Eur Arch Otorhinolaryngol (2017) 274:3551 DOI 10.1007/s00405-017-4539-2 LETTER TO THE EDITOR Reply to: ‘Conservative’ approach to periocular necrotising fasciitis with paranasal sinus involvement 1 2 1 1 Richmond Quan Qing Lim · Jin Keat Siow · David Loke · Tze Choong Charn Received: 11 March 2017 / Accepted: 13 March 2017 / Published online: 3 April 2017 © Springer-Verlag Berlin Heidelberg 2017 Dear Sir/Madam, to undergo aggressive serial debridement of facial tissue and repeat endoscopic sinus surgeries before there was Thank you for your interest in our article and for your valu- recovery. able comments. In our review of the literature, there were four other Our two patients were immunocompromised—one had immunocompromised and seven immunocompetent just completed chemotherapy for lymphoplasmacytic lym- patients with necrotising sinus and facial infections. Three phoma and the other had poorly controlled diabetes due to of the four immunocompromised patients had to undergo non-compliance to medication. aggressive and repeated surgeries. Unfortunately, two of Our first patient who underwent orbital exenteration the immunocompromised patients passed away. Compara- was initially managed conservatively with antibiotics and tively, four of the seven immunocompetent patients under- endoscopic sinus drainage from which she recovered par- went more aggressive and repeated surgeries compared to tially but then deteriorated over a week. A second endo- the other three. All of the immunocompetent patients sur- scopic sinus surgery procedure was performed to drain the vived. Although admittedly a limited sample size, one can loculation of pus in the orbit medial to the optic nerve. By see that a preexisting immunocompromised state may make then, the patient had already become blind. As anticipated, the prognosis worse and when a low threshold for further this medial surgical drainage was inadequate to address surgery, radical as necessary, would be lifesaving. the reservoir of pus lateral to the optic nerve. As the eye We acknowledge the debilitating nature of orbital exen- was already blind and the patient noted to be immunocom- teration and extensive debridement of facial tissue. While promised with impending septicemia, orbital exentera- a more conservative approach may initially be attempted tion was performed to remove all the pus in the orbit that for patients with no comorbidities and a healthy immune could potentially set her into septic shock despite antibiotic system, a significant proportion of patients with necrotising treatment. sinus and facial infections are immunocompromised and at The second patient was initially treated with endoscopic high risk of mortality from sepsis. Hence, we believe that sinus drainage and debridement of unhealthy orbital tis- aggressive and lifesaving measures should be considered sue. However, as there was progression of disease, he had early in such patients. This reply refers to the comment available at doi:10.1007/s00405- 017-4534-7. * Richmond Quan Qing Lim email@example.com Department of Otorhinolaryngology, Khoo Teck Puat Hospital, Singapore, Singapore Department of Otorhinolaryngology, Tan Tock Seng Hospital, Singapore, Singapore Vol.:(0123456789) 1 3
European Archives of Oto-Rhino-Laryngology – Springer Journals
Published: Apr 3, 2017
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