Orbital complications of sinusitis are a group of eye socket diseases that develop against the background of inflammatory lesions of the paranasal sinuses. The main clinical manifestations include edema and hyperemia of the eyelids, restriction of eyeball movements, exophthalmos, pain during palpation or at rest, intoxication syndrome. Diagnostics includes the collection of anamnesis and complaints of the patient, evaluation of the results of physical examination, rhinoscopy, ophthalmoscopy, laboratory tests, radiography or computer and magnetic resonance imaging. Treatment is based on antibacterial, detoxification therapy. With purulent forms of complications, surgical interventions are indicated.
O01 P05.0 P05.2
Orbital complications of sinusitis are observed mainly in children and account for 8 to 30% of all eye socket pathologies. Infants predominate in the structure of morbidity – up to 65%. Among preschool and school-age children, intraocular lesions on the background of sinusitis occur in 33-38% and 23-26%, respectively. In adults, pathology is relatively rare. The prevalence rate in people over 20 years of age is in the range of 0.4-7.9% of all diseases of the paranasal sinuses. Non-purulent complications are more often detected in all age categories of patients, they account for up to 50% of the total number of cases. Of the purulent forms, subperiosteal abscess (up to 40%), retrobulbar abscess (less than 15%), phlegmon of the eye socket (up to 13%) predominate.
Intraocular lesions can occur in both acute and chronic purulent sinusitis. In childhood, complications are more often caused by acute processes, in the middle and older – chronic. Pathogenic microflora in most cases is represented by the same microorganisms that provoke uncomplicated sinusitis: Str. pneumoniae, H. influenzae, M. catarrhalis. Predisposing factors are:
- Immunodeficiency conditions. Immune disorders caused by genetic abnormalities, diabetes mellitus, hypothyroidism, HIV infection, malignant diseases, recently undergone radiation and polychemotherapy contribute to the destruction of the bone walls of the sinuses and the spread of the pathological process towards the orbit.
- Anomalies of development. Deformities of the upper jaw and frontal bone, the presence of pathological anastomoses (degenerations) or cystic sprains in them, thinning of the walls of the cavities of the sinuses and eye sockets, and other similar changes increase the likelihood of pathogenic microflora from the primary focus into adjacent anatomical structures.
- Traumatic injuries. Severe injuries of the facial skull can disrupt the physiological configuration of the cavities of the accessory sinuses, making their walls more susceptible to purulent processes. Similar changes can cause previously transferred operations in this area.
The formation of orbital complications in sinusitis occurs due to the anatomical proximity of the sinuses and eye sockets, the presence of vascular and nerve communications. The predominant hematogenic pathway of infection is realized through the anterior orbital vein and the pterygoid plexus, which collect blood from the anterior paranasal sinuses and the posterior nasal cavity. Less common is the contact path of propagation, due to a total violation of the hemodynamics of the orbit and the destruction of bone structures. In children, the nasolacrimal canal can serve as a conductor for bacteria and their waste products. In infants, due to an insufficiently formed upper jaw, the dental rudiments are directly adjacent to the lower wall of the eye socket. This causes the development of pathologies of the orbit against the background of combined lesions of the maxillary sinus, oral cavity and alveolar processes.
The clinical picture depends on the variant of the complication. Reactive edema of the orbit and eyelid fiber is manifested by moderate exophthalmos, the formation of pale, almost transparent swellings, painless when touched. Body temperature and general condition – as in primary sinusitis. With diffuse non-purulent inflammation of the tissues of the orbit, there is a visually noticeable protrusion of the eyeball, hyperemia and swelling of the skin, soreness, chemosis. In children, unlike adults, signs of intoxication syndrome may worsen. With osteoperiostitis of the orbit, acute pain, limited mobility and displacement of the eye are added to the above symptoms, the direction and localization of which indicate the area of the bone wall lesion.
With an abscess or phlegmon of the eyelid, the eyeball often cannot be examined, since it is closed by a sharply edematous, hyperemic, immobile upper or lower eyelid. Palpation determines a positive symptom of fluctuation. There is fever up to 39.0 ° C, weakness, malaise. The fistulas of the eyelid and the walls of the orbit are characterized by the formation of a pathological connection of the surface of the root of the nose, lower or upper eyelid with the adjacent paranasal sinuses. Intoxication syndrome is poorly expressed. Subperiosteal and retrobulbar abscesses are alternately developing stages of progressive osteoperiostitis of the orbit, therefore they are accompanied by similar symptoms. Additionally, systemic intoxication increases, there is a sharp pain when pressing and moving the eyes, a transient visual impairment is detected, which occurs with lesions of the deep parts of the eye socket.
With phlegmon of the orbit, there is a strong exophthalmos, restriction of the mobility of the eyeball up to total ophthalmoplegia, intense pain during attempts at ophthalmological examination, severe intoxication syndrome, as well as the aforementioned inflammatory changes of the eyelids and conjunctiva. If it is possible to perform ophthalmoscopy, stagnant phenomena on the fundus are visualized. Thrombosis of regional veins and cavernous sinus is characterized by edema, redness and compaction of first one, then the second eyelid, mild exophthalmos, pain syndrome, visualization of affected venous vessels on the surface of the skin, ophthalmoplegia. The general condition is very severe – there are disturbances of consciousness, the body temperature reaches 40-41 ° C.
Complications of orbital lesions are associated with inadequate or untimely therapy. With rapidly increasing swelling of the cellular tissue of the orbit, compression and ischemia of the ocular nerve occur. This causes persistent deterioration of vision up to blindness. In children under 1 year of age and people with compromised immune systems, early generalization of the process with the formation of metastatic foci of infection (sepsis and septicopiemia) is noted. In the future, infants may develop persistent visual disturbances in the form of a decrease in acuity to 0.5 diopters, skin growth defects at the edge of the orbit, lesions of the lacrimal sac, a decrease in the amplitude of eye movements. Retrobulbar abscess and phlegmon of the eye socket at any age can cause meningitis, brain abscesses, venous sinus thrombosis and other intracranial complications.
Diagnosis of this group of pathologies is carried out by an otolaryngologist and an ophthalmologist, based on anamnestic data, complaints of the patient or his parents, the results of physical, laboratory and instrumental studies. An important aspect is the confirmation of concomitant pathologies of the paranasal sinuses. If it is impossible to establish their presence by questioning and general examination of the patient, a sample is used with a tampon soaked in a 5% solution of cocaine, which is injected into the middle nasal passage for 2 hours. An improvement in vision against this background is a sign of sinus damage. The full examination program includes:
- Physical methods. At the initial examination of the patient, in addition to the symptoms of sinusitis, the specialist determines hyperemia, swelling of the upper or / and lower eyelid, exophthalmos, impaired mobility of the eye. On palpation, there is pain, a local increase in temperature. In some patients, the eyelids completely cover the eyeball.
- Rhinoscopy. When examining the nasal cavity, the otolaryngologist reveals swelling and redness of the mucous membrane, the presence of catarrhal or purulent discharge. Depending on which sinuses are affected, pathological masses are found in the middle or lower nasal passage, on one or two sides.
- Ophthalmoscopy. If possible, the affected eyelids are opened, the fundus is examined. An ophthalmologist can confirm the presence of edema of the optic nerve disc, dilation of the blood vessels of the inner shell of the eye, loss of the orbital, pupillary reflex – symptoms characteristic of the phlegmon of the orbit. In other variants, such changes are not clearly expressed or absent.
- Laboratory tests. In the general blood test, high leukocytosis is detected with a shift in the formula towards young and rod-shaped neutrophils, an increase in ESR. In the presence of nasal secretions, their sample is taken for bacteriological seeding in order to identify the pathogen, determine its sensitivity to the main groups of antibiotics.
- Hardware visualization methods. Radiography of the paranasal sinuses and orbit is used as a basic study. In the pictures, the walls of these formations may be thickened and the cavities darkened, which are signs of an inflammatory process and accumulation of purulent masses. Also, the X-rays show defects in the walls, pathological anastomoses between the eye socket and sinuses. If the method is insufficiently informative, MRI and CT of the facial skeleton are prescribed.
Treatment is carried out in an ophthalmological or otolaryngological hospital. Its main goals are the rehabilitation of the primary and secondary foci of infection, prevention of further spread of the process into the cranial cavity, if necessary, reconstruction of the walls of the orbit and paranasal sinuses. To do this , use:
- Medications. Submaximal or maximum doses of broad-spectrum antibiotics are used. To eliminate the symptoms of intoxication, intravenous infusions of sorbents and plasma substitutes are carried out. In the future, the antibiotic therapy regimen is adjusted in accordance with the results of the antibiotic sensitivity test. Decongestants, diuretics, antihistamines, proteolytic enzyme inhibitors, vitamin complexes are prescribed as symptomatic drugs. With non-purulent complications, such therapy regimens are the basis of treatment.
- Surgical interventions. They consist in puncture of the affected sinus, aspiration of purulent exudate, followed by washing of the cavity with solutions of antiseptics, corticosteroids, antibiotics. In case of purulent pathologies of the orbit, an endonasal autopsy of the affected sinuses is performed, after which the otolaryngologist, together with an ophthalmologist, sanitizes foci of infection in the orbital cavity, revision of fistulas and installation of drains.
- Physiotherapy procedures. They are used after the main course of treatment to normalize regional blood circulation, accelerate the processes of repair and regeneration. Usually, UFO, magnetotherapy, electrophoresis, darsonvalization are prescribed.
Prognosis and prevention
The outcome depends on the timeliness of the diagnosis of the disease, the quality of the therapy and the individual characteristics of the patient’s body. As a rule, the prognosis for the patient’s life is favorable. It is not always possible to achieve complete recovery, especially with chronic sinusitis. Specific prophylaxis against orbital complications of paranasal sinus pathologies has not been developed. Non-specific preventive measures include early detection and relief of sinus diseases with strict compliance with the recommendations of the attending specialist, correction of immunodeficiency conditions, prevention of traumatization of the eye socket area.