Predictors of surgical intervention and visual outcome in bacterial orbital cellulitis

Pediatric preseptal and orbital cellulitis - a 6 year experience from a London tertiary centre

PURPOSE

This study reports the experience of pediatric preseptal and orbital cellulitis at a London tertiary centre during a 6-year period and highlights the role of orbital surgeons in the management of subperiosteal abscess (SPA).

METHODS

A retrospective review was conducted of all pediatric patients hospitalised for preseptal and orbital cellulitis.

RESULTS

A total of 201 children including 152 cases of preseptal cellulitis and 49 cases of orbital cellulitis were admitted at a London tertiary centre over the study period. Patients with orbital cellulitis and especially those managed surgically had higher rates of fever, higher presenting white cell count and C-reactive protein level compared to cases of preseptal cellulitis. 77.6% of patients with orbital cellulitis had SPA. 81.6% of SPA had a medial component, while 28.9% had superior component. 61.2% of orbital cellulitis cases were managed surgically. Surgical intervention was carried out by otorhinolaryngologists (ENT) in 76.7% of cases, jointly between ENT and orbital surgeons in 16.7% of cases and by orbital surgeons alone in 6.7% of cases. Of the 11 SPA involving the orbital roof, all were surgically managed and orbital surgeons were involved in 54.5% of cases. When SPA involved the medial wall, orbital surgeons were only involved in 6.5% of cases.

CONCLUSIONS

We recommend all patients with superior SPA be treated at a centre with both ENT and orbital surgeons as these may not be amenable to drainage by ENT alone.

Orbital subperiosteal abscess in adolescents and adults: predictors and outcomes of nonsurgical management and surgical approaches

PURPOSE

The aim of this study was to assess predictors and outcomes of subperiosteal abscess (SPA) management in adolescents and adults at two tertiary care centers.

METHODS

This retrospective cohort study included cases of SPA from January 1 2000 to October 9 2022 at two institutions. Patients 9 years or older were categorized into surgical and nonsurgical cohorts. Surgical subgroups included those who underwent functional endoscopic sinus surgery (FESS) alone, external (transcutaneous or transconjunctival) orbitotomy alone, or combined FESS and external surgery. The presented features were assessed as potential treatment predictors. Outcomes included length of stay (LOS), final best-corrected visual acuity (BCVA), readmission rate, and reoperation rate.

RESULTS

Of the 159 SPA cases included, 127 (79.9%) underwent surgery and 32 (20.1%) were managed nonsurgically. The nonsurgical cohort was younger (p = .003) with smaller abscesses (p < .001) that were more likely to be medial (p < .001). The nonsurgical cohort had shorter LOS (p < .001); final BCVA and readmission rates were similarly favorable. Abscess location was correlated with surgical approach. Superior SPA that underwent FESS or external surgery alone had higher reoperation rates (57.1.0% and 58.3%, respectively) than combined (17.9%). External approach and FESS alone resulted in lower reoperation rates (15.4% and 15.0%, respectively) than combined (27.3%) for medial SPA. Subgroup analysis in the sinusitis cohort yielded similar results.

CONCLUSIONS

A trial of nonsurgical management may be safe and effective for select patients aged 9 years and older with sinusitis-derived, medial, and small SPA. When surgery is indicated, approach should be guided by abscess location to minimize reoperation risk.

Qualitative and Quantitative Magnetic Resonance Imaging in Bacterial Orbital Cellulitis

PURPOSE

To summarise the qualitative and quantitative parameters of bacterial orbital cellulitis (OC) on magnetic resonance imaging (MRI) and explore their clinical correlations.

METHODS

Multi-centre retrospective study with inclusion of patients of all ages with OC who underwent MRI. Patients with isolated pre-septal cellulitis, bilateral disease and poor-quality scans were excluded. An enlargement ratio for extraocular muscles (EOMs) was calculated by dividing maximal EOM measurements from the affected side by the contralateral side.

RESULTS

Twenty MRI scans from twenty patients (Mean age: 40.8 ± 24.3 years old, M: F = 15:5) between 2011 and 2022 were analysed. Three (15.0%) cases were paediatric patients (<18 years old). All cases had both pre-septal and orbital fat involvement. The EOM were affected in nineteen cases, with the superior muscle complex (18/19, 94.7%) most commonly affected. Mean enlargement ratio (1.30, Range: 1.04-1.82) was greatest for the medial rectus on axial views on T1 and fat-suppressed contrast-enhanced T1 (FS CE T1). Optic peri-neuritis was present in eleven (55.0%) patients, whilst two (9.5%) cases had optic neuritis. A greater degree of proptosis was observed in patients with optic neuropathy and those who underwent surgical intervention compared to those without (p = .002 and p = .002, respectively).

CONCLUSION

MRI remains an important imaging modality for evaluating complicated OC. However, qualitative features may lack accuracy and is not a reproducible means of analysis. Simple quantitative parameters, such as proptosis and EOM measurements, correlate with high-risk clinical features and may have utility in predicting clinical course.

Subperiosteal and Orbital Abscesses: A Comparison of Clinical Features, Management, and Outcomes

PURPOSE

To compare the clinical features, management, and outcomes between orbital cellulitis patients with subperiosteal abscess (SPA) and those with orbital abscess (OA).

METHODS

A retrospective study was conducted at a tertiary care center through medical record search to identify patients with orbital cellulitis from January 1, 2000 to December 31, 2022. Charts were screened for those with radiographic evidence of SPA or OA. Demographic data and presenting clinical features were compared between the 2 cohorts. Primary outcomes compared included rates of surgical intervention, reoperation, and readmission; and length of hospital stay and final vision.

RESULTS

A total of 189 patients, 162 with SPA and 27 with OA, met the criteria. The OA group (mean 46.5 ± 18.6 years) was older than the SPA group (mean 19.1 ± 21.4 years). Comorbid sinusitis was significantly more common in the SPA cohort (95.7% SPA; 70.4% OA; p < 0.001), while OA was more likely to occur with orbital trauma (29.6% vs. 8.0%; p = 0.003), implanted hardware (11.1% vs. 0.6%; p = 0.005), and comorbid diabetes (22.2% vs. 4.3%; p = 0.001). OA patients more often presented with a relative afferent pupillary defect (21.7% vs. 3.9%; p = 0.005), vision worse than 20 of 50 (42.3% vs. 16.2%; p = 0.005), and methicillin-resistant Staphylococcus aureus infection (20.8% vs. 5.8%; p = 0.036). OA was associated with a higher reoperation rate (47.8% vs. 21.3%; p = 0.019), readmission rate (18.5% vs. 5.6%, p = 0.047), and limited extraocular motility at follow-up (4.3% vs. 25%; p = 0.013); while mean length of hospital stay and final visual acuity were similar.

CONCLUSION

OA may affect an older population with a divergent risk factor profile compared with SPA. OA may cause more severe functional impairment on presentation, warranting more aggressive management to achieve visual outcomes similar to SPA.

Microbiology and Antibiotic Resistance Profiles of Orbital Subperiosteal Abscesses: A Comparison of Pediatric, Adolescent, and Adult Populations

PURPOSE

The purpose of this study was to compare the microbiology and antibiotic resistance profiles of orbital subperiosteal abscesses (SPA) among 3 age cohorts.

METHODS

A retrospective study was conducted at a tertiary care center through a medical record search to identify patients with orbital cellulitis and SPA on imaging from January 1, 2000 to September 10, 2022. Patients were categorized into pediatric (<9 years old), adolescent (9-18 years old), and adult (>18 years old) cohorts. Primary outcomes included culture and antibiotic susceptibility results. Secondary outcomes included antibiotic therapy and surgical intervention.

RESULTS

Of the 153 SPA patients included, 62 (40.5%) were in the pediatric cohort (4 months-8 years, mean 5.0 ± 2.7), 51 (33.3%) were adolescent (9-18 years, 12.7 ± 2.8), and 40 (26.1%) were adult (19-95, 51.8 ± 19.3). Viridians group Streptococci were the most frequent organisms isolated across groups. The anaerobic infection rate was higher in the adult compared to the pediatric group (23.0% vs, 4.0%, p = 0.017), while that of the adolescent did not differ significantly from either. Pediatric patients carried a lower rate of clindamycin resistance than adolescent and adult cohorts, who shared similar rates (0 vs. 27.0% and 28.0%, respectively; p = 0.016). There were progressive increases in duration of intravenous antibiotic therapy ( p < 0.195) and rate of surgical intervention ( p < 0.001) going from younger to older cohorts.

CONCLUSION

Organisms isolated from orbital SPA from the past 2 decades demonstrate a predominance of Streptococcal species. Older age may be associated with anaerobic infection, clindamycin resistance, and more aggressive management. Adolescent infections are more similar to adult rather than pediatric counterparts but may require less aggressive management than the former.

Bacterial orbital cellulitis - A review

Infections of orbit and periorbita are frequent, leading to significant morbidity. Orbital cellulitis is more common in children and young adults. At any age, infection from the neighboring ethmoid sinuses is a likely cause and is thought to result from anatomical characteristics like thin medial wall, lack of lymphatics, orbital foramina, and septic thrombophlebitis of the valveless veins between the two. Other causes are trauma, orbital foreign bodies, preexisting dental infections, dental procedures, maxillofacial surgeries, Open Reduction and Internal Fixation (ORIF), and retinal buckling procedures. The septum is a natural barrier to the passage of microorganisms. Orbital infections are caused by Gram-positive, Gram-negative organisms and anaerobes in adults and in children, usually by Staphylococcus aureus or Streptococcus species. Individuals older than 15 years of age are more likely to harbor polymicrobial infections. Signs include diffuse lid edema with or without erythema, chemosis, proptosis, and ophthalmoplegia. It is an ocular emergency requiring admission, intravenous antibiotics, and sometimes surgical intervention. Computed tomography (CT) and magnetic resonance imaging (MRI) are the main modalities to identify the extent, route of spread from adjacent structures, and poor response to intravenous antibiotics and to confirm the presence of complications. If orbital cellulitis is secondary to sinus infection, drainage of pus and establishment of ventilation to the sinus are imperative. Loss of vision can occur due to orbital abscess, cavernous sinus thrombosis, optic neuritis, central retinal artery occlusion, and exposure keratopathy, and possible systemic sequelae include meningitis, intracranial abscess, osteomyelitis, and death. The article was written by authors after a thorough literature search in the PubMed-indexed journals.

Factors Associated with Surgery and Imaging Characteristics in Severe Orbital Infections

OBJECTIVES

To evaluate risk factors associated with surgical intervention and subperiosteal/orbital abscess in hospitalized children with severe orbital infections.

STUDY DESIGN

We conducted a multicenter cohort study of children 2 months to 18 years hospitalized with periorbital or orbital cellulitis from 2009 to 2018 at 10 hospitals in Canada. Clinical details were extracted, and patients were categorized as undergoing surgical or medical-only management. Primary outcome was surgical intervention and the main secondary outcome was clinically important imaging. Logistic regression was used to identify predictors.

RESULTS

Of 1579 patients entered, median age was 5.4 years, 409 (25.9%) had an orbital/subperiosteal abscess, and 189 (12.0%) underwent surgery. In the adjusted analysis, the risk of surgical intervention was associated with older age (age 9 to <14: aOR 3.9, 95% CI 2.3-6.6; and age 14 to ≤18 years: aOR 7.0, 95% CI 3.4-14.1), elevated C-reactive protein >120 mg/L (aOR 2.8, 95% CI 1.3-5.9), elevated white blood cell count of 12-20 000/μL (aOR 1.7, 95% CI 1.1-2.6), proptosis (aOR 2.6, 95% CI 1.7-4.0), and subperiosteal/orbital abscess (aOR 5.3, 95% CI 3.6-7.9). There was no association with antibiotic use before hospital admission, sex, presence of a chronic disease, temperature greater than 38.0°C, and eye swollen shut. Complications were identified in 4.7% of patients, including vision loss (0.6%), intracranial extension (1.6%), and meningitis (0.8%).

CONCLUSIONS

In children hospitalized with severe orbital infections, older age, elevated C-reactive protein, elevated white blood cell count, proptosis, and subperiosteal/orbital abscess were predictors of surgical intervention.

Systemic inflammatory markers differentiate between orbital cellulitis and non-specific orbital inflammation

PURPOSE

Bacterial orbital cellulitis (OC) and diffuse non-specific orbital inflammation (DNSOI) may be challenging to differentiate clinically. This study investigates the utility of systemic inflammatory markers, namely white cell count (WCC) and C-reactive protein (CRP), in differentiating between OC and DNSOI.

METHODS

A single-centre retrospective study of patients diagnosed with OC or DNSOI, between 2003 to 2021, who had WCC and/or CRP obtained at presentation. The mean levels of these factors and the proportion of positivity were compared between OC and DNSOI. A receiver operating characteristic (ROC) analysis was conducted to calculate the specificity and sensitivity of WCC or CRP in each group.

RESULTS

49 patients were included in this study. The mean age was 56 ± 20 years, and 21 patients were females. 26 (53.1%) patients had OC, and 23 (46.9%) patients had DNSOI. Mean WCC for OC and DNSOI were 14.5 × 10³/μL and 9.27 × 10³/μL, respectively (P = 0.001). Mean CRP for OC and DNSOI were 104.4 mg/L and 10.0 mg/L, respectively (P < 0.001). The optimal CRP cut-off value of 20.2 mg/L demonstrated 90.9% sensitivity and 90.5% specificity (AUC = 0.946, P < 0.001) for differentiating between OC and DNSOI. CRP was more predictive of OC than WCC (P = 0.017). 7/26 (26.9%) OC patients with fever also had an elevated CRP, while 1/23 (4.3%) of DNSOI with fever had a normal CRP.

CONCLUSIONS

An elevated WCC is suggestive of OC. However, a normal WCC can neither exclude nor differentiate between OC and DNSOI. CRP may be a more accurate predictor of OC compared to WCC.

Sinogenic Orbital Complications

BACKGROUND

The term "orbital complication" does not designate an independent nosological entity, but is rather a collective designation for diseases or disease effects that involve the orbit and its internal structures by extension from outside. In general, their most prominent manifestation is swelling of the orbital soft tissues, usually unilaterally. The incidence of sinogenic orbital complications is approximately 1.6 per 100 000 children and 0.1 per 100 000 adults per year.

METHODS

This review is based on publications retrieved by a selective search of the literature on the epidemiology, diagnosis, and treatment of sinogenic orbital complications.

RESULTS

Acute sinusitis is the most common cause of orbital complications. These are diseases of the orbit with potentially serious consequences for the eye and the risk of intracranial complications such as cavernous sinus thrombosis, meningitis, or brain abscess. Aside from acute sinusitis, many other infectious and non-infectious diseases can extend to and involve the orbit. Because of the complexity and severity of the condition, its diagnosis and treatment are always an interdisciplinary matter. The treatment is primarily conservative, under observation in a hospital, and generally consists of the treatment of acute sinusitis with measures to combat edema along with the administration of broad-spectrum antibiotics. Surgical intervention is needed in severe cases or if there is an abscess. An endonasal approach is usually used for drainage.

CONCLUSION

In 95-98% of cases in stages I-IV, healing is complete and without further sequelae. Even if vision is affected preoperatively, it usually recovers fully when therapy is appropriate. Approximately 15% of the patients who undergo surgery need more than one operative procedure.