Research

Original Investigation

Trends in Orbital Complications of Pediatric Rhinosinusitis

in the United States
Gregory Capra, MD; Bryan Liming, MD; Mark E. Boseley, MD; Matthew T. Brigger, MD, MPH

IMPORTANCE Several studies have documented the prevalence and treatment of orbital
complications secondary to pediatric rhinosinusitis, but to our knowledge, none have
investigated the national health care burden of this disease since the introduction of the
heptavalent pneumococcal vaccine (PCV-7).

OBJECTIVE To identify the current public health burden of orbital complications of pediatric
rhinosinusitis, and to determine if the introduction of the PCV-7 has resulted in a change in
national practice patterns.

DESIGN, SETTING, AND PARTICIPANTS Population-based study using the 2000 and 2009 Kids’
Inpatient Databases to gather data on a sample of all pediatric discharges in the United States
during the years 2000 and 2009. Children diagnosed as having orbital complications of
sinusitis were identified by corresponding International Classification of Diseases, Ninth
Revision (ICD-9) codes. Database analyses generated national estimates of summary statistics
and comparison of trends over the 9-year period.

INTERVENTIONS Database analysis.

MAIN OUTCOMES AND MEASURES National health care trends according to year. End points
assessed included prevalence, age, sex, length of hospital stay, and treatment of disease.

RESULTS The estimated prevalence of orbital complications of sinusitis requiring

hospitalization in the United States has slightly decreased from 5338 (95% CI, 4956-5720)
admissions in 2000 to 4511 (95% CI, 4165-4858) in 2009. However, the mean age has
increased from 4.77 (95% CI, 4.56-4.97) years to 6.07 (95% CI, 5.87-6.26) years. The
proportion of children undergoing surgical treatment increased from 0.108 (95% CI,
0.093-0.123) to 0.195 (95% CI, 0.176-0.213). Total charges increased from $4 140 000 (95%
CI, $3 440 000-$4 830 000) to $10 000 000 (95% CI, $8 480 000-$11 600 000) with a
mean charge per admission increasing from $8390 (95% CI, $7096-$9685) in 2000 to
$22 656 (95% CI, $19 997-$25 314) in 2009. The mean length of stay remained stable at 3.67
(95% CI, 3.37-3.97) to 4.05 (95% CI, 3.81-4.29) hospital days.

CONCLUSIONS AND RELEVANCE The public health impact of orbital complications of pediatric
rhinosinusitis continues to be substantial. Since the institution of the PCV-7 vaccine, national
trends demonstrate a slightly decreased prevalence of hospital admissions. However, there is
a shifting trend toward an older age at admission and a higher proportion of children
undergoing surgical treatment. Author Affiliations: Department of
Otolaryngology–Head and Neck
Surgery, Naval Medical Center San
Diego, San Diego, California (Capra,
Brigger); Department of
Otolaryngology–Head and Neck
Surgery, Madigan Army Medical
Center, Tacoma, Washington
(Liming, Boseley).
Corresponding Author: Matthew T.
Brigger, MD, MPH, Department of
Otolaryngology–Head and Neck
Surgery, Naval Medical Center San
Diego, 34800 Bob Wilson Dr, San
JAMA Otolaryngol Head Neck Surg. 2015;141(1):12-17. doi:10.1001/jamaoto.2014.2626 Diego, CA 92134 (matthew.brigger
Published online October 23, 2014. @med.navy.mil).

12 jamaotolaryngology.com

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 Orbital Complications of Pediatric Rhinosinusitis
O
rbital complications are known sequelae of pediatric
rhinosinusitis. In fact, published clinical practice
guidelines for the diagnosis and treatment of pediat-
ric acute bacterial sinusitis recognize that intraorbital compli-
cations are the most common complication of acute bacterial
sinusitis.1 The ethmoid sinus is the nidus of orbital spread in
most cases, with the frontal and maxillary sinuses the source
less frequently.2-5 One study6 found that 100% of patients with
subperiosteal abscesses (SPAs) demonstrated concurrent si-
nusitis in at least 1 sinus, while 63% had multiple sinus in-
volvement. Theories suggesting why a sinus infection causes
a subsequent postseptal orbital complication generally re-
volve around the ease by which infection and inflammation
can traverse the lamina papyracea. This thin bony septa be-
tween the orbit and the paranasal sinus is naturally porous, is
susceptible to congenital dehiscences, has large vascular fo-
ramina, and has the potential for open suture lines. All of these
properties have been implicated as possible routes of infec-
tious transmission between the paranasal sinuses and orbit.4,5
In contrast, preseptal disease is commonly a complication of
trauma or dacrocystitis.2
As described by Chandler et al,7 periorbital and orbital in-
fections are categorized based on location of infection. The cat-
egories represent a progression of severity from mild presep-
tal cellulitis to potentially deadly cavernous sinus thrombosis.
Given the potential morbidity and even mortality, treatment
strategies include aggressive intravenous antibiotics, topical
nasal decongestants, and potentially surgical drainage. While
there has been controversy over the evolving roles of surgery
vs medical treatment, it is clear that orbital complications of
rhinosinusitis remain a clinically significant problem.3,8-11
Traditionally, Streptococcus pneumoniae, Haemophilus in-
fluenzae, and Moraxella catarrhalis have been the most com-
monly implicated pathogens in acute bacterial rhinosinusitis.1
The introduction of the H influenza type b (HiB) vaccine in 1985
altered the landscape of many pediatric infectious diseases.2,4,9
Although HiB has not been completely eradicated, studies have
shown a shift in microbiological trends of acute pediatric in-
fections related to epiglottitis, meningitis, rhinosinusitis, peri-
orbital infections, and otitis media.12-16
The heptavalent pneumococcal conjugate vaccine (Prev-
nar or PCV-7) was introduced in 2000 for children younger than
24 months. Many authors have studied the effects of the vac-
cine on common pediatric diseases. McKinley et al15 discov-
ered that few orbital infections were S pneumoniae in origin
in the post–PCV-7 population. Similarly, Peña et al16 con-
cluded that fewer S pneumoniae infections occurred, while an
increase in Staphylococcus aureus prevalence was seen in these
types of infections. With changing microbiologic characteris-
tics of orbital complications secondary to pediatric rhinosinu-
sitis over the first decade of the PCV-7 introduction, it could
be expected that the national health care impact of this dis-
ease may similarly be affected. The purpose of this study was
to examine these national trends with regards to the preva-
lence, treatment, and overall charges of orbital complications
of pediatric rhinosinusitis for the years 2000 and 2009, corre-
sponding to the introduction and widespread administration
of the PCV-7 vaccine.
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Original Investigation Research
Methods
This study was approved by the institutional review board of
the Naval Medical Center San Diego. The data are from the Kids’
Inpatient Database (KID), Healthcare Cost and Utilization Proj-
ect (HCUP), Agency for Healthcare Research and Quality
(AHRQ).17 The 2000 and 2009 KIDs were used to gather data
on a sample of all pediatric discharges younger than 18 years
in the United States during 2000 and 2009. These data are a
representative sample of discharges occurring in the United
States during those years. The sampling strategy is single stage
and is designed to select 10% of uncomplicated in-hospital
births as well as 80% of complicated births and other pediat-
ric admissions from each frame hospital. Discharge weights
were according to AHRQ protocol using poststratification of 6
characteristics of each hospital (ownership or control, bed size,
teaching status, rural or urban location, and US region, free-
standing children’s hospital) in order to calculate national es-
timate data. The 2000 KID includes 2784 hospitals from 27
states, and the 2009 KID includes 4121 hospitals from 44 states.
Given the known natural association of orbital cellulitis
with sinusitis, all children requiring admission with a diagno-
sis of orbital cellulitis were identified by the International Clas-
sification of Diseases, Ninth Revision (ICD-9) code 37601. Chil-
dren who had a trauma or injury code were excluded from the
analysis. The population generated by this search was then
stratified according to applicable HCUP Procedure Clinical Clas-
sification Software codes for nasal or orbital surgical proce-
dures. Other information, such as sex, mean total charges, and
mean length of hospital stay was also obtained. Analysis using
each database’s weighted sampling schema generated na-
tional estimates of summary statistics.
Results
The national public health burden of pediatric orbital compli-
cations in 2000 and 2009 is estimated in the Table. Based on
the weighted estimates, the prevalence of orbital complica-
tions for the years 2000 and 2009 were 5338 (95% CI, 4956-
5720) and 4511 (95% CI, 4165-4858), respectively, for individu-
als 18 years or younger. The US census population data
estimates of this age group for the years 2000 and 2009 were
72.3 million and 74.5 million, respectively.18,19 This gives an ap-
proximate estimate of incidence for these 2 populations of
nearly 7.38 children per 100 000 in 2000 and 6.05 per 100 000
in 2009. Mean ages between the 2 groups demonstrated an in-
crease from 4.77 (95% CI, 4.56-4.97) years to 6.07 (95% CI, 5.87-
6.26) years over this time span. The median age showed a simi-
lar trend. Sex distribution remained stable, with a slight male
predominance at 57.6% (CI, 55.4%-59.7%) in 2000 and 59.9%
(CI, 58.1%-61.8%) in 2009.
Children hospitalized in the year 2000 incurred hospital
charges greater than $4 million and accounted for 19 592 (95%
CI, 17 488-21 696) inpatient days. These charges more than
doubled in 2009 to $10 million, although the total inpatient
days of 18 293 (95% CI, 16 378-20 209) were not significantly
JAMA Otolaryngology–Head & Neck Surgery January 2015 Volume 141, Number 1 13
 Research Original Investigation Orbital Complications of Pediatric Rhinosinusitis

of stay between these 2 groups was similar, 6.69 (95% CI, 5.83-
Table. National Estimates for Admissions for Orbital Complications
of Sinusitisa 7.56) and 6.89 (95% CI, 6.14-7.63) days, respectively. Simi-
larly, the length of stay for the medically treated patients was
(95% CI)
not significantly different between the 2 years, with a mean
Characteristic 2000 2009
of 3.21 (95% CI, 2.89-3.52) days in 2000 compared with 3.33 (95%
Patients, total No. 5338 (4956-5720) 4511 (4165-4858)
CI, 3.16-3.49) days in 2009. The total charges for these years
Male sex, % 57.6 (55.4-59.7) 59.9 (58.1-61.8)
were $6371 (95% CI, $5405-$7337) and $15 298 (95% CI, $13 552-
Age, mean, y 4.77 (4.56-4.97) 6.07 (5.87-6.26)
$17 403) in 2000 and 2009, respectively.
Median 3 5
Charges, $
Total 4 140 000 10 000 000 (8 480 000-
(3 440 000-4 830 000) 11 600 000) Discussion
Mean 8390 (7096-9685) 22 656 (19 997-25 314)
The effect of vaccines has been substantial in combatting child-
Median 4586 11 089
hood infectious diseases. This is no more evident than with
Total hospital days 19 592 (17 488-21 696) 18 293 (16 378-20 209)
the introduction of the HiB vaccine.16 However, the overall ef-
Length of stay, d
fect from a national perspective may be difficult to extrapo-
Mean 3.67 (3.37-3.97) 4.05 (3.81-4.29)
late from single-institution studies. Although a vaccine may
Median 3 3
reduce the prevalence of a specific causative pathogen, dis-
Surgically treated, 579 (493-665) 879 (760-998)
total No. ease trends themselves can go unchanged, and vaccines could
Total, % 10.8 (9.3-12.3) 19.5 (17.6-21.3) hasten the emergence of new pathogens. Furthermore, it is im-
Age, mean, y 8.43 (7.72-9.14) 9.02 (8.63-9.41) portant in this era of increased awareness of health care eco-
Length of stay, 6.69 (5.83-7.56) 6.89 (6.14-7.63)
nomics to identify how health care dollars are spent. This
mean, d knowledge will better shed light on allocation of resources and
Charges, mean, $ 25 348 (17 294-33 401) 53 251 (43 881-62 620) the burden with which a disease places on the health system.
Medically treated Large-scale population level databases fill our knowledge gap
Total, % 89.1 (87.6-90.6) 80.5 (78.6-82.3) and are essential in providing accurate epidemiologic data that
Age, mean, y 4.29 (4.08-4.51) 5.33 (5.13-5.52) can be applied toward better understanding national trends.
Length of stay, d 3.21 (2.89-3.52) 3.33 (3.16-3.49) However, they are not without their own limitations. When
Charges, mean, $ 6371 (5405-7337) 15 298 (13 552-17 043) coupled with institutional studies, the information we can
a glean from large databases may shed light on a disease and aid
The data are from the Kids’ Inpatient Database, Healthcare Cost and Utilization
Project, Agency for Healthcare Research and Quality.17 in developing new prevention strategies.
Our goal was to compare pre–PCV-7 era and post–PCV-7 era
hospitalizations related to orbital complications of pediatric
different. Mean charges were substantially more in 2009, with rhinosinusitis in order to detect trends related to the vaccina-
estimates of $22 656 (95% CI, $19 997-$25 314) per hospital- tion for S pneumococcus in the pediatric population. To our
ization compared with $8390 (95% CI, $7096-$9685) in the year knowledge, no prior study has evaluated this relationship on
2000. Despite the differences in total and mean charges per a national level. Using the same rationale described by Peña
hospital stay, the length of stay of 3.67 (95% CI, 3.37-3.97) days et al16 regarding the concept of herd immunity, we chose to
prior to PCV-7 was similar to the post–PCV-7 era at 4.05 (95% compare KID data from 2000 and 2009. Between these years,
CI, 3.81-4.29) days. we found a slight decrease in prevalence of severe rhinosinu-
The data showed an increasing trend toward surgery, sitis resulting in hospital admission for orbital complications
whereby the estimated total number of those surgically treated from 2000 to 2009. It is difficult to impart a definite cause and
increased from 579 (95% CI, 493-665) in 2000 to 879 (95% CI, effect relationship between the decrease in S pneumoniae in-
760-998) in 2009. This represents an increase from 10.8% (95% fections and the decrease in severe pediatric orbital compli-
CI, 9.3%-12.3%) of patients to 19.5% (95% CI, 17.6%-21.3%) be- cations of rhinosinusitis. It may also depend on specific bac-
tween these years. The surgical age was consistent between terial isolates combined with other factors.1 In fact, the study
the 2 groups, with an average age of 8.43 (95% CI, 7.72-9.14) by Peña et al16 supports this theory. When comparing these 2
years in 2000 and 9.02 (95% CI, 8.63-9.41) years in 2009. In con- eras, they found a 13% rise in cases after the introduction of
trast, a slight increase in age for medically treated patients was the vaccine. Cultures from their patients prior to the vac-
seen. An increase from 4.29 (95% CI, 4.08-4.51) years to 5.33 cine’s introduction predominately demonstrated the pres-
(95% CI, 5.13-5.52) years was observed for the age of medi- ence of S pneumoniae, but this pathogen was absent in all as-
cally treated patients for these years. Across the years, medi- pirates for their post–PCV-7 group. Instead, a dramatic rise in
cally treated patients were younger than the surgical age of pa- S aureus was seen in these patients, with a trend toward a grow-
tients. As would be expected, the total charges for surgical ing percentage of cultures demonstrating methicillin-
patients between these 2 groups were significantly different. resistant S aureus (MRSA). These data are supported by an-
In 2000, mean charges for surgically treated patients were other study,13 which showed S pneumonia to predominate prior
$25 348 (95% CI, $17 294-$33 401), while in 2009 it increased to 2000. However, in the late 2000s, infections caused by S
to $53 251 (95% CI, $43 881-$62 620). However, the mean length pneumoniae have occurred less frequently giving way to more

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 Orbital Complications of Pediatric Rhinosinusitis
staphylococcal infections, including MRSA.2,8,9,11,20-22 Al-
though these data suggest that PCV-7 has had a dramatic affect
in the reduction of invasive S pneumoniae infections, other fac-
tors may be at work, such as emerging antibiotic resistance, S
pneumoniae strains not covered by PCV-7, or other uneluci-
dated host factors.16,21 In 2010 the PCV-13 vaccine was made
available, which may ultimately further shift bacterial iso-
lates. As these data become more widely available, future in-
vestigations are warranted.
Historically, males have been more likely than females to
present with orbital complications of rhinosinusitis.9,11,21-23 This
was the case in our data, which showed a male predominance
in the pre–PCV-7 and post–PCV-7 eras that has not signifi-
cantly changed. In these 2 groups, males represented 57.6% and
59.9% of the populations for 2000 and 2009. This is consis-
tent with the findings of another database study for 2006,24
which found that males comprised 59.5% of patients, and with
the report by Peña et al,16 who found that males were more
likely to be affected regardless of the vaccine.
Historically, orbital complications of sinusitis tend to oc-
cur in children younger than 10 years.9,11,21 In studies prior to
PCV-7 immunizations, Garcia and Harris10 found an average
age at complications of 7.2 years. In the post–PCV-7 era, Sed-
aghat et al23 found patients had an average age of 8.6 years,
although they found that age was not associated with in-
creased complication rates based on multivariate analysis. For
the years 2000 and 2009, our study demonstrated an in-
crease in the mean age at presentation from 4.77 to 6.07 years,
suggesting a trend of increased age of presentation as more chil-
dren were vaccinated. Likewise, Peña et al16 found that older
children were more commonly affected by orbital complica-
tions in the post–PCV-7 era. The exact reason for this dispar-
ity in age between the years 2000 and 2009 is unclear but once
again may have to do with the interaction of bacterial isolate
and host factors. One could argue that despite the wide-
spread dissemination of PCV-7 in 2000, not all children were
initially vaccinated. Peña et al16 suggested that true herd im-
munity did not occur until 2003, and thus it is possible that
the older age of presentation in the post–PCV-7 group may re-
flect children who failed to benefit from herd immunity. An-
other argument may lie in the type of microbiologic infec-
tions in older children. A 2012 study25 of chronic rhinosinusitis
aspirates in children found that Staphylococcus species ac-
counted for most cases, of which older children were more
likely to experience polymicrobial infections. This is in con-
trast to younger children, who seem to be single nasopharyn-
geal pathogen carriers.26 The companion studies by Gordts et
al13,27 support this theory in their findings prior to 2000. They
found that middle meatus aspirates in 50 children were most
likely to be represented by the common upper respiratory tract
pathogens H influenzae, M catarrhalis, and S pneumoniae,
which represented 50% of cultures. In contrast, only 2% of
adults had S pneumoniae cultures. Adult pathogens were in-
stead highly represented by coagulation-negative Staphylo-
coccus species, Corynebacterium species, and S aureus.27
Both historically and in these databases, age also seems
to affect the surgical rate of patients with orbital complica-
tions. In one study,28 age was predictive of the need for sur-
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Original Investigation Research
gery, with nonsurgical patients averaging 6.1 years while sur-
gical patients averaged 10.1 years. Peña et al16 also found that
older children were taken back to the operating room earlier
than younger children, but the exact reason for this was un-
clear. However, this same study found no significant differ-
ence in surgery rates (17% and 22%) for the pre–PCV-7 and post–
PCV-7 eras. Garcia and Harris10 showed that children younger
than 9 years were successfully treated medically, while older
children had an increased likelihood of requiring surgical drain-
age. Our national data support these findings. In both 2000 and
2009, the mean age of surgically treated patients was signifi-
cantly higher than those who were medically treated (Table).
In both years the medically treated mean age averaged about
age 5 years, while the surgical patient was close to the age of 9
years. Although polymicrobial or more virulent infections may
account for the age discrepancy, another explanation may lie
in the development of the paranasal sinuses. Dewan et al6
found that children with frontal sinusitis or nonmedial SPAs
were more likely to be older and require surgical treatment
compared with their younger counterparts. This may be ex-
plained by the lack of paranasal sinus development in the
younger population.
Since the publication of the article by Garcia and Harris10
in 2000, it has been thought that a shift away from surgical
treatment of orbital complications toward primarily medical
treatment of this disease has occurred.3,6,8 These authors10
showed prospectively that 93% of children younger than 9 years
with small, medial SPAs, no frontal sinusitis, and no visual im-
pairment could be safely treated medically. Since its publica-
tion, authors2,8,9,22,29 have sought to better define other char-
acteristics of patients who can be safely treated medically.
These studies have regularly focused on the radiographic size
and location of SPAs. In contrast to the perception that pa-
tients are treated more conservatively today than in years past,
our data suggest that surgical rates have actually increased with
time. We found that despite stricter criteria for medical treat-
ment, surgical rates nearly doubled from 10.8% in 2000 to
19.5% in 2009. This is compared with the study by Mahalingam-
Dhingra et al,28 which showed that surgical rates of 12.4% for
2006, which are closer to our pre–PCV-7 data surgical rates. Our
data also are not in agreement with those of Peña et al,16 who
found no significant difference in surgical rates between their
study groups. The reason for this discrepancy remains un-
clear. Again, this may reflect the age of patients, presumed mi-
crobiological nature of infection, regional variation in KID data
sources, or the sample size.
Regardless of the increase in surgical rates between 2000
and 2009, it seems that the length of hospital stays has not
changed over the decade. A direct comparison of children who
were surgically treated also showed that they did not have lon-
ger stays, and neither did those medically treated. However,
within each year group, length of stay was significantly differ-
ent between the medical and surgical patient groups. These data
are in agreement with those of one study16 that found surgi-
cally treated patients averaged 7.1 days of hospital admission
compared with 3.4 days for their medically treated counter-
parts. Factors that may affect length of hospital stays are nu-
merous and are not accounted for in this study. A natural con-
JAMA Otolaryngology–Head & Neck Surgery January 2015 Volume 141, Number 1 15
 Research Original Investigation Orbital Complications of Pediatric Rhinosinusitis

clusion is that surgically treated patients represent failed medical
treatment or a more virulent disease process, and therefore their
length of stay is greater. Abscess reaccumulation may also affect
length of stay, as Dewan et al6 found in their study. They also
found that surgical technique influences duration of hospital
stay. Those patients with combined endoscopic sinus surgery
and SPA drainage had significantly shorter length of stay, likely
related to fewer abscess reaccumulation rates. Another study22
also noted that hospital stays can be influenced by location of
orbital complications. Ketenci et al22 found that patients with
medial abscesses spent 3 to 9 days as in-patients, whereas those
with superior abscesses spent 6 to 11 days on average. Finally,
health care administrative factors, such as insurance policies,
may also effect duration of hospital stay.
To no one’s surprise, health care charges for orbital com-
plications of acute rhinosinusitis have dramatically risen over
the previous decade. This is another important set of infor-
mation that institutional studies fail to discuss. We found that
the rates of charges more than doubled from 2000 to 2009, with
the most recent data showing $10 million in total charges av-
eraging $22 656 per hospital visit. Surgical treatment was more
expensive in 2009 ($53 251) than in 2000 ($25 348). Medical
charges more than doubled from $6371 in 2000 to $15 298 in
2009. However, it is important to acknowledge that although
charges have significantly increased, our analysis did not fo-
cus on the true cost of care or health care dollars collected,
which may be markedly different from the amount charged.
As with any database study, there are limitations to the
data. Foremost, the use of ICD-9-CM coding is only as accu-
rate as the data coded. Some patients with inaccurate diagno-
ses may be erroneously included or excluded from this data
set. Furthermore, the data do not include all 50 states, but in-
stead represent a sample of the population used to make pro-
jections based on a weighted sampling algorithm. As a result,
the health care burden may be inaccurate and may affect the
generalizability of these data. These patients also represent the
more severe cases of orbital complications that required in-
patient admission, and it may reflect a change in criteria for
outpatient treatment over time. However, it can be assumed
that mildly effected patients likely provide a less significant
burden on our health care system. Finally, hospital charges do
not necessarily correlate with true health care costs, which can-
not be accounted for with these data.
Conclusions
The public health impact of pediatric patients with orbital com-
plications secondary to rhinosinusitis continues to be sub-
stantial. In the post–PCV-7 era, many of the characteristics of
disease remain stable, including a male predominance, a sig-
nificantly older surgical population, and the average length of
stay. In contrast, the prevalence has slightly decreased, the av-
erage age of patients has increased from 4.77 to 6.07 years, and
surgical rates have nearly doubled from 2000 to 2009. Fi-
nally, health care charges have shown a dramatic increase in
just 9 years, which places an added burden on an already
stressed health care system.

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Submitted for Publication: June 24, 2014; final
revision received August 23, 2014; accepted August
31, 2014.
Published Online: October 23, 2014.
doi:10.1001/jamaoto.2014.2626.
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Author Contributions: Dr Capra had full access to
all of the data in the study and takes responsibility
for the integrity of the data and the accuracy of the
data analysis.
Study concept and design: Capra, Boseley, Brigger.
Acquisition, analysis, or interpretation of data:
Capra, Liming, Brigger.
Drafting of the manuscript: Capra, Liming.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Capra, Brigger.
Administrative, technical, or material support:
Capra.
Study supervision: Boseley, Brigger.
Conflict of Interest Disclosures: None reported.
Disclaimer: The views expressed in this article are
those of the authors and do not necessarily reflect
the official policy or position of the Department of
the Navy, the Department of the Army, the
Department of Defense, or the US Government.
Previous Presentation: This study was presented
at the 2014 Annual Meeting of the American
Society of Pediatric Otolaryngology; May 16-18,
2014; Las Vegas, Nevada.
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of periorbital cellulitis. Clin Otolaryngol. 2011;36(1):
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orbital complications of sinusitis in pediatric
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pathogenesis of orbital complications in acute
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