Orbital Abscess Secondary to Nasolacrimal Duct Obstruction in an Extremely Preterm Infant

Orbital abscesses are rarely encountered in children younger than 1 year. The literature is limited to isolated case reports and a few case series. Most such cases are reported in infants born at term, with the earliest reported gestational birth age at 34 weeks. Children are more prone to orbital cellulitis compared with adults due to their underdeveloped sinuses and immature immune systems, and the origin is most commonly an ethmoid sinus infection. Orbital cellulitis secondary to dacryocystitis is even less common, with only a few isolated cases reported in infants and children. Herein, the authors present a case of a large extraconal and intraconal orbital abscess secondary to nasolacrimal duct obstruction and dacryocystitis in an extremely preterm infant. We discuss the diagnosis and multidisciplinary management of this challenging case.

Pott's Puffy Tumor: A Rare, Life-Threatening Presentation of Periorbital Edema

Pott's puffy tumor (PPT) describes forehead swelling with associated frontal bone osteomyelitis and a subperiosteal abscess (SPA) requiring a high suspicion index for optimal outcomes. PPT is a life-threatening complication of frontal sinusitis typically found in adolescents. Our case is one of the youngest in the literature. This report describes a 3-year-old patient who developed multifocal abscesses in the epidural space with frontal and orbital SPA, requiring surgical intervention. Additionally, her course was complicated by a superior sagittal venous thrombosis, a complication commonly associated with PPT. We present an unusual case of orbital SPA and aim to highlight a life-threatening pediatric condition that is often underrecognized.

Infectious and Inflammatory Processes of the Orbits in Children

Most primary orbital pathology in children is due to bacterial infection. Radiologists typically encounter these cases to evaluate for clinically suspected postseptal orbital involvement. Contrast-enhanced cross-sectional imaging is important for the detection and early management of orbital infection and associated subperiosteal/orbital abscess, venous thrombosis, and intracranial spread of infection. Benign mass-like inflammatory processes involving the pediatric orbit are rare, have overlapping imaging features, and must be distinguished from orbital malignancies.

Seasonal variations, acute rhinosinusitis and orbital infections in children

BACKGROUND

Orbital infections in children are commonly secondary to acute bacterial rhinosinusitis (ABRS). It is unclear whether seasonal variations can predispose to these complications mirroring acute rhinosinusitis incidence.

OBJECTIVE

To determine the incidence of ABRS as a cause of orbital infections and whether seasonality is a risk factor.

METHODS

A retrospective review of all children who presented to West Virginia University children's hospital between 2012 and 2022 were reviewed. All children with CT evidence of orbital infection were included. Date of occurrence, age, gender, and presence of sinusitis were reviewed. Children with orbital infection secondary to tumors, trauma, or surgery were excluded.

RESULTS

118 patients were identified with mean age of 7.3 years with 65 (55.1 %) males. 66 (55.9 %) children had concomitant sinusitis on CT scan, and the distribution of orbital complications per season showed 37 (31.4 %) cases occurred in the winter season, followed by 42 (35.6 %) cases in spring, 24 (20.3 %) cases in summer, and 15 (12.7 %) in fall. Children with orbital infections during winter & spring had sinusitis in 62 % of children vs. 33 % in other seasons (P = 0.02). Preseptal cellulitis was present in 79 (67 %) children, 39 (33 %) children with orbital cellulitis, and 40 (33.9 %) children with abscesses. 77.6 % children were treated with IV antibiotics and 94 % with oral antibiotics, and 14 (11.9 %) with systemic steroids. Only 18 (15.3 %) children required surgery.

CONCLUSIONS

There seems to be a seasonal predisposition for orbital complications mainly in the winter and spring seasons. Rhinosinusitis was present in 55.6 % of children presenting with orbital infections.

LEVEL OF EVIDENCE: 4

[Orbital cellulitis secondary to odontogenic superior maxillary sinus septum infection: a case report]

A 66-year-old woman presented with recurrent erythema, swelling and pain in her right eye. She had a history of extraction of the right upper second molar 5 months ago with subsequent development of an abscess which was incised and drained 4 months ago. Orbital CT scan revealed the formation of subperiosteal sinus cavity with an abscess in the right maxillary sinus and infraorbital foramen. The diagnosis was orbital honeycombing caused by odontogenic maxillary sinus septum infection. Utilizing the anterior lacrimal recess approach under nasal endoscope,incision and drainage of ocular abscess and debridement and drainage of right orbital abscess plus partial resection of the inner wall of the jaw were performed successfully with maxillary sinus septal drainage and maxillary sinus opening. The patient improved significantly after the operation.

Hemicentral Retinal Artery Occlusion: A Rare Complication of Orbital Cellulitis

A 14-year-old boy presented with acute vision loss and swelling of the right eye. An anterior segment examination revealed a relative afferent pupillary defect, severe proptosis, and ophthalmoplegia in his right eye. The fundus examination revealed inferior hemicentral retinal artery occlusion. Although the authors proceeded with systemic medical treatment, the findings did not improve. An endoscopic orbital decompression was performed. With both medical and surgical treatment, the orbital cellulitis resolved and the patient's visual acuity improved. [J Pediatr Ophthalmol Strabismus. 2020;57:e51-e55.].

Impact of superior ophthalmic vein thrombosis: a case series and literature review

Purpose: To present nine new cases of superior ophthalmic vein thrombosis (SOVT) and compare these with the literature, and to assess the impact of SOVT for the clinician. Methods: Using the data bases of the Department of Ophthalmology of the AMC, we searched for patients with radiologically evidenced SOVT between January 2006 and December 2014. In addition, a PubMed search, using the mesh term 'superior ophthalmic vein thrombosis', was done. Results: We found nine patients with SOVT. In three patients, SOVT was related to dural arteriovenous fistulae. In one patient, it was caused by the acute reversal of warfarin by vitamin K. In two patients, an infectious cause was found. In three patients, the cause of SOVT was not found despite screening for coagulation and other disorders. All patients presented with eyelid swelling, proptosis, and/or motility impairment. We found complete recovery in four patients. Three patients had mild sequelae and two patients had severe visual impairment. In the literature, we found 60 cases reporting on SOVT with various aetiologies. Clinical presentation, treatment modalities, and outcomes were comparable to our findings. Conclusion: Our case series and literature review show that SOVT can occur simultaneously with cavernous sinus thrombosis (CST) but can also be a separate entity. Clinical presentation can mimic orbital cellulitis (OC) or CST and when no signs of OC can be found, an alternative cause for SOVT should be sought. When timely and adequate treatment is conducted, the prognosis is predominantly favourable.

Radiographic Course of Medically Managed Pediatric Orbital Subperiosteal Abscesses

PURPOSE

To describe the natural radiographic course of subperiosteal orbital abscesses that were managed medically in pediatric patients.

METHODS

A retrospective case review was undertaken at Children's Mercy Hospitals and Clinics of Kansas City, Missouri. All patients admitted to the hospital and diagnosed as having orbital cellulitis or subperiosteal abscess from 2008 to 2017 were included in the study. Of the 418 patients identified, 15 patients had repeat imaging and did not undergo surgery prior to the second scan. The initial size of the empyema, size of the empyema on repeat imaging, and clinical course were recorded for each patient.

RESULTS

The size of the empyemas increased 240% on average in the first 2 to 3 days. Imaging up to 11 days after the diagnosis showed that 9 cases persisted; meanwhile, 4 cases had radiographic resolution, with the earliest by 21 days. Two cases recurred months later. The largest increase in size was 500% over 3 days, but the initial empyema was only 0.3 cm³.

CONCLUSIONS

This review describes the natural history of radiographically reimaged subperiosteal empyema. Empyema size will increase for a few days prior to a gradual resolution in 1 to 3 weeks. An ultimate resolution of radiographic evidence of an empyema takes up to 21 days. This information will help guide clinical management and decision making in caring for patients with pediatric orbital cellulitis with subperiosteal empyema. [J Pediatr Ophthalmol Strabismus. 2018;55(6):387-392.].

Severely infected pneumoceles of the frontal sinus in patients with mental retardation and brain atrophy treated by endoscopic sinus surgery

We herein present three cases of abnormally expanded frontal sinuses (pneumoceles) with severe infection in patients with mental retardation and brain atrophy. Two patients previously underwent laryngotracheal separation surgery, and bacteriological examinations of purulent nasal discharge revealed infections caused by drug-resistant bacteria such as Pseudomonas aeruginosa and Acinetobacter baumannii. As conservative medical treatments were ineffective, all three patients were treated by computed tomography-guided endoscopic sinus surgery. This navigation system is useful for safer surgery in the area of anatomic deformity. The clinical findings, possible etiologies and surgical treatment of these cases are discussed.

Intracranial Infectious Aneurysm in Orbital Cellulitis

Infectious intracranial aneurysm and cavernous sinus thrombosis are rare complications of orbital cellulitis. We report the case of a 46-year-old male presenting with sinusitis and orbital cellulitis complicated by the development of an orbital mass. Following orbitotomy with debulking, the patient underwent bony orbital decompression for increasing proptosis postoperatively. While his exam stabilized, the patient developed complete ptosis and extraocular motor palsy in the contralateral eye after undergoing bilateral sinus debridement. Imaging was notable for the presence of a pseudoaneurysm of the internal carotid artery, which was treated with a stent. This report demonstrates rare complications of orbital cellulitis. These patients should be monitored carefully with noninvasive imaging studies, such as cerebral angiography, for early detection of vascular abnormalities that can progress rapidly.

Orbital cellulitis: clinical course and management challenges. the Lagos State University Teaching Hospital experience

BACKGROUND

Orbital cellulitis is a devastating acute infection of orbital soft tissues located posterior to the orbital septum. It is both vision and life-threatening. It is an ocular emergency which most often present in childhood.

OBJECTIVE

This article reviewed cases presenting during the study period with the view of examining the pattern of presentation, clinical course and management challenges.

METHODS

A retrospective study was conducted on patients presenting with orbital cellulitis between January 2008 and June 2011. Socio-demographic data, entry and discharge visual acuity, presenting complaints, predisposing factors, duration of complaints, admission period and complications were extracted from clinical records and analyzed.

RESULTS

Seventeen (17) patients presented with orbital cellulitis constituting 6.2% of ocular emergency admissions during the study period. Twelve (70.6%) were males. Thirteen (76.5%) were children. The major predisposing factors were upper respiratory tract infections, and facial and globe injuries in five (22.7%) cases respectively. Only five (29.4%), presented within three days of disease onset. Average duration of admission was 10.6 days. Complications during the course of disease were category 4 and 5 blindness in five (23.5%), orbital abscess four (23.5%), cavernous sinus thrombosis two (11.8%), contralateral preseptal cellulitis two (11.8%) and exposure keratopathy in one (5.9%).

CONCLUSION

Orbital cellulitis has remained a disease with high ocular morbidity. The major management challenges were poor financial status of patients precluding necessary diagnostic laboratory and imaging studies. Early recognition, diagnosis and treatment are crucial to the preservation of vision and reduced occurrence of complications. The importance of record keeping is also highlighted.

[Clinical case of the month. Sudden orbital cellulitis in the emergency unit]

We report a case of infectious orbital cellulitis complicating a frontal sinusitis in a seventy-three-year-old patient. The onset of this orbital complication was sudden. A clinical examination and an orbital CT-scan allowed an early diagnosis. Despite an appropriate surgical and medical treatment, the patient retains an altered visual function. We consider the clinical causes and consequences of orbital cellulitis as well as their surgical indications.

[Blindness due to acute ethmoiditis]

Orbital complications of ethmoiditis are well-described. This case presents a healthy ten-year-old boy who was admitted under the diagnosis of acute ethmoiditis. A computed tomography (CT) showed orbital cellulitis, but no definite abscess. The patient improved during intravenous antibiotic treatment, but suddenly complained about loss of vision. The clinical signs were central scotoma and visual impairment to 0.05. Both repeat CT, magnetic resonance imaging and ethmoidectomy were performed without signs of abscess. Blindness due to ethmoiditis without abscess in orbita is rare and probably results from neuritis in the nervus opticus.

Klebsiella pneumoniae orbital cellulitis with extensive vascular occlusions in a patient with type 2 diabetes

A 39-year-old woman visited the emergency room complaining of right eye pain and swelling over the preceding three days. The ophthalmologist's examination revealed orbital cellulitis and diabetic retinopathy in the right eye, although the patient had no prior diagnosis of diabetes. It was therefore suspected that she had diabetes and orbital cellulitis, and she was started on multiple antibiotic therapies initially. She then underwent computed tomography scans of the orbit and neck and magnetic resonance imaging of the brain. These studies showed an aggravated orbital cellulitis with abscess formation, associated with venous thrombophlebitis, thrombosis of the internal carotid artery, and mucosal thickening of maxillary sinus with multiple paranasal abscesses. Three days later, initial blood culture grew Klebsiella pneumoniae. She recovered after incision and drainage and antibiotic therapy for 37 days.

[Orbital phlegmon: clinical picture, diagnosis]

The purpose of the study was to enhance the efficiency of early diagnosis of orbital phlegmon, by examining its clinical picture and using instrumental studies. Sixty-three patients with orbital phlegmon were treated at hospital in 1985 to 2007. Its diagnosis employed ultrasound and X-ray studies. Orbital phlegmon was diagnosed in 30 patients with orbital injury and 33 patients with inflammatory diseases of the eyelids, face, nasal sinuses, and infection metastasis from septic foci. The disease was characterized by intoxication syndrome, eyelid inflammatory changes, chemosis, exophthalmos, and ophthalmoplegia. The following complications: neuritis, optic nerve ischemia, meningoencephalitis, brain abscess, cavernous sinus thrombosis, and sepsis were observed. Ultrasound and X-ray (computed tomography, magnetic resonance imaging) studies provide the diagnosis of the disease in early periods and timely medical and surgical treatments.

Combined central retinal artery and vein occlusion complicating orbital cellulitis

Orbital Cellulitis is a dreaded ophthalmologic disease. It may destroy vision and the eye and may even become life threatening. Often visual loss is the result of exposure and subsequent destruction of ocular tissue commonly the cornea and the uvea. We report a case of combined central retinal artery and vein occlusion complicating orbital cellulitis in a 35 year old patient who was 37 weeks pregnant resulting in loss of vision in the affected eye. There have been few case reports of this type of complication of orbital cellulitis.

Clinical analysis of computed tomography-staged orbital cellulitis in children

BACKGROUND AND PURPOSE

Bacterial infection of the orbital structures can affect all age groups, but is more frequent in pediatric populations. Prompt recognition, correct diagnosis, and adequate management are important if serious complications are to be avoided. This study sought to delineate the clinical, bacteriological and radiological findings, management and outcome of orbital cellulitis.

METHODS

This retrospective study reviewed 80 children admitted to Chang Gung Children's Hospital with a diagnosis of orbital cellulitis who were staged by computed tomography (CT), between January 1999 and August 2005. The staging classification was as follows: stage I, inflammatory edema (preseptal); stage II, subperiosteal phlegmon and abscess; stage III, orbital cellulitis; stage IV, orbital abscess; and stage V, ophthalmic vein and cavernous sinus thrombosis. The patients were categorized into 2 groups: preseptal (stage I) and postseptal (stage II-V).

RESULTS

Of the 80 children, 50 were male and the mean age was 6.8 years. Sinusitis and upper respiratory tract infection were the most common predisposing factors. Forty one percent of patients in stage I presented with symptoms that indicated postseptal involvement. The patients with postseptal involvement had a significantly higher rate of proptosis and limitation of extraocular motility. Bacterial pathogens were identified in 31 patients (39%), the 2 most common pathogens being Staphylococcus and Streptococcus. Ten patients (13%) had polymicrobial infection. Twenty three patients underwent sinus and/or orbital and/or intracranial surgery, including all 5 patients (100%) in stage IV, 3 of 6 patients (50%) in stage III, 13 of 35 patients (37%) in stage II, and 2 of 34 patients (6%) in stage I. Complete resolution without complication was achieved in 72 children. Eight patients had complications, including intracranial infection in 3, recollection of abscess in 2, ophthalmoplegia in 2, and corneal scar in 1.

CONCLUSIONS

Proptosis and limitation of extraocular motility may be considered the most important signs on CT examination in children with suspicious orbital cellulitis. Given that polymicrobial infection is common, broad-spectrum antibiotics are indicated initially. Surgery should be considered not only when an abscess is demonstrated by CT scan but also if clinical deterioration occurs within 24 to 36 h of adequate intravenous antibiotic treatment.