DISCUSSION
Orbital involvement is the most frequent complication of acute
ethmoiditis. Its frequency is about 91% of the complications of
ethmoiditis in children, cerebral involvement being rarely observed
[4]. In the present study, we report the case of an adolescent girl
who presented with acute ethmoiditis complicated by cerebral empyema,
orbital cellulitis, and intraorbital abscess. The clinic was dominated
by a fever of 39.9° Celsius, headache, a sensitive swelling of the left
upper eyelid and the external canthus, chemosis, left exophthalmos with
preservation of ocular mobility and visual acuity (10/10), a normal eye
fundus with the notion of repeated rhinopharyngitis, and is in line with
the literature which finds in the majority of cases similar
symptomatology and rarely ophthalmoplegia and papilledema in cases of
acute ethmoiditis in children [4, 5]. A brain scan revealed acute
ethmoiditis of the left maxillary sinus, complicated by
right-predominant medial frontal cerebral empyema and a left
superior-external intraorbital abscess (Chandler IV classification). The
cerebral empyema observed in this case is consistent with data in the
literature that supports the idea that children with upper orbital
abscesses are more likely to have intracranial abscesses [1]. The
blood count revealed a hyperleukocytosis of 17,000 elements/mm3 with a
neutrophilic predominance and an increase in CRP and Pro-Calcitonin to
107 mg/L and 5.04 ng/ml, respectively. Several recent studies show that
emergency ethmoidal-orbital and cerebral CT remain the examinations of
choice for making the diagnosis and specifying the locoregional
extension of the complications, allowing emergency treatment to be
instituted. Our patient’s clinical picture (high fever of 39.9° Celsius,
painful swelling, and protrusion of the left eye for several days the
following nasopharyngitis) indicated this from the first day of
hospitalization. [6–11Inflammation with hyperleukocytosis remains an
observation in several studies [5, 12]. According to Chandler, most
of the authors recommend empirical broad-spectrum antibiotic therapy by
the intravenous route, combining 3rd generation cephalosporins or
amoxicillin-clavulanic acid with quinolones, aminoglycosides, and
imidazoles, depending on the stage of the disease.[1, 5, 13, 14]
While others recommend the combination of 3rd generation cephalosporins
and anti-staphylococci as they support the idea that children under 10
years of age are more likely to be infected with Streptococcus
pneumoniae or Staphylococcus aureus and those over 10 years of age are
more likely to be infected with polymicrobial pathogens [3, 12, 15].
In this case, antibiotic therapy with Ceftriaxone, ciprofloxacin,
gentamycin, metronidazole, and drainage of the intra-orbital abscess
were used. Orbital and sub-periosteal abscesses, as well as orbital
cellulitis, are the complications of ethmoidomaxillary sinusitis found
by several authors [2, 5, 16], but in the present study, the medial
frontal cerebral empyema and focal signs were found beyond the orbital
cellulitis and the Chandler IV retro-orbital abscess, and this would be
explained by the indirect propagation of the infection by the
hematogenous route through the ophthalmic veins without valves. In our
study, blood culture before starting antibiotic therapy and the search
for soluble antigens would have increased the probability of identifying
the germ in our study [6, 17].