Br J Ophthalmol 1986 Bergin 174 8
6
British Journal o f Ophthalmology, 1986, 7 0 , 174-178 Orbital cellulitis DON LD J ERGIN ND JOHN E WRIGHT From t h e Orbital Clinic, Moorfields E y e Hospital, City Road, London EC I V2PD SUMMARY Forty-nine cases of orbital cellulitis were reviewed. T h e average a g e o f patients a t presentation was 3 1 years. T h e onset o f symptoms varied from seven days o r less i n 2 8 patients, o ne t o four weeks i n 1 7 patients, a n d more than four weeks i n four patients. T h e leucocyte count, available i n 33 patients, w a s greater than 109/l i n only nine. Abnormal sinuses were noted radiographically i n 6 1 . Computed tomography scans, performed o n nine patients, revealed non- localised inflammation i n three a n d a n orbital mass i n six. Cultures, i n general, were disappointing. Seventeen surgical procedures were performed on 14 patients. Th e complications o f orbital cellulitis, occurring i n five patients, included osteomyelitis of t he maxillary bone, strabismus, afferent pupillary defect, chronic draining sinus, a n d scarred upper eyelid. Usually t h e treatment o f orbital cellulitis requires aggressive parenteral antibiotic therapy a n d judicious surgical inter- vention. Orbital cellulitis i s a n uncommon, potentially lethal disease. Prior t o t h e discovery o f antibiotics mortality rates o f 20 t o 50 , a n d blindness i n 20 t o 5 5 o f t h e survivors, were reported. 2 Although improve- ment since that timehas been dramatic, several series have recorded significant morbidity a n d mortality despite t h e u s e o f antibiotics. 6 review o f 4 9 patients with orbital cellulitis seen i n t h e Orbital Clinic a t Moorfields E y e Hospital during a 13-year period demonstrates t h e advantages o f giving appro- priate antibiotics by t h e intramuscular o r intravenous route. There were no deaths i n this series, a n d damage tostructures within t he orbit w a s infrequent. Patients a n d methods T h e clinical recordsof a ll patients with a diagnosis o f orbital cellulitis between 1970 a n d 1983 were r e - viewed. Forty-nine patients ( 2 4 male, 2 5 female) composed t h e study group. Patients were included only i f they had postseptal orbital inflammation considered t o b e caused by bacteria, i f p u s w s drained from t he orbit, o r prompt resolution o f t h e signs a n d symptoms followed antibiotic therapy. Patients ranged i n a g e from 4 weeks t o 7 1 years, mean ag e 3 1 years. T e n patients were aged 1 4 years o r less. A l l patients h a d radiographs o f t h e skull, with under-tilted occipito-mental a nd oblique radiographs Correspondence t o Dr Donald J Bergin, B ox 1452, Letterman Army Medical Center, Presidio o f S a n Francisco, California 94129, USA. 1 7 4 showing details o f th e paranasal sinuses. I n a few patients axial hypocycloidal tomograms were o b- tained to reveal t h e anatomy o f t he ethmoid a n d sphenoid sinuses. Towards t h e e nd o f th e review period computed tomography (CT) scans were also obtained i n selected patients. T h e patients were treated with a wide range o f antibiotics. Those most commonly used were penicil- lin, synthetic penicillins effective against penicil- linase-producing bacteria, ampicillin, amoxicillin, a n d chloramphenicol. These antibiotics were used alone o r i n combination, i n large doses, a n d adminis- tered parenterally. Rifampin, ethambutol, a n d isoni- azid t o treat t w o patients wh o h ad tuberculous infections o f t he orbit. Surgical drainage was performed i n patients wh o had clinical and radiological evidence o f a n orbital abscess. In a number o f patients sinus drainage procedures were carried out, either during t h e infec- tious period o r a t a later date. W e included this surgery in t h e results only i f i t w as performed during t he period o f active orbital cellulitis. Follow-up data through complete resolution o f t h e orbital cellulitis were available in a l l cases. Results Thirty o f th e 4 9 patients with orbital cellulitis h a d left orbital involvement a nd 1 7 h a d right orbital involve- ment. I n t w o cases t h e orbital cellulitis w a s bilateral. Twenty-four o f t h e 4 9 patients presented i n t h e four group.bmj.com on December 20, 2013 - Published by bjo.bmj.com Downloaded from
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Transcript of Br J Ophthalmol 1986 Bergin 174 8
8/13/2019 Br J Ophthalmol 1986 Bergin 174 8
http://slidepdf.com/reader/full/br-j-ophthalmol-1986-bergin-174-8 1/6
B r i t i s h J o u r n a l o f O p h t h a l m o l o g y , 1 9 8 6 , 7 0 , 1 7 4 - 1 7 8
O r b i t a l c e l l u l i t i s
DON LD J ERGIN ND JOHN E WRIGHT
F r o m t h e O r b i t a l C l i n i c , M o o r f i e l d s E y e H o s p i t a l , C i t y R o a d , London EC I V2PD
SUMMARY F o r t y - n i n e cases o f o r b i t a l c e l l u l i t i s were r e v i e w e d . The average age o f p a t i e n t s a tp r e s e n t a t i o n was 3 1 years. T h e o n s e t o f symptoms v a r i e d f r o m s e v e n d a y s or l e s s i n 2 8 p a t i e n t s , onet o f o u r w e e k s i n 1 7 p a t i e n t s , a n d more t h a n f o u r w e e k s i n f o u r p a t i e n t s . T h e l e u c o c y t e c o u n t ,a v a i l a b l e i n 3 3 p a t i e n t s , wa s g r e a t e r t h a n l O x 1 0 9 / l i n o n l y n i n e . Abnormal s i n u s e s were n o t e dr a d i o g r a p h i c a l l y i n 6 1 . C o m p u t e d t o m o g r a p h y s c a n s , p e r f o r m e d on n i n e p a t i e n t s , r e v e a l e d n o n -l o c a l i s e d i n f l a m m a t i o n i n t h r e e a n d a n o r b i t a l mass i n s i x . C u l t u r e s , i n g e n e r a l , were d i s a p p o i n t i n g .S e v e n t e e n s u r g i c a l p r o c e d u r e s were p e r f o r m e d on 1 4 p a t i e n t s . The c o m p l i c a t i o n s o f o r b i t a l
c e l l u l i t i s , o c c u r r i n g i n f i v e p a t i e n t s , i n c l u d e d o s t e o m y e l i t i s o f t h e m a x i l l a r y b o n e , s t r a b i s m u s ,a f f e r e n t p u p i l l a r y d e f e c t , c h r o n i c d r a i n i n g s i n u s , a n d s c a r r e d up p er e y e l i d . U s u a l l y t h e t r e a t m e n t o fo r b i t a l c e l l u l i t i s r e q u i r e s a g g r e s s i v e p a r e n t e r a l a n t i b i o t i c t h e r a p y a n d j u d i c i o u s s u r g i c a l i n t e r -v e n t i o n .
O r b i t a l c e l l u l i t i s i s a n u n c o m m o n , p o t e n t i a l l y l e t h a ld i s e a s e . P r i o r t o t h e d i s c o v e r y o f a n t i b i o t i c s m o r t a l i t yr a t e s o f 20 t o 5 0 , a n d b l i n d n e s s i n 20 t o 55 o ft h e s u r v i v o r s , w e r e r e p o r t e d . 2 A l t h o u g h i m p r o v e -m e n t s i n c e t h a t t i m e h a s b e e n d r a m a t i c , s e v e r a l s e r i e s
h a v e r e c o r d e d s i g n i f i c a n t m o r b i d i t y a n d m o r t a l i t yd e s p i t e t h e u s e o f a n t i b i o t i c s . 6 r e v i e w o f 4 9p a t i e n t s w i t h o r b i t a l c e l l u l i t i s s e e n i n t h e O r b i t a lC l i n i c a t M o o r f i e l d s E y e H o s p i t a l d u r i n g a 1 3 - y e a rp e r i o d d e m o n s t r a t e s t h e a d v a n t a g e s o f g i v i n g a p p r o -p r i a t e a n t i b i o t i c s b y t h e i n t r a m u s c u l a r o r i n t r a v e n o u s
r o u t e . T h e r e w e r e n o d e a t h s i n t h i s s e r i e s , a n dd a m a g e t o s t r u c t u r e s w i t h i n t h e o r b i t w a s i n f r e q u e n t .
P a t i e n t s a n d m e t h o d s
T h e c l i n i c a l r e c o r d s o f a l l p a t i e n t s w i t h a d i a g n o s i s o fo r b i t a l c e l l u l i t i s b e t w e e n 1 9 7 0 a n d 1 9 8 3 w e r e r e -
v i e w e d . F o r t y - n i n e p a t i e n t s ( 2 4 m a l e , 2 5 f e m a l e )c o m p o s e d t h e s t u d y g r o u p . P a t i e n t s w e r e i n c l u d e do n l y i f t h e y h a d p o s t s e p t a l o r b i t a l i n f l a m m a t i o nc o n s i d e r e d t o b e c a u s e d b y b a c t e r i a , i f p u s w a sd r a i n e d f r o m t h e o r b i t , o r p r o m p t r e s o l u t i o n o f t h es i g n s a n d s y m p t o m s f o l l o w e d a n t i b i o t i c t h e r a p y .P a t i e n t s r a n g e d i n a g e f r o m 4 w e e k s t o 7 1 y e a r s , m e a na g e 3 1 y e a r s . T e n p a t i e n t s w e r e a g e d 1 4 y e a r s o r l e s s .
A l l p a t i e n t s h a d r a d i o g r a p h s o f t h e s k u l l , w i t hu n d e r - t i l t e d o c c i p i t o - m e n t a l a n d o b l i q u e r a d i o g r a p h s
C o r r e s p o n d e n c e t o Dr D o n a l d J B e r g i n , Box 1 4 5 2 , L e t t e r m a n ArmyM e d i c a l C e n t e r , P r e s i d i o o f S a n F r a n c i s c o , C a l i f o r n i a 9 4 1 2 9 , USA.
1 7 4
s h o w i n g d e t a i l s o f t h e p a r a n a s a l s i n u s e s . I n a f e wp a t i e n t s a x i a l h y p o c y c l o i d a l t o m o g r a m s w e r e o b -t a i n e d t o r e v e a l t h e a n a t o m y o f t h e e t h m o i d a n ds p h e n o i d s i n u s e s . T o w a r d s t h e e n d o f t h e r e v i e wp e r i o d c o m p u t e d t o m o g r a p h y ( C T ) s c a n s w e r e a l s o
o b t a i n e d i n s e l e c t e d p a t i e n t s .T h e p a t i e n t s w e r e t r e a t e d w i t h a w i d e r a n g e o f
a n t i b i o t i c s . T h o s e m o s t c o m m o n l y u s e d w e r e p e n i c i l -l i n , s y n t h e t i c p e n i c i l l i n s e f f e c t i v e a g a i n s t p e n i c i l -l i n a s e - p r o d u c i n g b a c t e r i a , a m p i c i l l i n , a m o x i c i l l i n ,a n d c h l o r a m p h e n i c o l . T h e s e a n t i b i o t i c s w e r e u s e da l o n e o r i n c o m b i n a t i o n , i n l a r g e d o s e s , a n d a d m i n i s -t e r e d p a r e n t e r a l l y . R i f a m p i n , e t h a m b u t o l , a n d i s o n i -a z i d w e r e u s e d t o t r e a t t w o p a t i e n t s wh o h a dt u b e r c u l o u s i n f e c t i o n s o f t h e o r b i t .
S u r g i c a l d r a i n a g e w a s p e r f o r m e d i n p a t i e n t s wh oh a d c l i n i c a l a n d r a d i o l o g i c a l e v i d e n c e o f a n o r b i t a la b s c e s s . I n a n u m b e r o f p a t i e n t s s i n u s d r a i n a g e
p r o c e d u r e s w e r e c a r r i e d o u t , e i t h e r d u r i n g t h e i n f e c -t i o u s p e r i o d o r a t a l a t e r d a t e . We i n c l u d e d t h i ss u r g e r y i n t h e r e s u l t s o n l y i f i t w a s p e r f o r m e d d u r i n gt h e p e r i o d o f a c t i v e o r b i t a l c e l l u l i t i s .
F o l l o w - u p d a t a t h r o u g h c o m p l e t e r e s o l u t i o n o f t h eo r b i t a l c e l l u l i t i s w e r e a v a i l a b l e i n a l l c a s e s .
R e s u l t s
T h i r t y o f t h e 4 9 p a t i e n t s w i t h o r b i t a l c e l l u l i t i s h a d l e f to r b i t a l i n v o l v e m e n t a n d 1 7 h a d r i g h t o r b i t a l i n v o l v e -m e n t . I n t w o c a s e s t h e o r b i t a l c e l l u l i t i s w a s b i l a t e r a l .T w e n t y - f o u r o f t h e 4 9 p a t i e n t s p r e s e n t e d i n t h e f o u r
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O r b i t a l c e l l u l i t i s
F i g . 1 M a r k e d e y e l i d o e d e m a a n d p r o p t o s i s i n a p a t i e n tw i t h o r b i t a l c e l l u l i t i s w i t h c h e m o s i s a n d d e c r e a s e d o c u l a r
m o t i l i t y .
m o n t h s b e t w e e n N o v e m b e r a n d F e b r u a r y , w i t h
f e w e r p a t i e n t s s e e n i n t h e summer m o n t h s .
S i g n s a n d symptoms were p r e s e n t f o r s e v e n d a y s or
l e s s i n 2 8 p a t i e n t s , f r o m o n e t o f o u r w e e k s i n 1 7
p a t i e n t s , a n d more t h a n f o u r w e e k s i n f o u r p a t i e n t s .T wo o f t h e s e f o u r p a t i e n t s h a d p r e s u m e d t u b e r -c u l o m a o f t h e o r b i t . C h e m o s i s a n d e y e l i d s w e l l i n g
were p r e s e n t i n a l l p a t i e n t s , a n d 4 5 h a d r e d u c t i o n o fo c u l a r m ov em ent s ( F i g . 1 ) . T h e e y e was d i s p l a c e df r o m i t s n o r m a l p o s i t i o n i n 4 6 p a t i e n t s ; i n t h e
m a j o r i t y i t was p r o p t o s e d a n d d i s p l a c e d l a t e r a l l y or
d o w n w a r d s . O n l y 1 6 p a t i e n t s h a d p y r e x i a when f i r s tseen; s e v e n o f t h e 1 6 were l e s s t h a n 1 4 years o f age.
T w e n t y - t h r e e p a t i e n t s h a d r e d u c e d v i s u a l a c u i t y o f
o n e S n e l l e n l i n e o r m o r e i n t h e a f f e c t e d e y e , a n d 2 0
p a t i e n t s h a d n o r m a l v i s i o n . T h r e e p a t i e n t s h a d e y e l i ds w e l l i n g t h a t p r e c l u d e d v i s u a l a s s e s s m e n t . I n t w o
i n f a n t s v i s i o n w a s n o t a s s e s s e d . One p a t i e n t h a d a n
a n o p h t h a l m i c s o c k e t .T h e l e u c o c y t e c o u n t , a v a i l a b l e o n a d m i s s i o n i n 3 3
p a t i e n t s , w a s l e s s t h a n 1 0 x 1 0 9 / l i n 2 4 , a n d 1 0 x 1 0 9 / l o r
g r e a t e r i n n i n e p a t i e n t s ( r a n g e , 5 - 3 5 x 1 0 9 / l ) . T h eW e s t e r g r e n s e d i m e n t a t i o n r a t e , a v a i l a b l e i n 2 5 c a s e s ,w a s 1 5 mm/h o r l e s s i n n i n e p a t i e n t s , a n d g r e a t e r t h a n
1 5 mm/h i n 1 6 ( r a n g e 2 t o 5 6 m m / h ) . S k u l l x - r a y ss h o w e d s i n u s a b n o r m a l i t i e s i n 61 o f p a t i e n t s , w i t h
t h e f r o n t a l , m a x i l l a r y , o r e t h m o i d s i n u s e s , a l o n e o r i nc o m b i n a t i o n , a l m o s t e q u a l l y i n v o l v e d ( F i g . 2 ) . S p h e -n o i d a l s i n u s i t i s w a s u n c o m m o n . L y t i c l e s i o n s o f t h e
s u p e r i o r t e m p o r a l o r b i t a l r i m ( F i g . 3 ) w e r e p r e s e n t i nt w o c a s e s o f p r e s u m e d o r b i t a l t u b e r c u l o s i s . One o f
t h e s e l e s i o n s e n l a r g e d o v e r a n 8 - m o n t h p e r i o d i nc o n c e r t w i t h a n e n l a r g i n g l u n g n o d u l e . I n o n e p a t i e n ta i r w a s p r e s e n t i n t h e o r b i t , n o t e d a t s u r g e r y t o h a v e a
d i r e c t c o m m u n i c a t i o n b e t w e e n t h e a n t r u m a n d t h e
o r b i t .C o m p u t e d t o m o g r a p h y s c a n s o f t h e o r b i t w e r e
p e r f o r m e d o n n i n e p a t i e n t s . I n s i x a n a b s c e s s w a ss h o w n ( F i g . 4 ) . F i v e o f t h e s e a b s c e s s e s w e r e s u r g i -c a l l y d r a i n e d , w i t h t h e r e l e a s e o f l a r g e q u a n t i t i e s o f
p u s , a n d o n e a b s c e s s r e s o l v e d o n m e d i c a l t h e r a p y
a l o n e . d i f f u s e i n f l a m m a t o r y r e a c t i o n w a s s h o w n i nt h r e e p a t i e n t s , w h i c h l a t e r c o m p l e t e l y r e s o l v e d o n
a n t i b i o t i c t h e r a p y .
T w e n t y p a t i e n t s w e r e o n a n t i b i o t i c t h e r a p y w h e nf i r s t s e e n . C u l t u r e s p e c i m e n s w e r e o b t a i n e d f r o m
t h e m a n d f r o m m o s t o f t h e r e m a i n d e r a f t e r i n i t i a t i o no f a n t i b i o t i c t h e r a p y . O n l y a f e w c u l t u r e s o f b l o o d o r
f r o m c o n j u n c t i v a , n o s e , a b s c e s s , o r a n t r u m w e r e
p o s i t i v e , a n d n o o n e o r g a n i s m , o r g r o u p o f o r g a n -
F i g . 2 S k u l l x - r a y s h o w i n g m a x i l -l a r y a n d e t h m o i d a l o p a c i f i c a t i o nw i t h i n c r e a s e d o r b i t a l s o f t t i s s u ed e n s i t y o n t h e s i d e o f o r b i t a lc e l l u l i t i s .
1 7 5
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D o n a l d J B e r g i n a n d J o h n E W r i g h t
F i g . 5 R e m a r k a b l e i m p r o v e m e n t i n same p a t i e n t a s i n f i g . 1 ,4 8 h o u r s a f t e r s u p e r o t e m p o r a l t r a n s e p t a l o r b i t a l a b s c e s s
d r a i n a g e .
F i g . 3 S k u l l x-ray s h o w i n g a s u p e r o t e m p o r a l o r b i t a l r i ml y t i c l e s i o n i n a p a t i e n t w i t h t u b e r c u l o u s i n f e c t i o n o f t h eo r b i t .
i s m s , e m e r g e d as t h e p r e d o m i n a n t cause o f t h e
o r b i t a l c e l l u l i t i s . C u l t u r e s a n d s t a i n s f o r a c i d - f a s tb a c i l l i i n t h e two cases o f p r o b a b l e t u b e r c u l o s i s were
n e g a t i v e . H i s t o l o g i c a l e x a m i n a t i o n o f t h e w a l l o f o n e
o f t h e s e a b s c e s s e s r e v e a l e d n o n - s p e c i f i c g r a n u l o -matous i n f l a m m a t i o n . S i m i l a r l y , t h e r e was g r a n u l o -matous i n f l a m m a t i o n w i t h v a s c u l i t i s a n d p e r i v a s c u l i t i si n a n o r b i t a l b i o p s y s p e c i m e n o b t a i n e d f r o m a p a t i e n t
F i g . 4 C o m p u t e d t o m o g r a p h y o f t h e o r b i t s s h o w s a s o f tt i s s u e mass i n t h e l a t e r a l o r b i t d i s p l a c i n g t h e g l o b e . A l s on o t e t h e c o n t r a l a t e r a l e y e l i d o e d e m a , w h i c h g i v e s t h ei m p r e s s i o n o f b i l a t e r a l o r b i t a l d i s e a s e .
w i t h p o s i t i v e s e r o l o g y a n d s y p h i l i t i c o r b i t a l c e l l u l i t i s .M a n y f a c t o r s may h a v e p r e d i s p o s e d t o t h e d e v e l -
o p m e n t o f o r b i t a l c e l l u l i t i s . E i g h t p a t i e n t s g a v e a
h i s t o r y o f c h r o n i c s i n u s i t i s . I n two p a t i e n t s o r b i t a lc e l l u l i t i s f o l l o w e d s i n u s s u r g e r y . P r o p t o s i s s u d d e n l yd e v e l o p e d i n a n 1 1 - m o n t h - o l d i n f a n t , t h r e e w e e k sa f t e r a v i r a l u p p e r r e s p i r a t o r y t r a c t i n f e c t i o n , r a s h ,a n d u v e i t i s were t r e a t e d w i t h s t e r o i d s . O t h e r p r e d i s -p o s i n g f a c t o r s i n c l u d e d i n f e c t e d c h a l a z i o n ( 2 ) ; e y e l i dl a c e r a t i o n ( 1 ) ; d e n t a l s u r g e r y ( 1 ) ; n a s a l s e p t u m
i n f e c t i o n ( 1 ) ; i n f e c t e d p e n e t r a t i n g k e r a t o p l a s t y ( 1 ) ;a n d h y p o g a m m a g l o b u l i n a e m i a ( 1 ) .S e v e n t e e n s u r g i c a l p r o c e d u r e s w e r e p e r f o r m e d on
1 4 p a t i e n t s ; t h e m a i n i n d i c a t i o n f o r s u r g e r y was t o
r e l e a s e p u s . I n 1 2 p a t i e n t s t h e o r b i t a l a b s c e s s wasi n c i s e d a n d d r a i n e d ( F i g . 5 ) ; i n t h r e e o f t h e s e 1 2
p a t i e n t s t h e p a r a n a s a l s i n u s e s w e r e d r a i n e d s i m u l -
t a n e o u s l y . D i a g n o s t i c o r b i t a l b i o p s i e s w e r e p e r -f o r m e d i n t h r e e p a t i e n t s . I n t w o p a t i e n t s a p e r s i s t e n td r a i n i n g s i n u s t r a c t w a s e x c i s e d .
F i v e p a t i e n t s h a d l o n g - t e r m c o m p l i c a t i o n s f o l l o w -i n g o r b i t a l c e l l u l i t i s : i n f o u r o f t h e m t h e c o m p l i c a t i o n sw e r e a t t r i b u t a b l e t o t h e o r b i t a l c e l l u l i t i s , a n d i n o n e
p a t i e n t , a 4 - w e e k - o l d i n f a n t , o s t e o m y e l i t i s o f t h em a x i l l a r y b o n e w a s p r e s e n t a f t e r d r a i n a g e o f a no r b i t a l a b s c e s s . T h e i n f a n t w a s t r e a t e d a t a n o t h e rh o s p i t a l a n d made a g o o d r e c o v e r y . I n o n e p a t i e n ts i n u s t r a c t d r a i n a g e f r o m t h e u p p e r e y e l i d p e r s i s t e df o r e i g h t m o n t h s a f t e r i n c i s i o n a n d d r a i n a g e o f a na b s c e s s a n d f o r f o u r m o n t h s a f t e r t h e s i n u s t r a c t wa ss u r g i c a l l y e x c i s e d . T h e s i n u s e v e n t u a l l y c l o s e d . V e r -t i c a l s h o r t e n i n g o f t h e u p p e r e y e l i d d e v e l o p e d a f t e rd r a i n a g e o f a n a b s c e s s . R e s t r i c t e d movement o f t h eg l o b e d e v e l o p e d i n a n o t h e r p a t i e n t , n e c e s s i t a t i n gm u s c l e s u r g e r y . One p a t i e n t h a d a r e s i d u a l a f f e r e n tp u p i l l a r y d e f e c t , b u t r e t a i n e d 6 / 9 v i s i o n .
1 7 6
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8/13/2019 Br J Ophthalmol 1986 Bergin 174 8
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O r b i t a l c e l l u l i t i s
D i s c u s s i o n
O r b i t a l c e l l u l i t i s u s u a l l y appears a s a n a c u t e i n f e c t i o nw h i c h , i n t h e p r e a n t i b i o t i c era f r e q u e n t l y l e d t o
b l i n d n e s s a n d e v e n d e a t h . S o m e t i m e s t h e s e p a t i e n t sp r e s e n t w i t h l e s s d r a m a t i c s i g n s a n d s y m p t o m s , w i t h
t h e r e s u l t t h a t t h e p h y s i c i a n may n o t v i g o r o u s l ypursue t h e courses o f t h e r a p y a v a i l a b l e t o d a y . 3 4 6 7 8I n our s e r i e s 43 o f p r e s e n t i n g symptoms were
p r e s e n t f o r more t h a n s e v e n d a y s , a n d f e v e r wa s
a b s e n t i n 66 o f p a t i e n t s . S i m i l a r l y , l a b o r a t o r y d a t a
s u c h as t h e l e u c o c y t e c o u n t a n d s e d i m e n t a t i o n r a t e
were o f t e n n o r m a l .
I t i s t h e r e f o r e i m p o r t a n t t h a t c l i n i c i a n s s h o u l d b e
aware t h a t o r b i t a l c e l l u l i t i s may occur w i t h o u t s i g n s
o f a c u t e i n f l a m m a t i o n so t h a t p a t i e n t s c an b e a d m i t -t e d t o h o s p i t a l a n d p a r e n t e r a l t h e r a p y s t a r t e d w i t h o u t
d e l a y . C h e m o s i s , g l o b e d i s p l a c e m e n t , a n d d e c r e a s e d
o c u l a r m ov em ent s are s i g n s o f o r b i t a l i n v o l v e m e n t .
c o m p l e t e h i s t o r y a n d a p h y s i c a l a n d o c u l a r e x a m i n -
a t i o n s h o u l d a l w a y s b e p e r f o r m e d . P r e d i s p o s i n g
f a c t o r s , e s p e c i a l l y a ny h i s t o r y o f s i n u s d i s e a s e or s i n u s
surgery s h o u l d b e s o u g h t . S i n u s x - r a y s , a n i n t e g r a lp a r t o f t h e e v a l u a t i o n o f o r b i t a l d i s e a s e , s h o u l d b e
o b t a i n e d i n a l l cases o f s u s p e c t e d o r b i t a l c e l l u l i t i s .A b n o r m a l r a d i o g r a p h s o f t h e s i n u s e s l e n d s u p p o r t t o
t h i s d i a g n o s i s . T h e r a d i o g r a p h i c e v i d e n c e o f s i n u sd i s e a s e f o u n d i n 61 o f our p a t i e n t s , w i t h e q u a l
i n v o l v e m e n t o f t h e m a x i l l a r y , e t h m o i d , a n d f r o n t a ls i n u s e s , i s i n c o n t r a d i s t i n c t i o n t o t h e w e l l - k n o w n
p r e d o m i n a n c e o f e t h m o i d s i n u s i t i s a s s o c i a t e d w i t h
o r b i t a l c e l l u l i t i s i n youn ger c h i l d r e n . 7 S i m i l a r l y ,Schramm e t a l . 4 n o t e d a 74 i n c i d e n c e o f c l i n i c a l a n d
r a d i o g r a p h i c e v i d e n c e o f s i n u s i t i s . T h i s f r e q u e n t
a s s o c i a t i o n o f s i n u s i t i s w i t h o r b i t a l c e l l u l i t i s may
e x p l a i n t h e h i g h e r i n c i d e n c e o f o r b i t a l c e l l u l i t i s i nw i n t e r t h a n i n s u m m e r . 4 P r e s u m a b l y t h e i n c r e a s e d
n u m b e r o f r e s p i r a t o r y t r a c t i n f e c t i o n s a s s o c i a t e d w i t h
t h e w i n t e r m o n t h s w o u l d r e s u l t i n a n i n c r e a s e i n t h ei n c i d e n c e o f s i n u s i t i s , w h i c h w o u l d t h e n b e r e f l e c t e d
i na n
i n c r e a s e d i n c i d e n c e o f o r b i t a l c e l l u l i t i s . Noreason f o r l e f t - s i d e d p r e d o m i n a n c e o f o r b i t a l c e l l u -l i t i s c a n b e d e t e r m i n e d i n our s e r i e s or o t h e r s . 4
Many p a t i e n t s h a v e b e e n s t a r t e d o a n t i b i o t i c s b y
t h e p r i m a r y p h y s i c i a n b e f o r e i n i t i a l r e f e r r a l . T h i s was
t h e case i n 40 o f our p a t i e n t s . F u r t h e r m o r e , manyo f t h e r e m a i n i n g p a t i e n t s were g i v e n a n t i b i o t i ct h e r a p y a f t e r r e f e r r a l a n d p r i o r t o o b t a i n i n g c u l t u r e s .T h i s p r o b a b l y l o w e r e d t h e n u m b e r o f p o s i t i v e c u l -t u r e s . N a s a l a n d c o n j u n c t i v a l c u l t u r e s h a v e n o t b e e nf o u n d t o h e l p i n e v a l u a t i n g t h e s e p a t i e n t s . 3 8 1 7 N a s a l
c u l t u r e s are r a r e l y p o s i t i v e f o r t h e o f f e n d i n g organ-
i s m , t h o u g h t h e y may o c c a s i o n a l l y p r o v i d e u s e f u l
i n f o r m a t i o n i n t h epresence
o f a c t i v e s i n u s d i s e a s e .B l o o d c u l t u r e s , w h i l e s e l d o m p o s i t i v e i n a d u l t s ( 1 2i n K r o h e l e t a l . 3 ) , are more p r o d u c t i v e i n t h e p a e d i a -
t r i c p o p u l a t i o n , w h e r e a 30 i n c i d e n c e o f b a c -t e r a e m i a w a s n o t e d b y S c h r a m m e t a l . 8 i n c h i l d r e n
u n d e r 5 . H a e m o p h i l u s i n f l u e n z aw a s m o s t c o m -
m o n l y c u l t u r e d i n t h i s g r o u p .
H a e m o p h i l u s i n f l u e n z a , S t r e p t o c o c c u s p n e u m o n i a e ,
S t a p h y l o c o c c u s a u r e u s , a n d S t r . p y o g e n e s a r e t h ec o m m o n e s t c a u s e s o f o r b i t a l c e l l u l i t i s . 8 9 A n a e r o b i c
b a c t e r i a a r e n o t c o m m o n l y s e a r c h e d f o r , b u t t h e ya l s o may c a u s e o r b i t a l c e l l u l i t i s . F o r t u n a t e l y t h e s eb a c t e r i a a r e s e n s i t i v e t o p e n i c i l l i n . 1 6 N o t s u r p r i s i n g l y ,t h e s e s a m e o r g a n i s m s a r e l i s t e d among t h e c o m -
m o n e s t c a u s e s o f s i n u s i t i s . 9
T h e r a p y i n c h i l d r e n u n d e r 4 y e a r s o f a g e s h o u l d
i n c l u d e c o v e r a g e o f H . i n f l u e n z a e . 7 2 2 A m p i c i l l i n ,2 00 m g /k g / d a y , i n d i v i d e d d o s e s c o m b i n e d w i t h a
p e n i c i l l i n a s e - r e s i s t a n t a n t i b i o t i c ( n a f c i l l i n o r o x a c i l l i n1 0 0 m g / k g / d a y ) s h o u l d b e a d m i n i s t e r e d p a r e n t e r a l l y .B e c a u s e o f t h e i n c r e a s e d i n c i d e n c e o f a m p i c i l l i n -r e s i s t a n t s t r a i n s o f H . i n f l u e n z a t h e u s e o f i n t r a v e n o u s
c h l o r a m p h e n i c o l ( 1 0 0 m g / k g / d a y ) s h o u l d b e c a r e -f u l l y c o n s i d e r e d . 2 2 I n a d u l t s t h e i n i t i a l t h e r a p ys h o u l d c o n s i s t o f h i g h d o s e s o f i n t r a v e n o u s p e n i c i l l i n( 2 0 00 0 00 u n i t s ) a l t e r n a t i n g w i t h n a f c i l l i n o r o x a c i l l i n ,1 5 g e v e r y f o u r h o u r s . T h i s s h o u l d b e g i v e n s o t h ep a t i e n t r e c e i v e s a n t i b i o t i c s e v e r y t w o h o u r s . I f t h ep a t i e n t h a s a h i s t o r y o f a n o n - a n a p h y l a c t i c r e a c t i o n t op e n i c i l l i n , c e f o t a x i m e 1 - 2 g e v e r y s i x h o u r s s h o u l d b e
s u b s t i t u t e d . I n t h e c a s e o f a p r e v i o u s a n a p h y l a c t i cr e a c t i o n t o p e n i c i l l i n o r i t s d e r i v a t i v e s c l i n d a m y c i n ,c h l o r a m p h e n i c o l , o r v a n c o m y c i n may b e g i v e n . 2 3
I f t h e p a t i e n t f a i l s t o i m p r o v e o n a g g r e s s i v ea n t i b i o t i c t h e r a p y , a n u m b e r o f f a c t o r s s h o u l d b e
c o n s i d e r e d . T h e i n f e c t i n g o r g a n i s m may n o t b e
s e n s i t i v e t o a p a r t i c u l a r a n t i b i o t i c o r c o m b i n a t i o n o fa n t i b i o t i c s , a n d o t h e r a n t i b i o t i c t h e r a p y may b e
s t a r t e d . T h i s d e c i s i o n i d e a l l y w o u l d b e b a s e d o n
p o s i t i v e n a s a l c u l t u r e s i n t h e p r e s e n c e o f a c t i v e s i n u sd i s e a s e o r o n p o s i t i v e b l o o d c u l t u r e s ; h o w e v e r , t h e s ed a t a u s u a l l y a r e n o t a v a i l a b l e . C o m p u t e d t o m o -
g r a p h y s c a n s o f t h e o r b i t s h o u l d b e o b t a i n e d f o r
p a t i e n t s u n r e s p o n s i v e t o a n t i b i o t i c t h e r a p y . 2 4 I f a no r b i t a l o r s u b p e r i o s t e a l a b s c e s s i s p r e s e n t , o r i f t h ec a s e h a s b e e n m i s d i a g n o s e d , a n d t h e p a t i e n t h a s ar h a b d o m y o s a r c o m a o r b i t a l p s e u d o t u m o u r , m e t a -
s t a t i c c a r c i n o m a w i t h n e c r o s i s , o r a n a t y p i c a l i n f e c -t i v e a g e n t s u c h a s t h e t u b e r c l e b a c i l l u s , t h e C T s c a n
w i l l u s u a l l y o u t l i n e t h e e x t e n t o f o r b i t a l i n v o l v e m e n t .
M o s t a b s c e s s e s a r e w e l l l o c a l i s e d e x c e p t i n a c u t e
c a s e s e v o l v i n g o v e r 2 4 t o 4 8 h o u r s . H e r e C T s c a n smay s h o w o n l y n o n - s p e c i f i c i n f l a m m a t i o n o f t h eo r b i t , s u c h a s s c l e r a l - u v e a l r i m t h i c k e n i n g a n d m u s c l e
e n g o r g e m e n t . When a n a b s c e s s i s s u s p e c t e d b u t n o t
c o n f i r m e d b y CT s c a n s , u l t r a s o n o g r a p h y may c o n -
f i r m i t s p r e s e n c e , w i t h i t s u s u a l i n t e r n a l a c o u s t i cc h a r a c t e r i s t i c s . 3I n d i c a t i o n s f o r s u r g e r y i n c l u d e u n r e s p o n s i v e n e s s
1 7 7
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D o n a l d J B e r g i n a n d J o h n E W r i g h t
t o a n t i b i o t i c s , d e c r e a s i n g v i s i o n , p r e s e n c e o f a no r b i t a l f o r e i g n b o d y , o r b i t a l o r s u b p e r i o s t e a l a b s c e s s ,a n d t h e n e e d f o r d i a g n o s t i c b i o p s y . L o c a l i s a t i o n b yCr s c a n n i n g b e s t d e t e r m i n e s t h e s u r g i c a l a p p r o a c h t ob e u s e d . O f t e n a c o m b i n e d o p h t h a l m o l o g i c a l -
o t o l a r y n g o l o g i c a l a p p r o a c h i s r e q u i r e d t o e s t a b l i s hd r a i n a g e o f b o t h t h e s i n u s a n d t h e o r b i t . T h e d r a i n sa r e l e f t i n p l a c e u n t i l d r a i n a g e s t o p s , a n d i n t r a v e n o u s
a n t i b i o t i c s a r e c o n t i n u e d f o r s e v e n d a y s t h e r e a f t e r .G r a v e c o m p l i c a t i o n s o f o r b i t a l c e l l u l i t i s , i n c l u d i n g
b l i n d n e s s a n d d e a t h , s t i l l o c c u r . O t h e r s e r i o u s c o m -p l i c a t i o n s , b e s i d e s t h o s e o c c u r r i n g i n o u r s e r i e s ,i n c l u d e c a v e r n o u s s i n u s t h r o m b o s i s , h y p o p i t u i t a r i s m ,s u b d u r a l e m p y e m a , c e r e b r a l a b s c e s s , a n d m e n i n -g i t i s . 4 5 2 5 H o w e v e r , a g g r e s s i v e , a p p r o p r i a t e p a r -e n t e r a l a n t i b i o t i c t h e r a p y a n d j u d i c i o u s s u r g i c a li n t e r v e n t i o n c a n c o n s i d e r a b l y d e c r e a s e t h e f r e q u e n c yo f t h e s e s e r i o u s c o m p l i c a t i o n s .
T h e a u t h o r s t h a n k M r s S a r a h C o l e , M r s E l o i s a C a u l k , a n d M r s N i n aS a n d e r s f o r t h e i r h e l p i n p r e p a r i n g t h i s m a n u s c r i p t ; Dr J o h n H a r r y ,I n s t i t u t e o f O p h t h a l m o l o g y , f o r a s s i s t i n g i n t h e e x a m i n a t i o n o f
t h e h i s t o l o g i c a l s p e c i m e n s ; Dr S L l o y d f o r i n t e r p r e t i n gt h e r a d i o g r a p h s ; a n d t h e D e p a r t m e n t o f O p h t h a l m o l o g y , E m o r yU n i v e r s i t y , f o r p r o v i d i n g t h e m e d i c a l i l l u s t r a t i o n s .
R e f e r e n c e s
1 G a m b l e R . A c u t e i n f l a m m a t i o n s o f t h e o r b i t i n c h i l d r e n . A r c hO p h t h a l m o l 1 9 3 3 ; 1 0 : 4 8 3 - 9 7 .
2 H a v e n e r WH . O r b i t a l c e l l u l i t i s . O h i o Med J 1 9 5 9 ; 5 5 : 1 3 8 9 .3 K r o h e l G , K r a u s s H , W i n n i c k V . O r b i t a l a b s c e s s . O p h t h a l -
m o l o g y ( R o c h e s t e r ) 1 9 8 2 ; 8 9 : 4 9 2 - 5 0 1 .4 S c h r a m m V , C u r t i n H , K e n n e r d e l J . E v a l u a t i o n o f o r b i t a l
c e l l u l i t i s a n d r e s u l t s o f t r e a t m e n t . L a r y n g o s c o p e 1 9 8 2 ; 9 2 : 7 3 2 - 8 .5 J a r r e t t W G u t m a n F . O c u l a r c o m p l i c a t i o n s o f i n f e c t i o n s i n t h e
p a r a n a s a l s i n u s e s . A r c h O p h t h a l m o l 1 9 6 9 ; 8 1 : 6 8 3 - 8 .6 F e a r o n B , E d m o n d s B , B i r d R . O r b i t a l - f a c i a l c o m p l i c a t i o n s o f
s i n u s i t i s i n c h i l d r e n . L a r y n g o s c o p e 1 9 7 9 ; 8 9 : 9 4 7 - 5 3 .
7 A m i e s D . O r b i t a l c e l l u l i t i s . J L a r y n g o l O t o l 1 9 7 4 ; 8 8 : 5 5 9 - 6 4 .
8 S c r a m m V , M y e r s E , K e n n e r d e l l J . O r b i t a l c o m p l i c a t i o n s o f
a c u t e s i n u s i t i s : e v a l u a t i o n , m a n a g e m e n t a n d o u t c o m e . O t o l a r y n -g o l o g y 1 9 7 8 ; 8 6 : 2 2 1 - 3 0 .
9 N o e l L , C l a r k e W , P e a c o c k e T . P e r i o r b i t a l a n d o r b i t a l c e l l u l i t i si n c h i l d h o o d . C a n J O p h t h a l m o l 1 9 8 1 ; 1 6 : 1 7 8 - 8 0 .
1 0 G a n s H , S e k u l a J , W l o d y k a J . T r e a t m e n t o f a c u t e o r b i t a lc o m p l i c a t i o n s . A r c h O t o l a r y n g o l 1 9 7 4 ; 1 0 0 : 3 2 9 - 3 2 .
1 1 B r o o k I , F r i e d m a n EM R o d r i g u e z W J , e t a l . C o m p l i c a t i o n s o f
s i n u s i t i s i n c h i l d r e n . P e d i a t r i c s 1 9 8 0 ; 6 6 : 5 6 8 - 7 2 .
1 2 G e g g e l H , I s e n b e r g S . C a v e r n o u s s i n u s t h r o m b o s i s a s a c a u s e o fu n i l a t e r a l b l i n d n e s s . Ann O p h t h a l m o l 1 9 8 2 ; 1 4 : 5 6 9 - 7 4 .
1 3 W e l c h L , W e l c h J . O r b i t a l c o m p l i c a t i o n s o f s i n u s d i s e a s e .L a r y n g o s c o p e 1 9 7 4 ; 8 4 : 8 4 8 - 5 6 .
1 4 H a y n e s R , C r a m b l e t t H . A c u t e e t h m o i d i t i s . m J D i s C h i l d
1 9 6 7 ; 1 1 4 : 2 6 1 - 7 .
1 5 W e i s s A , F r i e n d l y D , E g l i n K , C h a n g M , G o l d B B a c t e r i a lp e r i o r b i t a l a n d o r b i t a l c e l l u l i t i s i n c h i l d h o o d . O p h t h a l m o l o g y( R o c h e s t e r ) 1 9 8 3 ; 9 0 : 1 9 5 - 2 0 3 .
1 6 P a r t a m i a n L , J a y W , F r i t z K . A n a e r o b i c o r b i t a l c e l l u l i t i s . AnnO p h t h a l m o l 1 9 8 3 ; 1 S : 1 2 3 - 6 .
1 7 G e l l a d y A , S h u l m a n S , Ayoub E . P e r i o r b i t a l a n d o r b i t a l
c e l l u l i t i s i n c h i l d r e n . P e d i a t r i c s 1 9 7 8 ; 6 1 : 2 7 2 - 7 .1 8 H a r r i s G . S u b p e r i o s t e a l a b s c e s s o f t h e o r b i t . A r c h O p h t h a l m o l
1 9 8 3 ; 1 0 1 : 7 5 1 - 7 .
1 9 E v a n s FO J r , S y n d o r J B , M o o r e WEC e t a l . S i n u s i t i s o f t h em a x i l l a r y a n t r u m . N E n g l J Me d 1 9 7 5 ; 2 9 3 : 7 3 5 - 9 .
2 0 W a t t e r s E , W a l l a r P , H i l l e s D , M i c h a e l s R . A c u t e o r b i t a lc e l l u l i t i s . A r c h O p h t h a l m o l 1 9 7 6 ; 9 4 : 7 8 5 - 8 .
2 1 L o n d e r L , N e l s o n D . O r b i t a l c e l l u l i t i s d u e t o H a e m o p h i l u si n f l u e n z a e . A r c h O p h t h a l m o l 1 9 7 4 ; 9 1 : 8 9 - 9 1 .
2 2 G u t m a n L . A p p r o p r i a t e a n t i b i o t i c s i n o r b i t a l c e l l u l i t i s . A r c hO p h t h a l m o l 1 9 7 7 ; 9 5 : 1 7 0 .
2 3 K r o h e l G . O r b i t a l c e l l u l i t i s a n d a b s c e s s . I n : F r a u n f e l d e r F , RoyH , e d s . C u r r e n t o c u l a r t h e r a p y . 2 n d e d . P h i l a d e l p h i a : S a u n d e r s ,1 9 8 5 : 4 5 1 .
2 4 Z i m m e r m a n R , B i l a n i u k L . CT o f o r b i t a l i n f e c t i o n a n d i t sc e r e b r a l c o m p l i c a t i o n s . AIR 1 9 8 0 ; 1 3 4 : 4 5 - 5 0 .
2 5 C h a n d l e r J , L a n g e n b r u n n e r D , S t e v e n s E . T h e p a t h o g e n e s i s o fo r b i t a l c o m p l i c a t i o n s i n a c u t e s i n u s i t i s . L a r y n g o s c o p e 1 9 7 0 ; 8 0 :1 4 1 4 - 2 8 .
A c c e p t e d f o r p u b l i c a t i o n 1 2 J u l y 1 9 8 5 .
1 7 8
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doi: 10.1136/bjo.70.3.174 1986 70: 174-178Br J Ophthalmol
D J Bergin and J E Wright Orbital cellulitis.
http://bjo.bmj.com/content/70/3/174
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