[Dr. Gopi Shah]
Hello, everybody. Welcome to The BackTable ENT podcast. My name is Gopi Shah. I'm a pediatric ENT. Today, I would like to welcome a very, very special guest all the way from Vietnam. Today, I have Dr. Winty Tan Tui. She's a pediatric ENT practicing at Phoenix Medical Center in Ho Chi Minh City in Vietnam. She's also the head of pediatric and general ENT at the University Hospital in Ho Chi Minh City. She's an active member of the Asian Society of Pediatric Otolaryngology. She's here today to talk to us about orbital complications of acute sinusitis in children in Vietnam. Welcome to the show Winty. How are you?

[Dr. Winty Tan Tui]
Hi, everybody. It's very, very nice to be here. Today, I will talk with all of you about my experience with a very, very difficult disease in our hospitals. Orbit complication due to acute sinusitis in children.

(1) Presentation of Acute Sinusitis Orbital Complications in Vietnam vs. the United States

[Dr. Gopi Shah]
Let's get into it. In Vietnam, how do kids usually present to you in your practice with an orbital complication of acute sinusitis?

[Dr. Winty Tan Tui]
We have one clinical trial for five years. We have around 31 cases, 5 to 7 to 8 cases per year.

[Dr. Gopi Shah]
About 31 cases. That sounds about right in a big freestanding children's hospital or in a PD practice. How do the kids present and which complication do you see more commonly in Vietnam? Are you seeing a lot of pre-septal, post-septal cellulitis or do you see more of the subperiosteal abscesses or is it a little bit of everything?

[Dr. Winty Tan Tui]
The cases increase every year. We only receive children at the late stage. We want to talk about this disease. Everybody has something, maybe they have eye issues and spend a lot of time in the ophthalmologist in the eye hospital for a long time. Maybe one, two or in some cases three weeks to treat. When they come with us, they maybe cannot see anything. We do surgery in the emergency case and all of them are lucky they can treat it, but it's quite late.

[Dr. Gopi Shah]
That is very late. I would say for us, the most common, I think, in the outpatient setting and in the emergency room is probably just pre-septal cellulitis. Some kids, oral antibiotics but many get admitted for IV antibiotics. Then in terms of who gets surgery, most of the time it's the subperiosteal abscess kids. In terms of vision though, to get to you when the vision is nearly gone, that's very frightening.

[Dr. Winty Tan Tui]:
We receive them and after one or two hours must do surgery immediately because the vision is a fight. Then in all those cases they come with the very swelling of eye headache, loss of vision, and the symptoms of the nose, very stuffy nose, runny nose, a lot of pus in the nose. We must do a CT scan immediately and do the endoscopic sinus surgery for them immediately within one or two hours.

[Dr. Gopi Shah]
How hard is it for patients to get to you and your team or to get to the big centers? Is that why there's such a delay? I don't know if delay in care is the right word or maybe better to use a later presentation to your group. Is it difficult or why do they treat them in the eye hospitals for so long?

[Dr. Winty Tan Tui]
For the surgery, it's not difficult for us because we do all of this case with endoscopic sinus surgery with the IGS system. It's very not difficult for us to do this type of surgery. We don't know how we can solve the vision for this patient. We do all of them in an emergency state and we give them all of our medicine. We have the strongest antibiotics and high dose of steroids to solve the vision. I don't know how much we can solve. Okay. Is it good for us?

We don't worry about the volume of the pus, but the location of this abscess is very important. If the abscess is very nearby, very close, or depressing the optic nerve, this is a very, very serious case. We must drain all of this abscess. It is the case that we must do.

(2) Antibiotic Regimens

[Dr. Gopi Shah]
In terms of antibiotics, it sounds like they come to you so late. In terms of a trial, I would say that a lot of our kids even depend on their exam, their vision and how they look clinically. Many of the kids will get a trial of IV antibiotics sometimes 24 to 48 hours because we see them a little bit sooner than it sounds like your team has the opportunity to see them.

Depending on age, we tend to cover for a lot of the strep gram-positives. We tend to use things like unison, especially in kids that are under nine. In our older kids or adults, we'll do a little bit more polymicrobial and do a broader empiric antibiotics, sometimes in unison depending on if we are also worried that we may have to have something for better CNS. What antibiotics do you tend to use in terms of what you are trying to cover? What are some of the microorganisms that you see more commonly there?

[Dr. Winty Tan Tui]
If the kids don't use any kinds of antibody while previous time we have used antibiotics with beta-lactam groups.

[Dr. Gopi Shah]
In terms of immunizations in children in Vietnam, are there any risk factors associated with that that you've noticed? Is the immunization program in children pretty robust? Tell me a little bit about that.

[Dr. Winty Tan Tui]
I think that in Vietnam now, there's no problem with immunization for children. I stay in my legal channel, not only the children in the province but in the very big city they have privileges equal. I don't think immunization has had any wrong in this case. Maybe I think that they don't have enough treatment for the sinusitis. It's more important.

[Dr. Gopi Shah]
I see. I would say for us, it's similar. It's otherwise healthy kids. Immunizations are up to date. They don't really have a history of recurrent or chronic sinusitis. It sounds silly but a lot of times it's bad luck. Having to tell that to families, what does that mean really? Usually, there's not huge red flags or risk factors that we find. You said you see kids in your province as well as other major cities or other towns. Is it difficult for kids and families to get to you? Is it difficult to get to the emergency room or get to your clinic?

[Dr. Winty Tan Tui]
I think it's the same. I don't think they are any different. They come with us and we do it immediately as fast as possible.

[Dr. Gopi Shah]
If there's a concern of no vision, that forces your hand for sure. Then in terms of CT, do you tend to get contrast. Tell me about your choice of imaging.

(3) Imaging Techniques

[Dr. Winty Tan Tui]
Imaging? We do a CT scan first. In some cases, we want to have some difference about the identity it's in the Group 3 or 4. We do MRI, but if we have enough time. If we don't have enough time, there is no need to have an MRI. CT scan is not enough for surgery.

[Dr. Gopi Shah]
If there's a concern of vision, then you don't have time. Let's say the vision is actually okay. What are you looking for when you get an MRI or what are the things that you would get an MRI for?

[Dr. Winty Tan Tui]
MRI to help recognize the abscess located in or out of orbit. We want to be very clear about the Chandler group type Stage 3 or 4. We don't have any case of Chandler Stage 5. We don't have any cases. We want to have a distinction about the Chandler Stage 3 or 4 only. CT scan in our hospitals, the quality is very good. We do not need to extinguish different diseases with any tumor in the eye. We don't use MRI these days.

[Dr. Gopi Shah]
In my practice, I might consider an MRI if it's a very lateral subperiosteal orbital abscess. Sometimes those can have a higher risk of intracranial complications, or if I'm concerned of a CNS complication, but that might be based on the exam. You're right. Most of the time usually unless we're worried about something further, every once in a while if we have cavernous sinus thrombosis or we're looking for some thrombosis, an MRI might somehow come into play. It may not be on the initial arrival, it might be even a couple of days later.

(4) Chandler Stages of Infection

[Dr. Winty Tan Tui]
Some cases, before the surgery we think that it is a Chandler Stage 3, but after surgery, we change to Stage 4. Time is very important for us. CT is maybe not important because in our hospital we can do MRI. If we want to have an MRI we will send them to another hospital. We must have some time, maybe two or three or four hours or this. It takes a lot of time so in an emergency case, we may not do this.

[Dr. Gopi Shah]
Just for our listeners just to review the Chandler staging. Stage 1 is we said pre-septal cellulitis, Stage 2 would be post-septal, and you said in your practice you see mostly 3 and 4 which is your subperiosteal abscess or orbital abscess. Then for Stage 5 would be the cavernous sinus thrombosis which is less common, but every once in a while those might come in. Then in terms of steroids, I think that sometimes it can be controversial. I think, obviously, if the vision is of concern you give it because you have to do something for the optic nerve.

(5) Steroid Regimens

[Dr. Gopi Shah]
I feel like it can go both ways in the States in terms of how people practice for the child that might have post-septal orbital cellulitis, vision is okay. In terms of steroids, on one hand, people may say, "Well we don't want to mask an infection or we want to follow the white count." On the other hand, if it decreases inflammation, protects the nerve, why not? Admittedly, depending on the vision and how they're doing, I don't always use it preoperatively, but every once in a while I always wonder, "Should I be doing this more often or postoperatively?

We can talk about postoperative, of course, in a second. Sometimes in terms of inflammation, when do you use it and how. Do you tend to just do dexamethasone or is there a steroid of choice that you like to use, and how much do you normally like to give or is that for your ophthalmology team?

[Dr. Winty Tan Tui]
We use systemic steroids. We give Solu-Medrom yes.

[Dr. Gopi Shah]
Solu-Medrol?

[Dr. Winty Tan Tui]
Yes.

[Dr. Gopi Shah]
In terms of when a child gets to you, your team, do you talk to the infectious disease doctors? When do they get involved? Is the ophthalmologist still involved with you once they come to you? Or how does the coordination of care work in your practice?

[Dr. Winty Tan Tui]
In our practice in previous times, maybe two years ago some cases have a losing vision. For example, we must drain the pus in the eye. We invite the opthalmologist to come with us. When we do, they can see, give some opinion or some advice, something like that. Seven years later we don’t invite them anymore , because we think we can do it ourselves. The results are really good, so no need.

We can send our patient to have an eye examination before surgery if we have enough time, and then after we do surgery for maybe two days we send them again, and they check the vision and something like that for the conclusion about our results, about surgery. That's enough.

[Dr. Gopi Shah]
They definitely play a huge role in terms of exam. I would say again since your kids present so late having the baseline and plus they've already been with ophthalmology it sounds like for several weeks before, but we usually also have an exam when they get to us and post-ops are important.

[Dr. Winty Tan Tui]
Maybe some people can say that we play a wrong role something like that, because it is that the eye must be treated by ophthalmologist not ENT specialist, something like that, but we do surgery for a lot of patients and we think that there is no need lose time for this advice some patient, some doctor, another hospital. We must have one, two, three hours to wait and not worry. If we do when we can-- go ahead.

(6) Surgical Treatment Techniques

[Dr. Gopi Shah]:
You'd mentioned the image-guided system, so you do image-guided sinus surgery. When you're talking about surgery I know we're all doing the sinus surgery depending on how usually most of them will get anterior ethmoid, maxillary antrostomy, and then seeing what else they have on the scan. Take me through when you're operating and exactly what you're opening up.

[Dr. Winty Tan Tui]
We do endoscopic sinus surgery. The first, it's maxillary first, and then ethmoid, and then maybe the frontal sinus, and then according to the location of the abscess we can move out of the ethomid, and then if the pus come out with drainage that's enough, but we don't have any pus or something like that. We check the CT scan and check Stage 3 or 4, we go ahead. We do the surgery and then maybe we come to orbit.

[Dr. Gopi Shah]
I would say in terms of subperiosteal abscesses medial, we tend to be able to get endoscopically.

[Dr. Winty Tan Tui]
Yes.

[Dr. Gopi Shah]
We can do it endoscopically.

[Dr. Winty Tan Tui]
The second route, not endoscopies only but we do an outside incision below the eyebrow.

[Dr. Gopi Shah]
You're doing the orbitotomy on the outside if the abscess is superior or lateral?

[Dr. Winty Tan Tui]
Two ways, in the nose and out of the eye. We keep doing this for maybe two or three days. It's a very, very swollen eye surgery, but don't worry about that. If we do enough antibiotics and use steroids, and when all of the pus, all of the abscess come out, the swelling of the eye may be removed around five or seven days. That's okay.

[Dr. Gopi Shah]
I see. Are you getting a CT scan interop to see if you've cleared everything or you do the sinus endoscopic surgery, take down the lamina, express pus, and then you are scanning them the next day, and then going back if they're still pus in the superior or lateral aspects?

[Dr. Winty Tan Tui]
No.

[Dr. Gopi Shah]
Or is it in OR?

[Dr. Winty Tan Tui]
Yes, OR if there is space in one. No, check CT scan again.

[Dr. Gopi Shah]
Got it. If you're not getting a bunch of pus out you don't feel like you've drained it. You know ahead of time if it's superior or lateral and then you'll do your orbitotomy. I would say just to contrast it, in my practice that's where I do need our ophthalmology colleagues. They do come in with us to do the orbitotomy. I think our kids they're not presenting as acutely and as late, thankfully, and we do have a little bit of time to coordinate that.

The drain, it always makes sense to me to leave one in, our ophthalmologists don't always leave them in. You're right. The eye, postoperatively, might look great the first 6 to 12 hours, and then all of a sudden it's blown back up. I love that you're saying it's going to be okay, it's going to blow up. How do you manage that or how do you know that? How can you tell if it's just post-op swelling or it's a reaccumulation of pus that can be tricky for me.

[Dr. Winty Tan Tui]
It's according to a CT scan. We have an IGA system. When we do a sinus surgery, we check the CT scan and IGS and we compare.

(7) Post Operative Care

[Dr. Gopi Shah]
You get a CT post-op? How many days post-op?

[Dr. Winty Tan Tui]
CT scan, check again, maybe three or four days.

[Dr. Gopi Shah]
Is that part of the algorithm? You get it on everybody or only if the child isn't getting better or?

[Dr. Winty Tan Tui]
If you get better, there's no need to have a CT scan again.

[Dr. Gopi Shah]
Makes sense, okay. In terms of post-op steroids, again I don't always use it routinely but every once in a while the eye blows up and I'm like, "Give them steroids." Some kids do well and others don't. It's either I didn't drain it well enough the first time or it reaccumulated. Tell me about your post-op steroid use. Is it just the first 24/48 hours only if they're swelling? When do you initiate it?

[Dr. Winty Tan Tui]
We do systemic steroids for maybe three or four days after surgery. If the eye swelling is resolved, we stop, but if still have maybe we change the oral steroid maybe for one week more.

[Dr. Gopi Shah]
That makes sense. You're still doing Solu-Medrol?

[Dr. Winty Tan Tui]
Yes. Solu-Medrol and then we change later on.

[Dr. Gopi Shah]
In terms of post-op care, what kinds of complications have you seen after surgery? I think for us the big one is going to be that either we didn't get enough drainage the first time or it's reaccumulated. What other kinds of complications have you seen?

[Dr. Winty Tan Tui]
In all of my cases, no complications after surgery. It's according to the ESS that we do. If we do it very carefully, we take out all of the inflammation of the sinus, and all of the pus, or something like that. We shoot, we tear. We do it very, very carefully. No complications after surgery.

[Dr. Gopi Shah]
Then in terms of post-op care, do you see some of these kids back in your clinic for a checkup and follow them? How does your post-op care look?

[Dr. Winty Tan Tui]
After five days, then after every week for one month.

[Dr. Gopi Shah]
Is there any long-term follow-up or any reason to follow long-term in your practice?

[Dr. Winty Tan Tui]
No reason. I talk with my patient that if they have any problem, please come back here and see me.

[Dr. Gopi Shah]
I would sometimes see them about a week or two after discharge, then sometimes I would see them again about six weeks just to make sure we're moving in the right direction. Early on in my first few years out, I would follow them again to make sure there's no adhesions, chronic infections. I found that even with adhesions, if they had them, they never had issues symptomatically. I agree in terms of long-term, I don't think there's great data in terms of why, and who, and what happens. They all seem to be okay. Even if they are scared, they seem to be okay.

[Dr. Winty Tan Tui]
Some cases, they have chronic sinusitis in both sides of the nose, so we treat one side and one side we must treat this disease. That's enough. Maybe I found much more for four or five weeks okay.

[Dr. Gopi Shah]
Do you start sinus rinses the next day after surgery? What's your sinus rinse regimen like?

[Dr. Winty Tan Tui]
The neti pot or the rinse bottle. Yes, the normal saline. After, when they come back home, we prescribe another steroid for them.

(8) Cavernous Sinus Thrombosis

[Dr. Gopi Shah]:
Do you have much experience with cavernous sinus thrombosis in your practice at all?

[Dr. Winty Tan Tui]
We don't have that.

[Dr. Gopi Shah]
We had maybe two. In eight years, I think I saw two kids. It just depended on when they came in, what Hematology said, what Infectious Disease said. For one kid, I think we did sinus surgery to get a bug. For another one, we did antibiotics. Some of them depending on hematology, do you do anticoagulants or not? That's always balls in the air and seeing in a multidisciplinary team what exactly, and the timing in terms of how we started anticoagulation or not, and is that indicated.

[Dr. Winty Tan Tui]
How about the results? The final results of this case?

[Dr. Gopi Shah]
They all did okay, because they got antibiotics. I felt like they used to do a lot of anticoagulation therapy as well because hematology would get involved and so most of the kids did okay. The question is, is there a role for FESS in these? I don't know, but it depends on when ENT is involved and the timing of that, and then in the timing of the anticoagulation. Once they're on it, then hold it and do a FESS. What we are doing it for is always a little tricky too, and how old is the kid, all that kind of stuff.

(9) Challenges in Pediatric Procedures

[Dr. Gopi Shah]
As we start to slowly round it out and wrap it up, tell me, do you have any tips or tricks for your sinus surgery? A lot of times the kids are, especially five to seven-year-olds and have a hot inflamed sinus, it's tight, it's bloody. Any tips that you use to help you visualize and for hemostasis?

[Dr. Winty Tan Tui]
Yes. It's very difficult for very, very young children. We have youngest children around nine months. It's very narrow for us, and a lot of bleeding, and things like that. I think that we must go slowly in the first step. We do adrenaline with normal saline, and we put in the match through the nose and maybe wait for 5 or 10 minutes before surgery, so it's not get bloody. Very easy to see framework or something like that in the nose. We do it step-by-step and it is very easy for us. In some very difficult cases, we have an IGS system.

[Dr. Gopi Shah]
In terms of the adrenaline, what concentration do you use, and does age play a role like for the 9-month-old versus the 12-year-old or the 6-year-old? Do you do 1 in 10,000? 1 in 1,000? What kind of concentration?

[Dr. Winty Tan Tui]
1 to 10,000 is okay.

[Dr. Gopi Shah]
In terms of taking the lamina down, once you're kind of, "Okay, I've gotten my ethmoids down." Then you start to take your lamina down, what do you like to use and how do you like to get into it without getting into the periorbital? That's a big fear. If there's enough pus there, you probably won't be getting into the periorbital.

[Dr. Winty Tan Tui]
I think it's not much difficult for this, because we see the ophthalmologist to do this one time. Then after that, we can do it ourselves.

[Dr. Gopi Shah]
Not the orbitotomy, but endoscopically. Do you have any tips or tricks for the ENTs, our listeners who are ENTs that are going to be taking the lamina of the ethmoid down? How do you usually like to get into that? What instruments do you like to use?

[Dr. Winty Tan Tui]
Instrument is a normal instrument, not a very special instrument. Not very difficult for us to do this. Open the endpoint and we control the bleeding. Then we have access and we drain it.

[Dr. Gopi Shah]
For us, I think it's the same. There's nothing special. It's the basic sinus instruments, the coddle. I like making a little break in the bone. Sometimes there's already a little breach there. You might even see a little pus trickling out if it's enough pressure, but just using a coddle to make a little fracture in the lamina. Then it's just flaking it away using the flat side. Once you have to go on the inside of it, create a little flap or a plane to open some bone and to have a good amount, not being scared to take some of that bone down so that all that pus can come out.

The other thing I find, especially when I was working with residents or our fellow students, is getting the mucosa off of the lamina. I think we're not going to be able to get into the bone if there's still tissue there. It's just getting comfortable doing everything that we're not supposed to do in sinus surgery. This is our one time that we have to do it except for getting into the periorbita, we don't want to get into the fat or anything like that. Then I'll have the person push the eye on the outside to express and milk it out too.

[Dr. Winty Tan Tui]
That's necessary. In my experience, I think that the drainage is as wide as possible. We must check again how we drain all of this pus, and after surgery, how it can drain itself. It's very important.

[Dr. Gopi Shah]
How big is your opening usually in the bone? How big do you think that opening is?

[Dr. Winty Tan Tui]
According to the volume of the access. If it is very small, there is no need to open it widely. If the access is very, very big, we must open as much as possible, because it's not helpful for their eyes after this kind of surgery. We open as much as possible, and we must make sure that they can bring it inside. It's very important.

[Dr. Gopi Shah]
As we wrap up Dr. Winty Tan Tui, any final pearls that you have to share with our audience or final tricks or tips that you have?

[Dr. Winty Tan Tui]:
The audience, I have some recommendations. If your children have one swollen eye it is a very, very serious case. If we give them to the ophthalmologist, please ask your doctors about the true disease of the eye. After one or two days of treatment, if they still have no improvement, the CT scan is very necessary, and send them to the specialist. It is very important that we don't want our children to have any effects in their futures.

[Dr. Gopi Shah]
Thank you so much, Dr. Tan Tui, all the way from Vietnam. Thank you for sharing your insight and your practice. For our listeners, Dr. Winty, are you on any social media if our audience wants to connect with you, is there anything, LinkedIn, or how can they get ahold of you?

[Dr. Winty Tan Tui]
Very nice for me to see all of you tonight and to talk about and embrace this topic. In the near future, we have some topics that you, some audience and some of our colleagues are interested in and we want to discuss together.

[Dr. Gopi Shah]
That sounds great. Remember, the Asian Society of Pediatric Otolaryngology also has annual meetings and conferences. If you're in the area, that might be also a great way to continue your education. I think it's a wrap. Thank you so much.

Podcast Contributors

Dr. Thuy Nguyen

Dr. Thuy Nguyen is an otolaryngologist.

Dr. Gopi Shah

Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2023, July 11). Ep. 119-2 – Orbital Complications of Acute Sinusitis in Children in Vietnam [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.