|Year : 2013 | Volume
| Issue : 1 | Page : 32-36
Successful endoscopic management with Mitomycin C application for sinusitis with orbital cellulitis
Anil S Harugop, RS Mudhol, Rishav Garg, VG Ashwin, S Ganesh
Department of ENT and HNS, J. N. Medical College, Belgaum, Karnataka, India
|Date of Web Publication||28-Mar-2013|
Anil S Harugop
Department of ENT and HNS, J. N. Medical College, Belgaum - 590 010
Source of Support: None, Conflict of Interest: None
Background: Sinusitis with orbital complication is a potentially fatal disease that has been known since the days of Hippocrates. Primary sinus infection is the most common cause of orbital cellulitis. It is an emergency that threatens not only vision but also life from complications such as meningitis, cavernous sinus thrombosis, and brain abscess. Surgical intervention is mandatory whenever antibiotic treatment fails. There are two surgical options for the drainage, an external approach via a Lynch incision and an intranasal endoscopic procedure. Materials and Methods: Five patients with orbital cellulitis secondary to acute on chronic rhinosinusitis were included in the study from the period of 2010 - 2011. All five patients did not respond to medical management and hence underwent endoscopic sinus surgery with treatment of orbital pathology. At the end of the surgical procedure Mitomycin C in a concentration of 0.4mg/ml was applied with a cottonoid for a period of 4 minutes to prevent chance of adhesion formation. Results: In this series 3 females and 2 male patient with orbital cellulitis secondary to acute on chronic rhinosinusitis underwent endoscopic sinus surgery with treatment of orbital pathology. All 5 patients showed subjective and objective improvement within one week of endoscopic management. Conclusion: Though antibiotics have altered the course of sinusitis, its grave complications still persist in our environment. The excellent results and the absence of any major complications of endoscopic sinus surgery and drainage of abscess with application of Mitomycin C can be recommended as the preferred surgical technique.
Keywords: Complication of sinusitis, endoscopic surgery, Mitomycin C application, orbital cellulitis, sinusitis
|How to cite this article:|
Harugop AS, Mudhol R S, Garg R, Ashwin V G, Ganesh S. Successful endoscopic management with Mitomycin C application for sinusitis with orbital cellulitis. J Sci Soc 2013;40:32-6
|How to cite this URL:|
Harugop AS, Mudhol R S, Garg R, Ashwin V G, Ganesh S. Successful endoscopic management with Mitomycin C application for sinusitis with orbital cellulitis. J Sci Soc [serial online] 2013 [cited 2020 Apr 8];40:32-6. Available from: http://www.jscisociety.com/text.asp?2013/40/1/32/109693
| Introduction|| |
Acute on chronic sinusitis of the ethmoid and maxillary complex is the most frequent cause of subperiosteal abscess (SPA). The close anatomical relationship of the orbit to the paranasal sinuses predisposes to the contiguous spread of infection through the ophthalmic venous system which anastomoses freely with the facial, pterygoid, and cranial nerve system.  Primary sinus infection is the most common cause of orbital cellulitis.  Infection of the sinuses spreads to the orbit either by direct extension through the thin bone (lamina papyracea) found in the lateral wall of the ethmoid complex, the floor of the frontal sinus, and roof of the maxillary antrum and local thrombophlebitis or by infected thrombi along valveless venous connections. , Complications are more frequent due to ethmoiditis, and in adults, the frontal sinus is frequently responsible. Retrograde spread of infection can lead to complications such as endophthalmitis, cavernous sinus thrombosis, meningitis, brain abscess, or death.  Once the clinical diagnosis of SPA is made, axial and coronal computed tomography (CT) scan views should be obtained of the sinuses and intravenous antibiotic treatment is begun. Though antibiotics have altered the course of sinusitis, its grave complications still persist in our environment. Currently, surgical intervention is recommended after 24-48 h of intravenous antibiotic therapy has failed and there is progression of orbital changes.  There are two surgical options for the drainage: An external approach via a Lynch incision and an intranasal endoscopic procedure. The excellent results and the absence of any major complications of endoscopic sinus surgery and drainage of abscess make it an effective alternative for external approach. 
The topical application of Mitomycin C may help to reduce the chances of adhesion formation.  The study was taken up to know the effectiveness of sinus surgery in management of orbital complications and the role of Mitomycin C in preventing adhesion formation. ,
| Case Reports|| |
The patients were admitted at KLE's Hospital and MRC, Belgaum. Patients' informed consent was taken and the risks were explained in their own language. The institutional ethical clearance was obtained for the study.
A 15-year-old boy presented with fever with frontal headache for 4 days, swelling over left eye for 2 days, and swelling over right eye for 2 days
Anterior rhinoscopy reveals revealed Deviated to Nasal Septum to left with right middle turbinate hypertrophy and pus filling the middle meatus. Palpation of paranasal sinuses revealed tenderness in all sinuses bilaterally.
Ophthalmic examination showed
There was B\L swelling of lids with erythema, more of the left eye, with restricted movements.
CT PNS showed bilateral pansinusitis with erosion of lamina papyracea.
Patient did not respond to medical treatment on the first day; cellulitis spread to the other eye and forced us to perform endoscopic sinus surgery with orbital decompression.
Patient's right eye proptosis reduced on the first postoperative day and the left eye improved drastically within 1 week of the surgery.
A 68-year-old female presented with swelling of right eye since 3 days with associated history of nose block and running nose since 15 days. The patient, a known case of diabetic mellitus and hypertension, was on regular treatment.
Anterior rhinoscopy showed mucopurulent discharge in middle meatus on the right side. Sinus examination showed tenderness in the right frontal, ethmoids, and maxillary sinus regions. Ophthalmic examination showed proptosis and erythema of the right eye, with restriction of movements of the eye on the right temporal region.
CT PNS showed features suggestive of right frontal mucocele, ethmoid, and maxillary sinusitis with extension to the orbit on the right side.
An endoscopic anterior ethmoidectomy, drainage of the frontal sinus, and removal of the lamina papyracea for orbital decompression were performed with application of Mitomycin C.
A 25-year-old female patient presented with right-sided headache for 1 week, pain and redness in right eye for 5 days, and fever for 3 days. She also presented with history of restricted eye movements on the right side but no diminution of vision.
Tenderness was present over right frontal, ethmoids, and maxillary area. On anterior rhinoscopy, mucopurulent discharge was present in middle meatus in the right side. Ophthalmic examination revealed proptosis with erythema of the right eye; movements of the eye were restricted on right temporal region. Purulent secretions were seen over the eye lids.
CT PNS showed maxillary, ethmoid, frontal, and sphenoid sinusitis, and an SPA.
The patient did not respond to IV antibiotics and underwent functional endoscopic sinus surgery with an ethmoidectomy; opening of the maxillary, frontal recess and drainage of the SPA was done. Patient improved drastically within 1 week.
A 10-year-old male child presented with left eye swelling and headache since 1 week.
PNS tenderness was present on the left side. Mucopurulent discharge was present in middle meatus on the left side. Also, there was swelling of the left eye lid with erythema and restricted eye movements.
CT PNS revealed left pansinusitis.
Patient underwent endoscopic management of sinusitis with Mitomycin C application and improved postoperately within 1 week.
A 45-year-old female patient presented with right eye swelling since 1 week and nose block, headache, and cold since 15 days.
PNS tenderness was present on the right side. Mucopurulent discharge was present in middle meatus on the right side. Also, there was swelling of the right eye lid and erythema with thick purulent discharge and proptosis with restricted eye movements.
CT PNS revealed right maxillary and ethmoid sinusitis.
Patient was taken for endoscopic management of sinusitis with Mitomycin C application and she improved postoperately within 1 week.
| Discussion|| |
The paranasal sinus is a group of air-filled spaces in the skull that surround the nasal cavity, extending superiorly to the skull base and laterally to encompass the medial wall and floor of the orbit.  Paranasal sinus infection is most frequently encountered in the medical practice, and with higher, broad-spectrum, and newer antibiotics, the majority of cases are managed without any complication. Orbital complication of sinogenic origin is an age-old disease that has been described even during the days of Hippocrates.  Due to the close proximity of the orbit with the ethmoid, maxillary, frontal, and sphenoid sinuses, any sinonasal infection, if not diagnosed early and treated adequately, can lead to the spread of infection.
Routes of spread
Predisposing factors responsible for complications
- Bacterial infections from the sinuses can spread through natural dehiscences and weakness of the bony barriers. In chronic infections, the surrounding bone undergoes sclerosis, while in acute sinusitis, massive osteolysis is commonly seen.
- Lamina papyracea is a paper-thin bone separating the orbit from the ethmoidal sinuses. Congenital dehiscences of this bone are commonly seen through which spread of infection can occur from the ethmoids into the orbit. In childhood, the frontal sinuses are underdeveloped and orbital complications are caused commonly by acute ethmoiditis.
- Floor of the frontal sinuses form the roof of the orbit. In older children and in adults, frontal sinus infections can spread into the orbit causing orbital complications.
- Venous connections between the sinuses and the orbit do not have any valves facilitating spread of infection from the sinuses to the orbit.
Orbital complications of sinusitis include edema, orbital cellulitis, and SPA. Lateral displacement of MR muscle by at least 2 mm is diagnostic of a rim- enhancing SPA. Other complications include orbital abscess, cavernous sinus thrombosis, and in advanced stage, intracranial complications such as meningitis and brain abscess.  Orbital complication of sinogenic origin should always be treated as an emergency and should be treated aggressively as it poses life-threatening intracranial complications and blindness. The causes of vision loss in orbital infections include optic neuritis, traction on the optic nerve, or and retinal artery thrombosis. Clinically there is progressive proptosis with displacement of globe anteriorly and laterally and due to swelling of the involved ipsilateral medial rectus muscle and/or pressure on the globe by pressure on the globe by collection of the pus. Although many clinicians recommend open surgical drainage of a sinus abscess, both Stammberger and Stankiewicz et al., recommend endoscopic attempt at trans nasal sinus decompression of cases with SPA.
- Immunocompromised patient (e.g., HIV)
- Diabetes mellitus
- Irregular treatment for sinus infections
- Inappropriate/inadequate antibiotic therapy
In 1937, Hubert was the first to classify orbital complications of sinusitis into five groups. 
Hubert's classification of orbital complications of sinusitis
Group I: Inflammatory edema of eyelids with or without edema of orbital contents
Group II: SPA with edema of lids or spread of pus to the lids
Group III: Abscess of orbital tissues
Group IV: Mild to severe orbital cellulitis with phlebitis of ophthalmic veins
Group V: Cavernous sinus thrombosis
Smith and Spencer classification of orbital complications
Group I: Preseptal cellulitis - Characterized by edema of eyelids without tenderness, visual loss, or limitation of ocular mobility
Group II: Orbital cellulitis without abscess formation - Characterized by diffuse edema of adipose tissues of orbit
Group III: Orbital cellulitis with SPA formation with displacement of the globe. May or may not be associated with visual loss. Ocular mobility is restricted
Group IV: Orbital cellulitis with intraperiosteal abscess. Here the displacement of globe is severe with restriction of ocular mobility
Group V: Cavernous sinus thrombosis
The latest classification was introduced by Chandler in 1970 and is well accepted today. 
Chandler's classification of orbital complications of sinusitis
Long-term sequelae of orbital complications
- Vision loss
- Exposure keratitis due to corneal anesthesia
Intracranial complications are less common than orbital complications of sinusitis. These complications can coexist. Intracranial complications are common in adolescents and young adults because the diploic system of veins reaches its peak during adolescence. Males are more commonly affected than females.
Intracranial complications can be divided into:
Surgical indications include:
- Abscesses - extradural, subdural, or intracerebral
- Cavernous sinus thrombosis, superior sagittal sinus thrombosis.
The endonasal endoscopic approach for SPAs involves intranasal ethmoidectomy and removing portions of the LP, allowing the pus to drain into the middle meatus and the nasal cavity 
- Deterioration in visual acuity.
- Relative Afferent Pupillary Defect (RAPD).
- Continuing fever after 36 hours of medical treatment.
- Clinical deterioration after 48 hours.
- No improvement after 72 hours of medical treatment.
Advantages of endoscopic surgery in orbital abscesses are:
It is needless to stress the importance of post-op follow-up and suction clearance in such case.
- Unsurpassed and magnified view of the medial orbital wall.
- Lateral and " round-the-corners" view with angled telescopes.
- Simultaneous dealing of sinonasal cavities.
- No facial incisions.
- Local Mitomycin C application helped in prevention of adhesion formation 
| Conclusion|| |
Though antibiotics have altered the course of sinusitis, its grave complications still persist in our environment. Endoscopic sinus surgery and drainage of abscess with application of Mitomycin C to prevent adhesions can be recommended as the preferred surgical technique due to the excellent results and the absence of any major complications.
| References|| |
|1.||Rahbdar R, Robson Cd. Management of subperiosteal abscess in children. Arch Otolaryngol Head Neck Surg 2001;127:281-6. |
|2.||Lavania A, Sharma V, Reddy NS, Baksh R. Orbital cellulitis: A Complication of sinusitis. Kathmandu Univ Med J 2005;3:292-3. |
|3.||Nwaorgu OG, Awobem FJ, Onakoya PA, Awobem AA. Orbital cellulitis complicating sinusitis: A 15 year review. Niger J Surg Res 2004;6:14-6. |
|4.||Younis RT, Lazar RH, Bustillo A, Anand VK. Orbital infection as a complication of sinusitis: Are diagnostic and treatment trends changing? Ear Nose Throat J 2002;81:771-5. |
|5.||Eviatar E, Gavriel H, Pitaro K, Vaiman M, Goldman M, Kessler A. Conservative treatment in rhinosinusitis orbital complications in children aged 2 years and younger. Rhinology 2008;46:334-7. |
|6.||Tanna N, Preciado DA, Clary MS, Choi SS. Surgical treatment of subperiosteal abscess. Arch Otolaryngol Head Neck Surg 2008;134:764-7. |
|7.||Gupta M, Motwani G. Role of mitomycin C in reducing adhesion formation following endoscopic sinus surgery. J Laryngol Otol 2006;120:921-3. |
|8.||Tan BK, Chandra RK. Postoperative prevention and treatment of complications after sinus surgery. Otolaryngol Clin North Am 2010;43:769-79. |
|9.||Sütbeyaz Y, Aktan B, Yoruk O, Ozdemir H, Gundogdu C. Treatment of sinusitis with corticosteroids in combination with antibiotics in experimentally Induced rhinosinusitis. Ann Otol Rhinol Laryngol 2008;117:389-94. |
|10.||Konstantinidis I, Tsakiropoulou E, Vital I, Triaridis S, Vital V, Constantinidis J. Intra- and postoperative application of Mitomycin C in the middle meatus reduces adhesions and antrostomy stenosis after FESS. Rhinology 2008;46:107-11. |