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Journal de radiologie
Vol 80, N° 6  - mai 1999
p. 569
Doi : JR-06-1999-80-6-0221-0363-101019-ART5
ETHMOID SINUSITIS IN CHILDREN: VALUE OF ORBITAL US
 

ORIGINAL ARTICLE

Journal de radiologie1999; 80: 569
© Masson, Paris, 1999

V Pinzuti-Rodné(1), , M Elmaleh(1)(3), M François(2), , M Williams(3), , P Narcy(2), , M Hassan(1)

(1)Service d'Imagerie Pédiatrique, Hôpital Robert Debré, 48, Boulevard Sérurier, 75019 Paris.
(2)Service d'ORL, Hôpital Robert Debré, 48, Boulevard Sérurier, 75019 Paris.
(3)Service d'Imagerie, Fondation Ophtalmologique A de Rothschild, 25, rue Manin, 75019 Paris.

SUMMARY

Ethmoïd sinusitis in children: value of orbital US

Purpose

To assess the value of orbital sonography (US) compared to CT in the management of children with ethmoid sinusitis.

Material and methods

A total of 13 consecutive patients admitted for non-complicated ethmoid sinusitis (absence of visual or neurological symptoms) were prospectively evaluated at US and CT.

Results

Three patients had no evidence of postseptal involvement at US. Ten patients had variable degree of postseptal involvement at US: hypoechoic area of fluid collection in the extraconal fat along the medial orbital wall. Results were confirmed at CT in all patients.

Conclusion

US is useful to confirm the presence of postseptal involvement in patients with ethmoid sinusitis. Contrary to CT, findings at US remain non-specific as to the nature of involvement. Nonetheless, US is helpful for patient management.

Key words : Children. , Orbit, CT. , Orbit, infection. , Orbit, sonography. , Sinusitis. , Sinus, ethmoid.

RÉSUMÉ

Intérêt de l'échographie orbitaire dans les ethmoïdites de l'enfant

Objectif

Étudier l'apport de l'échographie orbitaire par rapport au scanner dans la prise en charge des ethmoïdites chez l'enfant.

Matériels et méthodes

Dans une étude prospective, une échographie orbitaire et un examen TDM ont été réalisés chez treize enfants hospitalisés pour une ethmoïdite sans signes de complications neurologiques ou ophtalmologiques.

Résultats

Trois échographies n'ont pas montré d'extension rétroseptale, les 10 autres ont montré une atteinte rétroseptale (hypoéchogénicité ou collection dans la graisse extraconique le long de la paroi interne de l'orbite).

Dans tous les cas, les résultats ont été confirmés par la TDM.

Conclusion

L'échographie permet d'affirmer, comme la TDM, l'existence d'une atteinte rétroseptale, sans orienter vers sa nature, contrairement à la TDM; elle permet néanmoins de guider la prise en charge des ethmoïdites.

Mots clés : Enfants. , Orbite, TDM. , Orbite, infection. , Orbite, échographie. , Sinusite. , Sinus ethmoïde.


INTRODUCTION

In children, the presence of peri-orbital cellulitis and fever is worrisome for acute ethmoid sinusitis. The severity of sinusitis is related to the presence or absence of postseptal involvement. The orbital septum divides the orbit into two compartments: preseptal (eyelids) and postseptal (conjunctiva and orbital content). This septum is continuous with the periosteum of the orbital rim and terminates in the eyelids (fig. 1) .

Peri-orbital cellulitis most commonly is limited to the preseptal space and responds well to medical management. However, involvement of the postseptal compartment is an indicator of poor prognosis. Postseptal involvement requires hospital admission under surgical (ENT) supervision.

Clinical findings suggesting postseptal and skull base involvement from ethmoid sinusitis are not always easily detectable in children (table I) [1, 2, 3]. Urgent CT scan should be performed whenever there is clinical suspicion of ophthalmologic or neurologic complications. US could be of value, as a complement to clinical evaluation, to confirm or exclude the presence of postseptal extension. The purpose of this study was to assess the role of orbital US for initial management of children with acute ethmoid sinusitis.

MATERIALS AND METHODS

From a prospective study conducted between January 1995 and August 1996 to evaluate the role of orbital US in children with peri-orbital cellulitis and fever, a total of 13 patients were selected. The mean age was 6.5 years (range: 6 months-14 years). There were 8 girls and 5 boys. All patients were diagnosed with ethmoid sinusitis based on clinical and imaging findings as well as follow-up.

All children were admitted to the ENT service for unilateral peri-orbital cellulitis and fever. None of the patients had evidence of ophthalmologic or neurologic deficits (cranial nerve palsy, decreased visual acuity). Orbital US was performed in all patients prior to CT. CT was obtained within 48 hours of presentation (availability constraints). Results at US were compared to results at CT (gold standard). CT examinations were obtained as follows: contiguous postcontrast 2.5 mm thick axial and direct coronal images or postcontrast helical acquisition using 2.5 mm thick axial images with overlapping reconstructions and multiplanar reformatted images. Children less than 4 years of age were sedated using chloral hydrate p.o. (0.75 mg/kg) or Thérelène® p.o. and nembutal p.r. US was performed, using a high-frequency transducer (7.5-10.0 MHz), by radiologists experienced in US imaging but without specialized training in orbital sonography.

Sedation was not used for US evaluation: for infants, the head was held by the parents or an assistant; non-irritating gel was placed on the eyelid and the transducer was placed along the lateral orbit and angled medially to better assess the medial portion of the orbit. No pressure was applied on the globe.

Children admitted for clinical suspicion of ethmoid sinusitis that was not confirmed at CT were excluded. Final diagnoses in this group of patients included: dacryocystitis, embryonal sarcoma and desmoid fibromatosis. A diagnosis of dacryocystitis had been suggested at US (enlarged lacrimal sac containing thick fluid) but a diagnosis of tumor had not been suggested at US for the other children.

A child with acute ethmoid sinusitis and clinical suggestion of increased ICP was also excluded because urgent CT was obviously needed.

A total of six children with clinical suspicion of ethmoid sinusitis where US and CT were performed have been excluded from this study.

RESULTS (table II)

US showed postseptal involvement in 10 cases. The pattern of extraconal involvement was either as a hypoechoic linear collection (fig. 2) or a small rounded collection (fig. 3) along the medial orbital wall, causing lateral displacement of the medial rectus muscle. In the remaining three cases, US showed no evidence of postseptal involvement and the medial extraconal fat was intact (fig. 4) .

CT findings correlated well with US findings in all cases (fig. 5) .

The outcome was good in all cases (table II) . Three patients underwent surgery: persistence of clinical symptoms at day 15 in a patient with an extraconal collection at CT; a patient with ethmoid mucocele underwent early surgery; percutaneous drainage and C+S in a patient with G6PD deficiency.

DISCUSSION

The incidence of postseptal involvement was very high in our patient population compared to prior studies [2, 3, 4, 5, 6, 7, 8] due to a selection bias: only patients admitted for clinical suspicion of postseptal extension of ethmoid sinusitis were included. The purpose was to assess the role of orbital US in children and infants with peri-orbital cellulitis and fever. In our institution, these patients first undergo evaluation by the ER physician. This screening practice was not modified during our study. The goal was to evaluate if US could detect postseptal involvement. Therefore, we only included patients that were admitted and would undergo CT. All US examinations were performed by pediatric radiologists who were familiar with the US protocol.

US was as sensitive as CT to detect postseptal involvement. The diagnosis of unilateral peri-orbital cellulitis varies based on the presence or absence of postseptal involvement [4, 5, 9, 10]. Preseptal cellulitis is more common and may be secondary to mucosal or skin lesions: viral (zona), bacterial (impetigo, erysipele, secondary infection after trauma), toxic (insect bite), post-URTI (sinusitis), ophthalmologic lesion (conjunctivitis, dacryocystitis), or secondary to a tooth infection. The outcome of preseptal cellulitis is good following appropriate medical management.

Postseptal cellulitis is less common. It may complicate preseptal cellulitis (irrespective of the underlying etiology) or be the presenting symptom. In children, postseptal cellulitis commonly complicates acute ethmoid sinusitis due to spread through the medial orbital wall or via transvenous spread (ethmoidal veins). It may also be secondary to tumoral processes leading to inflammation: mucocele, dermoid cyst, retinoblastoma, primary orbital or ethmoid sinus tumor (rhabdomyosarcoma), chloroma. Rarely, it may be due to an inflammatory pseudotumor. Appropriate management is required to avoid complications from the postseptal cellulitis or from the primary process.

Clinical findings from postseptal cellulitis may be difficult to detect at clinical examination, and symptoms sometimes occur late. Management of ethmoid sinusitis will differ based on the site of involvement relative to the orbital septum. Over the recent years, medical management has decreased the number of patients requiring surgical treatment and also decreased the rate of complications [3, 4, 6, 8, 10]. At our institution, the management protocol implemented is as follows: out-patient management with antibiotics p.o. and follow-up at 24-48 hours if a diagnosis of ethmoid sinusitis without postseptal involvement can be made with relative certainty. All other patients are admitted. If patients initially managed as out-patients fail to improve within 24-48 hours, they are admitted as well. Admitted patients undergo CT and infectious work-up (C+S) [2] and IV antibiotics are administered. Other groups are more aggressive with use of IV antibiotics and CT evaluation for all patients [3, 4]. The main underlying principle is the need for IV antibiotics and close clinical surveillance for all patients with ethmoid sinusitis and postseptal involvement.

Plain radiographs are of little value [2, 12, 13]. CT is more accurate for diagnosis and evaluation of the extent of disease. Sedation often is required for younger patients. Iodinated contrast is needed as well. CT allows evaluation of the paranasal sinuses, orbits, and skull base. The pattern of orbital involvement is also well demonstrated at CT: extraconal fat involvement with enhancing inflammatory tissue, presence of a subperiosteal abscess, involvement of the intraconal fat. Thrombosis of the SOV and cavernous sinuses can also be confirmed or excluded. Coronal images are useful for surgical planning [2, 5, 6, 12, 13]. Currently, US does not play a major role in the management of these patients, even if it is performed in some centers [2, 3, 6]. Yet, US allows a good evaluation of the orbit: eyelids, preseptal space, lacrimal sac, globe, optic nerve, intra- and extraconal fat, postseptal space and extra-ocular muscles. Doppler US is useful to detect signs of venous thrombosis (flow reversal in the SOV) [14, 15, 16, 17, 18] (difficult to assess in infants, and not evaluated in this study). In our study, the correlation between US and CT findings was excellent. US was useful to exclude the presence of postseptal involvement, hence enabling out-patient treatment with antibiotics p.o. and clinical follow-up. The sensitivity of US for detection of postseptal involvement was similar to the sensitivity of CT. Patients with postseptal enhancement require hospital admission and IV antibiotics to prevent intraconal and/or intracranial extension. Unless required by the severity of clinical symptoms at presentation, CT could be performed in a selected groups of patients without clinical improvement under treatment. CT would no longer be performed to confirm or exclude the presence of postseptal involvement, but to characterize the degree of postseptal involvement. Indeed, in patients failing IV antibiotics treatment, the possibility of abscess or an alternate diagnosis must be considered. US does not allow etiological diagnosis or evaluation of the bony orbit, ethmoid sinusitis, orbital apex, or skull base. CT allows a more comprehensive and complete evaluation of such patients.

CONCLUSION

Similar to CT, US enables detection of postseptal involvement in children with peri-orbital cellulitis. Therefore, orbital US would be useful to decrease the number of CT examinations performed for diagnosis in patients without apparent postseptal involvement at US and favorable response to treatment.

 


Diagram.

(Les tableaux sont exclusivement disponibles en format PDF).

Figure 2.
Case no 6. Left ethmoiditis with postseptal involvement. US. Left orbit (LO), axial plane: hypoechogenicity (*) along the medial wall of the orbit (→), with lateral displacement of the extra-conal fat and medial rectus muscle (MRM) (▹). The optic nerve (n) appears normal. Right orbit (RO), axial plane: the MRM (▹) abuts the medial orbital wall (→).
Cas no 6. Ethmoïdite gauche avec atteinte rétroseptale. Échographie. Orbite gauche (OG) coupe axiale: liseré hypoéchogène (*) le long de la paroi osseuse interne (→) hyperéchogène, refoulant la graisse extraconique et le muscle droit interne (DI) (▹). Aspect normal du nerf optique (n). Orbite droite (OD) coupe axiale: DI (▹) contre la paroi osseuse (→).

Figure 3.
Case no 8. Right ethmoiditis with postseptal involvement. US. LO: normal. RO: rounded lesion (*) abutting the medial orbital wall (→) with lateral displacement of the MRM (▹). CT (not shown) showed a subperiostal abscess.
Cas no 8. Ethmoïdite droite avec collection rétroseptale. Échographie. OG: aspect normal. OD: processus occupant arrondi (*) au contact de la paroi osseuse (→) refoulant le muscle DI (▹), qui correspond à la TDM (non montrée) à un abcès sous-périosté.  


Case no 3. Right ethmoiditis without postseptal involvement.o

(Les tableaux sont exclusivement disponibles en format PDF).

 


Case no 9. Right ethmoiditis with subperiosteal abscess.o

(Les tableaux sont exclusivement disponibles en format PDF).

Table I.
Tableau I.

(Les tableaux sont exclusivement disponibles en format PDF).

Table II.
Tableau II.

(Les tableaux sont exclusivement disponibles en format PDF).



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[4] Harboun-Cohen E, Véricel R, Bobin S. Ethmoïdites. Éditions techniques. Encycl Méd Chir (Paris-France), Oto-Rhino-Laryngologie, 20-440-A-10, 1992,9 p.

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[7] Jackson K, Baker SR, Arbor A. Clinical implications of orbital cellulitis. Laryngoscope 1986;96:568-74.

[8] Israele V, Nelson JD. Periorbital and orbital cellulitis. The Pediatr Infect Dis J 1987;6:404-10.

[9] Flament J, Kunnert-Speeg CL, Bourjat P. Les affections inflammatoires de l'orbite. Encycl Méd Chir (Paris-France), Ophtalmologie, 21-620-A-10, 1988, 9 p.

[10] Skedros DG, Haddad J, Bluestone CD, Curtin HD. Subperiosteal orbital abscess in children: Diagnosis, microbiology, and management. Laryngoscope 1993;103:28-32.

[11] Page EL, Wiatrak BJ. Endoscopic vs external drainage of orbital subperiosteal abscess. Arch Otolaryngol Head Neck Surg 1996;122:737-40.

[12] Hassan M, Garel C, Elmaleh M, Narcy Ph. Techniques et indications des examens d'imagerie en ORL pédiatrique. L'imagerie moderne en ORL. Arnette, édit., Paris, 1994, 25-34.

[13] Fontanel JP, Ferrié JP. Pathologie naso-sinusienne. L'imagerie moderne en ORL. Arnette, édit., Paris, 1994, 201-40.

[14] Berrocal T, De Orbe A, Prieto C et al. US and Color Doppler imaging of ocular and orbital disease in the pediatric age group. RadioGraphics 1996;16:251-72.

[15] Belden CJ, Abbitt PL, .Beadles KA. Color Doppler US of the orbit. RadioGraphics 1995;15:589-608.

[16] Ramji FG, Slovis TL, Baker JD. Orbital sonography in children. Pediatr Radiol 1996;26:245-58.

[17] Poujol J. Échographie. Éditions Techniques. Encycl Méd Chir (Paris-France), Ophtalmologie, 1992, 14 p.

[18] Berges O, Torrent M. Échographie de l'œil et de l'orbite. Vigot, édit., Paris, 1986.


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