10.14639/0392-100X-suppl.1-41-2021-11
Orbital infection complicating sinonasal inflammatory disorders may lead to serious sequelae, including blindness and death, if untreated. Communication between the otorhinolaryngologist, neuroradiologist, ophtalmologist, neurosurgeon and maxillo-facial surgeon is critical and time-sensitive for a successful treatment. The large majority of pre-septal cellulitis cases resolves after broad-spectrum antibiotic therapy. Also orbital cellulitis has been found responsive to pharmacological approach in most cases. The management of the subperiosteal abscess (SPA) is more controversial. An aggressive surgical approach is always recommended also in case of cavernous sinus thrombosis. In cases of surgical indication, debate is still open on the timing and the approach (endoscopic or external). The surgeon should be prepared to convert an endoscopic approach to an external one if needed and this should be included in the informed consent. Decompression of one or more orbital walls may be necessary if orbital pressure remains elevated. Immediate surgery is indicated in children with large SPA or orbital abscesses (OA), or in immune-compromised patients. Moreover, any worsening in the ophthalmological function must be carefully considered as a landmark in candidacy to surgery.
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en
Matteo Alicandri-Ciufelli
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ACTA Otorhinolaryngologica Italica
orbital cellulitis
Surgical multidisciplinary approach of orbital complications of sinonasal inflammatory disorders
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Matteo Alicandri-Ciufelli
2021/05/14
10.14639/0392-100X-suppl.1-41-2021-11
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Otolaryngology, Head and Neck Surgery Department, Policlinico di Modena, University of Modena and Reggio Emilia, Italy
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orbital cellulitis
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Surgical multidisciplinary approach of orbital complications of sinonasal inflammatory disorders
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ACTA OTORHINOLARYNGOLOGICA ITALICA 2021;41(SUPPL.1):S108-S115; doi: 10.14639/0392-100X-suppl.1-41-2021-11




Surgical multidisciplinary approach of orbital
complications of sinonasal inflammatory disorders
Approccio chirurgico multidisciplinare nel management delle complicanze orbitarie
delle patologie infiammatorie naso-sinusali
Livio Presutti1, Daniela Lucidi1, Federico Spagnolo1, Giulia Molinari1, Silvia Piccinini2, Matteo Alicandri-Ciufelli1
1
    Otolaryngology, Head and Neck Surgery Department, Policlinico di Modena, University of Modena and Reggio Emilia, Italy;
2
    Neuroradiology Department, Nuovo Ospedale Civile Sant’Agostino Estense, Modena, Italy


SUMMARY
Orbital infection complicating sinonasal inflammatory disorders may lead to serious seque-
lae, including blindness and death, if untreated. Communication between the otorhinolaryn-
gologist, neuroradiologist, ophtalmologist, neurosurgeon and maxillo-facial surgeon is crit-
ical and time-sensitive for a successful treatment. The large majority of pre-septal cellulitis
cases resolves after broad-spectrum antibiotic therapy. Also orbital cellulitis has been found
responsive to pharmacological approach in most cases. The management of the subperiosteal
abscess (SPA) is more controversial. An aggressive surgical approach is always recommended
also in case of cavernous sinus thrombosis. In cases of surgical indication, debate is still
open on the timing and the approach (endoscopic or external). The surgeon should be pre-
pared to convert an endoscopic approach to an external one if needed and this should be
included in the informed consent. Decompression of one or more orbital walls may be               Received: November 12, 2020
necessary if orbital pressure remains elevated. Immediate surgery is indicated in children        Accepted: February 9, 2021
with large SPA or orbital abscesses (OA), or in immune-compromised patients. Moreover,
any worsening in the ophthalmological function must be carefully considered as a landmark         Correspondence
in candidacy to surgery.                                                                          Daniela Lucidi
                                                                                                  Otolaryngology, Head and Neck Surgery De-
KEY WORDS: sinusitis, orbit, Chandler’s classification, orbital abscess, orbital cellulitis
                                                                                                  partment, Policlinico di Modena, University of
                                                                                                  Modena and Reggio Emilia
RIASSUNTO                                                                                         largo del Pozzo 71, 41125 Modena, Italy
L’infezione orbitaria come complicanza di una patologia infiammatoria nasosinusale può            E-mail: dani.lucidi@gmail.com
portare a gravi sequele, incluse cecità e morte, se non trattata. La comunicazione tempe-
stiva e diretta tra l’otorinolaringoiatra, il neuroradiologo, l’oculista, il neurochirurgo e      Funding
il chirurgo maxillo-facciale è fondamentale per garantire un trattamento di successo. Le          None.
celluliti pre-settali si risolvono con terapia antibiotica ad ampio spettro. Anche la cellulite
orbitaria è responsiva al trattamento farmacologico nella maggior parte dei casi. Il ma-          Conflict of interest
                                                                                                  The Authors declare no conflict of interest.
nagement dell’ascesso subperiosteo (SPA) è invece controverso. Un approccio chirurgico
aggressivo è sempre consigliato in caso di trombosi del seno cavernoso. Il timing e il tipo
di approccio (endoscopico o esterno) sono oggetto di dibattito nella scelta chirurgica. Il          How to cite this article: Presutti L, Lucidi D,
chirurgo dovrebbe essere preparato a convertire un approccio endoscopico in uno esterno,            Spagnolo F, et al. Surgical multidisciplinary
se necessario. La decompressione di una o più pareti orbitarie può essere necessaria se la          approach of orbital complications of sinonasal
pressione rimane elevata. La chirurgia è immediata nei bambini con SPA o ascesso orbita-            inflammatory disorders. Acta Otorhinolaryngol
rio di grandi dimensioni o in pazienti immunocompromessi. Un eventuale peggioramento                Ital 2021;41(SUPPL.1):S108-S115. https://doi.
                                                                                                    org/10.14639/0392-100X-suppl.1-41-2021-11
della funzione oftalmologica deve essere attentamente considerato come un fattore depo-
nente per un trattamento chirurgico.
                                                                                                  © Società Italiana di Otorinolaringoiatria
PAROLE CHIAVE: sinusite, orbita, classificazione di Chandler, ascesso orbitario, cellulite        e Chirurgia Cervico-Facciale
orbitaria
                                                                                                                 OPEN ACCESS

                                                                                                  This is an open access article distributed in accordance with
                                                                                                  the CC-BY-NC-ND (Creative Commons Attribution-Non-
Introduction                                                                                      Commercial-NoDerivatives 4.0 International) license. The
                                                                                                  article can be used by giving appropriate credit and mentio-
                                                                                                  ning the license, but only for non-commercial purposes and
Despite differential diagnosis of orbital infection is broad, sinonasal inflam-                   only in the original version. For further information: https://
matory disorders are responsible for around 75% of cases. Being surrounded                        creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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                                                                                                       Multidisciplinary approach of rhinogenic orbital complications




by sinuses on three sides, the orbit is susceptible to contigu-                        surface of the frontal bone and the lesser wing of the sphe-
ous spread of infection, and notwithstanding the decreased                             noid. On this “roof”, two depressions are clearly visible:
incidence of this event in the antibiotic era, orbital infection                       the trochlear fossa and the supraorbital foramen, through
without appropriate treatment may lead to serious sequelae,                            which pass the homonymous vessels and nerve. The infe-
including blindness and death 1.                                                       rior wall, which hosts the infraorbital canal, separates the
Chandler’s classification distinguishes orbital complications                          orbital cavity from the maxillary sinus. The apex represents
according to the extent of infection into the orbital content                          the communication between the orbit and the middle cra-
and the surrounding structures 2. Diagnostic work-up should                            nial fossa, and is in close relationship with the lateral wall
include prompt radiological investigation, CT scan and MRI                             of the sphenoid sinus. It hosts the ophthalmic artery and
playing a complementary role in this setting 1.                                        vein, the optic and oculomotor nerves. The lamina papyra-
A crucial point in the treatment of orbital complications is                           cea (LP) of the ethmoidal bone represents the medial wall,
whether to choose a conservative or non-conservative (sur-                             and marks the bound between the orbital cavity laterally
gical) protocol. In cases of surgical indication, debate is still                      and nasal cavity medially, representing one of the most im-
open on the timing and the approach (open or endoscopic).                              portant landmarks in functional endoscopic sinus surgery 3.
Overall, clear communication between the otorhinolaryn-                                Further details regarding the anatomic relationship between
gologist, neuroradiologist, ophtalmologist, neurosurgeon                               the orbit and the sinonasal cavity are depicted in Figure 1.
and maxillo-facial surgeon is critical and time-sensitive,
both in treatment planning and performance.                                            Physiopathology
A review of the literature was performed to thoroughly in-
vestigate on orbital complications of sinonasal inflamma-                              Local complications of sinusitis could be orbital, intrac-
tory disorders, in particular to assess which are the indi-                            ranial and osseous. The orbit is susceptible to contigu-
cations to surgical treatment and when a multidisciplinary                             ous spread of infection as it is surrounded by sinuses on
approach is recommended or optional in the management                                  three sides. This is more relevant in children, because of
of such complications.                                                                 their thinner bony septa and sinus wall, greater porosity of
                                                                                       bones, open suture lines, and larger vascular foramina.
                                                                                       Indeed, infections can spread directly by penetration of the LP
Anatomy                                                                                through its small bony dehiscence or extend directly by tra-
The orbital cavity has a pyramidal shape with four walls                               versing through the anterior and posterior ethmoidal foramina.
and an apex. The superior wall is made up by the inferior                              Since the ophthalmic venous system has no valves (Brechet’s




                                       SOM: superior oblique muscle; MRM: medial rectus muscle;
                                       IOM: inferior oblique muscle; NLD: nasolacrimal duct; MS: maxillary sinus

Figure 1. Lamina papyracea (LP) and its relationship with the orbital content (drawing realised by Elisa Aggazzotti Cavazza).



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L. Presutti et al.




veins), the extensive venous and lymphatic communication            Table I. Chandler’s classification.
between the sinuses and the surrounding structures enables           I                                  Preseptal cellulitis
retrograde thrombophlebitis. This is caused by an increase in        II                                  Orbital cellulitis
pressure, due to the inflammation, that reverts the venous flow,     III                             Subperiosteal abscess
which normally goes towards to the sinus. Although frontal si-       IV                                  Orbital abscess
nusitis alone rarely causes orbital complications, communica-        V                            Cavernous sinus thrombosis
tion from the frontal sinus to the orbit may occur in three sites
of dehiscence in the frontal bone: behind the trochlear fossa,
                                                                    tion of pus. This rare condition occurs when OC diagnosis
behind the supraorbital notch and at the junction of the middle
                                                                    is delayed or in immunocompromised patients.
and outer thirds of the sinus floor 2,4.
                                                                    Cavernous sinus thrombosis (CST) results from the direct
Differential diagnosis of orbital involvement includes bac-
                                                                    retrograde spread of infection from nasal cavities (sphe-
teremia, facial infections, trauma, iatrogenic causes, tu-
                                                                    noid > ethmoid > frontal) through the superior and inferior
mors and dacryocystitis. However, sinusitis is responsible
                                                                    ophthalmic veins, or also as an OC complication.
for a least 75% of cases 1.
                                                                    In a large review on 465 pediatric patients with orbital com-
                                                                    plications, nearly 50% had PC, 35% had OC, 15% had SPA
Orbital complications                                               and fewer than 1% had an OA 6. This illustrates that in the
Orbital involvement is typically a complication of acute rhi-       antibiotic era, PC is the most common orbital complication
nosinusitis (ARS) and is associated, in order of decreasing         of ARS. The most commonly isolated organisms in chil-
frequency, with ethmoid, maxillary, frontal and sphenoid            dren are S. pneumoniae, H. influenzae, M. catarrhalis, and
sinus infection. Despite oral and intravenous antibiotics           S. aureus. The adult population differs in the polymicrobial
have decreased the incidence of this event, orbital infection       and anaerobic nature of the pathogens and in the most com-
                                                                    monly odontogenic origin of infection.
without appropriate treatment may lead to serious seque-
                                                                    Mucoceles of the paranasal sinuses represent another possible
lae, including blindness and death. Chandler’s classifica-
                                                                    inflammatory source of orbital complication. Mucoceles are
tion (Tab. I) distinguishes orbital complications according
                                                                    chronic cystic lesions, covered with columnar epithelium, that
to the extent of infection into the structures surrounding the
                                                                    grow within the cavity of the sinus. They originate as an ac-
orbit and the orbital content itself 2,3.
                                                                    cumulation of mucoid secretion and desquamated epithelium
Preseptal cellulitis (PC) describes an infection limited to
                                                                    inside the sinus with distension of its walls. The most frequent
the skin and subcutaneous tissues of the eyelid, anterior to
                                                                    cause is the obstruction of the sinus ostium due to inflamma-
the orbital septum. The orbital septum is a membranous
                                                                    tory processes, tumors or surgical interventions. The sinuses
sheet that fuses with the levator palpebrae on the upper eye-
                                                                    most commonly involved are the frontal, the ethmoid, the
lid and with the tarsal plate on the inferior eyelid. It is the
                                                                    maxillary and the sphenoid, in decreasing order 7,8.
most common and least severe complication, especially in
children, and results from impeded venous and lymphatic
drainage from the obstructed sinus.                                 Clinical features
Orbital (or post-septal) cellulitis (OC) is an infectious pro-      PC usually presents with eyelid swelling and erythema
cess that occurs within the orbit, behind the orbital septum,       without impaired visual acuity. Diagnosis relies on clinical
that occurs when an increase in sinus venous pressure is            inspection and CT scans.which are only used when symp-
transmitted to the orbital vasculature, resulting in transuda-      toms do not improve by 72 hours of antibiotic, since it is
tion and leakage through the vessel walls. The orbital con-         unusual for untreated PC to progress to OC.
tent shows diffuse edema, without abscess formation. Sub-           Clinical presentation of OC may include orbital pain, prop-
periosteal abscess (SPA) most commonly develops in the              tosis and ocular motility impairment, without visual acuity
medial orbit when an ethmoidal sinusitis breaks through             symptoms. In PC the local examination, which may evoke
the LP or travels through the ethmoidal foramina, and cre-          pain and be difficult due to swollen eyelids, does not show
ate a collection in the subperiosteal space. A SPA could            globe displacement, as opposed to OC and SPA.
expand rapidly and may lead to blindness by compromising            SPA is suspected when a patient with OC develops wors-
optic nerve function through several possible mechanisms:           ening proptosis and gaze restriction. The ability to distin-
direct optic nerve compression, elevation of intraorbital           guish colors may be used as a guide of disease progression
pressure, or proptosis.                                             because increasing intraorbital pressure causes loss of red/
Orbital abscesses (OA) may occur inside or outside the              green perception before deterioration of visual acuity.
muscle cone, when orbital cellulitis coalesces into a collec-       In children up to 9 years, SPA is likely to respond to antibi-



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                                                                                                Multidisciplinary approach of rhinogenic orbital complications




otic therapy, since it is usually due to a single aerobic path-                  Radiologic assessment
ogen. Also medial abscesses are highly amenable to antibi-
otic treatment, whereas more superiorly located abscesses                        CT scan and MRI represent the two complementary im-
(which tend to occur in older children) carry a greater risk                     aging modalities for the assessment of the orbital cavity.
of associated intracranial spread. Considering the lack of                       Radiological appearance according to Chandler’s classifi-
frontal sinus aeration in younger patients, especially pa-                       cation is depicted in Table II.
tients with frontal sinusitis are more prone to intracranial                     It is possible to encounter clinical conditions whose ra-
extension through the diploic veins, which run across the                        diological expressions overlap, especially when paranasal
orbit to the dural compartment.                                                  cavities do not seem involved. Differential radiological di-
OA may be clinically indistinguishable from OC. It may                           agnosis includes the whole spectrum of infiltrative inflam-
present with more severe proptosis, globe displacement,                          matory pathologies, such as pseudotumor and sarcoidosis,
and ophthalmoplegia related to inflammation of the oculo-                        especially as regards PC and OC. Not to forget is the meta-
motor muscles, and patients are more likely to appear toxic.                     static infiltration of the retrobulbar adipose tissue, such
Infection may extend to the orbital apex, causing decreased                      as in breast cancer, which clinically expresses itself with
visual acuity, or intracranially.                                                enophthalmos instead of exophthalmos. When the cavern-
CST is a potentially life-threatening complication; al-                          ous sinus is involved, Toulouse-Hunt syndrome must be
though in proximity to the orbit, it is de facto considered                      considered. Conversely, there are inflammatory diseases,
an intracranial complication. Even with rapid recognition                        such as fungal infections or mucoceles, whose radiologi-
and treatment, this condition may rapidly progress to loss                       cal expression can be expansive rather than infiltrative, thus
of vision, meningitis, and death. Intracranial involvement                       simulating the presence of a neoplasm. In post-traumatic
may present with oculomotor nerve palsies, mental status                         infectious processes, orbital hematomas could simulate a
changes, contralateral cranial nerve palsy, or bilateral orbit-                  mycetoma or abscess (both subperiostal and intra-orbital),
al cellulitis. Headache is the most common symptom and                           especially in the subacute phase.
generally precedes fever and periorbital signs.
                                                                                 Another inflammatory lesion with radiological behaviour
It is of paramount importance that facial pain is interpreted
                                                                                 similar to expansive lesions is the mucocele. This pathology
considering the main sinonasal inflammatory entities 9.
                                                                                 has the characteristics of a chronic process; therefore, local
Careful ophthalmologic and neurologic examination with
                                                                                 invasiveness predominates over diffusion in the perilesional
attention to the cranial nerves should be performed, as the
                                                                                 soft tissues. Its content consists of proteinaceous mucous
oculomotors nerves and the internal carotid artery could be
involved. Around 60-70% of patients with CST will have                           secretions, thus the cavity is completely obliterated, airless
an abnormal fundoscopic exam with papilledema or dilated                         and expanded, with remodelling of the bone based on dem-
retinal veins noted 10. Extension of phlebitis into the cav-                     ineralization rather than erosion. CT scan is the method of
ernous sinus results in a progression of the process to the                      choice; in MRI the T1 and T2 signal varies considerably,
opposite eye, a distinguishing feature of CST.                                   increasing the T1 hyperintensity and the T2 hypointensity
Mucoceles may have variable presentation: a sphenoidal                           in relation to the density of the secretions. In post-contrast
mucocele commonly presents with headache and visual                              images, the mucosal wall has a slight enhancement, which
loss, while in fronto-ethmoidal mucoceles, ophtalmic                             often becomes irregular if superinfection is present. Being a
symptoms are frequent (proptosis, diplopia, reduced ocular                       chronic process, the main radiological differential diagnoses
motility and epiphora). Maxillary mucoceles may present                          are indolent lesions such as inclusion cysts (dermoid/epi-
with enophtalmos and globe proptosis 7,8,10,11.                                  dermoid) or chronic post-traumatic hematomas (Figs. 2, 3).

Table II. Radiological features of the main orbital complications from sinonasal inflammatory disorders.
 Chandler scale                                                                             Radiologic characteristics
 Pre-septal cellulitis                                       Periorbital tissues swelling with paranasal sinuses involvement on CT. No contrast needed
 Orbital cellulitis                                      “Stranding” of the intraorbital adipose tissue both at CT and MRI; contrast needed to differentiate
                                                                                           edema from cellulitis and abscess
 Subperiosteal abscess                                   DWI restriction of extraconal collections on MRI. Possible association with retrobulbar cellulitis or
                                                                            involvement of extrinsic muscles or optic nerve. Contrast needed
 Orbital abscess                                                                 Same MRI features as SPA, but with intraconal location
 Cavernous sinus thrombosis                                   Bulging of the cavernous sinus with reduced contrast enhancement on both CT and MRI
DWI: Diffusion-weighted imaging.




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Management                                                                     pediatric population, some authors stated that surgery is not
                                                                               always the first choice. Garcia and Harris defined the crite-
In the treatment of orbital complications, a crucial point is
                                                                               ria for management of patients with SPA. They found a 93%
whether to choose a conservative or non-conservative protocol.
                                                                               response rate in medically managed selected patients (< 9
When planning the treatment, clear communication between
                                                                               years of age, with a medial, small SPA of nondental origin,
the otorhinolaryngologist, neuroradiologist, ophtalmologist,
neurosurgeon and maxillo-facial surgeon is critical and time-                  and without optic nerve impairment, gas in abscess space,
sensitive. Despite difficult in ill children with periorbital oede-            frontal sinusitis or chronic sinusitis) 12. Other authors have
ma, baseline eye examinations is critical: serial eye examina-                 sought to use medical therapy in all SPA patients without
tions should be completed by an experienced team member,                       preselecting surgical cases, demonstrating that only 26%
preferably the same individual, since the treatment choices                    could be managed without surgical intervention 13.
heavily relies on the validity of this examination.                            Clearly, there are patients in whom immediate surgery is
According to a systematic review focusing on orbital compli-                   indicated, such as child with large SPA or OA, marked
cations, consensus has been found in the PC management: the                    proptosis, multiple fields of restricted gaze, reduced visual
large majority of cases resolve after broad-spectrum antibiot-                 acuity, afferent papillary defect or immunocompromised
ic therapy. Also OC has been found responsive to pharmaco-                     status. At the present state, however, there is no consensus
logical approach in 77-100% of the pediatric population 10.                    on what ocular criteria predict the success of medical man-
The management of the SPA is more controversial. In the                        agement 13.




  A                                                 B                                                  C




 D                                                                            E



Figure 2. CT scan (A and B) and MRI (C) of a sphenoidal mucopyocele with bone erosion of optic foramen, lamina papyracea, orbital apex, carotid canal and
sella turcica. Intraoperative view of the mucopyocele sac before (D) and after (E) its endoscopic drainage.



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                                                                                                Multidisciplinary approach of rhinogenic orbital complications




  A                                                                            B

Figure 3. MRI (A) and CT scan (B) of left pansinusitis with orbital abscess.


Few studies in literature address management of OA, due
to its rarity nowadays. In general, prompt antibiotic therapy
in association with surgical drainage is mandatory. An ag-
gressive surgical approach is always recommended also in
case of CST, since neurological and vascular complications
can be lethal, while the role of anticoagulants and steroids
remains controversial. A proposal for a management algo-
rithm for pediatric patients with SPA or OA is presented in
Figure 4 14.

Surgical techniques
The aims of surgical management of orbital complications
include:                                                                           Figure 4. Management algorithm for pediatric patients with suspected sub-
• draining the purulent collection;                                                periosteal or orbital abscess. CT, computed tomography; SPA, subperiosteal
                                                                                   abscess (from Bedwell, Bauman, 2011 14, mod.).
• addressing the offending sinuses, enlarging their natural
   ostia;
• obtaining intraoperative cultures.                                               Historically, open drainage via Lynch incision, combined
Decompression of one or more orbital walls may be neces-
                                                                                   with external ethmoidectomy, was the preferred way for
sary if orbital pressure remains elevated despite drainage
                                                                                   draining SPA and OA.
procedure. Both endoscopic or external approaches may
                                                                                   In 1993, Manning reported a successful endoscopic ap-
be performed, with the surgeon weighing the advantages
and disadvantages of each approach. The surgeon should                             proach, consisting of ethmoidectomy, maxillary antrosto-
always be prepared to convert an endoscopic approach to                            my and limited opening of the LP 15.
an external one if needed and this eventuality should be                           Since then, numerous studies have confirmed the endo-
included in the informed consent. In particular, external ap-                      scopic approach as a well-tolerated and effective method
proaches could benefit from a multidisciplinary team, con-                         for management of medial SPA. The main limitation is
sisting of otorhinolaryngologist, ophthalmologist, maxillo-                        related to the bleeding potential of the inflamed mucosa,
facial surgeon, and neurosurgeon.                                                  which may seriously compromise visualization, especially



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L. Presutti et al.




in pediatric nose and even for experienced endoscopists.          sequelae, whereas the external group experienced facial
Meticulous dissection and identification of landmarks, pos-       scarring, delayed healing, stitch abscess, unresolved di-
sibly with the support of image navigation systems, should        plopia, or recurrent cellulitis. The authors recommended
be employed to prevent injury to noble structures.                exclusive use of endoscopic drainage for medial SPA with
The endoscopic procedure for SPA involves anterior and            an external approach reserved for drainage of superior
posterior ethmoidectomy associated with frontal sinusot-          OA 17. Another study by Yang and coworkers confirmed
omy and maxillary antrostomy, with the aim of exposing            that in cases of laterally seated SPA or when OC is associ-
the LP.                                                           ated with ophthalmoplegia or visual loss, decompression
After the uncinated process is removed and the ethmoidal          and drainage of the orbit should be performed with no
bulla is opened, the LP should be visualized and carefully        delay through an external approach 19. Gavriel et al. found
skeletonized with through-cutting instruments in prepara-         that location of abscess dictates the surgical approach:
tion for the abscess drainage. Sometimes pus can be seen          for more anterolateral collections, a combined approach
streaming from the orbit during ethmoidectomy, through            is indicated, while for posterior localization an endonasal
a natural dehiscence or a crack in the LP, especially when        approach is more suitable 19.
orbital pressure is elevated. Drainage of the pus may be          Many approaches are indicated to perform external
initiated by cracking the LP with a Cottle or freer elevator.     ethmoidectomy and/or anterior orbitotomy, although the
Access through the orbital medial wall may be allowed also        most common remains the Lynch incision. A 2.5-3 cm
by a diamond cutter, to reduce its thickness and facilitate       curvilinear incision is made midway between the medial
removal, reducing the risk of periorbita damage.                  canthus and nasion, under the eyebrow and anterior to the
It is advisable to preserve a few millimeters of LP ante-         lacrimal sac, taking care not to transect the supratrochlear
riorly (just posterior to the bony canal of the nasolacri-        and supraorbital nerves. A Z-plasty can be done to reduce
mal duct) to avoid injuring the trochlea of the ​​ trochlear      scar retraction. The angular artery is encountered deep in
muscle, while posteriorly the dissection should reach an          the incision and it is ligated. The orbit is lateralized, taking
imaginary line that corresponds to the sphenoethmoidal            care not to injure the periorbita, exposing the periosteum of
recess.                                                           the medial orbital wall. This is elevated and separated from
An incision of the periorbita is necessary to drain an OA.        the LP. It is important to identify the fronto-ethmoidal su-
This should be done using a sharp sickle knife, with the tip      ture line, which works as a landmark corresponding to the
of the knife remaining superficial; a horizontal incision is      level of the cribriform plate and the anterior and posterior
made from posterior to anterior, following a line between         ethmoidal foramina. Once the vessels are ligated, ethmoid-
the lower third and the middle third of the periorbita, to        ectomy is obtained by perforating the LP immediately be-
preserve the medial rectus muscle. The intraconal adipose         hind the posterior lacrimal crest, keeping below the fronto-
tissue is spread apart to ensure maximum drainage of the          ethmoidal suture; this ethmoidotomy provides direct access
abscess collection with immediate decrease in intraorbital        to the anterior ethmoid. Then ethmoidectomy is completed
pressure. In both operations, there is no need to reconstruct     by opening the floor of the ethmoid bulla directing posteri-
the orbital wall since it is soon replaced by a thick scar tis-   orly 21. In alternative, transconjunctival and transcaruncolar
sue. In a patient with high intraorbital pressure the surgeon     approaches have been described with excellent cosmetic
should be prepared to perform a wide orbital decompres-           outcomes, compared to the Lynch incision.
sion in addition to the endoscopic drainage.
Despite the widespread adoption of endoscopic tech-
niques, a role for open drainage remains. Occasionally,
                                                                  Conclusions
restrictive anatomy combined with florid inflammation             Although severe clinical evolutions are far less common in
may make endoscopic manipulation impossible. Tanna et             the post-antibiotic era, a worsening in the ophthalmologi-
al. in 2008 reported that 29% of patients who required            cal function must be carefully considered as a landmark
SPA surgical drainage underwent a combined open/en-               in candidacy to surgical drainage. Orbital complications of
doscopic approach, and a further 38% underwent open               sinonasal inflammatory disorders need a multidisciplinary
drainage only 16. Those who underwent an open approach            counselling involving ophtalmologists, maxillo-facial sur-
were more likely to have superolateral abscess, and dem-          geons and neuroradiologists (Tab. III).
onstrated more extensive muscle involvement than the en-          Imaging and interpretation by a dedicated neuroradiolo-
doscopic group. Also Migirov et al. examined 22 children          gist is advisable for a correct diagnostic work-up and ap-
with medial SPA subjected to endoscopic versus open               propriate surgical approach. When considering endoscopic
approach. The endoscopic group had no postoperative               versus external approaches, the intraoperative availability



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                                                                                                   Multidisciplinary approach of rhinogenic orbital complications




Table III. Final recommendations.
                                                                    Multidisciplinary approach
    Pre-septal cellulitis             Optional
    Orbital cellulitis                Recommended (ophtalmologist, maxillofacial, infectious disease specialist and neuroradiologist involved for differential
                                      diagnosis and appropriate medical therapy)
    Subperiosteal abscess             Optional, depending on the location (mandatory maxillofacial and/or ophtalmologist cooperation for superior and lateral
                                      location)
    Orbital abscess                   Optional, depending on the location (mandatory maxillofacial and/or ophtalmologist cooperation for superior and lateral
                                      location, or for intraconal lesions)
    Cavernous sinus thrombosis        Recommended
    Maxillary mucocele                Optional
    Sphenoidal mucocele               Optional
    Frontal mucocele                  Optional, depending on the location (recommended maxillofacial and/or neurosurgical cooperation for lesion extending to
                                      the anterior cranial fossa)



of ophthalmologist, maxillofacial surgeon or neurosurgeon                           9
                                                                                         De Corso E, Kar M, Cantone E, et al. Facial pain: sinus or
                                                                                         not? Acta Otorhinolaryngol Ital 2018;38:485-496. https://doi.
is extremely helpful and encouraged, since the surgeon                                   org/10.14639/0392-100X-1721
should always be prepared to convert to an external ap-                             10
                                                                                         Wong SJ, Levi J. Management of pediatric orbital cellulitis: a system-
proach if needed.                                                                        atic review. Int J Pediatr Otorhinolaryngol 2018;110:123-129. https://
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                                                                                    11
                                                                                         Garber P, Abramson A, Stallman P, et al. Globe ptosis secondary to max-
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