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.

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.

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.

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.

Methicillin-Resistant Staphylococcus aureus Sepsis and Orbital Cellulitis Leading to a Combined Central Retinal Artery and Vein Occlusion: A Case Report.

Combined central retinal artery and vein occlusion (CCRAVO) is a rare entity characterized by features of tortuous retinal veins, retinal hemorrhage, optic disk edema and pallor, macula edema, cherry-red spot, and cotton-wool spots. The occurrence of CCRAVO in the adult population is often in the setting of systemic disease; while CCRAVO in the pediatric population is frequently associated with infection of the sinuses, preseptal cellulitis, or orbital cellulitis. It has been hypothesized that CCRAVO can result from methicillin-resistant Staphylococcus aureus (MRSA) sepsis-induced coagulation disturbances, orbital cellulitis, and even orbital compartment syndrome; however, there are insufficient reports of this complication. This case report sheds light on one such case with irreversible vision loss as a sequela.

[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.

Imaging of Painful Ophthalmologic Disorders.

Cross-sectional imaging with computed tomography (CT) and MRI are diagnostic examinations useful in the diagnosis of painful ophthalmologic disorders and their potential complications. CT is a first-line imaging study for suspected orbital infections, particularly useful in differentiating preseptal cellulitis and orbital cellulitis and detecting complications such as orbital abscess. When compared with CT, MRI is better for orbital soft tissue evaluation, particularly useful for optic neuritis, ocular diseases such as endophthalmitis, and invasive fungal rhinosinusitis with orbital involvement. CT angiography is the preferred noninvasive imaging modality for the detection and classification of carotid cavernous fistula.

Preseptal and Orbital Cellulitis: Analysis of Clinical, Laboratory and Imaging Findings of 123 Pediatric Cases From Turkey.

BACKGROUND: We aimed to compare the clinical and laboratory characteristics and imaging methods of patients diagnosed with preseptal cellulitis and orbital cellulitis in the pediatric age group. METHODS: The study was designed retrospectively, and the medical records of all patients who were hospitalized with the diagnosis of preseptal cellulitis and orbital cellulitis were reviewed. The findings of preseptal cellulitis and orbital cellulitis groups were compared. The risk factors for the development of orbital involvement were analyzed. RESULTS: A total of 123 patients were included, 90.2% with preseptal cellulitis and 9.8% with cellulitis. The male gender ratio was 60.2%, and the mean age was 72 ± 43 months. While all patients had eyelid swelling and redness, 20.3% had fever. Ocular involvement was 51.2% in the right eye and 4.9% in both eyes. The most common predisposing factor was rhinosinusitis (56.1%). Radiologic imaging (computed tomography/magnetic resonance imaging) was performed in 83.7% of the patients. Subperiostal abscess was detected in 7 cases (5.6%) in which three of the cases were managed surgically and four were treated with medically. The levels of C-reactive protein were significantly higher in patients with orbital involvement (P = 0.033), but there was no difference between the presence of fever, leukocyte and platelet values. CONCLUSIONS: Rhinosinusitis was the most common predisposing factor in the development of preseptal cellulitis and orbital cellulitis. Orbital involvement was present in 9.8% of the patients. It was determined that high C-reactive protein value could be used to predict orbital involvement.

Periocular Necrotizing Fasciitis Causing Posterior Orbitopathy and Vision Loss: How to Manage?

Necrotizing fasciitis (NF) is a rare, rapidly progressive bacterial infection. Periorbital NF may spread from the eyelid into the posterior orbit. Extent of the infection is critical in planning surgical debridement. A diabetic 70-year-old man presented with a black wound and severe pain in the left periorbital area following a mild trauma. Clinical findings were consistent with NF involving the eyelids, temporal and malar regions. In addition, he had proptosis, diffuse ophthalmoplegia, and central retinal artery occlusion, suggesting deep orbital involvement. Computed tomography showed soft tissue abnormalities in the anterior orbit. The patient was successfully treated with subcutaneous debridement, antibiotherapy, and metabolic support. Periorbital NF may be complicated with posterior orbital cellulitis-like symptoms and retinal vascular occlusions, possibly because of remote vascular thrombi induced by bacterial toxins. This clinical manifestation should be distinguished from true bacterial invasion of the posterior orbit, which may require more aggressive surgical treatments such as exenteration.

Celulite orbital por rinossinusite maxilar, etmoidal e frontal em paciente adulto: relato de caso / Orbital cellulitis by maxillary, etmoidal and frontal rhinosinusitis in an adult patient: case report

A celulite orbital é uma complicação incomum após quadro de rinossinusite. O objetivo do presente trabalho é relatar um caso de um paciente do sexo masculino, adulto-jovem, 22 anos de idade, que compareceu ao serviço de emergência apresentando edema periorbitário direito, proptose, oftalmoplegia, cefaléia, obstrução nasal e febre. O diagnóstico foi realizado por uma equipe multidisciplinar. A tomografia computadorizada pré-operatória apresentou edema difuso em região periorbitária direita, velamento dos seios: maxilar, esfenoidal e frontal ipsilateral. O paciente foi internado para abordagem cirúrgica e antibioticoterapia. A celulite orbitária associada a rinossinusite é uma complicação rara, sendo comum em crianças, que necessita de um diagnóstico e abordagem multidisciplinar e precoce para evitar extensões cranianas... (AU)

Orbital cellulitis is an uncommon complication after rhinosinusitis. The aim of the present study is to report a case of a 22-year-old male patient, young, 22 years old, who attended the emergency department with right periorbital edema, proptosis, ophthalmoplegia, headache, nasal obstruction and fever. The diagnosis was made by a multidisciplinary team. Preoperative computed tomography showed diffuse edema in the right periorbital region, veiling of the sinuses: maxillary, sphenoidal and ipsilateral frontal. The patient was admitted for surgical approach and antibiotic therapy. Orbital cellulitis associated with rhinosinusitis is a rare complication, common in children, which requires a multidisciplinary and early diagnosis and approach to avoid cranial extensions... (AU)

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.

Septic Cavernous Sinus Thrombosis Associated With Orbital Cellulitis: A Report of 6 Cases and Review of Literature.

PURPOSE: To describe risk factors, clinical parameters, treatment, and prognosis for patients with septic cavernous sinus thrombosis presenting with orbital cellulitis. METHODS: Retrospective case series of 6 patients identified with septic cavernous sinus thrombosis and orbital cellulitis confirmed by magnetic resonance imaging at a tertiary care center from January 1980 to December 2016. Medical records were reviewed for demographics, risk factors, symptoms, etiology, radiographic diagnosis, complications, treatments, and outcomes. In addition, a literature review was performed from 2005 to 2018, and 119 cases of septic cavernous sinus thrombosis confirmed by imaging were included for aggregate comparison. This study adheres to the tenets of the Declaration of Helsinki, and institutional review board approval was obtained. RESULTS: All 6 cases presented with headache, fever, ocular motility deficit, periorbital edema, and proptosis. The primary source of infection included sinusitis (n = 4) and bacteremia (n = 2). Identified microorganisms included methicillin resistant Staphylococcus aureus (n = 3) and Streptococcus anginosus (n = 1). All cases were treated with broad-spectrum intravenous antibiotics and anticoagulation, and one case underwent endoscopic sinus surgery. The mean time between initial presentation to diagnosis of cavernous sinus thrombosis was 2.8 days, and the average length of hospital admission was 21 days. The mortality rate was 0%, but 4 cases were discharged with neurological deficits including vision loss (n = 1) and ocular motility disturbance (n = 3). Literature review produced an additional 119 cases. CONCLUSIONS: Early diagnostic imaging with contrast-enhanced CT or MRI should be initiated in patients with risk factors and ocular symptoms concerning for cavernous sinus thrombosis. Treatment entails early administration of broad-spectrum intravenous antibiotics, anticoagulation, and surgical drainage when applicable.

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.

Orbital Perivenous Abscess Complicating the Diagnosis and Management of Orbital Cellulitis.

An 11-year-old female presented with orbital cellulitis, bacterial sinusitis, enlarged left superior ophthalmic vein, dural venous sinuses, and internal jugular vein. The patient underwent endoscopic sinus surgery and was started on intravenous antibiotics and anticoagulation with limited improvement in orbital signs and symptoms. A magnetic resonance imaging/magnetic resonance venography of the orbits and brain revealed a dilated left superior ophthalmic vein with absence of flow but no clearly discernible orbital abscess. Intravenous corticosteroids resulted in dramatic improvement of pain, hypoglobus, proptosis, and extraocular motility, all of which rapidly recurred on discontinuation. Serial imaging revealed progression of what eventually manifested as a well-defined, rim-enhancing peri-superior ophthalmic vein abscess, which was incised and drained with prompt resolution of orbital cellulitis and complete visual recovery.

Orbital Cellulitis in a Psoriatic Patient Treated With Adalimumab.

INTRODUCTION: Psoriatic patients on tumor necrosis factor alpha inhibitors (TNFi) may be at increased risk for upper respiratory tract infections, including chronic rhino-sinusitis (CRS). Rarely, CRS can progress to orbital cellulitis (OC), an emergent ophthalmic complication wherein respiratory flora from paranasal sinus disease intrude the retro-orbital space. MATERIALS AND METHODS: Single case report. RESULTS: We report the first case, to our knowledge, of an invasive sinusitis that rapidly evolved into OC in a patient receiving adalimumab treatment for plaque psoriasis and psoriatic arthritis. After TNFi withdrawal and appropriate medical and surgical intervention, the patient fully recovered. However, on resumption of TNFi therapy, symptoms of recalcitrant CRS returned. CONCLUSION: More investigation is needed to explore how TNFi might predispose to chronic, refractory rhino-sinusitis and subsequent progression to OC. Military physicians and other medical providers should be aware of this proposed new disease entity and the potential for rapidly evolving and invasive infections in immunocompromised patients. Screening and monitoring for chronic infectious disease, such as CRS before initiating and during TNFi therapy is warranted.