Acutely Ill, Miserable Baby With Swollen Right Eye

HISTORY
A 3-day-old infant whose right eye has become swollen. Gestation and birth history unremarkable. Neither parent has had a recent upper respiratory tract infection.

PHYSICAL EXAMINATION
Apprehensive, acutely ill, miserable baby. Temperature 40.5°C (104.9°F). Face as shown. Remainder of physical examination unrevealing. Child is not wheezing. SaO₂ satisfactory.

WHAT'S YOUR DIAGNOSIS?
(Answer on next page.)

WHAT'S YOUR DIAGNOSIS?
ANSWER: ETHMOID AND MAXILLARY SINUSITIS

Close description constitutes an essential step in recognition and diagnosis, particularly when, as here, one may not know at a glance what is amiss—and I certainly did not. There is puffiness over the right infraorbital zone which, if isolated, might suggest orbital cellulitis. Mucopurulent matter (or therapeutic ointment) is present in and about the narrowed right palpebral fissure, from the medial canthus to the apex of the cheek swelling. The right nasolabial fold is expanded diffusely, and the right infraorbital crease is obliterated by a mass effect that includes the regions over the maxillary and ethmoid sinuses and the bridge of the nose, and seems to be related to a swollen ridge of the right supraorbital skin.

Although the right naris appears displaced and distended, no exudate is dripping from it. The neck is thick but may be normal.

This is clearly far worse than a blepharitis or even, it would seem, than an orbital cellulitis. Marked swelling and erythema below the right eye, with involvement of the lower lid and perhaps the upper, suggest either facialperiorbital cellulitis¹ or periorbital cellulitis complicating ethmoid sinusitis, a known complication in infants.^2,3 In fact, ethmoid sinusitis was diagnosed. Coexistent maxillary sinusitis was inferred from extension of the process inferiorly and medially; the cheek and the bridge of the nose have become grotesquely swollen and somewhat reddened. By contrast, the blush over the philtrum and the chin appears to be unrelated to the acute process.

Culture revealed Staphylococcus aureus. Antibiotic therapy and surgical drainage were undertaken promptly.

WHAT DISTINGUISHES SINUSITIS?
The literature on the diagnosis of sinusitis is rife with problems. Among these are a preponderance of cases of maxillary sinusitis,^4-10 so that information on the other infections of air sinuses—sphenoid, frontal, and ethmoid—is sparse, old, and often unreliable. Hence, the comments that follow will refer to infective sinusitis in general, unless ethmoiditis is mentioned specifically.

The duration of an upper respiratory tract syndrome beyond 7 days is the most common clinical feature to distinguish acute sinusitis from the common cold.⁴ This makes good sense in view of CT studies that show asymptomatic opacification of paranasal sinuses in common colds. Given that the sinuses have been shown to contain fluid even in routine colds, it stands to reason that the more virulent attack on the same area in sinusitis might produce only a worsening of “cold” symptoms of cough, sore throat, and rhinorrhea.

In some but not all cases of sinusitis, more anatomically specific features develop, such as nasal voice quality, pain or pressure over the midface or the sinuses, and hyposmia or anosmia. Note that all of these symptoms can help localize the process to the sinuses rather than to other parts of the upper airway or aerodigestive tract, but they do not distinguish bacterial infection from viral infection nor either infection from allergy.

The microbiologic pattern of acute bacterial sinusitis differs from that of common colds: although viruses account for at least one fifth of acute  sinusitides, bacteria are a very common cause, particularly Streptococcus pneumoniae and Hemophilus influenzae. Staphylococci cause only some 4% of adult cases and a fraction of pediatric ones, most often in children with cystic fibrosis or leukocyte disorders.

SYMPTOMS, SIGNS, AND PREDICTIVE VALUE
Erythema and tenderness over the surface projection of any air sinus carry a high positive predictive value for sinusitis, but are insensitive markers that serve as rare diagnostic windfalls. That is, their absence does not militate against sinusitis.² In precisely the setting shown, however—namely, ethmoiditis in an infant—fortunately, there is diagnostic help in the form of a higher rate of inflammation of the overlying skin and subcutis.^4,5

Fever is not a sensitive indicator of sinusitis (occurring in only half of cases^4,5). However, it adds some specificity, such that high fever in a child with a cold is one clue that there may be sinusitis.³

In concert, 5 features in the history and physical examination appear to increase the likelihood of acute or subacute maxillary sinusitis^4,5:
•History of purulent nasal discharge. (Some clinicians stipulate “colored nasal discharge” but, given the commonness of yellow and green color of ordinary nasal mucus, false-positives abound.)
•Physical finding of purulent nasal discharge. Pus coming from the nostril is the most familiar indicator of sinusitis, although it is not pathognomonic (Figure). Purulent pharyngeal discharge, resulting from postnasal pooling, provides a worthwhile cross-check, since exudate in the pharynx cannot be wiped away by a diligent parent as is similar material expelled from a nostril. Of course, depending on its tenacity, pus in the pharynx may be lost from view down the esophagus, via swallowing or by the rinsing effect when the patient takes fluid.
•Maxillary toothache, which occurs not only in the minority of cases of maxillary sinusitis that complicate dental disease but also in many sinusitis cases of conventional respiratory (nasal) origin.
•Poor response to nasal decongestants.
•Abnormal sinus transillumination, especially complete opacification rather than mere murkiness, in a person who does not have preexisting chronic sinus disease. (Chronic sinusitis can opacify the sinus in between acute flare-ups, rendering opacification nonspecific in this setting.)




Virulent critiques of sinus transillumination have been published, but the method may be useful with the proper instrument—a sinus transilluminator attached to the ophthalmoscope body rather than a mere penlight—and good technique, including performance in a completely darkened room.

An important risk factor for sinusitis is a nasogastric tube or a nasotracheal tube, in place either at the time of presentation or recently beforehand. Thus, when any patient has had such a tube and later has a fever, even without local signs, consider sinusitis. This caveat is more familiar in ICUs than elsewhere.

INFERENCES
The enumerated features individually and collectively lack ideal sensitivity or specificity. So do the old 4-view sinus radiographs. Although CT is far more sensitive, it carries the hazard of overdiagnosis, with opacification of sinuses noted in a high fraction of normal children or those with the common cold.⁹ Hence, this technology is best used only when there is an intermediate pretest probability of sinusitis; it must be interpreted strictly in clinical context. For these reasons, the CT epitomizes the need to use technology in tandem with clinical findings and clinical reasoning, not as a substitute for either. Technology is not in competition with clinical examination; both subserve the same ends: accurate diagnosis and help for the patient. MRI sometimes provides an answer when CT does not.¹⁰

The “moderate” usefulness of both physical examination and imaging in diagnosis of acute maxillary sinusitis is established in comparison to a research gold standard of the otorhinolaryngologist’s sinus puncture, something that is acknowledged as outside the realm of feasible daily office practice for the generalist.^6,7,9,10

NONMAXILLARY SINUSES
Frontal sinusitis often fails to produce the expected swelling and tenderness over the surface projection of the frontal sinus: again, the physical finding has poor sensitivity. This will be a disappointment to those who, like the author, have been looking for a “Pott’s puffy tumor” ever since reading about it in medical school.

Eyelid edema is one characteristic of ethmoid sinusitis that is seen here. In the photograph, another characteristic feature of ethmoid involvement—lacrimation—is not clear. If limited eye movements or exophthalmos should develop, orbital invasion would be considered, and both orbital cellulitis and orbital abscess can complicate acute ethmoiditis in babies.^2,3 Meningismus or marked change in mental status raise the prospect of other grave complications: meningeal infection, intracranial extension, and even cavernous sinus thrombosis. In the antibiotic era, we are accustomed to curing sinusitis, but these dreadful complications still can occur and warrant vigilance until the patient with sinusitis has recovered completely.

Besides acute bacterial infection, there are case reports of bizarre afflictions of the ethmoid sinuses. Tuberculosis¹¹ and metastatic breast cancer in the ethmoid that mimicked acute ethmoiditis¹² are two of them.