orbital cellulitis

32 year old male with pmhx HTN presents with left maxillary pain and pain/swelling of L eye. The patient’s symptoms began ~ 7 days ago with left maxillary dental pain and nasal congestion, and headache. This progressed to the point patient was seen in the ED 5 days ago on Wednesday. He was diagnosed with acute sinusitis and otitis media and was sent home with a course of augmentin. His symptoms continued to progress however and he developed left facial swelling. He presented back to OSH 3 days ago and was diagnosed with periorbital cellulitis in addition to sinusitis. He was given IV steroids and levoquin. Facial swelling seemed to improve and the patient was discharged to home on oral levoquin. He however continued to have symptoms with fevers up to 103 and progressive periorbital edema. He presented back to the ED where a CT scan was done which revealed possible orbital cellulitis also. He was transferred to OSUMC for further workup. The patient denies any numbness/facial weakness. He denies any blurry vision or loss of vision. He continues to have left facial pain; dental pain; ear pain; headaches; congestion.  

PE:
Blood pressure 147/85, pulse 70, temperature 98.5 degrees F (36.9 degrees C), temperature source Oral, resp. rate 20, height 6′ 4″ (1.93 m), SpO2 94.00%.
Constitutional: Well developed, ill appearing, in pain.
Head: Normocephalic.
ENT: TMs clear. Normal light reflexes bilaterally.  Normal nasal mucosa, nonboggy, noninjected.  No obvious nasal drainage. Oropharynx clear, non exudative.  Moist.  Exquisite L frontal and maxillary sinus pain. 
Eyes: Moderate erythema/edema of L eyelid throughout the entire circumference of the L orbit. Mild proptosis is evident. Limited range of motion of EOMs on patient’s L eye. Restricted lateral gaze and subjective diplopia and pain with lateral left gaze. Similar with upward vertical gaze. Visual acuity baseline. No afferent pupillary defect (APD).
CVS: WNL
Resp: Clear. No wheezing, crackles.
Abd: Soft. NT
Skin: Warm, dry. No rash.

DDx: Periorbital (preseptal) cellulitis vs Orbital (septal) cellulitis

Labs:
SODIUM: 139
POTASSIUM: 3.2
CHLORIDE: 102
CARBON DIOXIDE (CO2): 30
BUN: 10
CREATININE SERUM: 0.62

WBC: 11.3 (H)
RBC: 3.81 (L)
HEMOGLOBIN (HGB): 11.9 (L)
HEMATOCRIT (HCT): 35.3 (L)
PLATELET COUNT, MANUAL ENTER: 250

OSH CT:
Maxillofacial CT (official report not available)
– proptosis OS
– subcutaneous edema OS
– fat stranding
– significant maxillary sinus opacity with possible septations OS
– no retained foreign body

MDM: This was an orbital cellulitis which likely extended from a maxillary sinusitis with the above CT evidence of orbital disease.  He had recieved unasyn prior to transfer which would cover the usual ENT flora. Vancomycin was added to his ATBs to cover for MRSA given the severity/refractory nature of his infectious process. (MRSA coverage is likely the rule, and no longer the exception as classically only patients with risk factors for MRSA (recent hospitalization, dialysis, etc.)  needed such coverage.)  Ophthamology and ENT were both consulted to weigh in on the management of this patient.  The patient did clinically well in ED with ATBs and symptom control.  Special thanks to ophthamology who elected to primarily manage this patient on their service in the hospital.

The basic pathology of eye sepsis can be divided by its relation to the orbital septum. Disease anterior of the septum is ‘pre-septal’ whilst disease posterior is ‘post-septal’. The main distinction between these is that, while pre-septal disease can expand in an unrestricted manner anteriorly, post-septal disease is confined to a rigid box made up of the bony orbit and the orbital septum. Uncontrolled swelling within this box leads to a rise in pressure, effectively an orbital compartment syndrome, causing stretch and ischemia of the optic nerve which if not rapidly relieved leads to blindness. Other mechanisms of visual insult are described including, corneal exposure by proptosis, raised intraocular pressure and vascular events.3 All these events can occur over a few hours leading to blindness. This patient arrived with a CT maxillofacial demostrating orbital involvement of his cellulitis

Teaching points:

1. When in doubt, a patient with sinusitis and eye symptoms, especially pain and swelling should be CT scanned

2. The clinical distinction between pre-septal and post-septal is the presence of proptosis, ophthalmoplegia and loss of vision.  Pain with eye movements is from infection and inflammation of the eye muscles

3.  The most common cause of post-septal infection is from sinusitis with infection spreading into the orbit from the adjacent sinus (usually the ethmoids via the lamina papyracea).

4.  Pre-septal disease is generally caused by non-sinus problems such as trauma, insect bites and dacrocystitis.

5.  Pre-septal disease rarely extends into the orbit.

6.  The venous drainage from the orbit is into the cavernous sinus.  This in some cases can lead to cavernous sinus thrombosis.

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