ABSTRACT
Objective: This review aims to investigate and compare the effectiveness of endoscopic drainage techniques against external drainage techniques for the treatment of orbital and subperiosteal abscesses as a complication of rhinosinusitis.
Introduction: Transnasal endoscopic drainage and external drainage techniques have been used in the management of subperiosteal orbital abscesses secondary to rhinosinusitis. Each of these approaches has its own advantages and disadvantages, with extensive literature describing each technique separately. However, there is a lack of guidance in the studies on assessing and comparing the safety, effectiveness and suitability of these techniques. This review aims to compare the effectiveness of these techniques based on measuring outcomes in the literature such as: length of postoperative hospital stay, rate of revision surgery and complication rates.
Inclusion criteria: Eligible studies will include people of all ages diagnosed with subperiosteal abscess, orbital abscess or cavernous sinus thrombosis (Chandler stages III-V) secondary to rhinosinusitis disease, who have also undergone drainage via either an endoscopic approach, external approach or combined surgical approach.
Methods: A comprehensive search of both published and unpublished literature will be performed to uncover studies meeting the inclusion criteria. Reference lists of studies included in final analyses will also be manually searched and subject matter experts contacted to investigate other sources of literature. Two reviewers will screen studies and a third reviewer will resolve disagreements. Studies will, where possible, be pooled in statistical meta-analysis with heterogeneity of data being assessed using the standard Chi-squared and I2 tests.
Article Content
Introduction
Rhinosinusitis is defined as symptomatic inflammation of the nasal mucosa and paranasal sinuses.1 Symptoms include nasal obstruction, mucopurulent discharge, facial pressure and fullness, and anosmia.2,3 It is a common condition with a prevalence of 12.6% in the US,4 10.9% in Europe,5 8% in China6 and 8.4% in Australia.7 It is one of the most common primary care presentations in Australia, with 1.4 of every 100 visits being for management of acute and chronic rhinosinusitis.8 There has been a four-fold decrease in rhinosinusitis complications in developed countries since the 1950 s, associated with increasing antibiotic treatment.9 Nonetheless, orbital complications are reported to occur in 5-7% of patients with acute rhinosinusitis.10-12 Orbital complications are ocular emergencies presenting as pre-septal (periorbital) or post-septal (orbital) cellulitis, subperiosteal abscess or orbital abscess. These emergencies can then progress to life-threatening complications, such as cavernous sinus thrombosis, meningitis and brain abscess.13
The paranasal sinuses are air-filled spaces surrounding the nasal cavity, comprising the maxillary, ethmoid, frontal and sphenoid sinuses. The ethmoid sinus is most commonly affected by infection, followed by the maxillary, frontal and sphenoid sinuses, respectively.14-18 The medial wall of the ethmoid sinus contains a paper-thin bony wall called the lamina papyracea, which separates the ethmoid sinus from the orbit. The orbital septum (palpebral fascia) is a piece of fibrous connective tissue separating the preseptal (eyelid) and postseptal compartments (eyeball and neuromuscular components), thereby acting as a barrier against eyelid infections progressing to the orbit.19,20 The subperiosteal space is a potential space located between the periorbita (periosteum of orbital bone) and bony orbital wall in which abscesses can develop.21 Acute bacterial rhinosinusitis is usually preceded by a viral upper respiratory tract infection that leads to nasal mucosal congestion and ostial obstruction, thereby impairing sinonasal drainage and airflow. There is associated mucociliary transport dysfunction with mucus thickening and stasis, all of which promote concordant bacterial infection with pathogens such as Staphylococcus aureus (most common in adults22) and Streptococci (most common in children22). The orbit is susceptible to contiguous spread of infection from the surrounding paranasal sinuses. Congenital or acquired Zuckerhandl dehiscences of the lamina papyracea allow for pathogens to penetrate through to the orbit from the ethmoid sinus.23 Infection may also traverse through the anterior and posterior ethmoid neurovascular foramina.23 The valveless orbital venous drainage system allows for both anterograde and retrograde dissemination of bacteria, thereby enabling thrombophlebitis formation.23 The combination of these factors allows for the propagation of an infectious and inflammatory process through to the orbit, with the medial wall of the orbit being the most common region for orbital abscess and subperiosteal abscess formation.21 Once there is orbital infection, the disease can spread intracranially to the cavernous sinus and contralateral eye through the cavernous sinus dura mater which is contiguous with the orbital periosteum.24
Orbital complications of acute rhinosinusitis most commonly affect younger children under the age of 10, with orbital cellulitis presenting at a mean age of 7.2 years.25-28 Children younger than nine years of age tend to develop singular aerobic infections while older children and adolescent patients are more predisposed to polymicrobial infections.25 One explanation for this is that in older children there is sinus cavity maturation without the accordant enlargement of the ostia, which fosters anaerobic conditions and promotes sequestration and growth of aerobic and anaerobic pathogens.28
Identifying clinical features of orbital complications can be challenging, particularly in children where history taking is difficult.29 Common clinical features include eyelid edema, conjunctival chemosis, ophthalmoplegia, visual acuity changes, diplopia, painful eye movements, orbital proptosis and globe displacement. Cavernous sinus thrombosis is an uncommon yet devastating intracranial complication that presents with decreased visual acuity bilaterally; cranial nerve III, V, VI palsies; prostration; septicemia; and meningism.4,30,31 Computed tomography (CT) imaging is the radiological imaging of choice as it is widely accessible, has a short imaging time, displays bony anatomy detail accurately and provides high spatial resolution images of retrobulbar and intraconal masses.19,32-35 Magnetic resonance imaging (MRI) provides greater soft tissue and vascular detail, and is used to assess for complications such as orbital abscess and cavernous sinus thrombosis.33,36,37
Since the work of Hubert in 1937,38 various classifications stratifying the orbital complications from rhinosinusitis have been developed.38-45 Chandler's classification,43 which was developed in 1970, is the system most commonly used today and chooses to classify infections based on their anatomical location within the periorbita, sinuses and cranium (see Table 1). The categories provide an important indicator of morbidity and mortality with a progression in severity from pre-septal infection to the deadly cavernous sinus thrombosis.
Management of the orbital complications of rhinosinusitis involves hospitalization with involvement of pediatricians, ophthalmologists, otorhinolaryngologists and infectious disease physicians. All patients with clinical symptoms fitting in Chandler's classification system are normally provided with intravenous antibiotics. The treatment of Chandler stages I (pre-septal cellulitis) and II (post-septal cellulitis) solely involves medical treatment. This most commonly includes the commencement of intravenous broad-spectrum antibiotics with additional use of nasal decongestant therapy and intravenous steroids. A common antibiotic regime for treatment of the orbital complications of sinusitis involves the combination of a beta-lactamase resistant penicillin, clindamycin and a third-generation cephalosporin, such as ceftriaxone.23 The evolving presence of Methicillin-resistant Staphylococcus aureus (MRSA) has also necessitated the use of vancomycin as appropriate. Concurrent treatment of sinusitis is important when treating the orbital complications associated with it. Nasal saline irrigation and decongestants has been demonstrated to improve sinonasal drainage and subperiosteal abscess treatment outcomes.46,47 Corticosteroid use in orbital complications of sinusitis continues to be debated due to the risk of disease progression from immunosuppression. Yet, they are associated with a reduction in scarring, inflammatory cytokines and mucosal edema.48-52 This is particularly useful for reducing inflammation from bacterial lysis following antibiotic therapy.53 When used as an antibiotic adjunct, corticosteroids can decrease the incidence of adhesions, sinus swelling and stenosis, thereby improving surgical outcomes for subperiosteal abscesses.53-55
The majority of orbital infections secondary to sinusitis will resolve with medical management. However, when there is minimal symptom resolution with medical therapy, surgical intervention may be required. Chandler's original classification system identifies that subperiosteal abscess (Chandler stage III) and orbital abscess (Chandler stage IV) require surgical drainage.43 There have been various recommendations as to when surgical intervention is necessary. Younis17 and Harris28 have suggested various parameters for surgical drainage. They include worsening visual acuity, ophthalmoplegia, severe orbital complications (e.g. blindness, afferent pupillary defect), frank orbital abscess or large subperiosteal abscess formation, and lack of clinical improvement within 48 hours of medical management.
The management of medial subperiosteal abscesses (Chandler stage III) remains contentious, with a lack of consensus as to whether surgical drainage is required, particularly in children. Souliere's56 retrospective case series suggested that subperiosteal abscesses may be managed with 48 hours of antibiotics in the absence of any deteriorating ophthalmological symptoms and signs, intracranial extension or systemic toxicity. Parameters such as proptosis, patient age and abscess size have been suggested as predictors for surgical intervention.26,28,34,46,57-59 Rahbar's57 multivariate analysis of a retrospective series suggested that proptosis itself is the only indicator for surgery. Oxford's26 data also supported this, with 55% of medically treated patients having proptosis greater than 2 mm. Age is another conflicting predictor with several studies suggesting older children were more likely to undergo surgical drainage due to the increased risk of polymicrobial infections.28,46,58,59 However, Oxford's26 findings did not find any statistical difference in age for the medically and surgically treated patients in the study. Abscess size is a more consistent predictor for surgery, with both Oxford26 and Ryan34 reporting significantly greater abscess width in surgically treated compared to medically managed patients. In lieu of the results, Oxford26 suggested criteria of normal vision, no ophthalmoplegia, intraocular pressure < 20 mmHg, proptosis <= 5 mm, and abscess width <= 4 mm as suitable indications for medical therapy.
The surgical techniques aimed at draining subperiosteal (Chandler stage III) or orbital abscesses (Chandler stage IV) include an external approach via a skin or conjunctival incision, a transnasal endoscopic approach or a combination of both.60,61 The approach taken depends on the skillset of the surgeon, abscess location and extraocular muscle involvement. Tanna et al.'s61 retrospective case series showed that abscesses involving external drainage were more likely to involve the medial rectus, superior rectus and superior oblique muscles. Several studies report the transnasal endoscopic approach as an appropriate technique for medially positioned abscesses61-65 whilst superomedial or superior abscesses should be drained via an external approach alone26,66 or a combined approach.62,67,68 Superiorly based abscesses can be difficult to access endoscopically due to their anatomical position. As such, there are difficulties in gaining adequate drainage, which predisposes disease relapse and the need for a second operation.26,63,66,69-75 Roithmann et al.,76 however, describe a transnasal endoscopic approach with special care needing to be taken to avoid the anterior ethmoidal artery. External drainage or a combined approach are recommended for abscesses extending laterally towards the roof or floor of the orbit.77 Some studies suggest that irrespective of the location of the abscess, a transnasal endoscopic approach is sufficient in treating the pathology.62,78 One center favored external drainage over an endoscopic approach for abscesses with extraocular involvement.61
There are a variety of external skin or conjunctival incisions that may be made, dependent on the location of the abscess. Such techniques include the Lynch-Howarth/Modified Lynch Approach and transcaruncular approach for medial abscesses, sub-brow incision for superior abscesses, and sub-ciliary incision and subconjunctival approach for inferior abscesses.79 The traditional approach for drainage of a medial orbital collection is via a Lynch-Howarth or Modified Lynch incision that allows for an external ethmoidectomy to be performed under general anesthesia. Dissection is performed towards the subperiosteal space, where a penrose drain is inserted to drain the abscess. Advantages of this approach include that it provides the most direct route to the abscess and offers good visualization of the loculations. The incision can also be extended superiorly in the event of frontal sinus involvement or a superior compartment abscess.80 Disadvantages of this technique are that it necessitates a facial scar, potential webbing, delayed healing and suture abscess.18,63,79,81,82
The advent of endoscopic sinus surgery by Messerklinger's cadaveric study in 1978 and development of techniques by Messerklinger83 and Stammberger84 and Lusk85 have allowed for minimally invasive approaches to treat orbital complications of sinusitis. The majority of abscesses treated via a solitary endoscopic approach, are located medially and involve drainage of the abscess and contributing infected paranasal sinus. Manning et al.60 were the first to advocate for the use of endoscopic approaches in draining subperiosteal abscesses in children. The procedure is performed under general anesthesia where an endoscopic uncinectomy is performed followed by widening of the maxillary sinus ostium so as to provide access to drainage of any maxillary sinus disease.60 Using curettage, the anterior and posterior ethmoid cells are removed and the lamina papyracea is resected to allow for drainage.79 There are differing views on how much of the lamina papyracea to resect with much research recommending a conservative endoscopic approach to reduce the risk of postoperative facial skeleton growth retardation.62,73,74,86 Conversely, an extensive resection of the lamina papyracea is proposed to prevent incomplete drainage and pus reaccumulation.75 Several advantages to this technique include concurrent drainage of the abscess and infected paranasal sinus, avoidance of a facial scar, inferior morbidity, and shorter hospital stay in comparison to external drainage.78,79,87-90 Disadvantages of this approach include medial rectus muscle or optic nerve damage, poor visibility secondary to hyperemic mucosal bleeding, limited manoeuvrability within small nasal passages, and inadequate drainage requiring a second operation.67,71,80,88,89,91-94
A preliminary search of the JBI Database of Systematic Reviews and Implementation Reports, the Cochrane Library, MEDLINE, Embase and CINAHL revealed no systematic review protocols or review reports investigating this topic.
The purpose of this systematic review is to evaluate the effectiveness of external drainage techniques compared to endoscopic drainage techniques in the management of orbital complications. It aims to identify the best treatment approach with the lowest rate of complications and revision surgery. Transnasal endoscopic drainage is considered to be a safe procedure with decreased morbidity, improved cosmesis and shorter hospital stay. However, it has also been proposed to have an increased rate of incomplete drainage requiring a subsequent operation. Although there is extensive literature describing endoscopic or external drainage techniques separately, there is a lack of guidance in these studies for assessing the safety, effectiveness and suitability of each technique in treating various forms of subperiosteal and orbital abscesses. There is also a lack of studies directly comparing the safety and effectiveness of external approaches against endoscopic drainage. Hence, this review aims to compare the effectiveness of these techniques based on measuring outcomes of length of postoperative hospital stay, rate of revision surgery and complication rates in the literature. We hope the findings from our review may have clinical impact in the surgical management of orbital complications by reducing hospital costs through decreased hospital stays and operating theatre costs, lower hospital re-presentations, fewer medical specialists required in the patient's care, and avoidance of any cosmetic deformities in young children and adults.
Review question
What is the effectiveness of endoscopic compared to external surgical approaches in the treatment of orbital and subperiosteal abscesses as a complication of rhinosinusitis?
Inclusion criteria
Participants
The participants to be included in the review include people of all ages who have been diagnosed with subperiosteal abscess, orbital abscess or cavernous sinus thrombosis (Chandler stages III-V) secondary to rhinosinusitis disease. This may be with or without the support of computed tomography or magnetic resonance imaging. The participants involved must also undergo abscess drainage via either an endoscopic approach, external approach or combined surgical approach.
Exclusion criteria include patients with a mucocele or pyocele in the paranasal sinuses, history of active malignancy, history of maxillofacial trauma, previous organ transplantation, cases of orbital abscess and subperiosteal abscess without paranasal sinus disease etiology, anatomical abnormalities of the orbit or paranasal sinuses, post-traumatic sinusitis, immunosuppressive states, and cases of Chandler stages I and II orbital complications of sinusitis.
Interventions
This review will consider studies that evaluate endoscopic drainage with or without medical therapy, and combined approach (endoscopic plus external drainage) with or without medical therapy.
Comparator
This review will consider studies that compare the intervention to external drainage with or without medical therapy.
Outcomes
This review will consider studies that include the following outcomes:
* Number of postoperative days in hospital
* Length of inpatient stay in hospital in days
* Surgical failure rate/rate of revision surgery within 12 weeks post-surgery
* Complication rate (e.g. blindness and visual loss, ptosis, surgical damage to orbital structures, hemorrhage, intracranial sepsis, facial scarring, stitch abscess, diplopia, enophthalmos)
* Rate of cure of symptoms.
Types of studies
The review will consider both experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental studies, before and after studies, prospective and retrospective cohort studies. Studies will only be included if they have a sample size of five patients or greater.
Studies published in English will be included. Studies published from 1978 to present will be included.
Methods
The proposed systematic review will be conducted in accordance with the Joanna Briggs Institute methodology for systematic reviews of effectiveness evidence.95
Search strategy
The search strategy will aim to locate both published and unpublished studies. An initial limited search of MEDLINE and CINAHL was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles, were used to develop a full search strategy for MEDLINE (PubMed) database (see Appendix I). The search strategy, including all identified keywords and index terms, will be adapted for each included information source. The reference lists of all studies selected for critical appraisal will be screened for additional studies.
Information sources
The databases to be searched include: MEDLINE (PubMed), CINAHL, Embase and Scopus. Gray literature will be searched through Cochrane Central Register of Controlled Trials (CENTRAL) and ProQuest.
Study selection
Following the search, all identified citations will be collated and uploaded into EndNote (Clarivate Analytics, PA, USA) with duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and their citation details imported into JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; Joanna Briggs Institute, Adelaide, Australia). The full text of selected studies will be retrieved and assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full text studies that do not meet the inclusion criteria will be recorded and reported in the systematic review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion, or with a third reviewer. The results of the search will be reported in full in the final report and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.96
Assessment of methodological quality
Eligible studies will be critically appraised by two independent reviewers at the study level for methodological quality in the review using the standardized critical appraisal instruments from JBI for experimental and quasi-experimental studies.97 Authors of papers will be contacted to request missing or additional data for clarification, where required. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. The results of critical appraisal will be reported in narrative form and in a table.
All studies, regardless of their methodological quality, will undergo data extraction and synthesis (where possible).
Data extraction
Data will be extracted manually from studies included in the review by two independent reviewers using the standardized JBI data extraction tool in JBI SUMARI supplemented by Microsoft Excel (Redmond, Washington, USA). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. These parameters include age, sex, temperature, white cell count, C-reactive protein, symptom profile (e.g. diplopia, vision loss, chemosis, swelling, ocular motility changes), signs (e.g. proptosis, visual acuity changes), antibiotics used, steroid use, Chandler classification of orbital complications of sinusitis, abscess location, abscess size, location of affected sinus, microorganism identified on pus culture, symptom duration before surgery (days), surgical approach, length of hospitalization (days), length of postoperative stay (days), rate of revision surgery, revision surgery surgical approach, complication rate (e.g. blindness and visual loss, ptosis, surgical damage to orbital structures, hemorrhage, intracranial sepsis, facial scarring, stitch abscess, diplopia, enophthalmos), and follow-up (weeks). Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.
Data synthesis
Studies will, where possible, be pooled in statistical meta-analysis using JBI SUMARI, Cochrane's RevMan (Copenhagen: The Nordic Cochrane Centre, Cochrane) or StatsDirect (Cambridge, UK). For head to head comparisons, effect sizes will be expressed as either odds ratios (for dichotomous data) or weighted (or standardized) mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard chi-squared and I2 tests. The choice of model (random or fixed effects) and method for meta-analysis will be based on the guidance by Tufanaru et al.98 Subgroup analyses will be conducted where there is sufficient data. Subgroups of interest for this systematic review are based on Chandler's classification grading, anatomical location of the subperiosteal abscess, age of patients, diagnostic imaging modalities used, and time taken from admission to surgery. Sensitivity analyses will be conducted to test decisions made regarding the model analysis and the impact of low-compared to high-quality studies (according to the results of critical appraisal). Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation, where appropriate.
A funnel plot will be generated to assess publication bias if there are 10 or more studies included in a meta-analysis. Statistical tests for funnel plot asymmetry (Egger test, Begg test, Harbord test) will be performed where appropriate. Where comparative data is not available, single-group proportional meta-analysis will be conducted for dichotomous data with data transformed using the Freeman-Tukey method in a random effects model using the DerSimonian-Laird approach.99,100 Single group weighted or standardized means will be calculated where feasible for continuous data.
Assessing certainty in the findings
The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach for grading the certainty of evidence will be followed101 and a Summary of Findings (SoF) will be created using GRADEPro GDT 2015 (McMaster University, ON, Canada). The SoF will present the following information where appropriate: absolute risks for the treatment and control, estimates of relative risk, and a ranking of the quality of the evidence based on the risk of bias, directness, heterogeneity, precision and risk of publication bias of the review results. The outcomes reported in the SoF will be:
* Number of postoperative days in hospital
* Length of inpatient stay in hospital in days
* Surgical failure rate/rate of revision surgery within 12 weeks post-surgery
* Complication rate (e.g. blindness and visual loss, ptosis, surgical damage to orbital structures, hemorrhage, intracranial sepsis, facial scarring, stitch abscess, diplopia, enophthalmos
* Rate of cure of symptoms.
Acknowledgments
The authors acknowledge and thank Ms Vikki Langton (Librarian) for her contribution, guidance and feedback in developing a search strategy.
Appendix I: Search strategy for PubMed
Search conducted on 17 February 2019
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