{"id":54398,"date":"2023-12-31T10:32:39","date_gmt":"2023-12-31T10:32:39","guid":{"rendered":"https:\/\/biomedpharmajournal.org\/?p=54398"},"modified":"2024-01-05T06:58:49","modified_gmt":"2024-01-05T06:58:49","slug":"early-endoscopic-sinus-surgery-versus-antibiotics-alone-for-orbital-cellulitis-from-acute-rhinosinusitis-a-retrospective-cohort-study","status":"publish","type":"post","link":"https:\/\/biomedpharmajournal.org\/staging\/vol16no4\/early-endoscopic-sinus-surgery-versus-antibiotics-alone-for-orbital-cellulitis-from-acute-rhinosinusitis-a-retrospective-cohort-study\/","title":{"rendered":"Early Endoscopic Sinus Surgery Versus Antibiotics Alone for Orbital Cellulitis from Acute Rhinosinusitis \u2013 A Retrospective Cohort Study"},"content":{"rendered":"\n

Background<\/strong><\/p>\n\n\n\n

Orbital cellulitis is a common complication of acute rhinosinusitis caused by the spreading of the organism from the sinus to the orbit.(1)<\/sup> 74-85% of orbital cellulitis was arising from acute rhinosinusitis. Other etiologies were lacrimal sac infection, eye foreign body, eye trauma, dental infection, endophthalmitis, previous eye surgery, eye tumors, and local skin inflammation.(2, 3)<\/sup> <\/p>\n\n\n\n

The ethmoid sinus is a common site of infection that spreads into the eye socket due to the ethmoid sinus and the orbit is only separated by a thin layer of bone i.e., lamina papyracea.(4)<\/sup> Infection from other sinuses may spread to the orbit by local thrombophlebitis. Although orbital cellulitis has a relatively low incidence, it can cause serious complications such as vision loss, intracranial infection, and even death.(5)<\/sup>  <\/p>\n\n\n\n

In the past when antibiotics were not widely used, morbidity and mortality of orbital cellulitis from acute rhinosinusitis were 20.5% and 17% respectively.(6)<\/sup> At present, the morbidity and mortality were reduced to 3-11% and 1-2.5% respectively.(7)<\/sup> The common bacterial pathogens found included Streptococcus spp<\/em>., Staphylococcus aureus<\/em>, anaerobic\/facultative gram-negative rods, and anaerobic gram-positive cocci.(8)<\/sup><\/p>\n\n\n\n

The current standard treatment for orbital cellulitis from acute rhinosinusitis is to administer intravenous antibiotics and closely monitor the visual acuity. Surgery will be considered in the patients who had been given intravenous antibiotics, and whose condition worsens or does not improve within 24-48 hours.(9)<\/sup> Surgery is performed to drain pus and correct inflammation, including widening of sinus obstruction.(1, 4)<\/sup> The surgery can be performed by external approach or endoscopic approach.<\/p>\n\n\n\n

The intravenous antibiotics had a treatment failure rate of up to 40 percent.(10)<\/sup> Due to this reason, a recent study advocated early surgical intervention when the patients present with some markers for severe orbital cellulitis.(11)<\/sup> Another study also found that from 2008 to 2013, the trend of surgical intervention was increasing.(12)<\/sup><\/p>\n\n\n\n

In\nthis study, we explored the benefit of early endoscopic sinus surgery to\nimprove the clinical outcome of the patients. The objective of this study was to\nstudy the clinical outcomes of orbital cellulitis from acute rhinosinusitis\npatients who were treated with early endoscopic sinus surgery (within 48 hours\nafter admission) versus antibiotics alone.<\/p>\n\n\n\n

Methods<\/strong><\/p>\n\n\n\n

Study design\nand setting<\/strong><\/p>\n\n\n\n

We conducted the retrospective\nCohort study comparing early endoscopic sinus surgery (within 48 hours after\nadmission) versus antibiotics alone in orbital cellulitis from acute\nrhinosinusitis patients. We collected the data from the Otorhinolaryngology\nDepartment, Khon Kaen Hospital, Thailand from January 2013 to May 2023.<\/p>\n\n\n\n

Inclusion\nand exclusion criteria<\/strong><\/p>\n\n\n\n

The inclusion criteria were orbital\ncellulitis from acute rhinosinusitis patients. The exclusion criteria were the\npatients who cannot trace medical records, diagnosed with sinonasal or\nnasopharyngeal carcinoma, and existing eye diseases.<\/p>\n\n\n\n

Data\nCollection<\/strong><\/p>\n\n\n\n

Information retrieved from the patient\u2019s\nadmission records included gender, age, underlying diseases, symptoms and\nsigns, eye symptoms, white blood cell count, finding in CT paranasal sinus and\norbit, treatment modality, antibiotics received, duration of hospital stay,\nduration of intravenous antibiotic administration, signs, and symptoms\nimprovement at 48 hours after admission.<\/p>\n\n\n\n

All patients are given intravenous\nantibiotics. Pre-operative CT scan of the paranasal sinus was performed in the\ncase underwent endoscopic sinus surgery. All patients were closely monitored\nfor eye symptoms. If the symptoms worsen or do not improve 48 hours after\nadmission, they will be treated with endoscopic sinus surgery.<\/p>\n\n\n\n

Definition\nof improvement<\/strong><\/p>\n\n\n\n

The definition of improvement at 48\nhours after admission was defined as no fever at 48 hours after admission and\nimprovement of clinical signs such as proptosis, chemosis, visual impairment,\nand ophthalmoplegia.<\/p>\n\n\n\n

Statistical\nAnalysis<\/strong><\/p>\n\n\n\n

The analysis was done using Stata software (version 9, StataCorp LP, Texas, USA). Continuous. For the continuous outcomes, we test the hypothesis using the unpaired t-test or Mann-Whitney U test. For the categorical outcomes, we test the hypothesis using Pearson’s \u03c72-test.<\/p>\n\n\n\n

The odds ratio was used to evaluate the clinical efficacy of endoscopic sinus surgery compared to intravenous antibiotics alone. The p-value of < 0.05 was considered statistically significant.<\/p>\n\n\n\n

Ethics<\/strong><\/p>\n\n\n\n

Approval was sought from the Khon\nKaen Hospital Ethics Committee for Human Research before initiating the study (ID: KEXP66047). The need for informed consent was waived by the\nethics review board according to the nature of a retrospective study.<\/p>\n\n\n\n

Results<\/strong><\/p>\n\n\n\n

There was a total of 77 patients\nwith orbital cellulitis secondary to acute rhinosinusitis. Of these 32 were\nmales (41.56%), and 45 were females (58.44%). The mean age for all patients was\n43.7 years (range 1-82 years). The most common underlying diseases were\ndiabetes and hypertension. The most common symptoms and signs were periorbital\nswelling and chemosis.<\/p>\n\n\n\n

The side of orbital cellulitis\nbetween group and sinus involvement were comparable between groups (p >\n0.05). However, the early endoscopic sinus surgery group had a significantly\nhigher white blood cell count (p = 0.004) (Table 1)<\/p>\n\n\n\n

Table 1:  Demographic data.<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
\n

 <\/strong><\/p>\n<\/td>\n

\n

Early sinus surgery<\/strong><\/p>\n

(n=44)<\/strong><\/p>\n<\/td>\n

\n

Antibiotics alone<\/strong><\/p>\n

(n=33)<\/strong><\/p>\n<\/td>\n

\n

p-value<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Sex (n, percent)<\/strong><\/p>\n<\/td>\n

\n<\/td>\n\n<\/td>\n\n<\/td>\n<\/tr>\n
\n

–        Male<\/p>\n<\/td>\n

\n

18 (40.91)<\/p>\n<\/td>\n

\n

14 (42.42)<\/p>\n<\/td>\n

\n

0.894<\/p>\n<\/td>\n<\/tr>\n

\n

–        Female<\/p>\n<\/td>\n

\n

26 (59.09)<\/p>\n<\/td>\n

\n

19 (57.58)<\/p>\n<\/td>\n

\n<\/td>\n<\/tr>\n
\n

Age (mean, SD)<\/strong><\/p>\n<\/td>\n

\n

45.82 (23.32)<\/p>\n<\/td>\n

\n

40.88 (23.64)<\/p>\n<\/td>\n

\n

0.363<\/p>\n<\/td>\n<\/tr>\n

\n

Underlying disease (n, percent)<\/strong><\/p>\n<\/td>\n

\n<\/td>\n\n<\/td>\n\n<\/td>\n<\/tr>\n
\n

–        DM<\/p>\n<\/td>\n

\n

16 (36.36)<\/p>\n<\/td>\n

\n

9 (27.27)<\/p>\n<\/td>\n

\n

0.276<\/p>\n<\/td>\n<\/tr>\n

\n

–        AIDS<\/p>\n<\/td>\n

\n

0 (0.00)<\/p>\n<\/td>\n

\n

2 (6.06)<\/p>\n<\/td>\n

\n

0.387<\/p>\n<\/td>\n<\/tr>\n

\n

–        CKD<\/p>\n<\/td>\n

\n

2 (4.55)<\/p>\n<\/td>\n

\n

2 (6.06)<\/p>\n<\/td>\n

\n

0.762<\/p>\n<\/td>\n<\/tr>\n

\n

–        Others<\/p>\n<\/td>\n

\n

6 (13.64)<\/p>\n<\/td>\n

\n

5 (15.15)<\/p>\n<\/td>\n

\n

0.839<\/p>\n<\/td>\n<\/tr>\n

\n

Symptoms and signs (n, percent)<\/strong><\/p>\n<\/td>\n

\n<\/td>\n\n<\/td>\n\n<\/td>\n<\/tr>\n
\n

–        Periorbital swelling<\/p>\n<\/td>\n

\n

42 (95.45)<\/p>\n<\/td>\n

\n

32 (96.97)<\/p>\n<\/td>\n

\n

0.734<\/p>\n<\/td>\n<\/tr>\n

\n

–        Chemosis<\/p>\n<\/td>\n

\n

42 (95.45)<\/p>\n<\/td>\n

\n

31 (93.94)<\/p>\n<\/td>\n

\n

0.767<\/p>\n<\/td>\n<\/tr>\n

\n

–        Ophthalmoplegia<\/p>\n<\/td>\n

\n

24 (54.55)<\/p>\n<\/td>\n

\n

15 (45.45)<\/p>\n<\/td>\n

\n

0.430<\/p>\n<\/td>\n<\/tr>\n

\n

–        Proptosis<\/p>\n<\/td>\n

\n

19 (43.18)<\/p>\n<\/td>\n

\n

10 (30.30)<\/p>\n<\/td>\n

\n

0.248<\/p>\n<\/td>\n<\/tr>\n

\n

–        Visual impairment<\/p>\n<\/td>\n

\n

9 (20.45)<\/p>\n<\/td>\n

\n

6 (18.18)<\/p>\n<\/td>\n

\n

0.803<\/p>\n<\/td>\n<\/tr>\n

\n

Side of eye (n, percent)<\/strong><\/p>\n<\/td>\n

\n<\/td>\n\n<\/td>\n\n

\n<\/p><\/td>\n<\/tr>\n

\n

–        Left<\/p>\n<\/td>\n

\n

23 (52.27)<\/p>\n<\/td>\n

\n

19 (57.58)<\/p>\n<\/td>\n

\n

0.644<\/p>\n<\/td>\n<\/tr>\n

\n

–        Right<\/p>\n<\/td>\n

\n

21 (47.73)<\/p>\n<\/td>\n

\n

14 (42.42)<\/p>\n<\/td>\n

\n

\n<\/p><\/td>\n<\/tr>\n

\n

Sinus involvement (n, percent)<\/strong><\/p>\n<\/td>\n

\n<\/td>\n\n<\/td>\n\n<\/td>\n<\/tr>\n
\n

–        Frontal<\/p>\n<\/td>\n

\n

19 (43.18)<\/p>\n<\/td>\n

\n

10 (30.30)<\/p>\n<\/td>\n

\n

0.248<\/p>\n<\/td>\n<\/tr>\n

\n

–        Maxillary<\/p>\n<\/td>\n

\n

36 (81.82)<\/p>\n<\/td>\n

\n

27 (81.82)<\/p>\n<\/td>\n

\n

0.999<\/p>\n<\/td>\n<\/tr>\n

\n

–        Ethmoid<\/p>\n<\/td>\n

\n

38 (86.36)<\/p>\n<\/td>\n

\n

24 (72.73)<\/p>\n<\/td>\n

\n

0.135<\/p>\n<\/td>\n<\/tr>\n

\n

–        Sphenoid<\/p>\n<\/td>\n

\n

22 (50.00)<\/p>\n<\/td>\n

\n

14 (42.42)<\/p>\n<\/td>\n

\n

0.510<\/p>\n<\/td>\n<\/tr>\n

\n

–        Pansinusitis<\/p>\n<\/td>\n

\n

9 (20.45)<\/p>\n<\/td>\n

\n

7 (21.21)<\/p>\n<\/td>\n

\n

0.935<\/p>\n<\/td>\n<\/tr>\n

\n

White blood cell count (n, percent)<\/strong><\/p>\n<\/td>\n

\n<\/td>\n\n<\/td>\n\n<\/td>\n<\/tr>\n
\n

–        < 4,000 cell\/cm<\/p>\n<\/td>\n

\n

0 (0.00)<\/p>\n<\/td>\n

\n

2 (6.06)<\/p>\n<\/td>\n

\n

0.395<\/p>\n<\/td>\n<\/tr>\n

\n

–        4,000 \u2013 10,000<\/p>\n<\/td>\n

\n

11 (25.00)<\/p>\n<\/td>\n

\n

17 (51.52)<\/p>\n<\/td>\n

\n

0.017*<\/p>\n<\/td>\n<\/tr>\n

\n

–        > 10,000<\/p>\n<\/td>\n

\n

33 (75.00)<\/p>\n<\/td>\n

\n

14 (42.42)<\/p>\n<\/td>\n

\n

0.004*<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

* – Statistically significant difference<\/p>\n\n\n

All patients were given the initial empirical antibiotic treatment to cover common pathogens consisting of ceftriaxone and clindamycin, ceftazidime and clindamycin, amoxicillin-clavulanic acid, ampicillin-sulbactam or piperacillin-tazobactam. Within 48 hours surgery was performed in the early endoscopic sinus surgery group.<\/p>\n\n\n\n

At 48 hours, 43 of 44 patients\n(97.73%) in the early endoscopic sinus surgery group improved. However, only 21\nof 33 patients (63.64%) in antibiotics alone improved (Odds ratio 24.57, 95% CI\n2.99 to 201.80, p = 0.003). (Table 2)<\/p>\n\n\n\n

Table 2: Clinical outcome at 48 hours.<\/strong><\/p>\n\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

Early sinus surgery<\/strong><\/p>\n

(N= 44)<\/strong><\/p>\n<\/td>\n

\n

Antibiotics alone<\/strong><\/p>\n

(N = 33)<\/strong><\/p>\n<\/td>\n

\n

Odds ratio<\/strong><\/p>\n

(95% CI)<\/strong><\/p>\n<\/td>\n

\n

p-value<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Improved<\/strong><\/p>\n<\/td>\n

\n

43 (97.73)<\/p>\n<\/td>\n

\n

21 (63.64)<\/p>\n<\/td>\n

\n

24.57<\/p>\n

(2.99 to 201.80)<\/p>\n<\/td>\n

\n

0.003*<\/p>\n<\/td>\n<\/tr>\n

\n

Not improved\/required surgery<\/strong><\/p>\n<\/td>\n

\n

1 (2.27)<\/p>\n<\/td>\n

\n

      12 (36.36)<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

* – Statistically significant difference<\/p>\n\n\n

For the average duration of intravenous antibiotic administration, the early endoscopic sinus surgery group had significantly lesser use of intravenous antibiotics (p = 0.020). However, there was no statistically significant difference in length of stay (p = 0.065). (Table 3)<\/p>\n\n\n\n

The pus culture was positive in 16 of 37 specimens (43.24%). The most common pathogens were Staphylococcus spp<\/em>., Streptococcus spp<\/em>., and Klebsiella spp<\/em>. <\/p>\n\n\n\n

Table 3: Intravenous antibiotics duration and length of stay.<\/strong><\/p>\n\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

Early sinus surgery<\/strong><\/p>\n

(N= 44)<\/strong><\/p>\n<\/td>\n

\n

Antibiotics alone<\/strong><\/p>\n

(N = 33)<\/strong><\/p>\n<\/td>\n

\n

Mean difference<\/strong><\/p>\n

(95% CI)<\/strong><\/p>\n<\/td>\n

\n

p-value<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Intravenous antibiotics duration (mean, SD)<\/strong><\/p>\n<\/td>\n

\n

6.83 (2.99)<\/p>\n<\/td>\n

\n

9.27 (5.88)<\/p>\n<\/td>\n

\n

2.44<\/p>\n

(0.39 to 4.49)<\/p>\n<\/td>\n

\n

0.020*<\/p>\n<\/td>\n<\/tr>\n

\n

Length of stay (mean, SD)<\/strong><\/p>\n<\/td>\n

\n

7.50 (3.64)<\/p>\n<\/td>\n

\n

9.94 (7.55)<\/p>\n<\/td>\n

\n

2.44<\/p>\n

(-0.15 to 5.03)<\/p>\n<\/td>\n

\n

0.065<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

* – Statistically significant difference<\/p>\n\n\n

Discussion<\/strong><\/p>\n\n\n\n

Orbital cellulitis can cause high\nmorbidity and mortality. A careful examination of signs and symptoms of orbital\ncellulitis is important.(13)<\/sup> In this study, the most common\nsymptoms and signs were periorbital swelling and chemosis. The results are\nconsistent with other studies that found that all patients with orbital\ncellulitis would come with periorbital edema and redness. Other symptoms and\nsigns included proptosis, reduced vision, and ophthalmoplegia.(9,\n14)<\/sup><\/p>\n\n\n\n

We found that the orbital cellulitis\nfrom acute rhinosinusitis commonly occurred in males. This finding was\ninconsistent among the literature which one study found this condition more in\nfemales.(15)<\/sup> while another study found this\ncondition more common in males.(16)<\/sup> <\/p>\n\n\n\n

In this study, the origin of\ninfection was found to be commonly from the ethmoid sinus and maxillary sinus\nwhich is comparable with another study.(17)<\/sup> Orbital cellulitis was more prone\nto infect the left eye than the right eye.<\/p>\n\n\n\n

Empirical antibiotics are the\nstandard treatment.(18)<\/sup> The antibiotic should cover common\npathogens such as Staphylococcus spp<\/em>.,\nStreptococcus spp<\/em>., and anaerobes.(19,\n20)<\/sup> The antibiotic should be adjusted\nafterward according to culture and sensitivity results. The most common\npathogens in this study were Staphylococcus\nspp<\/em>., Streptococcus spp<\/em>., and Klebsiella spp<\/em>. <\/p>\n\n\n\n

There was no standard recommendation\nfor surgical intervention in orbital cellulitis from acute rhinosinusitis. This\nstudy found that 43 of 44 patients (97.73%) in the early endoscopic sinus\nsurgery group improved. However, only 21 of 33 patients (63.64%) in antibiotics\nalone improved (Odds ratio 24.57, 95% CI 2.99 to 201.80, p = 0.003).<\/p>\n\n\n\n

In this study, surgery within 48\nhours significantly reduced the intravenous antibiotics used (p = 0.020) and\ncould reduce the length of stay (p = 0.065). These will reduce the cost of\nmedical treatment and the expenses of patients.<\/p>\n\n\n\n

A\nrecent review of the management options for orbital complications from\nrhinosinusitis found that the decision to choose surgery and conservation\napproaches is controversial, especially in subperiosteal abscesses. In orbital\ncellulitis, broad-spectrum antibiotics can improve the symptoms of the patients\nranging from 77 to 100 percent which is comparable to this study which had an antibiotics\nresponse rate of 63.64 percent.(21)<\/sup><\/p>\n\n\n\n

In\nthis study, the early endoscopic sinus surgery group had a significantly higher\nwhite blood cell count representing a more severe feature (p < 0.05). We\ninferred that the benefit (odds ratio) of early sinus surgery will be increased\nif all clinical features are comparable.<\/p>\n\n\n\n

Surgical treatment requires the\nknowledge and expertise of the surgeon. Complications from surgery are also\npossible including blindness and brain damage. The best approach to treatment\nfor this condition is therefore a joint decision of the physician and the\npatient.<\/p>\n\n\n\n

The limitation of this study\nincluded the nature of the retrospective studies which may result in a lack of\ncompleteness of the data. In future studies, we suggest collecting data on a\nforward basis in order to make concrete evidence on early surgical intervention\nin the future. Moreover, exploring the possibility of using tools such as artificial\nintelligence for clinical diagnosis and decision-making processes may be\nuseful.(22)<\/sup><\/p>\n\n\n\n

Conclusions<\/strong><\/p>\n\n\n\n

The early endoscopic sinus surgery\nin orbital cellulitis from acute rhinosinusitis patients may improve clinical\noutcomes, shorter intravenous antibiotics duration, and hospital stay.<\/p>\n\n\n\n

More\nrobust studies are needed to confirm the benefit of early endoscopic sinus\nsurgery such as a larger sample size study or a randomized controlled trial.<\/p>\n\n\n\n

Acknowledgement<\/strong><\/p>\n\n\n\n

None<\/p>\n\n\n\n

Conflict of Interest<\/strong><\/p>\n\n\n\n

There are no conflict of interest.<\/p>\n\n\n\n

Funding Source <\/strong><\/p>\n\n\n\n

There is no funding sources<\/p>\n\n\n\n

References<\/strong><\/p>\n\n\n\n

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