Case Report/Clinical Techniques

Orbital Abscess during Endodontic Treatment: A Case ReportEduardo Henrique Pantosso de Medeiros, DDS, Andr�e Oliveira Pepato, DDS, MSc,C�assio Edvard Sverzut, DDS, PhD, and Alexandre Elias Trivellato, DDS, PhD

Abstract

Introduction: Orbital infections may result in perma-nent morbidity because of the severity of infection.Furthermore, delayed diagnosis or treatment of orbitalinfections can lead to intracranial complications andeven death. The majority of orbital infections developfrom paranasal sinus infections, cutaneous infections,and periorbital trauma. Dacryocystitis and odontogenicinfection are also accounted as potential etiologies butare scarcely reported in scientific literature. Methods:The patient revealed a history of having endodontictreatment on left maxillary second molar performed2 weeks previously. Moreover, she exhibited signs offacial pain accompanied by sinusitis symptoms, fever,and nasal obstruction the week after this endodonticprocedure. The patient presented proptosis, impairmentof ocular motility to the right side, facial tenderness,palpebral erythema, and referred decreased visualacuity. Intraoral exam revealed root fragments of leftmaxillary first molar and an extensive carious lesionon left maxillary second molar. Computed tomographyenabled the observation of frontal sinus, left-sidedmaxillary, opacity of sphenoidal and ethmoidal sinuses,and apical lesion of left maxillary first and secondmolars, all suggesting the presence of their apex inthe maxillary sinus. In addition, images revealed ocularproptosis and presence of high-density areas suggestiveof pus in the medial orbital wall region. Results: Thepatient was submitted to surgical drainage undergeneral anesthesia approximately 8 hours after the clin-ical evaluation. Conclusions: Early detection of orbitalinfection, proper diagnostic tests, and treatment mayprovide successful outcomes of this rarely occurringdisease. (J Endod 2012;38:1541–1543)

Key WordsDental infection, odontogenic orbital abscess, orbitalinfection

From the Department of Oral and Maxillofacial Surgery andPeriodontology, School of Dentistry of Ribeir~ao Preto, Universityof S~ao Paulo, Ribeir~ao Preto, S~ao Paulo, Brazil.

Address requests for reprints to Dr Alexandre Elias Trivel-lato, Department of Oral and Maxillofacial Surgery and Peri-odontology, School of Dentistry of Ribeir~ao Preto, Universityof S~ao Paulo, Av do Caf�e, s/n- Campus USP, 14040-904 Ribeir~aoPreto, S~ao Paulo, Brazil. E-mail address: eliastrivellato@forp.usp.br0099-2399/$ - see front matter

Copyright ª 2012 American Association of Endodontists.http://dx.doi.org/10.1016/j.joen.2012.06.039

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Orbital cellulitis is usually a complication of paranasal sinus infection (1–4) andmayresult in permanent morbidity because of the severity of associated infection (5).Intraorbital abscess may be formed as a result of a progressive and localized cellu-

litis. Less common etiologies include periocular trauma and history of surgical inter-vention, skin infections, dental surgery and infection, upper respiratory tractinfection, varicella, and other systemic infections. Retrograde spread of infection canlead to complications such as cavernous sinus thrombosis, meningitis, cerebritis, brainabscess, or death (1, 3, 4, 6–8).

In the preantibiotic eramany patients with periorbital cellulitis had permanent lossof vision and died of central nervous system complications. Nowadays, despite antimi-crobial and surgical management, a substantial amount of patients with subperiostealabscess still develop various visual sequelae (6, 8). Some signs and symptoms related toorbital infections are proptosis, chemosis, and extraocular muscle dysfunction. Notuncommonly noted is decreased visual acuity (1).

In the context of odontogenic infections, spreading of dental infections beyond theimmediate proximity of the alveolar process is common and contributes substantially tothe epidemiology of patients admitted to surgical maxillofacial units. On the other hand,early involvement of the orbit after infections of dental origin is an extremely rare event(3). Because of the scarcity of reports on this subject, this article reports the successfulmanagement of a healthy patient presenting with an orbital abscess caused by compli-cation derived from root canal treatment of a maxillary second molar.

Case ReportThe present case took place at the Santa Casa Hospital of Ribeir~ao Preto/SP, Brazil.

During the oral andmaxillofacial team evaluation the patient revealed a history of havingendodontic treatment on left maxillary second molar performed 2 weeks previously.Furthermore, the patient revealed that 1 week after that endodontic procedure, sheexhibited signs of facial pain accompanied by sinusitis symptoms, fever, and nasalobstruction. During facial exam, the patient presented proptosis, impairment of ocularmotility to the right side, facial tenderness, palpebral erythema, and referred decreasedvisual acuity. Intraoral exam revealed root fragments of left maxillary first molar and anextensive carious lesion on left maxillary second molar (Fig. 1A–C).

Further diagnosis consisted of helical computed tomography (CT) imaging in axialscan to evaluate regional anatomic integrity of the face. Image analysis enabled theobservation of frontal sinus, left-sided maxillary, opacity of sphenoidal and ethmoidalsinuses, and apical lesion of left maxillary first molar and left maxillary secondmolar, allsuggesting the presence of apex in the maxillary sinus. In addition, images revealedocular proptosis and presence of high-density areas suggestive of pus in the medialorbital wall region (Fig. 1D). Because of the CT results, surgical draining was indicatedand performed under general anesthesia to effectively treat this comorbidity. Amoxi-cillin 875 mg and clavulanic acid 125 mg were adopted as early empiric antibiotictherapy and administered intravenously every 6 hours. Ketoprofen 100mg every 8 hourswas prescribed as anti-inflammatory and pain control therapy. Additional analgesicmedication was prescribed and given intravenously every 6 hours if needed. Completeblood cell count and coagulogram exams were solicited. White blood cell countrevealed mild leukocytosis.

The patient underwent surgery under general anesthesia approximately 8 hoursafter the clinical evaluation. This interval was required to collect blood sample andaccomplish the imaging exams; moreover, this interval was also recommended bythe anesthetists owing to the last food intake of the patient.

Orbital Abscess during Endodontic Treatment 1541

Figure 1. Preoperative clinical aspects. Proptotic left globe, periorbital swelling preventing spontaneous opening of the eye, subconjunctival ecchymosis, andimpairment of ocular motility to the right side (A and B). CT scan in axial view. Maxillary sinus filled with pus. Close relationship between upper molar root apexesand maxillary sinus (C). Intraoral view of residual root of tooth #26 affected by extensive carious lesion (D).

Case Report/Clinical Techniques

Before surgery, sampling of purulent material by means of a punc-ture incision was performed for culture and antibiogram tests. Surgicaldrainage of pus into the maxillary sinus was accomplished with the Cald-well–Luc technique. Drainage of pus out of the orbital cavity was per-formed by the superior medial palpebral technique and inferiorpalpebral technique. It was noted that a large amount of pus drainedfrom the superior medial incision; nevertheless, only serosanguineousfluid could be drained from the inferior palpebral incision. Left maxillarysecond molar, the primary infectious source, and left maxillary firstmolar, a potential source for future infections, were extracted. The extrac-tions and treatment of alveolar spaces enabled the visualization of an or-oantral communication in the dental alveolus left maxillary secondmolar,thus confirming the close proximity of the tooth with the maxillaryantrum. Such communication was closed with the aid of the buccal fatpad of the left cheek. After drainage, Penrose drains were placed in sub-ciliary incisions and intraoral approach and were sutured. Penrosedrains were kept in for 3 days and removedwhen the clinical state showedgreat improvement. Results from culture and sensitivity were negative.

On the fourth day after surgery, intravenous antibiotic therapy wasswitched to oral amoxicillin (875 mg) and clavulanic acid (125 mg)every 6 hours for the duration of 2 weeks. The patient was dischargedon the fourth day after surgery.

Three weeks after surgery, patient had significant improvement ofclinical symptoms with no sequelae (Fig. 2).

1542 de Medeiros et al.

DiscussionOdontogenic orbital infection can rarely occur as a result of a tooth

abscess, exacerbated periapical lesions, extraction, or dental surgery(3, 8).

The orbital septum delineates these infections into preseptal andpostseptal disease, which is important because the latter has the poten-tial to cause severe complications. The orbital septum acts as a barrierto the spread of infection from the skin to the deeper structures, limitingthe inflamed orbital subcutaneous tissue to the front of the orbitalseptum and avoiding exophthalmos. Pupillary reflex should be withinnormal limits in this form of infection. Transition to postseptal orbitalinfection can occur through breaching of the orbital septum. CT hasbeen shown to be very useful in the differential diagnosis of preseptalor postseptal cellulitis (5, 6).

Orbital abscess or orbital cellulitis is usually a result of paranasalsinuses (approximately 84%). Other causes are periorbital trauma,orbital reconstruction, ascending thrombophlebitis, infection of thenasal septum, infected penetrating keratoplasty, skin infections, vari-cella, and upper respiratory tract infection or complication of purulentotitis media. Odontogenic orbital infections are less common andaccount for 2%–5% of all orbital cellulitis cases. In a small numberof cases systemic disease may be the cause of orbital cellulitis suchas subacute bacterial endocarditis, influenza, scarlet fever, herpes

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Figure 2. Three weeks after surgery, patient exhibits good scar repair andabsence of facial edema, subconjunctival ecchymosis, and ocular motilityimpairment.

Case Report/Clinical Techniques

simplex, or herpes zoster (1–4, 6, 8). We described a patient whounderwent a root canal procedure 2 weeks before the onset ofsymptoms that was the most likely trigger of the orbital abscess.

Microorganisms involved in odontogenic infections can enter theorbit because of the intimate relation of the orbit to the surroundingsinuses, and its extensive vascular communication with congruentstructures increases the susceptibility to infection arising from nearbytissues. Three basic routes of spread of infection have been describedfor odontogenic orbital infection (4, 6, 8–10). In the present case, anapical abscess of the left maxillary second molar invading the leftmaxillary sinus could be seen with CT. From the maxillary sinus theinfection gained access to the orbit.

Orbital abscesses exhibit common signs and symptoms such as che-mosis, periorbital edema of the eyelid, reddening, hyperthermia, prop-tosis, extraocular muscle dysfunction, and decreased visual acuity(1, 5, 10). Further pursuit of diagnosis includes advanced imagingtechniques such as CT, and it is indicated if patient presents withproptosis, ophthalmoplegia, decreased visual acuity, and extremepalpebral edema that prevent an adequate ophthalmologic examinationor obscure the patient’s awareness of any change in vision (2, 8). Thispatient presented with eyelid edema, erythema, ophthalmoplegia,decreased visual acuity, and fever, and CT was indicated and proved tobe a helpful tool in the assessment of postseptal abscess.

Postseptal orbital infection can be depicted by CT or magneticresonance imaging. Both methods are able to illustrate the extent ofsoft tissue involvement, coexisting inflammatory lesions in the paranasalsinuses, and intracranial complications. When appropriately per-formed, CT can reveal odontogenic sources of infection that are not clin-ically suspected for presenting signs and symptoms that are oftennonspecific. There are only few reported cases of imaging for odonto-genic orbital cellulitis, and these cases are limited to exclusive imagingof the orbit (10). Thus, imaging plays a key role in the diagnosis ofodontogenic orbital cellulitis. The findings of dental infection on CTscans include abnormal periapical density, loss in definition of thelamina dura, widening of the periodontal ligament (PDL) space, andunilateral or asymmetrical severe sinus hyperdensity ipsilateral to theinfected orbit (10). This patient reported recent endodontic treatment

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of left maxillary second molar. Tomographic findings suggesting odon-togenic etiology were apical hypodensity in first and second maxillaryleft molars, increased PDL space of the same teeth, and hyperdensityof the left maxillary and ethmoidal and frontal sinuses.

Treatment of these lesions depends on the location and progres-sion of the infection. Preseptal cellulitis can be successfully treatedwith antibiotic therapy; however, if there is radiographic evidence ofan orbital abscess, poor vision on initial presentation, or worseningof orbital signs and/or worsening vision while on therapy, drainage ofthe orbital abscess and involved sinuses is recommended (4, 5, 8,10). In the presented case, at the earliest presentation the visualdifficulties were associated to an ocular hypomotility, and furthertomographic display of an abscess in the orbit indicated surgicaltreatment as first choice of treatment.

Even with surgery, the appropriate antibiotic therapy is extremelyimportant for solving the case (6). Culture and sensitivity tests werenegative; however, this it is not uncommon for head and neck sites.Sterile cultures have been reported in 25%of cases of infectious processin this region (3).

Odontogenic orbital cellulitis is usually polymicrobial, with prolif-eration of both aerobic and anaerobic species. Initial treatment consistsof empiric antibiotic coverage for aerobic gram-positive and anaerobicorganisms but should also cover for typical oral pathogens (8). Thus,we used amoxicillin and clavulanate to establish antibiotic coverageagainst these types of microorganisms.

The aim of treatment is to reestablish visual acuity, contain thespread of orbital infection, and avoid possible fatal complications(4). The incidence of visual loss in cases of odontogenic orbital cellu-litis reached up to 46% of severe vision loss (8). Other sequelaereported for orbital infections are meningitis, cavernous sinus throm-bosis, brain abscess, hemiparesis, seizures, subdural empyema, supe-rior orbital fissure syndrome, orbital apex syndrome, and death (1–6,8–10). In this case, no permanent visual or systemic sequelae wereobserved. Therefore, it can be concluded that early detection oforbital infection, proper diagnostic tests, and treatment can providesuccessful outcomes of this rarely occurring disease.

AcknowledgmentsThe authors deny any conflicts of interest related to this study.

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