Overview
Definition:
Complicated sinusitis in children refers to acute or chronic bacterial sinusitis with extension into surrounding structures, particularly the orbit
Orbital signs are critical indicators of potential morbidity and the need for urgent intervention, often requiring ENT and ophthalmology collaboration.
Epidemiology:
Acute sinusitis is common in children, with viral etiology predominating
Bacterial sinusitis occurs in 5-10% of cases
Orbital complications, though rare, are more frequent in younger children (under 10 years) due to the thin orbital septum and rich vascularity
Common pathogens include Streptococcus pneumoniae, Haemophilus influenzae (non-typable), and Moraxella catarrhalis.
Clinical Significance:
Prompt recognition of orbital signs is paramount in pediatric sinusitis
Untreated orbital complications can lead to permanent vision loss, intracranial spread (meningitis, brain abscess), cavernous sinus thrombosis, and sepsis
This necessitates a high index of suspicion and timely, multidisciplinary management.
Clinical Presentation
Symptoms:
Persistent purulent nasal discharge
Fever, often high-grade
Facial pain or pressure, which may be difficult to localize in young children
Worsening cough or lethargy
Eye symptoms: Periorbital swelling and erythema
Pain with eye movements
Decreased vision
Diplopia
Nasal obstruction.
Signs:
Proptosis or exophthalmos (forward displacement of the eyeball)
Ophthalmoplegia (restriction of eye movements)
Diplopia (double vision)
Chemosis (conjunctival edema)
Eyelid edema and erythema
Reduced visual acuity
Marcus Gunn pupil (afferent pupillary defect)
Palpable orbital mass or tenderness
Purulent nasal discharge
Pharyngeal erythema.
Diagnostic Criteria:
Generally diagnosed clinically based on the presence of orbital signs in a child with symptoms suggestive of sinusitis
Imaging confirmation is crucial
Classification systems (e.g., Chandler's classification) help stratify severity and guide management: Stage I: Preseptal cellulitis
Stage II: Orbital cellulitis
Stage III: Subperiosteal abscess
Stage IV: Orbital abscess
Stage V: Intracranial extension.
Diagnostic Approach
History Taking:
Detailed history of sinus symptoms duration and severity
Onset and progression of eye symptoms
History of recent upper respiratory infection
Previous episodes of sinusitis or otitis media
Trauma to the face or orbit
Fever
Lethargy
Any visual complaints
Allergies
Immunization status.
Physical Examination:
Comprehensive ENT examination: nasal endoscopy to assess for purulent discharge, mucosal swelling, and polyps
Otoscopy
Oropharyngeal examination
Crucially, a detailed ophthalmological assessment: visual acuity testing (Snellen chart, Allen cards), pupillary light reflexes, extraocular movements (assessing for restriction and diplopia), intraocular pressure, funduscopy to rule out papilledema or optic nerve compromise
Careful palpation of periorbital tissues for tenderness and fluctuance.
Investigations:
Complete blood count (CBC) with differential to assess for leukocytosis and neutrophilia
C-reactive protein (CRP) for inflammatory markers
Blood cultures if sepsis is suspected
Imaging: Contrast-enhanced computed tomography (CECT) of the orbits and paranasal sinuses is the investigation of choice, demonstrating sino-orbital disease, abscess formation, bony erosion, and intracranial extension
Magnetic resonance imaging (MRI) may be useful for evaluating intracranial complications or soft tissue detail
Ultrasound of the orbit can be helpful for detecting fluid collections (abscesses) and assessing globe position.
Differential Diagnosis:
Preseptal cellulitis (infection confined anterior to the orbital septum, with normal vision and motility)
Dacryocystitis (infection of the lacrimal sac)
Orbital pseudotumor
Orbital cellulitis from other sources (e.g., dental infection, facial trauma)
Periorbital edema from allergic reactions or insect bites
Periorbital edema from systemic illness (e.g., nephrotic syndrome)
Orbital rhabdomyosarcoma (rare malignancy)
Meningococcal sepsis.
Management
Initial Management:
Immediate referral to ophthalmology and ENT
Admission to hospital for close monitoring
Intravenous (IV) antibiotics are initiated promptly, covering common pathogens
Analgesia and antipyretics for symptom control
Nasal decongestants may be used cautiously if no contraindication.
Medical Management:
IV antibiotics: Initial broad-spectrum coverage typically includes a third-generation cephalosporin (e.g., ceftriaxone 75-100 mg/kg/day divided q12-24h) plus clindamycin (10-15 mg/kg/dose q6-8h) or vancomycin if MRSA is suspected
Duration of IV therapy is usually 7-14 days, followed by oral antibiotics for a total course of 3-4 weeks, guided by clinical response and imaging
Corticosteroids (e.g., oral prednisolone) may be considered in select cases of severe inflammation to reduce edema, but their use requires careful consideration of risks and benefits, particularly in the presence of infection.
Surgical Management:
Surgical intervention is indicated for Stage III (subperiosteal abscess), Stage IV (orbital abscess), or if there is no clinical improvement with medical management within 48-72 hours
Surgical drainage aims to relieve pressure on the globe, prevent vision loss, and obtain pus for culture and sensitivity
Endoscopic sinus surgery is the preferred approach for draining subperiosteal and orbital abscesses, allowing access to the ethmoid and maxillary sinuses
Incision and drainage of periorbital abscesses may also be required.
Supportive Care:
Close monitoring of vital signs, neurological status, and visual acuity
Strict fluid balance management
Pain management
Nutritional support
Humidification of inspired air
Prophylaxis against deep vein thrombosis (if immobile)
Patient and family education regarding the condition and treatment plan.
Complications
Early Complications:
Permanent vision loss (due to optic nerve compression, central retinal artery occlusion, or endophthalmitis)
Strabismus and diplopia
Globe rupture
Cavernous sinus thrombosis
Meningitis
Brain abscess
Sepsis.
Late Complications:
Chronic sinusitis
Nasal polyposis
Orbital scarring and deformity
Persistent visual field defects
Post-infectious ophthalmoplegia
Synechiae
Orbital cellulitis recurrence.
Prevention Strategies:
Prompt and appropriate treatment of acute bacterial sinusitis
Early recognition and aggressive management of initial orbital signs
Judicious use of antibiotics
Adequate surgical drainage when indicated
Good nasal hygiene
Prevention of upper respiratory infections through vaccination and hygiene measures.
Prognosis
Factors Affecting Prognosis:
The stage of orbital involvement at presentation is the most critical factor
Earlier diagnosis and intervention lead to better outcomes
Aggressive treatment with IV antibiotics and timely surgical drainage significantly improve prognosis
Underlying immune status and virulence of the pathogen also play a role.
Outcomes:
With prompt and appropriate management, the prognosis for most children with complicated sinusitis involving orbital signs is generally good, with resolution of infection and preservation of vision
However, delays in treatment or severe involvement can lead to permanent vision impairment or other serious complications.
Follow Up:
Close follow-up is essential after discharge
This typically includes regular ophthalmological and ENT evaluations for several weeks to months to monitor for recurrence, assess visual recovery, and manage residual symptoms
Long-term management of chronic sinusitis may be required.
Key Points
Exam Focus:
Recognize orbital signs as emergencies in pediatric sinusitis
Understand Chandler's classification
CECT scan is the investigation of choice for diagnosis and staging
Differentiate preseptal from orbital cellulitis
Indications for surgical drainage
Common pathogens and antibiotic choices.
Clinical Pearls:
Always perform a thorough ophthalmological assessment in any child with worsening sinusitis
Even subtle proptosis or reduced eye movements warrant urgent attention
Trust imaging findings
they are crucial
Multidisciplinary approach (ENT, Ophthalmology, Infectious Disease) is key for optimal outcomes.
Common Mistakes:
Delaying definitive imaging or surgical intervention
Inadequate antibiotic coverage
Misinterpreting orbital signs as benign periorbital edema
Underestimating the risk of intracranial spread
Failing to involve ophthalmology early.