Besides antibiotics, what else should be given to a patient with sinusitis complicated by orbital cellulitis?

Management of Sinusitis Complicated by Orbital Cellulitis

Besides antibiotics, you must immediately obtain a contrast-enhanced CT scan of the paranasal sinuses and orbits, arrange multidisciplinary consultation with otolaryngology, ophthalmology, and infectious disease specialists, and hospitalize the patient for continuous monitoring. 1

Immediate Imaging Requirements

• Obtain a contrast-enhanced CT scan immediately to differentiate preseptal from postseptal cellulitis and identify abscess formation, as this distinction is critical for determining whether surgical intervention is needed 2, 1
• MRI with contrast is an alternative imaging modality, though CT is typically preferred for acute assessment 2
• The imaging is essential because clinical examination alone cannot reliably distinguish between orbital cellulitis and subperiosteal abscess, which have dramatically different management approaches 3, 4

Mandatory Multidisciplinary Consultation

• Immediate consultation is required with otolaryngology, ophthalmology, and infectious disease specialists for all patients with sinusitis complicated by orbital cellulitis 1, 5
• This multidisciplinary approach is necessary because orbital complications can rapidly progress to vision loss or intracranial extension 6, 3

Hospitalization and Monitoring Protocol

• Continuous in-house evaluation is essential, with reassessment every 12-24 hours for specific parameters 1
• Monitor visual acuity changes, pupillary response, extraocular movements, degree of proptosis, fever, and systemic symptoms at each assessment 1, 3
• Patients with proptosis, impaired visual acuity, impaired or painful extraocular mobility, eyelid >50% closed, or any postseptal involvement require immediate hospitalization 1, 5

Adjunctive Medical Therapies

• Consider intranasal corticosteroids to reduce mucosal edema and improve sinus drainage 5
• Short-course systemic corticosteroids may be used as an adjunct to antibiotics, though one case report demonstrated dramatic improvement with IV corticosteroids in a complex orbital abscess case 7
• Provide adequate hydration, analgesics for pain control, and recommend head elevation to reduce orbital venous congestion 5

Surgical Intervention Criteria

• Surgery is indicated when there is no improvement within 24-48 hours of IV antibiotic therapy, loss of visual acuity, or presence of a subperiosteal or orbital abscess 6, 3
• Endoscopic sinus surgery has become the preferred surgical approach over external drainage for most cases, allowing drainage of affected sinuses and eradication of disease from the ostiomeatal complex 8, 6
• Combined endoscopic and external approaches may be necessary for superior subperiosteal abscesses 6

Critical Pitfalls to Avoid

• Never treat postseptal cellulitis as an outpatient—hospitalization is mandatory regardless of how stable the patient appears 1, 5
• Never delay CT imaging when orbital involvement is suspected, as clinical examination alone is insufficient 1, 3, 4
• Never discharge without confirmed daily follow-up arrangements, as progression can occur rapidly even after initial improvement 5
• Delayed or inadequate treatment can result in permanent blindness, intracranial complications including cavernous sinus thrombosis, meningitis, or death 1, 5

Monitoring for Life-Threatening Complications

• Continuously assess for intracranial extension including epidural or subdural abscess, brain abscess, venous thrombosis, and meningitis 5
• Watch for progression from orbital cellulitis to subperiosteal abscess, orbital abscess, or cavernous sinus thrombosis 2, 5
• The average hospitalization duration is approximately 7 days with appropriate combined medical and surgical therapy 6