Effectiveness of endoscopic versus external surgical approaches in the treatment of orbital complications of rhinosinusitis: a systematic review and meta-analysis

Abstract

Objective: This review aims to investigate and compare the effectiveness of endoscopic drainage techniques against external drainage techniques for the treatment of orbital abscesses, subperiosteal abscesses and cavernous sinus thrombosis as a complication of rhinosinusitis. Introduction: Transnasal endoscopic drainage and external drainage techniques have been used in the management of subperiosteal orbital abscesses secondary to rhinosinusitis. Each of these approaches has its own advantages and disadvantages, with extensive literature describing each technique separately. However, there is a lack of guidance in the studies on assessing and comparing the safety, effectiveness and suitability of these techniques. This review aims to compare the effectiveness of these techniques based on outcome measures in the literature such as: length of postoperative hospital stay, rate of revision surgery and complication rates. Inclusion criteria: Eligible studies included people of all ages diagnosed with subperiosteal abscess, orbital abscess or cavernous sinus thrombosis (Chandler stages III–V) secondary to rhinosinusitis disease, who have also undergone drainage via either an endoscopic approach, an external approach or a combined surgical approach. Methods: A comprehensive search of both published and unpublished literature was performed to uncover studies meeting the inclusion criteria. Reference lists of studies included in final analyses were also manually searched. Two reviewers screened studies and a third reviewer was engaged to resolve any disagreements. Studies were, where possible, pooled in statistical meta-analysis, with heterogeneity of data being assessed using the standard Chi-squared and I2 tests. Results: This review identified nine studies (of limited quality) assessing either endoscopic, external or combined surgical drainage techniques for subperiosteal orbital abscesses. Each of these techniques encompassed a wide variety of surgical approaches, with some variation. Recurrence rates were lower in the combined drainage group, with comparative meta-analysis with external drainage not indicating a statistically significant higher risk of recurrence with external drainage (RR 0.25, 95% CI 0.05-1.29 p = 0.10). Single group analysis of recurrence showed that the overall rate of recurrence was much lower in the combined group (4%, 95% CI 0.08-17.12) in comparison with the external (24%, 95% CI 11-40) or endoscopic groups (26%, 95% CI 10-45). Analysis of total hospitalisation revealed endoscopic drainage was associated with longer total hospitalisation than external drainage, although this difference was not significant (mean difference 0.10 days, 95% CI -4.76 to 4.96 p=0.97). Combined drainage was associated with a slightly longer total hospitalisation than external drainage (mean difference 0.94 days, 95% CI -0.79 to 2.67 p = 0.29). Combined drainage was associated with a longer total hospitalisation than endoscopic drainage (mean difference -0.70 days, 95% CI -3.48 to 2.07 p = 0.62). Post-operative stay analysis revealed longer post-operative stay in the external drainage group when compared to the combined drainage group (mean difference -0.16 days, 95% CI -1.15-0.83 p = 0.76). Conclusion: Imminent treatment of subperiosteal orbital abscesses via medical and surgical treatment methods is vital, given the high morbidity associated with the disease. This review identified nine studies (of limited quality) assessing either endoscopic, external or combined surgical drainage techniques for subperiosteal orbital abscesses. Each of these techniques encompassed a wide variety of surgical approaches with some variation. All drainage strategies have acceptable outcomes in relation to recurrence rates, total hospitalisation (days), post-operative stay (days) and complication rate. It is important to clinically identify the presence of subperiosteal orbital abscess, organise for an immediate computed tomography scan of the orbit and sinuses, and commence intravenous antibiotics quickly prior to deciding whether surgery is required or not. This review supports the view that surgeons should choose the appropriate surgical technique based on what they are comfortable and familiar with and what would be the safest option for the patient.