PeriorbitalPeriorbital and Orbital and Orbital InfectionsInfections

Morning ReportMorning ReportAugust 2005August 2005

Orbital SeptumOrbital Septum

Key to understanding the difference Key to understanding the difference between between periorbitalperiorbital and orbital and orbital cellulitiscellulitisImpervious barrier to spread of infection Impervious barrier to spread of infection to the orbitto the orbitInfection anterior to orbital septum = Infection anterior to orbital septum = PreseptalPreseptal or or PeriorbitalPeriorbital cellulitiscellulitisInfection posterior to orbital septum = Infection posterior to orbital septum = PostseptalPostseptal or Orbital or Orbital cellulitiscellulitis

PreseptalPreseptal CellulitisCellulitis

Infection does not respect the orbital septum Infection does not respect the orbital septum because it is anterior to this structure and runs because it is anterior to this structure and runs freely above or below the orbital rimfreely above or below the orbital rimInfection occurs in 3 settings:Infection occurs in 3 settings:–– Secondary to localized infection or inflammationSecondary to localized infection or inflammation–– Secondary to Secondary to hematogenoushematogenous dissemination of dissemination of

nasopharyngeal pathogens to the nasopharyngeal pathogens to the periorbitalperiorbital tissuetissue–– Manifestation of inflammatory edema in acute Manifestation of inflammatory edema in acute

sinusitis due to venous obstructionsinusitis due to venous obstruction

ConjunctivitisConjunctivitis

Lids are crusted and thickenedLids are crusted and thickenedConjunctiva are hyperemicConjunctiva are hyperemicMucopurulentMucopurulent discharge often presentdischarge often presentHaemophilusHaemophilus influenzaeinfluenzae ((nontypeablenontypeable))Streptococcus Streptococcus pneumoniaepneumoniaeAdenovirus (age > 6)Adenovirus (age > 6)Associated OM in 25% with bacterial Associated OM in 25% with bacterial conjunctivitisconjunctivitisTopical therapy with Topical therapy with polymyxinpolymyxin--bacitracinbacitracin, , trimethoprimtrimethoprim--polymyxinpolymyxin B, B, ofloxacinofloxacin

HordeolumHordeolum

StyeStye = External = External hordeolumhordeolumBacterial infection of sebaceous and sweat Bacterial infection of sebaceous and sweat glands/hair follicle on eyelidglands/hair follicle on eyelidLocalized infectionLocalized infectionPoints to the lid margin as a pustulePoints to the lid margin as a pustuleLid swelling and Lid swelling and erythemaerythemaUsual cause is Usual cause is Staphylococcus Staphylococcus aureusaureusResolve spontaneously in up to a weekResolve spontaneously in up to a week

HordeolumHordeolum vs. vs. ChalazionChalazion

Internal Internal HordeolumHordeolum = bacterial infection of a = bacterial infection of a meibomianmeibomian gland whose orifice is at the lid margingland whose orifice is at the lid marginChalazionChalazion = persistent, = persistent, nontendernontender, localized bulge or , localized bulge or nodule in the lid, overlying skin is normal; sterile nodule in the lid, overlying skin is normal; sterile lipogranulomatouslipogranulomatous reactionreaction

DacryoadenitisDacryoadenitis

Infection of the Infection of the lacrimallacrimal glandglandSudden onset of softSudden onset of soft--tissue swelling tissue swelling maximal over the outer portion of the maximal over the outer portion of the upper lid marginupper lid marginConstitutional symptoms are commonConstitutional symptoms are commonBacterial = extremely tenderBacterial = extremely tenderViral = less tenderViral = less tender

DacryocystitisDacryocystitis

Bacterial infection of the Bacterial infection of the lacrimallacrimal sacsacRare bacterial complication of a viral URIRare bacterial complication of a viral URIInfants < 3months affected due to delayed Infants < 3months affected due to delayed opening, secretions, anatomyopening, secretions, anatomyAfter few days of fever, impressive After few days of fever, impressive erythemaerythema, , swelling and exquisite tenderness developsswelling and exquisite tenderness developsPurulent material can be expressed from Purulent material can be expressed from lacrimallacrimalpunctapuncta, should be cultured, should be culturedCommonly caused by gramCommonly caused by gram--positive positive coccicocciMost require inpatient hospitalizationMost require inpatient hospitalization

Local Skin TraumaLocal Skin Trauma

PreseptalPreseptal cellulitiscellulitis may result from secondary may result from secondary bacterial infection of sites of local skin trauma bacterial infection of sites of local skin trauma (insect bites)(insect bites)Loosely bound soft tissues permit impressive Loosely bound soft tissues permit impressive swellingswellingErythemaErythema, textural changes, intense swelling, , textural changes, intense swelling, shininessshininessBacteremiaBacteremia is rareis rareCausative organisms are S Causative organisms are S aureusaureus or group A or group A StreptococcusStreptococcus

BacteremicBacteremic PeriorbitalPeriorbital CellulitisCellulitis

Most often in infants < 18 monthsMost often in infants < 18 monthsPreceding URIPreceding URIAcute onset and rapid progression of Acute onset and rapid progression of eyelid swelling; obscure eyeballeyelid swelling; obscure eyeballErythematousErythematous or or violaceousviolaceousPeriorbitalPeriorbital tissues tissues nontendernontenderEOMI and no EOMI and no proptosisproptosisIf inadequate exam If inadequate exam --> Orbital CT> Orbital CT

Bacterial Bacterial PeriorbitalPeriorbital CellulitisCellulitis

Pre HIB vaccine, Pre HIB vaccine, H H influenzaeinfluenzae type B was type B was causative organism in 80% of cases causative organism in 80% of cases S S pneumoniaepneumoniae accounted for 20%accounted for 20%HematogenousHematogenous dissemination from a portal of dissemination from a portal of entry in entry in nasopharynxnasopharynxRarely arises from Rarely arises from paranasalparanasal sinus cavitiessinus cavitiesParenteralParenteral therapy required with advanced therapy required with advanced generation cephalosporin until improved generation cephalosporin until improved Oral antimicrobial therapy x 10 day courseOral antimicrobial therapy x 10 day course

Inflammatory Edema of SinusitisInflammatory Edema of Sinusitis

Bacterial infection is confined to sinusesBacterial infection is confined to sinusesSympathetic effusion as a form of Sympathetic effusion as a form of preseptalpreseptalcellulitiscellulitisGradual evolution of lid swellingGradual evolution of lid swellingVenous drainage is impededVenous drainage is impededGlobe is not displaced, EOMIGlobe is not displaced, EOMIBlood and tissue cultures negativeBlood and tissue cultures negativeS S pneumoniaepneumoniae, H , H influenzaeinfluenzae, M , M CatarrhalisCatarrhalisPO trial of antibiotics if nonPO trial of antibiotics if non--toxic; + follow uptoxic; + follow up

ORBITAL CELLULITISORBITAL CELLULITIS

Orbital Orbital cellulitiscellulitis is rareis rareHigh risk of severe ocular and neurological High risk of severe ocular and neurological complications make early diagnosis and complications make early diagnosis and adequate therapy essentialadequate therapy essentialComplications include meningitis, Complications include meningitis, thrombophlebitisthrombophlebitis, , empyemaempyemaPathogenesis is sinusitisPathogenesis is sinusitis

ORBITAL INFECTIONSORBITAL INFECTIONS

Infections behind the orbital septum such Infections behind the orbital septum such as as subperiostealsubperiosteal abscess, orbital abscess, abscess, orbital abscess, cavernous sinus thrombosis, cavernous sinus thrombosis, panophthalmitispanophthalmitis, , endophthalmitisendophthalmitisAll labeled All labeled ““orbital orbital cellulitiscellulitis””Sudden onset of Sudden onset of erythemaerythema and swellingand swellingProptosisProptosis (displaced (displaced anteriorlyanteriorly and down), and down), impaired EOM, loss of visual acuity and impaired EOM, loss of visual acuity and elevated WBC are presentelevated WBC are present

ORBITAL INFECTIONSORBITAL INFECTIONS

Most involve formation of Most involve formation of subperiostealsubperiosteal abscess abscess from from ethmoiditisethmoiditis and and ethmoidethmoid osteitisosteitis in young in young children, whereas it results from frontal sinusitis children, whereas it results from frontal sinusitis in adolescentsin adolescentsEthmoidEthmoid bone (lamina bone (lamina papyraceapapyracea) is often ) is often involved involved Rarely, it evolves by direct spread from the Rarely, it evolves by direct spread from the ethmoidethmoid sinus to the orbit via bony sinus to the orbit via bony dehiscencesdehiscencesin the bones of the orbitin the bones of the orbit

IMAGINGIMAGING

CT ScanCT Scan Recommended in the evaluation of Recommended in the evaluation of children with children with periorbitalperiorbital inflammation in inflammation in whom, whom, proptosisproptosis, , ophthalmoplegiaophthalmoplegia, or loss , or loss of visual acuity develops, or in whom of visual acuity develops, or in whom severe eyelid edema prevents adequate severe eyelid edema prevents adequate eye examination. eye examination.

Pediatrics 1978Pediatrics 1978

IMAGINGIMAGING

Orbital CTOrbital CTReveals evidence of unilateral or Reveals evidence of unilateral or bialteralbialteralsinusitis, particularly involving the sinusitis, particularly involving the adjacent sinusadjacent sinusHelps differentiate presence of Helps differentiate presence of subperiostealsubperiosteal abscess, orbital abscess that abscess, orbital abscess that may need drainingmay need draining

OUR PATIENT: RADIOLOGYOUR PATIENT: RADIOLOGY

CTCTRightRight--sided sided proptosisproptosisStranding of fatStranding of fatmedial to right medialmedial to right medialrectusrectus musclemuscleSubperiostealSubperiosteal fluid collectionfluid collectionRight medial Right medial rectusrectus enlargement c/w enlargement c/w myositismyositisPeriorbitalPeriorbital soft tissue swellingsoft tissue swellingB/L maxillary sinuses, B/L maxillary sinuses, ethmoidethmoid air cells air cells opacifiedopacified

MANAGEMENTMANAGEMENT

Presence of a large wellPresence of a large well--defined abscess, defined abscess, complete complete ophthalmoplegiaophthalmoplegia, or impairment , or impairment of vision = surgical drainage of the of vision = surgical drainage of the sinuses/abscesssinuses/abscessIntranasal approach, Intranasal approach, endoscopyendoscopyCULTURE material from sinusesCULTURE material from sinusesNo abscess, only inflammatory tissue No abscess, only inflammatory tissue manage with IV antibioticsmanage with IV antibiotics

OPERATIVE FINDINGSOPERATIVE FINDINGS

Thick, tenacious, purulent debris in Thick, tenacious, purulent debris in bilateral bilateral ethmoidethmoid sinuses sinuses Thin purulent material in bilateral Thin purulent material in bilateral maxillary sinusesmaxillary sinusesCultures from bilateral Cultures from bilateral ethmoidethmoid and and bilateral maxillary sinuses grewbilateral maxillary sinuses grew……

Group A StreptococcusGroup A Streptococcus

ORBITAL CELLULITISORBITAL CELLULITIS

Secondary to Bilateral Secondary to Bilateral Maxillary Sinusitis and Maxillary Sinusitis and EthmoidEthmoid SinusitisSinusitis

withwithGroup A StreptococcusGroup A Streptococcus

BUGSBUGS

StaphStaph aureusaureusStrep Strep pyogenespyogenes (group A)(group A)anaerobic bacteria of upper anaerobic bacteria of upper respresp tract tract ((bacteroidesbacteroides, , prevotellaprevotella, , fusobacteriumfusobacterium, , veillonellaveillonella))Strep Strep pneumoniaepneumoniae, H , H influenzaeinfluenzae, M , M CatarrahalisCatarrahalis associated with sinusitisassociated with sinusitis

TREATMENTTREATMENT

IV ANTIBIOTICS IV ANTIBIOTICS Cultures guide consideration for additional Cultures guide consideration for additional antibiotic therapy antibiotic therapy Guide therapy accordingly and maintain IV Guide therapy accordingly and maintain IV therapy until patient examination is therapy until patient examination is normalnormalOral antibiotic therapy to complete 3 week Oral antibiotic therapy to complete 3 week course of treatmentcourse of treatment

PERIORBITALPERIORBITALCELLULITISCELLULITIS

Trauma or Trauma or bacteremiabacteremia

Age 21 monthsAge 21 months

PeriorbitalPeriorbital warmth, warmth, erythemaerythema, tenderness, , tenderness, indurationinduration

StaphStaph A, group A Strep, A, group A Strep, Strep Strep pneumopneumo

ORBITALORBITALCELLULITISCELLULITIS

SinusitisSinusitis

Age 12 yearsAge 12 years

ProptosisProptosis, , opthalmoplegiaopthalmoplegia, visual , visual acuityacuity

Strep Strep pnemopnemo, H. flu, M. , H. flu, M. caterhaliscaterhalis, group A , group A Strep, Strep, StaphStaph AA