmologic evaluation should be discussed, including status
of the optic nerve and extraocular muscles, degree of proptosis, and orbital
pressures. This information is crucial to planning both the timing and extent
of the surgical intervention. For example, in a patient who has an intraorbi-
tal abscess and high orbital pressures, the surgeon must be prepared to
perform a wide orbital wall decompression, in addition to incising the
ENDOSCOPIC MANAGEMENT OF ORBITAL ABSCESSES 1041
periorbita and draining the abscess. In this case, failure to recognize the high
orbital pressures or to decompress the orbit may result in persistently ele-
vated pressures and, ultimately, an unfavorable outcome. The intraopera-
tive availability of an ophthalmology colleague is extremely helpful and,
in fact, encouraged, especially when dealing with an intraorbital abscess.
Careful preoperative review of the CT scan in both the coronal and axial
planes is imperative, and provides a road map for the surgical procedure.
Most SPAs are located medially within the orbit, but many could extend
superiorly or inferiorly, especially when associated with frontal and maxil-
lary sinusitis, respectively. The surgeon should study carefully the bony
anatomy of the sinonasal cavity and the skull base to recognize variant con-
figurations and minimize intraoperative complications.
Objectives
The objectives of the surgical management of a subperiosteal or intraor-
bital abscess include draining the orbital collection, addressing the offending
sinuses, and obtaining intraoperative cultures. In addition, decompression
of one or more orbital walls may be necessary if intraoperative orbital pres-
sures continue to be elevated, despite an adequate drainage procedure.
Additional steps
Postoperative care
In adults, postoperative care is performed as in routine sinus surgery.
Patients are instructed to perform twice-daily nasal saline irrigations. Endo-
scopic debridement is performed after 1 week, to remove debris and crusts,
Fig. 2. Endoscopic view of a left extraconal intraorbital abscess that was drained using the
transnasal endoscopic approach. The lamina papyracea (white arrow) has been widely decom-
pressed. The periorbita (black arrow) has been incised to expose and drain an extensive intra-
orbital collection (þ).
ENDOSCOPIC MANAGEMENT OF ORBITAL ABSCESSES 1045
errors may not be recognized by the unsuspecting surgeon unless the accu-
racy of the system is confirmed periodically against known anatomic land-
marks. Failure to recognize these errors may place the patient at risk for
devastating complications.
The guidelines for using CAS technology remain general, reflecting the
absence of consensus on whether CAS is considered standard of care. The
American Academy of Otolaryngology–Head and Neck Surgery [20] has
the following policy statement regarding the intraoperative use of CAS:
The American Academy of Otolaryngology – Head and Neck Surgery en-
dorses the intraoperative use of computer-aided surgery in appropriately
select cases to assist the surgeon in clarifying complex anatomy during sinus
and skull base surgery. examples of indications in which use of computer-
aided surgery may be deemed appropriate include.disease abutting the
skull base, orbit, optic nerve or carotid artery.
Because of the difficulty of obtaining evidence to support the role of CAS,
the merit of this technology in the surgical management of orbital abscesses
is currently based on surgeon preference and expert consensus opinion.
Compounding the problem is the recent move of some insurance providers
to label CAS as experimental, and therefore deny reimbursement for the use
of this technology.
Summary
Optimal management of orbital abscesses requires a multidisciplinary ap-
proach. Surgical management is indicated in most cases where orbital collec-
tions are present. Clear communication between the ophthalmologist and
the ENT surgeon is critical to guide the timing and extent of the surgical in-
tervention. The endoscopic approach to the medial orbit offers significant
advantages over the traditional external approach, but may have some lim-
itations in an acutely inflamed and bloody surgical field. The preoperative
and intraoperative use of CAS technology may be a useful adjunct in the
endoscopic management of orbital abscesses.
References
[1] Osguthorpe JD, Hochman M. Inflammatory sinus diseases affecting the orbit. Otolaryngol
Clin N Am 1993;26:657–71.
[2] Herrmann BW, Forsen JW. Simultaneous intracranial and orbital complications of acute
rhinosinusitis in children. Int J Pediatr Otorhinolaryngol 2004;68:619–25.
[3] Nathoo N, Nadvi SS, van Dellen JR, et al. Intracranial sybdural empyemas in the era of
computed tomography: a review of 699 cases. Neurosurgery 1999;44:529–36.
[4] Schramm V, Curtin H, Kenneerdell JS. Evaluation of orbital cellulites and results of treat-
ment. Laryngoscope 1982;92:723–38.
[5] Pereira KD, Mitchell RB, Younis RT, et al. Management of medial subperiosteal abscess of
the orbit in children – a 5 year experience. Int J Pediatr Otorhinolaryngol 1997;38:247.
ENDOSCOPIC MANAGEMENT OF ORBITAL ABSCESSES 1047
[6] Brown CL, Graham SM, Griffin MC, et al. Pediatric medial subperiosteal orbital abscess:
medical management where possible. Am J Rhinol 2004;18:321–7.
[7] Patt BS, Manning SC. Blindness resulting from orbital complications of sinusitis. Otolar-
yngol Head Neck Surg 1991;104:789–95.
[8] Vazquez E, Creixell S, Carreno JC, et al. Complicated acute pediatric bacterial sinusitis: im-
aging updated approach. Curr Probl Diagn Radiol 2004;33:127–45.
[9] Glasier CM, Ascher DP, Williams KD. Incidental paranasal sinus abnormalities on CT of
children: clinical correlation. AJNR Am J Neuroradiol 1986;7:861–4.
[10] Clary RA, Cunningham MJ, Eavy RD. Orbital complications of acute sinusitis: comparison
of computed tomography and surgical findings. Ann Otol Rhinol Laryngol 1992;101:
598–600.
[11] Kronemer KA, McAlister WH. Sinusitis and its imaging in the pediatric population. Pediatr
Radiol 1997;27:837–46.
[12] Kaplan DM, Briscoe D, Gatot A, et al. The use of standardized orbital ultrasound in the di-
agnosis of sinus induced infections of the orbit in children: a preliminary report. Int J Pediatr
Otorhinolaryngol 1999;48:155–62.
[13] Rahbar R, Robson CD, Petersen RA, et al. Management of orbital subperiosteal abscess in
children. Arch Otolaryngol Head Neck Surg 2001;127:281–6.
[14] Garcia GH, Harris GJ. Criteria for nonsurgical management of subperiosteal abscess of the
orbit: analysis of outcomes 1988–1998. Ophthalmology 2000;107:1454–6.
[15] Manning SC. Endoscopic management of medial subperiosteal orbital abscess. Arch Otolar-
yngol Head Neck Surg 1993;119(7):789–91.
[16] Arjmand EM, Lusk RP, Muntz HR. Pediatric sinusitis and subperiosteal orbital abscess
formation: diagnosis and treatment. Otolaryngol Head Neck Surg 1993;109(5):886–94.
[17] Page EL, Wiatrak BJ. Endoscopic vs external drainage of orbital subperiosteal abscess. Arch
Otolaryngol Head Neck Surg 1996;122(7):737–40.
[18] Froehlich P, Pransky SM, Fontaine P, et al. Minimal endoscopic approach to subperiosteal
orbital abscess. Arch Otolaryngol Head Neck Surg 1997;123(3):280–2.
[19] White JB, Parikh SR. Early experience with image guidance in endoscopic transnasal drain-
age of periorbital abscesses. J Otolaryngol 2005;34(1):63–5.
[20] American Academy of Otolaryngology–Head and Neck Surgery. Intra-operative use of
computer aided surgery. Available at: http://www.entlink.net/practice/rules/image-guiding.
cfm. Accessed February 27, 2006.