Orbital Abscess Following Sphenopalatine and Anterior
Ethmoidal Artery Ligation for Recurrent
Epistaxis
Peter Glasman,
Sachin Salvi
Peter Glasman,
St. Paul¡¯s Eye
Unit, Royal Liverpool University Hospital, Prescot Street, Liverpool, the
United Kingdom
Sachin Salvi, Royal Hallamshire Hospital, Sheffield,
the United Kingdom
Correspondence to:
Peter Glasman, St. Paul¡¯s Eye Unit, Royal Liverpool University Hospital, Prescot
Street, Liverpool, the United Kingdom
Email:
peter.glasman@doctors.net.uk
Telephone: +44-151-7062000
Received: June 30, 2015
Revised: July 21, 2015
Accepted: July 25, 2015
Published online: September 6, 2015
ABSTRACT
Orbital abscess is a rare but potentially blinding
condition which has not previously been reported following endoscopic sinus
surgery. We report an abscess which occurred after sinus surgery combined with
anterior ethmoidal artery ligation, necessitating surgical intervention. We
suggest that remedial measures may be advisable if a breach into the orbit is
noted intra-operatively.
© 2015 ACT. All rights reserved.
Key words: Orbit; Abscess;
Postoperative complications; Endoscopic sinus surgery
Glasman P, Salvi S. Orbital Abscess Following
Sphenopalatine and Anterior Ethmoidal Artery Ligation for Recurrent Epistaxis.. International Journal of Ophthalmic Research 2015; 1(2): 69-70
Available from: URL: http://www.ghrnet.org/index.php/ijor/article/view/1271
INTRODUCTION
We present a case of orbital abscess formation after endoscopic sinus
surgery for intractable epistaxis. Conservative treatment with intravenous
antibiotics was unsuccessful and the patient required external drainage. Signs
of optic neuropathy rapidly improved and the patient made an uneventful
recovery. This case highlights the dangers of instrument contamination between
the nasal space and orbit.
Case Presentation
A 71 year old man presented to the otorhinolaryngology department with
recurrent episodes of right nostril epistaxis over the previous 4 years; these
were increasing in severity and frequency and requiring admission on a regular
basis for nasal packing. He was treated by his general practitioner for
hypertension, which was well controlled on ramipril, doxazosin and furosemide.
He had no other past medical history and was not on any antiplatelet agent nor
anticoagulant. He was electively admitted for right sphenopalatine artery and
anterior ethmoidal artery ligation.
His operation
proceeded routinely under general anaesthesia. The sinuses were explored
endoscopically; mucopus was noted arising from the right maxillary antrum so
antrostomy was perfomed, 3 branches of the sphenopalatine artery were
identified and cauterised subperiosteally, and the anterior ethmoid artery was
identified and clipped through a Lynch-Howarth incision. The same instruments
were used for both endoscopic and ¡°open¡± procedures. During anterior ethmoidal
artery ligation, the surgeon noted that he has a small breach into the anterior
ethmiodal sinus. Intra-operative or post-operative antibiotic cover was not
given. He was well the following morning and allowed home for outpatient follow
up.
He was
re-admitted 12 hours later pyrexial with increasing pain, swelling and
discharge from around the right eye (Figure 1)
A provisional
diagnosis of postoperative infection was made, he was commenced on intravenous
antibiotics and CT imaging arranged (Figure 2).
This
demonstrated a breach of the medial wall of the orbit into the right anterior
ethmoidal sinus, subperiosteal collection and preseptal tissue swelling.
Despite medical treatment, his symptoms increased over the following 24 hours
and he developed signs of early optic neuropathy in the form of reduced colour
vision of the right eye.
He was
therefore taken urgently back to theatre. The previous incision was opened, pus
was found beneath the periosteum, and an anterior ethmoid break was noted. The
sub-periosteal pus was drained, a small amount of necrotic tissue debrided and
the ethmoids cleared. A corrugated drain was sited and the remaining wound
closed.
The patient
did well postoperatively, with resolution of pain and swelling.
The drain was
removed after 6 days. Microbiology confirmed staphylococcus aureus and group A
streptococcus from local swabs and peripheral blood cultures and he was treated
with a six week course of antibiotics.
At outpatient
follow up six weeks later, there was complete resolution and no recurrence of
symptoms.
Discussion
Spenopalatine artery ligation and anterior ethmoidal artery ligation is
a recognised treatment for recurrent epistaxis. Whilst complications including
scarring, facial oedema, damage to the medial canthal ligament (which may
affect drainage in lacrimal ducts and result in epiphora), orbital haemorrhage
and superior oblique palsy have been reported before[1,2,3] to the
authors knowledge this is the first report of an orbital abscess formation
following the procedure.
We believe the
orbital abscess was secondary to instrument contamination as the same
instruments were used to perform spheno-palatine artery ligation nasally and
the anterior ethmoidal artery ligation orbitally in the presence of mucopus
discharge from the maxillary antrum. Intra-operative antibiotic cover was not
given as per surgeon preference. The breach into the anterior ethmoid could
have been contributory but there was no demonstrable infection of the anterior
ethmoidal sinus during surgery.
Timely
surgical intervention prevented visual loss.
It may be advisable
that separate instrumentation should be used when operating between nose and
orbit in the presence of nasal infection and antibiotic cover used to prevent orbital abscess
formation.
CONFLICT
OF INTERESTS
The authors have no conflicts of
interest to declare.
REFERENCES
1
Couch JM, Somers ME, Gonzalez C. Superior oblique plasy after anterior
ethmoidal artery ligation. Arch Ophthalmol. 1990;108(8):1110-1113.
2
Yeh, S, Yen M. Orbital Apex Syndrome
After Ethmoidal Artery Ligation for Recurrent Epistaxis. Ophthalmic Plastic
& Reconstructive Surgery. 2004 Volume 20 392-394
3
Filho BCA, Pinheiro-Neto DC et al. Endoscopic ligation of the anterior
ethmoidal artery: a cadaver dissection study. Braz J Otorhinolaryngol.2011;77(1):33-8.
Peer reviewer: Yasuhiro Takahashi, MD, PhD, Department of Ophthalmology,
Aichi Medical University, 1-1, Yazakokarimata, Nagakute, Aichi 480-1195, Japan.
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