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0ORBITAL COMPLICATIONS IN RHINOSINUSITIS IN YOUNG
CHILDREN
Mamatova Sh.R.
Tashkent Pediatric Medical Institute https://doi.org/10.5281/zenodo.12975970
Abstract. In the course of the study, the features of orbital complications in rhinosinusitis in young children were studied. A patient admitted to the ENT department of TashPMI clinic with a diagnosis of left-sided acute purulent maxillary ethmoiditis, reactive tissue of the orbit and abscess of the left eyelid, who received traditional conservative treatment, was discharged 10 days later in a satisfactory condition.
Keywords: rhinosinusitis, orbital complications, children, ultrasound examination.
Relevance
Rhinosinusitis is the most common among diseases of the ENT organs in young children. Moreover, there is never the initial link in the chain of pathological changes and most often it develops as a result of ARVI. In the overwhelming majority of cases, with ARVI, the paranasal sinuses are affected, there is swelling of the mucous membrane and stagnation of secretions. Epidemiological statistics presented in the EPOS 2012 edition [2] showed that the prevalence of ARS is in the range of 6-15% in different countries of the world. Moreover, in children under 3 years of age, 788 cases are registered annually per 1000 people of the child population, and at the age of 12-17 years - 18 cases. Anatomical and physiological proximity of the nasal cavity, paranasal sinuses and orbit determines the possibility of rhinogenic (rhinosinusogenic) orbital complications. Inflammatory changes in the orbit can be a consequence of both acute and chronic sinusitis (in childhood, more often in acute processes, in adults - in chronic).
Infectious agents detected in orbital rhinogenic complications are similar to those in uncomplicated sinusitis (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis). The spread of the inflammatory process is possible by contact (destruction of the bone), lymphogenous, hematogenous pathways, through the vessels (thrombus formation in the veins, followed by purulent fusion of the thrombus), and through degradation.
There are the following rhinogenic orbital complications: 1) reactive edema of the tissue of the orbit and eyelids; 2) diffuse non-suppurative inflammation of the tissue of the orbit and eyelids; 3) osteoperiostitis of the orbit; 4) abscess of the eyelid; 5) fistula of the eyelid and orbital wall; 6) subperiosteal abscess; 7) retrobulbar abscess; 8) phlegmon of the orbit; 9) vein thrombosis of the tissue of the orbit, cavernous sinus. The first 3 of the listed diseases are conventionally referred to the group of non-purulent orbital complications, all the rest - to purulent. Patients with reactive edema of the tissue of the orbit and eyelids often consult an ophthalmologist, but they also have complaints typical of sinusitis. The recurrent appearance of reactive edema of the eyelids can be a symptom of latent chronic sinusitis. Swelling of the eyelids appears as pale, painless, translucent lumps. In most cases, the upper eyelid is affected, less often the lower. With edema of the orbital tissue, a slightly moderately pronounced exophthalmos may be observed. There is no tissue infiltration. In most patients, the general condition and temperature response correspond to those in sinusitis. Diagnosis and differential diagnosis: the diagnosis of rhinogenic inflammatory orbital complications should be preceded by the identification of the pathology of the paranasal
sinuses. Diagnosis of sinusitis is carried out on the basis of characteristic complaints of various forms of the retina of the orbit, retrobulbar abscess and phlegmon. Symptoms, anamnesis of physical methods (palpation, percussion), rhinoscopy data, radiography, computed or magnetic resonance imaging of the paranasal sinuses (if indicated) and diagnostic puncture in older children provide us with full information for making an accurate diagnosis.
The identification of sinusitis allows us to consider the inflammatory pathology of the orbit as a secondary disease of rhinogenic origin. When choosing a tactic for the treatment of rhinogenic orbital complications, an important element is treatment of rhinogenic inflammatory orbital complications, the main effect is on the primary focus of the disease, i.e. on the inflamed paranasal sinus. Therapeutic measures aimed only at the affected orbital tissues are doomed to failure. Currently, most specialists prefer a complex method of treatment, covering a wide range of activities, depending on the nature of the lesion of the orbit and sinuses. It is advisable to consider the tactics of treatment of rhinogenic orbital complications separately in acute sinusitis and exacerbation of the chronic process. The choice of a particular method depends on the treatment of the following main factors: 1) the nature of the lesion of the orbit; 2) the nature of the lesion of the sinus (sinuses); 3) the patient's visual condition; 4) the patient's age.
Orbital complications of acute sinusitis do not always require surgical treatment. In case of nonsuppurative complications (reactive edema of the tissue of the orbit and eyelids, diffuse nonsuppurative inflammation of the tissue of the orbit and eyelids, osteoperiostitis of the orbit) against the background of acute sinusitis, it is most advisable to start treatment with conservative measures (including sinus puncture).
However, if conservative treatment does not show clear positive dynamics during the first 2-3 days or the symptoms increase, an operation is performed on the corresponding paranasal sinus (s). With purulent orbital complications (subperiosteal abscess, eyelid abscess, eyelid fistula and orbital wall, retrobulbar abscess, orbital phlegmon, as well as vein thrombosis of the orbital tissue) of acute sinusitis, surgical treatment is indicated. Intervention involves not only reorganization of compliance.
picture №1 picture №2
Conclusion: on the roentgenogram of the paranasal sinuses, there is a decrease in the transparency of the ethmoid labyrinth cells and the maxillary sinus on the left (Fig. 1).
The patient's appearance on admission (No. 2). Laboratory data: UAC dated 07.11.19 Result Norm
Hemoglobin 88 125-150 g/l
Erythrocytes 3.44 4.0-5.0 1CTx12/l
Color indicator 0.76 0.85-1.05
Leukocytes 15.5 4.0-9.C 10 *9
Platelets 250 180-320 10*9/l
Clotting time 307-347
Neutrophils: 3 1-6%
Eosinophils 4 0.5-5%
Lymphocytes 17 19-37%
Monocytes 2 3-11%
ESR 38 2-10 mm/ch
OAM: dated 07.11.19
Indicators results
Colour: Straw to dark yellow
Smell Unsharp
Appearance Transparent
Relative density 1.010 to 1.025
pH 5 to 7.0
Protein 0.00-0.14 g / l
Glucose 0.00-1.00 mmol / L
Ketone bodies 0-0.5 mmol / l
Bilirubin 0-8.5 prnol / L
Urobilinogen 0-35 prnol / L
Hemoglobin Absent
Bacteria (nitrite test) Absent
Erythrocytes 0 to 2 per field of view
Leukocytes 0 to 5 per field of view
Epithelial cells 0 to 5 per field of view
Cylinders None, except for 1-2 hyaline cylinders
Crystals Discovered
Bacteria Absent
Yeast mushrooms Absent
Parasites Absent
Ultrasound examination of the paranasal sinuses: A two-dimensional echography of the paranasal sinuses was carried out with linear and sector transducers, with a frequency of 7.5-8.0 MHz on an ultrasound diagnostic apparatus "Sonoscape S22" (in these frequency modes, the posterior wall of the sinuses was better visualized).
The study of the maxillary cells of the ethmoid labyrinth on both sides was carried out. With two-dimensional echography of the paranasal sinuses, on the right, only soft tissues, the bony anterior wall of the sinuses and the mucous membrane were visualized; due to the airiness of the sinuses, the posterior wall was not determined. In a child, when examining the left maxillary sinus, edema of the mucous membrane was noted in the form of reduced echogenicity (edema of the mucous membrane up to 0.5 mm thick), which had a heterogeneous structure. Free secretion inside the sinus was determined as the presence of suspension or hyperechoic inclusions of an ellipsoidal mosaic structure. Edema of the ethmoid labyrinth mucosa was defined as a component of mixed echogenicity with a heterogeneous structure.
Conclusion: Echoes are characteristic of maxillary ethmoiditis on the left.
Clinical diagnosis: Left-sided acute purulent maxillary ethmoiditis, abscess of the left
eyelid.
Conservative treatment was carried out:
1. "Cefepime" 0.4 IV 2 times / day (antibiotic of the 4th generation)
2. Metronidazole 15ml IV drip 3 times / day (Antimicrobial and antiprotozoal agent)
3. "Nazivin" 0.25% 2 drops in the nose 2 times / day. (Vasoconstrictor drug, reduces swelling of the nasal cavity and restores nasal breathing).
4. Sanitation of the nasal cavity and paranasal sinuses according to Proets, using the solution "Metronidazole" 2 times / day
5. Acyclovir PO 1 tab. 3 times / day by mouth (Antiviral drug).
6. Florbiotic 1 powder 2 times / day by mouth (Probiotic, restores intestinal microflora)
7. Calcium gluconate 1% PO 30.0 ml intravenous drip (Anti-inflammatory, anti-allergic, and detoxification drug)
8. Performed a lymphotropic injection of 1 cm away from the outer corner of the left eye with a solution of Ceftriaxone and Dexamethasone, subcutaneously 1 / day, for 4 days.
Against the background of the treatment, the sick child's body temperature returned to normal on days 4-5, the child's general condition and appetite improved, nasal discharge decreased and nasal breathing was restored. Rhinoscopic and pharyngoscopic examinations normalized. Starting from the 5th day, purulent discharge from the left eye and swelling decreased, on the 67th day the abscess of the eyelid resolved, chemosis disappeared and the mobility of the eyeball was restored.
On the 5th and 8th day of treatment, repeated blood and urine tests were taken, in which normalization of all altered parameters was observed. On the 9th day, the child underwent repeated ultrasound of the paranasal sinuses.
CONCLUSION
Ultrasound of the paranasal sinuses: in a two-dimensional ultrasound study in dynamics against the background of treatment, as the amount of exudate in the paranasal sinuses (maxillary
and ethmoidal) decreased on the left, a decrease in the length of visualization of the posterior wall was observed until its complete disappearance, which corresponded to the restoration of pneumatization. On the 10th day, according to the recommendations, the patient was discharged from the department in a satisfactory condition. Thus, in this article we present a rare clinical case of rhinosinusitis in young children with an orbital complication, in particular, an abscess of the left eyelid. In this case, we are faced with self-resolution of the left eyelid abscess against the background of conservative treatment, without surgical intervention. And also such radiation methods as radiography and especially two-dimensional ultrasound are of great clinical importance in the diagnosis of rhinosinusitis in young children and in assessing the results of treatment.
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