Common Orbital Infections ~ State of the Art ~ Part I

Subperiosteal Abscess following tooth infection in early childhood: a case report

BACKGROUND

Medial Subperiosteal Abscess is a rare but serious life-threatening complication of orbital cellulitis. Although it often results from a sinus infection, its association with odontogenic infection is rare and underreported. This article highlights the importance of recognizing dental origins in orbital infections to avoid delays in treatment.

CASE PRESENTATION

This is a case of a 6-year-old female who presented with a rare Medial Subperiosteal Abscess due to an odontogenic infection. Symptoms began with toothache, headache, and progressive swelling around the right eye, which persisted despite initial antibiotic therapy. A CT scan revealed a Medial Subperiosteal Abscess that required urgent surgical intervention using the modified Lynch approach, followed by odontogenic surgery and antrostomy to extract the infected teeth and remove the antral polyps.

CONCLUSION

This case demonstrates one of the rare complications of dental infections in a paediatric patient, which highlights the importance of early diagnosis and prompt surgical intervention, as well as comprehensive multidisciplinary care, in order to prevent irreversible complications such as vision loss in paediatric orbital infections secondary to dental origin.

The Relevance and Potential Role of Orbital Fat in Inflammatory Orbital Diseases: Implications for Diagnosis and Treatment

The orbit is an important structure within the skull that houses the eye, optic nerve, and extraocular muscles. It also contains adipose/fat tissue, which provides a protective cushion for these components. Inflammatory orbital disease can affect any or all components of the orbit, often arising from various underlying pathologic conditions, including autoimmune, infectious, and vascular diseases. Typical signs and symptoms of orbital inflammation include swelling, redness, pain, discomfort, and potential loss of function. The role of orbital fat in the pathogenesis of inflammatory orbital diseases has not been fully explored. This review aims to provide a comprehensive description of orbital fat, its relevance and the potential role in inflammatory diseases of the orbit, and the use of radiologic imaging studies for evaluating this fat depot in cases of as inflammatory orbital diseases. Additionally, this review discusses the various procedures available for the treatment and management of these conditions. A range of interventions, including pharmacotherapy and surgical procedures, will be evaluated as promising therapeutic options. This review also explores the characteristics and potential applications of orbital fat-derived stem cells, with an emphasis on their regenerative abilities and anti-inflammatory effects. Understanding the role of orbital fat and its contribution to inflammatory orbital diseases is essential for optimizing diagnostic and treatment strategies.

Characteristics of Patients Treated for Orbital Infections: A Retrospective Study at a Tertiary Care Hospital

Introduction The orbital tissues of the eye can be affected by infections, a serious clinical illness that can have potentially fatal consequences. The study aimed to identify the demographic data, the categories of orbital infections based on Chandler's classification, and the underlying causes of orbital infections to ascertain the characteristics of patients admitted with orbital infections. We also looked at the management practices and their results. Materials and methods The Department of ENT - Head and Neck Surgery at the Pakistan Institute of Medical Sciences Hospital in Islamabad was the chosen site of this retrospective study. A total of 63 patients were included in the study. Data including patients' age, gender, type of orbital infection, inciting cause, management carried out, and treatment success were extracted from their discharge forms between January 2022 and December 2024. Following statistical analysis, the information collected was presented as tables and figures. Results Out of the total, 40 (63.49%) patients were female. The median age of patients was 34.5 years. Most patients were diagnosed with subperiosteal abscesses (33, 52.38%). The most common cause was sinusitis, which was present in 41 (65.07%) patients. Out of the total, 47 (74.60%) patients were successfully managed conservatively using broad-spectrum antibiotics and symptomatic treatment, and 12 (19.05%) underwent surgical intervention to drain the abscess. Conclusions The orbital infections were most common in middle-aged female patients, with subperiosteal abscess being the most common type. Sinusitis was the most common cause. Most patients were managed successfully with intravenous antibiotics, with few needing surgical intervention.

Dog Bites With Resultant Periorbital Cellulitis

This case study examines the delayed presentation of a facial dog bite, an uncommon occurrence in the periorbital area. Initially perceived as a minor injury, the wound was disregarded in its early stages. However, as the infection progressed, prompting urgent evaluation in the emergency department (ED) as the severity became evident. The patient was diagnosed with an acute facial infection carrying the potential for periorbital cellulitis and abscess formation, necessitating immediate imaging. Prompt evaluation of penetrating animal bites, particularly dog bites, is crucial due to their high infection risk. As emphasized by Hamed-Assam et al., immediate attention and prophylactic antibiotics are advised for such cases, preferably broad-spectrum antibiotics with anaerobic coverage. The patient underwent treatment in the ED approximately a day after the incident, receiving antibiotics and subsequently discharged following advanced diagnostic imaging. This case underscores the importance of recognizing and promptly addressing delayed dog bites, emphasizing the significance of immediate medical intervention post-penetrating animal bites.

[Orbital infections]

Orbital cellulitis is a rare occurrence in ophthalmology practice. It is heterogeneous in terms of etiology, anatomical form and severity. Most often, it occurs adjacent to a sinus infection (frequently ethmoidal). Management must be systematized, adapted to the clinical examination and ancillary testing, and above all, proactive, since in certain situations, the functional and/or vital prognosis may be at stake. A clinical examination and urgent CT scan are essential for making the correct diagnosis, enabling us to assess the severity of the condition and determine whether surgery is required in addition to antibiotic therapy.

Angioinvasive Rhino-Orbital-Cerebral Mucormycosis in a Patient with Type 2 Diabetes Mellitus: A Complex and Lethal Cause of Stroke

Rhino-orbital-cerebral mucormycosis is a rapidly progressive and often fatal fungal infection caused by molds of the order Mucorales, particularly affecting immunocompromised individuals. This infection is notorious for its angioinvasive properties, enabling the fungi to invade blood vessels and leading to tissue necrosis. We report the clinical course of a 59-year-old Caucasian man with poorly controlled type 2 diabetes (HbA1c 16.8%) who presented with unilateral headache, left-sided facial numbness, and incomplete left ocular motor paresis. Initial presentation raised suspicion of orbital phlegmon, leading to antibiotic and later corticosteroid pulse therapy, which worsened the patient's condition. Subsequent imaging demonstrated extensive inflammatory changes, including wall irregularities of the left intracranial internal carotid artery, accompanied by ocular protrusion and periorbital enhancement. New palatal lesions indicated mucormycosis, which was confirmed by molecular analysis of a palatal biopsy, leading to Amphotericin B treatment. Pre-surgery imaging revealed a malignant middle cerebral artery infarction, and the patient died 16 days after symptom onset and 12 days after initial presentation under palliative care due to a poor prognosis. This case of angioinvasive mucormycosis underscores the severe and often fatal course of rhino-orbital-cerebral mucormycosis in an immunocompromised individual. The rapid progression from initially vague and unspecific symptoms to extensive vascular involvement and stroke highlights the critical need for early and accurate diagnosis, as well as prompt intervention to prevent further disease progression. Additionally, this case also illustrates the potential risks associated with corticosteroid therapy in the presence of undiagnosed fungal infections, which can exacerbate the condition and lead to serious complications. Clinicians should maintain a high index of suspicion for mucormycosis in similar clinical scenarios, prioritizing adequate antifungal treatment and careful monitoring to improve patient outcomes. Early interdisciplinary collaboration is essential for the effective management of such complex cases.

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.

Visual outcomes following orbital decompression for orbital infections

OBJECTIVE

To analyze the visual outcomes and sequelae of endonasal intervention for orbital infections.

INTRODUCTION

Orbital infections pose a serious threat to vision in the pediatric population and can result in complications such as blindness, diplopia, intracranial involvement, and death. [1] Orbital decompression by endonasal intervention is a common treatment to address a variety of orbital infections including orbital cellulitis, orbital abscesses, and subperiosteal abscesses. [2] The outcomes of visual sequelae such as loss or limitation of visual acuity, extraocular movements, and increased intraocular pressure following orbital decompression via endonasal intervention have not been sufficiently investigated in the current literature.

METHODS

This retrospective cohort study was performed at our tertiary care pediatric hospital using data from 69 patients aged 0-18 years who were admitted between 2008 and 2018. Data was extracted from the electronic medical record system.

RESULTS

Following endoscopic sinus surgery, symptoms of orbital infection improved throughout the cohort. Improvement in visual acuity is demonstrated by a statistically significant decrease in the average logMAR value in both the right and left eye (P = 0.002 and P = 0.028 respectively). There was also a significant improvement to normal values postoperatively for patients who initially presented with abnormal tonometry, extraocular movement, and the appearance of eyelids and eyelashes.

CONCLUSION

There is no decline or loss of vision with otolaryngology surgical intervention for orbital cellulitis in our cohort. This retrospective chart review demonstrates the efficacy of surgical intervention on overall visual outcomes following endonasal intervention for orbital infections such as orbital cellulitis, orbital abscesses, and subperiosteal abscesses.

Management of oculo-orbital complications of odontogenic sinusitis in adults

Introduction: Odontogenic maxillary sinusitis (OMS) is an infectious inflammatory pathology caused by a dental condition. Considering the anatomical relations with the orbit, maxillary sinus infection can easily spread, evolving into severe oculo-orbital complications that can sometimes be life-threatening. Material and methods: We performed a retrospective study of over 2 years, examining the data of 18 patients diagnosed with OMS with oculo-orbital complications. The patients were evaluated regarding their dental history, symptoms, clinical and endoscopic findings, ophthalmologic evaluation, bacteriologic tests, computed tomography (CT) imaging, medical and surgical treatment, and outcomes. Results: The age of the patients was between 24 and 65 years old with an almost equal gender distribution: 10 female and 8 male patients. From the total, 7 patients had type II diabetes, 2 of whom were insulin-dependent, 1 patient had thrombophilia and 2 patients had renal failure with peritoneal dialysis. Regarding the type of oculo-orbital complications, 10 patients were diagnosed with preseptal cellulitis and 8 with orbital cellulitis. Just 5 patients with orbital cellulitis required surgical treatment and orbitotomy was performed, followed by endonasal endoscopic drainage. The evolution after surgical treatment was favorable for all operated patients. Discussions: Oculo-orbital complications of OMS are typically more severe than those of rhinogenic sinusitis because anaerobic bacteria are involved. Immunosuppression represents a favorable environment for the development of OMS and its complications, diabetes being the most common risk factor. A negative prognostic feature is the appearance of ophthalmological symptoms in both eyes, so visual function may be reduced. The treatment of oculo-orbital complications of OMS is urgent and depends on a broad-spectrum antibiotic therapy associated or not with surgical intervention. Conclusions: The diagnosis of oculo-orbital complications of OMS is complex and requires clinical experience as well as extensive medical knowledge to treat both the cause and the consequences of the conditions quickly and effectively. The proper management of oculo-orbital complications is based on a multidisciplinary team: ophthalmology, ENT, dentistry, imaging, and laboratory. Abbreviations: OMS = odontogenic maxillary sinusitis, CT = computed tomography, ENT = ear-nose-throat, MRI = magnetic resonance imaging, HNS = head and neck surgery.

Diagnosis of Endophthalmitis and Orbital Abscess by Ultrasound: A Case Report

Introduction

The diagnosis of ocular pathology by point-of-care ultrasound (POCUS) has been well established for entities such as retinal detachment, vitreous hemorrhage, posterior vitreous detachment, and lens dislocation.1 However, the use of ultrasound to detect other conditions such as orbital abscess and endophthalmitis in the emergency setting is rarely reported.

Case Report

We present a case in which POCUS was used to confirm the suspected diagnosis of endophthalmitis and orbital abscess. This case report will review the ultrasonographic findings of orbital abscess and endophthalmitis, as well as briefly discuss the literature for the use of ultrasound for these applications.

Conclusion

Point-of-care ultrasound can be used to rapidly diagnose infectious pathology of the eye and orbit, which could potentially decrease time to diagnosis and time to consultation of these vision-threatening pathologies.

Overwhelming orbital cellulitis in a neonate

This article discusses a rare ophthalmic manifestation of neonatal bacterial infection and its management, including surgical drainage. The case discussed is that of a neonate who presented with rapidly progressing ophthalmic symptoms suggestive of orbital cellulitis. The neonate also had extensive intracranial involvement and had spread to contiguous structures causing a temporal lobe abscess. As there was no local injury, a haematogenous spread was strongly considered. With blood culture and pus culture yielding the growth of Staphylococcus aureus, systemic antibiotics and surgical interventions were required to successfully manage the neonate. Through this case report, we emphasise that orbital infections are grave in neonates and may culminate into devastating intracranial complications; hence, it necessitates appropriate medical and surgical interventions right from hospital admission.

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 Increased Risk of Pediatric Orbital Cellulitis-Who Should Be Scanned?

BACKGROUND

Evaluation of a child with POC/OC is complicated due difficulties in physical examination and risks of imaging by computed tomography.

METHOD

Retrospective review of children 0-16 years admitted to the pediatric emergency department for POC/OC from 2009 to 2019.

RESULTS

Ten years study period, 243 children younger than 16 years presented to the pediatric emergency department with a diagnosis of POC/OC. OC was documented in 51 (20.6%) patients. The mean age was 7.8 years (±4.3 years). Fever (80.4%), upper respiratory tract infection (43%), swelling of both eyelids (96%), proptosis (33.3%), and tenderness on percussion (24.5%) were more common in comparison to POC (P = 0.0001, 0.03, 0.0001, 0.0001, 0.0001 respectively). All children with suspected diagnosis of OC underwent computed tomography scan. POC accounted for 196 patients. Mean age was 4.6 (±4.3) years. Twenty percent of the cases were recorded as local trauma or insect bite in the infected eye.Mean leukocyte count in the OC group had higher mean of 15.2 (109/L) versus 13.4(109/L) (P = 0.05), absolute neutrophil count was significantly higher in the OC 11.3(109/L) versus 7.2(109/L) (P = 0.0001) whereas the lymphocyte count was higher in the POC 4.5(109/L) versus 2.4(109/L) (P = 0.0001), NLR of 0.318 correlates with orbital cellulitis with sensitivity of 75.5% and specificity of 77.4%.Patients with OC had mean C-reactive protein levels of 11.7 (mg/dL) versus 4.9(mg/dL) (P = 0.0001), erythrocyte sedimentation rate was elevated in the OC 53.6 (cm/h) versus 36.4 (cm/h) (P = 0.02).Based on the aforementioned study a risk calculator for OC was formulated with 6 major variables.

CONCLUSIONS

Differentiation between POC/OC is cardinal. This study highlights the importance of ancillary laboratory tests especially C-reactive protein in the assessment of infections of the eye.

School Nurses on the Front Lines of Healthcare: Getting aHEAD of EmergENT Eye, Ear, Nose, and Throat Infections

School nurses may deal with various common infectious eye, ear, nose, and throat-related chief complaints in regular practice. Recognizing the signs and symptoms of severe infection is paramount to preventing life-threatening complications that can have both acute and long-term implications. Distinguishing urgent and emergent eye, ear, nose, and throat conditions to send to the emergency department is integral to reducing the morbidity associated with these conditions. This article discusses three different students presenting with various chief complaints, from the initial assessment by the school nurse to the appropriate disposition and follow-up.

CT definition of the surgical apex in the orbit

The orbital apex is an undefined but well understood concept of Orbital Surgeons. We sought to determine the surgical apex area specifically where the volume ratio decreases significantly impacting on the optic nerve. A retrospective analysis using PACS program processing, measured the right retrobulbar space volume changes in 100 randomly selected cases without orbital pathology where CT was performed for non-ophthalmic indications. Volume of the retrobulbar space was measured between two recognizable landmarks. The first landmark being the point of exit of the optic nerve from the eye and the second landmark the optic nerve's point of exit from the orbit. The measured length between these two points was divided into five equal segments, V1-V5. The volumes of all 5 segments were compared and the most significant area of volume depletion was established. The mean numeric value of measured orbital volumes was compared. A ratio difference of V1/V2 was less than 2, V2/V3 was 2.32 (± 0.27), V3/4 was 3.24 (± 0.39), and V4/V5 was 5.67 (± 1.66). The most remarkable difference in ratio was between V4 and V5 (mean 5.67 ± 1.66 with p < .0001). The V3 segment (the posterior 3/5 of the retrobulbar space volume) is the location where decrease in orbital volume impacts, and measured ratios are statistically significant. We defined the surgical apex as the posterior 3/5 of the retro-bulbar orbital space. It is consequently the area of higher risk for optic nerve compression. This definition could be routinely utilized by ophthalmologists and neuroradiologists when evaluating masses affecting the orbit.

Ocular manifestations of dermatological diseases part I: infectious and inflammatory disorders

Skin and eyes share a common embryological origin from the embryonic surface ectoderm. Ocular manifestations are one of the most important and common associations of dermatological diseases. Currently, there are few comprehensive reviews of the ocular manifestations of dermatological diseases. We have reviewed more than 40 published articles related to the ocular manifestations of the most important dermatological diseases. The search included Pubmed, Google Scholar, and Cochrane databases from 2014 to 2019. This review was divided into three parts including infections, inflammatory, genetics, connective tissue, autoimmune, neoplasms, and drug-related disorders. We excluded metabolic, endocrine, and nutrition-related dermatological diseases. The relationship of ocular manifestations and dermatological diseases is important to recognize for appropriate management since many dermatological diseases can manifest initially with ocular findings. In this part, we summarized the most common and significant ocular findings in infectious and inflammatory dermatological disorders with appropriate referral recommendations to ophthalmology.

Angioedema Masqueraders

Angioedema is a common reason for referral to immunology and allergy specialists. Not all cases are in fact angioedema. There are many conditions that may mimic its appearance, resulting in misdiagnosis. This may happen when a clinician is unfamiliar with conditions resembling angioedema or when there is a low index of clinical suspicion. In this article, we explore a list of differential diagnoses based on body parts, including the lips, the limbs, periorbital tissues, the face, epiglottis and uvula, as well as the genitalia, that may pose as a masquerader even to an experienced eye.

Combined central retinal vein, central retinal artery and cilioretinal artery occlusion with ischemic macular hole secondary to severe orbital cellulitis after black fly bite

Background: Orbital cellulitis is an infection of the ocular adnexal and orbital tissues behind the orbital septum. The complications are poor prognosis. This paper is to describe some severe rare complications of orbital cellulitis.

Case presentation: A case of 32-year-old female presented with acute severe progressive orbital cellulitis on the right eye after a black fly (Simuliidae spp.) bite. Orbital imaging with computed tomography and magnetic resonance imaging showed eyelid abscess with orbital abscess formation and superior ophthalmic vein thrombosis. She was promptly treated with intravenous vancomycin, piperacillin and had surgical procedures to release orbital pressure including lateral canthotomy, lateral cantholysis, and eyelid with orbital abscess drainage. Pus collection culture was positive for Staphylococcus aureus. Even though she responded well to antibiotics treatment, progression involved severe orbital inflammation with marked increased orbital pressure, and her visual acuity was such that she had no light perception. Combined central retinal vein, central retinal artery and cilioretinal artery occlusion were identified. Fundus examination showed retinal whitening at the posterior pole and a few scattered flame-shaped retinal hemorrhages. The cilioretinal artery presented with perivascular retinal whitening. A fundus fluorescein angiogram revealed cilioretinal and retinal artery filling delay and also delayed arteriovenous transit time. She also developed an ischemic macular hole after a week of treatment. We demonstrate an optical coherence tomography image showing the intact posterior hyaloid membrane that represents no traction on the macula to support the ischemic cause.

Conclusion: Multiple retinal vascular occlusion and ischemic macular hole could be an early complication of severe orbital cellulitis from increased orbital pressure; therefore, close monitoring of visual acuity with IOP, and prompt treatment when indicated might reduce the risk of consequent blindness.