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Ocular pathology for clinicians. 8. Orbital cellulitis.

Orbital cellulitis secondary to sinusitis has been the most common cause of proptosis in children. A case report is presented which emphasizes that the signs and laboratory findings in orbital cellulitis may be confusing, especially when modified by prior antibiotics. When orbital cellulitis is a possibility, adequate antibiotic therapy should be instituted while diagnostic studies are being performed. CT scanning is a new and useful modality for the evaluation of these patients, but cautious and experienced interpretation is essential. In patients who do not respond promptly to appropriate medical therapy, surgical intervention is indicated for drainage and biopsy.

Cellulitis↗

Post-traumatic orbital cellulitis.

Orbital cellulitis is uncommon. It may arise as a sequel to eyelid infection, or from direct spread of infection from the paranasal sinuses; it may be of odontogenic origin and has been reported after meningitis and after nasoorbital fractures with pre-existing sinusitis. Clinically, orbital cellulitis is of great importance, as it is a severe disease with potentially disastrous consequences. It may lead to optic neuritis, optic atrophy, blindness, cavernous sinus thrombosis, superior orbital fissure syndrome, meningitis, subdural empyema, and even death. We report two cases of severe post-traumatic orbital cellulitis with subperiosteal abscesses. These were managed surgically and vision was preserved. We describe the anatomy, a classification of orbital infection, and the importance of multidisciplinary management of these cases.

Adult↗

Solitary extramedullary plasmacytoma of the maxillary antrum and orbit presenting as acute bacterial orbital cellulitis.

Orbital involvement by plasma cell tumours is rare. Orbital tumours do not generally present as an acute orbital inflammatory disease in adults, though tumours such as rhabdomyosarcoma may cause clinical signs similar to an acute orbital cellulitis in children. We describe a patient with bacterial orbital cellulitis and sinusitis who was found to have an extra-medullary plasmacytoma of the maxillary antrum and orbit and coexisting testicular seminoma.

Cellulitis↗

Acute severe irreversible visual loss with sphenoethmoiditis-'posterior' orbital cellulitis.

Orbital cellulitis secondary to adjacent paranasal sinusitis presents with marked proptosis, ophthalmoplegia, eyelid edema, chemosis, and/or conjunctival hyperemia. These conditions often precede visual dysfunction. "Posterior" orbital cellulitis secondary to sphenoethmoidal sinusitis may be defined as the clinical syndrome in which early severe visual loss overshadows or precedes accompanying inflammatory orbital signs. The visual loss may be attributed to involvement of the intracanalicular or orbital apical segment of the optic nerve. Total irreversible unilateral visual loss developed in three patients with this syndrome. Severe visual loss was preceded by diplopia in one patient and by bilateral eyelid edema in another. One patient with chronic panparanasal sinusitis with acute visual loss presented with isolated optic disc edema. Proptosis and ductional restriction subsequently developed. The irreversible blindness in these cases may be due to a combination of intracanalicular edema and vasculitis causing optic nerve infarction.

Acute Disease↗

The place of endonasal endoscopy in the treatment of orbital cellulitis.

Orbital cellulitis secondary to acute sinusitis is uncommon, dangerous, and can lead to blindness and death. The ethmoid is the predominantly involved sinus. Management policy consists of early drainage of the affected sinus combined with systemic antibiotic therapy. If no improvement is achieved within the first 48 h, exploration of the fronto-ethmoidal region is mandatory. Endonasal endoscopic surgery facilitates early drainage of the affected sinus, eradication of the disease from the fronto-ethmoidal region, and drainage of the subperiosteal abscess. Sixteen cases of orbital cellulitis were treated successfully by endonasal endoscopic surgery with no complications.

Adolescent↗

Orbital cellulitis and orbital fractures.

Orbital cellulitis as a complication of orbital fracture is discussed. Three cases of orbital cellulitis that followed trauma to the orbit are presented. A description of the proposed mechanism by which an orbital fracture predisposes to cellulitis follows. Suggestions are made for prophylactic management.

Adult↗

Orbital cellulitis.

Orbital cellulitis is an emergency. It may cause blindness and progress to life-threatening sequelae such as brain abscess, meningitis and cavernous sinus thrombosis. Successful management is dependent upon urgent referral and immediate treatment. Although isolated eyelid erythema and swelling usually indicate primary infection anterior to the orbital septum, they may also be the first signs of an underlying frontal or ethmoidal sinusitis. The condition always requires emergency referral to both an ophthalmologist and otorhinolaryngologist.

Adult↗

Neutrophilic eccrine hidradenitis simulating orbital cellulitis.

Orbital swelling in patients with cancer can reflect neoplastic or infectious processes. Accurate diagnosis can be especially difficult in the face of associated fever and neutropenia. We treated a 30-year-old man undergoing induction chemotherapy for acute myelogenous leukemia, who had fever of unknown origin and periorbital swelling suggestive of orbital cellulitis. However, the periorbital findings were more compatible with passive swelling and hemorrhage. A skin biopsy specimen demonstrated isolated neutrophilic inflammation and necrosis of the eccrine glands. Cultures of the tissue for bacteria and fungi were negative. Pertinent literature regarding eccrine-gland inflammatory disease was reviewed. This unusual entity, termed neutrophilic eccrine hidradenitis, is most common in patients undergoing induction chemotherapy. Cases with infectious causes and cases in neutropenic patients have also been reported. No other patients, to our knowledge, with periocular involvement by neutrophilic eccrine hidradenitis have been described. Neutrophilic eccrine hidradenitis should be added to the differential diagnosis of cases of periocular hemorrhage and swelling in patients with cancer who receive chemotherapy.

Adult↗

Ethmoid osteoma, orbital cellulitis and orbital emphysema.

A possibly unique association of an osteoma of the ethmoid sinus with orbital emphysema and orbital cellulitis is described. The osteoma, which had eroded through the orbital periosteum, was removed; the orbital periosteum was grafted with fascia lata and a partial external ethmoidectomy performed.

Adolescent↗

Orbital cellulitis and preseptal cellulitis in childhood.

A study was made of 112 children with preseptal cellulitis, orbital cellulitis, subperiosteal abscess, and orbital abscess. These were consecutive admissions to the Royal Alexandra Hospital for Children, Sydney, during the period June 1976 to August 1985. The average age was 3 years 6 months. The clinical and radiological signs for each group were defined. Of the 112 children, 43.8% (with an average age of 3 years 3 months) had a clinical history of an upper respiratory tract infection. Trauma was a factor in 13.4% of patients. Haemophilus influenzae was recovered from blood culture in two patients and from conjunctival culture in seven patients. The average age of this group was 3 years 7 months. Plain radiographs taken of 53 patients revealed evidence of paranasal sinus disease in 29 (54.7%). Computerized tomography was performed in 14 patients. Of seven patients requiring surgical drainage of orbital or subperiosteal abscess (average age 7 years 2 months), five had clinical upper respiratory tract infection.

Abscess↗

Referral patterns in paediatric orbital cellulitis.

OBJECTIVES: Orbital cellulitis in children may result in severe visual morbidity and even mortality if not managed appropriately. The definitive management of orbital cellulitis is in the realms of the otolaryngologist, as the underlying pathology is associated with sinus disease in more than 90% of cases. Our observations suggest that there is a tendency for patients with suspected orbital cellulitis not to be referred promptly for otolaryngological opinion and management, which may result in adverse outcomes. The aim of this study was to determine the initial management by establishing general practitioners' attitudes to the referral and management of suspected orbital cellulitis. METHODS: Anonymous questionnaires were sent to general practitioners to ascertain details on their initial treatment modalities and preferred specialist referral. General practitioners in Worcestershire and North Staffordshire, two major regions in the West Midlands, UK, were targeted. RESULTS: The majority of general practitioners initially commenced patients on oral antibiotics, and referred patients primarily to ophthalmologists for further assessment, although significant variations in referral patterns were found. CONCLUSION: Better education for primary care physicians is needed regarding the initial management and referral of paediatric patients with suspected orbital cellulitis. They should be referred promptly for hospital admission. A good multidisciplinary approach with quick involvement of the three specialities (ear, nose and throat, ophthalmology and paediatrics) would avoid delays in the definitive management and ensure optimal outcomes.

Anti-Bacterial Agents↗

Orbital cellulitis: a rare complication after orbital blowout fracture.

PURPOSE: To report the incidence of orbital cellulitis after orbital blowout fracture. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: All patients with orbital cellulitis and a history of recent orbital fracture. METHODS: A medical record review of clinical history, imaging studies, and surgical and treatment outcome was performed. MAIN OUTCOME MEASURES: Resolution of orbital cellulitis and surgical and imaging findings. RESULTS: Four patients (3 male; mean age, 30 years [range, 4.5-58]) were treated for orbital cellulitis complicating orbital fracture. All patients had evidence of paranasal sinusitis before or after the orbital injury, and 2 also reported forceful nose blowing after sustaining orbital trauma. Although 3 patients received prophylactic oral antibiotics after the fracture, this failed to prevent infection. Sinusitis commenced 1 to 2 weeks before and as late as 5 weeks after orbital injury. All patients were treated with IV antibiotics. Two developed an orbital abscess that required surgical drainage; 1 patient improved after an endonasal maxillary antrostomy. One patient improved on IV antibiotics alone and underwent fracture repair at a later stage. These 4 patients represent 0.8% of all cases of orbital fractures treated in the study period. CONCLUSIONS: Orbital cellulitis is a rare complication of orbital fracture, and seems to be more common when paranasal sinus infection preexists or occurs within several weeks of the injury. Oral antibiotics given after the orbital injury may not prevent orbital cellulitis or abscess formation. Surgery may be required to drain orbital abscess or in nonresolving cellulitis to drain the paranasal sinuses. Fracture repair, if indicated, should be delayed, particularly if an alloplastic implant is used.

Acute Disease↗

Case report: dental infection leading to orbital cellulitis.

UNLABELLED: Orbital cellulitis is a rare but serious sequel of infection from a dental origin. Without prompt treatment, further spread of infection is likely to occur, resulting in loss of vision and possibly death. We report a case of orbital cellulitis secondary to infection originating in a recently endodontically-treated upper first molar tooth. The case was successfully treated by intravenous antibiotics. CLINICAL RELEVANCE: Odontogenic causes of orbital cellulitis and sinusitis should always be considered in the differential diagnosis. The importance of aggressive treatment of infections in maxillary teeth cannot be over emphasized. Correct diagnosis is vital to the success of therapy.

Adult↗

Investigation and management of adult periorbital and orbital cellulitis.

BACKGROUND: Orbital cellulitis has important complications. Despite this, there are few studies in the literature of large groups of cases of this condition. METHODS: We performed a retrospective case analysis of all patients admitted with periorbital and orbital cellulitis between 2002 and 2004. RESULTS: A total of 27 cases were included in the study. Of these, 25 had undergone a computed tomography scan, 19 of which had revealed significant sinus disease; 10 had had a microbiology result, with the most common organism being Streptococcus milleri; 20 had had a white cell count taken, with raised results in only 10; 12 had undergone surgery; and 25 had made a good recovery. One case had been found to be squamous cell carcinoma of the nasal cavity. CONCLUSIONS: In this study, sinus disease was the commonest cause of orbital cellulitis, with the commonest organism being Streptococcus milleri. Only 50 per cent of cases with proven disease had had a raised white cell count; this is therefore not a very sensitive test.

Adolescent↗

The role of technetium-99m-HMPAO-labeled WBC scintigraphy in the diagnosis of orbital cellulitis.

Bacterial orbital cellulitis is an infection of the soft tissues behind the orbital septum. Cellulitis is seen as a poorly defined area of increased CT density or T2 signal intensity within the fat. There is an amorphous enhancement following contrast infusion. Radiolabeled leukocytes or granulocytes are now established widely as a means of localizing various forms of inflammatory disease and infections. We report a case of orbital cellulitis detected with Tc-99m-HMPAO-labeled WBC scintigraphy and three-phase bone scintigraphy. Tc-99m-HMPAO-labeled WBC scintigraphy was superior to bone scintigraphy in delineating the extension and limits of the infectious process in the orbita. Tc-99m-HMPAO-labeled WBC scintigraphy is appropriate in the investigation of such infectious lesions, leading to early diagnosis and therapy to avoid severe complications.

Cefotaxime↗

An unusual organism causing orbital cellulitis.

Bacterial orbital cellulitis is a feared complication of paranasal sinus infection. Staphylococcus and Streptococcus species are the commoner pathogens involved in these cases. However, anaerobic bacteria and unusual Gram-negative organisms should be suspected as well. We treated a case of bacterial orbital cellulitis due to foci of infected paranasal sinuses caused by Eikenella corrodens, a Gram-negative rod. The patient was managed with intensive antibiotic coverage and surgical intervention.

Adult↗