10.14639/0392-100X-N0679
Orbital abscess is one of the most serious complications of acute rhinosinusitis and requires surgical management to avoid further complications such as visual loss and intracranial extension of the infectious process. Endoscopic sinus surgery is the most frequently used procedure in such cases, even if its use may be insufficient in some cases. The aim of the present study is to present our experience on the management of selected orbital abscesses through a superior eyelid endoscopic approach in combination with endonasal surgery. Personal considerations on four cases and lessons learned are described.
application/xml
1827-675X
679
6
en
Veronica Seccia
https://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
endoscopy
Effectiveness of superior eyelid endoscopic-assisted approach in the management of selected orbital abscess: considerations on 4 cases
Text.Serial.Journal
https://www.actaitalica.it/
40
Rhinology
2021-01-21
2020-02-11
2021-01-21
2021-01-21
1
Veronica Seccia
2020
10.14639/0392-100X-N0679
Otorinolaringoiatria Audiologia e Foniatria, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
1827-675X
6
endoscopy
Effectiveness of superior eyelid endoscopic-assisted approach in the management of selected orbital abscess: considerations on 4 cases
https://www.actaitalica.it/article/download/679/494
40
ACTA OTORHINOLARYNGOLOGICA ITALICA 2020;40:421-425; doi: 10.14639/0392-100X-N0679




Rhinology


Effectiveness of superior eyelid endoscopic-assisted
approach in the management of selected orbital
abscess: considerations on 4 cases
Ruolo dell’approccio trans-palpebrale superiore endoscopico-assistito nella gestione
delle complicanze infettive orbitarie multicompartimentali: considerazioni su 4 casi clinici
Iacopo Dallan, Lodovica Cristofani-Mencacci, Christina Cambi, Mariella Scarano, Augusto Pietro Casani, Veronica Seccia
Otorinolaringoiatria Audiologia e Foniatria, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy


SUMMARY
Orbital abscess is one of the most serious complications of acute rhinosinusitis and requires
surgical management to avoid further complications such as visual loss and intracranial
extension of the infectious process. Endoscopic sinus surgery is the most frequently used
procedure in such cases, even if its use may be insufficient in some cases. The aim of the
present study is to present our experience on the management of selected orbital abscesses
through a superior eyelid endoscopic approach in combination with endonasal surgery. Per-
sonal considerations on four cases and lessons learned are described.
KEY WORDS: abscess, sinusitis, rhinitis, orbital cellulitis, endoscopy
                                                                                                Received:February 11, 2020
                                                                                                Accepted: May 20, 2020
RIASSUNTO
Gli ascessi dell’orbita rappresentano una delle più temibili complicanze in corso di ri-        Correspondence
nosinusite acuta. La loro gestione è di tipo chirurgico nella maggior parte dei casi, con       Lodovica Cristofani Mencacci
l’obiettivo di drenare la raccolta ed evitare l’evoluzione verso quadri ancora più seri che     Otorinolaringoiatria Audiologia e Foniatria, Azien-
                                                                                                da Ospedaliero-Universitaria Pisana, via Paradisa 2,
possano comportare la perdita della vista o l’estensione intracranica del processo infet-
                                                                                                56124 Pisa, Italy
tivo. L’approccio chirurgico più frequentemente utilizzato è rappresentato dalla chirur-        Tel. +39 050 997501
gia endoscopica dei seni paranasali, pur risultando in alcuni casi insufficiente. Lo scopo      E-mail: lodovicacristofani@yahoo.it
del presente studio è quello di presentare la nostra esperienza nell’utilizzo dell’approccio
trans-palpebrale superiore in combinazione con la via endoscopica endonasale classica           Funding
nella gestione di casi selezionati di ascessi orbitari.                                         None.
PAROLE CHIAVE: ascesso, sinusite, rinite, cellulite orbitaria, endoscopia
                                                                                                Conflict of interest
                                                                                                The Authors declare no conflict of interest.


Introduction                                                                                      How to cite this article: Dallan I, Cristofani-
                                                                                                  Mencacci L, Cambi C, et al. Effectiveness of
Infectious orbital complications may occur secondary to acute rhinosinusitis,                     superior eyelid endoscopic-assisted approach
when pathogens spread from an infected sinus into the orbit. It may happen                        in the management of selected orbital ab-
                                                                                                  scess: considerations on 4 cases. Acta Otorhi-
directly, given the close proximity of the orbit to the paranasal sinuses, or                     nolaryngol Ital 2020;40:421-425. https://doi.
indirectly via the bloodstream. Chandler’s classification for orbital complica-                   org/10.14639/0392-100X-N0679
tions of sinusitis distinguishes five stages on the basis of involvement of the
                                                                                                © Società Italiana di Otorinolaringoiatria
orbital content 1. Conservative management is possible in earlier Chandler’s                    e Chirurgia Cervico-Facciale
stages, while surgical drainage is indicated in later stages or in cases of failure
to improve under medical treatment. The Chandler’s IV stage is represented                                     OPEN ACCESS
by an orbital abscess, in which purulent secretions are described within the                    This is an open access article distributed in accordance with
                                                                                                the CC-BY-NC-ND (Creative Commons Attribution-Non-
orbital content, deep to the periorbita. Patients experience proptosis, chemo-                  Commercial-NoDerivatives 4.0 International) license. The
sis, orbital pain and progressive ophthalmoplegia and, if not promptly treated,                 article can be used by giving appropriate credit and mentio-
                                                                                                ning the license, but only for non-commercial purposes and
visual impairment and visual loss 1. In this group of patients, surgical manage-                only in the original version. For further information: https://
ment is highly recommended in order to drain the abscess, release pressure in                   creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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I. Dallan et al.




the orbit, obtain material for culture and reduce the risk of
intracranial extension, including cavernous sinus thrombo-
sis, meningitis, cerebritis and cerebral abscess (Chandler’s
stage V) 2. Endoscopic sinus surgery is the most frequently
used procedure even if its use may be insufficient when
dealing with areas that are complex to treat. In other words,
the effectiveness of endonasal procedures depends on the
location of the disease within the orbit, eventually requir-
ing the association with or the necessity to switch to other
approaches.
The aim of the present study is to present our experience on
management of selected orbital abscesses through a supe-
rior eyelid endoscopic approach in combination with endo-
nasal surgery. Personal considerations and lessons learned
are described.

Materials and methods
In this retrospective cohort study, we report our experi-
ence with four adult patients treated with a superior eye-
lid transorbital endoscopic approach in combination with
endonasal surgery for rhinogenic orbital abscesses at the
University Hospital of Pisa between July 2016 and March
2019. Patients treated with an exclusive endonasal ap-
proach were not considered. Data collected included de-
mographic, known history of chronic rhinosinusitis, previ-
ous nasal or orbital surgical procedures, ongoing medical
treatments. All patients underwent a pre-operative eye
examination and CT scan to evaluate orbital involvement
(Fig. 1). All patients provided informed written consent for
the procedure. Patients were selected for a superior eyelid
endoscopic approach in combination with endonasal endo-
scopic surgery based on the location of the abscess within
the orbit. In other words, the main criterion to indicate the
need for a superior-eyelid approach was the location of the
abscess in the supero-lateral orbital quadrant. Surgical pro-
cedures performed, hospitalisation days and complications
were analysed. No statistical evaluations were performed
due to the low number of patients.

Notes on surgical technique
The transnasal approach consisted in subtotal resection of
the middle turbinate; complete spheno-etmoidectomy; ex-         Figure 1. Radiological and endoscopic images describing the time evolution
posure and removal of the lamina papyracea; periorbital ex-     of the orbital abscess in patient number 1. Radiological evidence of a left acute
posure and opening and eventually extraconal fat manage-        rhinosinusitis (A, B). Red arrow show orbital roof dehiscence with involvement
                                                                of the supero-lateral orbital compartment. Endoscopic evidence of pus during
ment and drainage of the abscess. The transorbital approach     the endonasal surgical approach (black arrow in C, D). Post-operative radio-
was performed via superior eyelid incision and included         logical images showing adequate surgical outcomes of a complete ethmoid-
identification of the orbicolaris oculi muscle; harvesting of   ectomy with orbital decompression (E, F). Red arrow shows the persistence of
                                                                the supero-lateral orbital abscess. Endoscopic images of the transorbital sur-
the suborbicolaris flap and dissection until the orbital rim;
                                                                gical approach (G, H). LOW: left orbital wall; SOF: superior orbital fissure; LRM:
dissection of the periorbita from the orbital bones and crea-   left rectus muscle; * shows the pus. Post-op radiological images showing ad-
tion of enough room for instrumentation; incision of the        equate surgical outcome and complete resolution of the orbital abscess (I, J).



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                                                                The management of selected orbital abscess: role of the superior eyelid endoscopic-assisted approach




periorbita and dissection within the orbital fat till abscess is                           all patients presented chemosis, proptosis and orbital pain;
reached. Drainage of the abscess was performed according                                   two patients presented visual impairment: deep reduction
to individual requirements. The drain was removed the day                                  of visual acuity in patient # 1; blindness in patient # 2
after surgery. Neuronavigation was used to confirm the ex-                                 (Tab. II).
act position of the abscess and to help the surgeon identify                               Surgery was represented by a combined transnasal-tran-
the abscess.                                                                               sorbital approach in three of four patients; one patient was
                                                                                           treated transnasally and transorbitally at different times
Results                                                                                    (patient # 1). Patient # 4 developed an asymptomatic epi-
                                                                                           dural abscess in the post-operative period that was success-
Four adult patients affected by sinogenic orbital abscess                                  fully treated with medical therapy in the infectious diseases
were treated with a combined transnasal-transorbital en-                                   ward. Long-term sequalae occurred in patient # 2 in terms
doscopic surgical procedure. Our cohort was formed by 3                                    of lack of improvement of blindness. All perioperative de-
males and 1 female, with a mean age of 39.75 ± 25 years.                                   tails are reported in Table III.
All patients presented acute rhinosinusitis with acute onset
of orbital symptoms. Two patients had a known history of
chronic rhinosinusitis, managed with topical steroids and
                                                                                           Discussion
in one patient with previous surgery. All patients were on                                 Orbital abscess is one of the most frightening complica-
antibiotic therapy when they came to our attention. Clinical                               tions of acute rhinosinusitis and should be considered a
details of the patients are reported in Table I. All patients                              very serious condition with possible permanent sequelae.
presented a Stage IV Chandler’s classification for acute                                   In case of orbital abscesses, surgery should become rapidly
rhinosinusits complications, as revealed by pre-operative                                  advisable, although conservative management could be at-
radiological evaluation. At pre-operative eye examination,                                 tempted in selected adult patients with limited subperiosteal


Table I. Clinical details of our cohort of patients.
 Patient number          Sex, Age (years)          Known CRS               Previous surgery          Days from onset of ARS               Ongoing antibiotic treatment
 1                               F, 75                      Y                       N                                9                             Amox/Clav Ac.
 2                               M, 40                      Y                       Y                                6                        Cefixime-Amox/Clav. Ac.
 3                               M, 27                      N                       N                                1                             Amox/Clav. Ac.
 4                               M, 18                      N                       N                                9                         Levoflox-Ceftriaxone
M: male; F: female; Known CRS: known history of chronic rhinosinusitis; Days from onset of ARS: days between onset of acute rhinosinusitis and onset of orbital symptoms; Amox/
Clav. Ac.: Amoxicillin/Clavulanic Acid; Levoflox: Levofloxacin



Table II. Ocular symptoms.
 Patient number         Chemosis                      Proptosis          Visual impairment              Ocular motility impairment                      Orbital pain
 1                                 Y                       Y                    Y, 1/10                                  Y                                    Y
 2                                 Y                       Y                    Y, 0/10                                  Y                                    Y
 3                                 Y                       Y                   N, 8/10                                   Y                                    Y
 4                                 Y                       Y                   N, 10/10                                  N                                    Y



Table III. Perioperative details, complications and sequalae in our cohort.
 Patient      Surgery performed Days of hospitalisation             Post-op CT scan                Second surgery            Short-term sequalae       Long-term sequalae
 number
 1                    Transnasal                      10                          OA                   Y, Transorb                    N                           N
 2                    Combined                         6                          Neg                        N                    Blindness                   Blindness
 3                    Combined                        10                          Neg                        N                        N                           N
 4                    Combined                    Other dept.                     EA                         N                        N                           N
Transnasal: Transnasal endoscopic surgery; Combined: Transnasal-transorbital endoscopic surgery; Transorb: Transorbital endoscopic surgery; Other dept: moved to other
department; OA: orbital abscess; Neg: negative for persistence of abscess or other complication; EA: Epidural abscess




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I. Dallan et al.




abscesses 3. Time is typically a critical factor, and, in such   rather to serve as a complementary tool to help the surgeon
“conservative” cases, patients need to be closely monitored      when facing challenging areas. Despite the high-risk ana-
in order to avoid possible evolution and thus serious com-       tomic location of the abscesses in our series, we have doc-
plications 4. Technically speaking, most of subperiosteal        umented the feasibility and excellent safety profile of the
abscesses can be managed transnasally. This is not always        superior eyelid approach. All abscesses were successfully
true in all cases of orbital abscesses. Thus, if endoscopic      reached and drained as intended (Fig. 2). In our series there
endonasal surgery is adequate in most cases, with the aim        were no new visual deficits, worsened diplopia, or ptosis.
of opening the sinuses involved, removing pus, allowing
direct cultures and providing a drainage pathway, this ap-
proach may be insufficient in cases of abscesses involving
the supero-lateral orbital compartments. These orbital areas
are normally involved due to spread of infection, although
septic emboli may occur 5. Hence, in suspected orbital ab-
scesses orbital imaging becomes mandatory to confirm the
suspicion and to choose the most appropriate approach. If
MRI with contrast is the best option to evaluate orbital le-
sions, it is quite clear that examination is rarely available
in such an urgent situation. Therefore, the vast majority of
these cases have to be managed using CT, if possible using
a contrast agent. We strongly advise, in such a scenario,
to prefer the rapidity of action in respect to searching for
the best imaging examination. Since most orbital abscesses
are related to acute rhinosinusitis, we consider, as stated
before, that the endonasal approach should be the first pro-
cedure to be performed in order to drain the purulence and
restore ventilation to the sinuses 3. On the other hand, there
are clear limitations for an exclusive endonasal approach
in managing selected sinogenic orbital complications, es-
pecially in case of supero-lateral or lateral abscesses. In
these cases, transnasal approaches offer an unfavourable
path-to-target trajectory, while other routes, like the supe-
rior eyelid approach, could be more efficient. Practically
speaking, in these complex cases, it could be necessary to
combine endonasal and transorbital approaches, and this is
what we did in our patients. We normally move first with
a transnasal approach and then a transorbital approach if a
supero-lateral abscess is demonstrated by imaging. In our
first case, imaging seemed to show a sub-periosteal abscess
extending from the medial orbital compartment to the supe-
rior ones. Thus, we performed, as a first surgical procedure,
an exclusive transnasal approach, although intraoperative-
ly, sub-periosteally, there was only a limited amount of in-
fected material. At post-operative CT, an abscess was still
demonstrated in the supero-lateral orbital compartment,
thus requiring a further surgical procedure via superior
eyelid (Fig. 1). Since that time, we shifted to a combined       Figure 2. Clinical, radiological and surgical images of a left orbital abscess.
procedure in case of supero-lateral orbital involvement.         Clinical presentation with significant proptosis, chemosis and inability to open
The effectiveness of the superior eyelid approach in the set-    the eye (A). Coronal and axial CT scan images showing the left orbital involve-
                                                                 ment in the context of a left acute rhinosinusitis (B, C). Endoscopic evidence
ting of intraorbital abscesses has been previously reported      and drainage of pus during the transorbital approach (D, E). Post-operative im-
by other authors 5. In fact, the superior eyelid approach is     age showing complete resolution of the proptosis and chemosis. There is no
not thought to replace transnasal or other approaches, but       evidence of enophthalmos (F).



424
                                              The management of selected orbital abscess: role of the superior eyelid endoscopic-assisted approach




Additionally, we did not experience unfavourable wound               Conclusions
healing, eyelid distortion, or poor cosmetic outcomes as-
                                                                     We present the transorbital endoscopic approach as an
sociated with the superior eyelid incision. Patient # 2 in our
                                                                     effective route to use in combination with the transnasal
cohort unfortunately experienced permanent vision loss,
                                                                     approach in cases of orbital abscess that involve multiple,
which was likely related to delayed surgery (about 24 hours
                                                                     not-necessarily-communicating compartments. More prac-
after onset). This patient was blind before surgery and vi-
                                                                     tically, the involvement of the supero-lateral compartment
sion did not recover. Although anecdotical, this stresses
                                                                     is a strong recommendation for the superior eyelid ap-
the importance of rapid management of such abscesses,
                                                                     proach. In this scenario, only accurate pre-operative radio-
considering that delayed surgery may be associated with a
                                                                     logical evaluation will allow choice of the most appropriate
reduced chance of visual recovery and an increased risk of
                                                                     surgical route.
intracranial complications. In this context, secondary vas-
cular damage (mostly venous related) of minor but critical
orbital vessels could be responsible of the dramatic wors-           References
ening of the vision. Lastly, in our opinion, the transorbital        1
                                                                         Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of
                                                                         orbital complications in acute sinusitis. Laryngoscope 1970;80:1414-
route should be considered a minimally invasive, safe and                28. https://doi.org/10.1288/00005537-197009000-00007
effective approach to be further developed in combination            2
                                                                         Howe L, Jones NS. Guidelines for the management of periorbital cel-
with transnasal surgery. Its role in the management of orbit-            lulitis/abscess. Clin Otolaryngol Allied Sci 2004;29:725-8. https://
al abscess should be considered based on the site and fea-               doi.org/10.1111/j.1365-2273.2004.00889.x
tures of the abscess by CT. On these grounds, the transorbi-         3
                                                                         Gavriel H, Jabrin B, Eviatar E. Management of superior subperiosteal
                                                                         orbital abscess. Eur Arch Otorhinolaryngol 2016;273:145-50. https://
tal endoscopic approach may overcome the limits of the                   doi.org/10.1007/s00405-015-3557-1
transnasal route, providing improved visualisation and ac-           4
                                                                         Harris GJ. Subperiosteal abscess of the orbit: older children and
cess to challenging anatomical areas. From a clinical point              adults require aggressive treatment. Ophthalmic Plast Reconstr Surg
of view, we strongly advise careful and rapid evaluation                 2001;17:395-7. https://doi.org/10.1097/00002341-200111000-00002
of this patients, and if a supero-laterally located abscess
                                                                     5
                                                                         Lim JH, Sardesai MG, Ferreira M Jr, et al. Transorbital neuroendo-
                                                                         scopic management of sinogenic complications involving the frontal
is suspected a combined transnasal-transorbital procedure                sinus, orbit, and anterior cranial fossa. J Neurol Surg B Skull Base
should be considered.                                                    2012;73:394-400. https://doi.org/10.1055/s-0032-1329617




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