Orbital abscess of odontogenic origin

Brent P. Allan, Mark A. Egbert, Robert W. 1". Myall University of Washington School of Dentistry, U.S.A.

Case report and review of the literature B. P. Allan, M. A. Egbert, R. W. T. Myall: Orbital abscess of odontogenic origin. Case report and review of the literature. J. Oral Maxillofac. Surg. 1991; 20." 268-270. Abstract. A case is discussed o f a p a t i e n t with a n orbital cellulitis a n d a post septal abscess secondary to infection f r o m a n u p p e r m o l a r t o o t h . Spread o f infection was to the maxillary sinus a n d thence to the o r b i t via a defect in the orbital floor. The clinical presentation, differential diagnosis, value of C T scanning, t r e a t m e n t a n d possible c o m p l i c a t i o n s are reviewed.

The diagnosis a n d t r e a t m e n t o f infections o f o d o n t o g e n i c origin is a c o m m o n concern o f O M F surgeons. One o f the rarer a n d m o r e o m i n o u s infections is orbital cellulitis, which is the result o f infection spreading f r o m maxillary teeth or other n e a r b y structures 1~15. Seventy to 80% of cases o f orbital cellulitis develop as a c o m p l i c a t i o n of infection of the p a r a n a s a l sinuses 2,3,5, while the r e m a i n i n g 30% occur as a result of spread f r o m the eyelids, tonsils, intracranial areas, the middle ear a n d o d o n t o g e n i c structures, either b y direct spread or t h r o u g h the l y m p h a t i c a n d vascular systems 2,H. In a small n u m b e r o f cases a systemic disease m a y be the cause o f orbital cellulitis as in s u b a c u t e bacterial e n d o c a r ditis, influenza, scarlet fever, vaccinia, herpes simples or herpes zoster ~2.

Case report A 20-year-old white male presented to the emergency room at Harborview Medical Center with a 3-day history of pain and swelling in the right periorbital region. Five days prior to presentation, the patient lost a restoration from his upper right first molar tooth. He was febrile at 39.4°C and had experienced rigors. The patient had been seen at another hospital on 2 occasions where he had received 2 g Oxacillin IV each time. He also had been given a prescription for cephradine and advised to see a dentist but the patient did not fill the prescription nor make an appointment. The patient had grand real seizures as a child with the last one 13 years ago. Physical examination revealed a moderately distressed patient with erythema a n d

edema of the right upper and lower eyelids, without complete closure of the eyelids. The right eye was proptotic, and exhibited chemosis, injection over the muscle insertions, mild ophthalmoplegia, and visual acuity of 20/30. He had diplopia in extreme upward gaze. He also had mild swelling and erythema of the right canine fossa region. The right maxillary first molar tooth was grossly carious and percussion-sensitive but there was no vestibular swelling, although there was tenderness over the right anterior maxillary wall. Panoramic and periapical radiographs revealed a grossly carious upper right first molar tooth with an apical radiolucent area. A diagnosis of orbital cellulitis and acute maxillary sinusitis secondary to an abscessed upper right first molar was made. The patient was admitted to hospital and placed on 2 million units of penicillin G and 500 mg metronidazole i.v. every 6 h. The abcessed tooth was extracted under local anesthesia without purulent drainage from the socket. Orbital CT scans consisting of axial and coronal 3 mm scans with i.v. contrast were imaged in soft tissue and bone algorithms. The CT scans disclosed proptosis of the right eye, a small abscess outside the extraocular muscle conus in the anterior inferior aspect of the right orbit, with enlargement of the right inferior and medial rectus muscles. There was no involvement of the right superior ophthalmic vein or cavernous sinus. The right ethmoid and right maxillary sinuses were clouded with indistinct bony margins suggesting periostitis. There was dehiscence of the right orbital bony floor which may be related to previous trauma or aggressive inflammatory disease (Fig. 1). The working diagnosis was expanded to include the identified orbital abscess. The patient was taken to the operating room and received general anesthesia via an oral endotracheal tube. A curvilinear incision was made in the right maxillary buccal sulcus,

Key words: orbital abscess; orbital cellulitis;

post-septal and pre-septal infection; computed tomography in diagnosis of orbital infection. Accepted for publication 5 June 1991

to expose the right anterior maxillary wall. An antrostomy 2 cm in diameter was made in the right maxillary sinus via a Caldwell Luc approach, and a copious flow of purulent material was encountered. The right maxillary sinus was irrigated with saline and on inspection a bony defect in the right orbital floor was noted with communication into the right orbit. Small fragments of bone were removed from the right orbital floor to enlarge the site of orbital communication and this produced a flow of purulent material from within the right orbit into the maxillary sinus. Blunt dissection revealed no further collections of purulent material, and no extension of the abscess cavity. Portions of thickened maxillary sinus mucosa were removed and sent for histological examination. A large intranasal antrostomy was made and a red rubber catheter was passed intranasally into the right maxillary sinus for irrigation of the sinus. The gram smear revealed: 3 + white blood cells; 1 + gram positive cocci; 1 + gram positive rods; 4 + red blood cells. Cultures grew 3 + fastidious streptococci and one colony of staphylococcus (coagulase negative). Microscopic examination of the sinus mucosa produced a diagnosis ~f acute sinusitis. Twenty-four hours post-admission the patient's oral temperature was 37.7°C, with a slight decrease in right periorbital swelling, increased swelling of the right cheek, decreased proptosis, continued restriction of upward gaze, and diplopia. Irrigation of the sinus through the rubber catheter returned blood-stained saline. Twenty-four hours postsurgery the oral ~temperature was 37.2°C, with decreased right periorbital swelling, slight restriction of upward ocular movements, resolving diplopia, decreased proptosis, visual acuity 20/20 in right eye, and clear fluid returned from sinus irrigation. The patient continued to improve with resolution of periorbital and buccal swelling, proptosis

Orbital abscess

and diplopia. The patient was subsequently discharged from hospital. Discussion

Since the advent of antimicrobial therapy, orbital cellulitis and abscesses of odontogenic origin are rare conditions. They have the potential, however, to produce serious complications such as optic neuritis, optic atrophy leading to loss of vision, cavernous sinus thrombosis, superior orbital fissure syndrome, orbital apex syndrome, meningitis,

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brain abscess, subdural empyema and death ~5'7,9,1~-~5. Because of the possible severity of the sequelae early diagnosis and institution of appropriate drainage and antimicrobial therapy is mandatory. In the presented case, the removal of the abscessed molar tooth without concurrent drainage and decompression of the abscess can be criticized for this reason. The desire to better define the entire process with radiologic study was given as explanation for the delay in surgical intervention, but the wisdom of this can be argued.

Fig. 2. Diagrammatic representation of the path of spread of odontogenic infection to the orbit.

Fig. 1. CT scan showing proptosis of the right globe, an intact muscle cone, a small extraconal abscess outside the muscle conus in the anterior inferior aspect of the right orbit, ethmoid sinus involvement, and dehiscence of the right orbital bony floor.

It is important to distinguish between preseptal cellulitis, postseptal cellulitis, and orbital abscess. Differential diagnosis is often difficult clinically, due to excessive swelling of the eyelids making it impossible to evaluate the globe 7. The orbital septum delineates these infections into pre- and post-septal disease, which is important as the latter has the potential to lead to more severe complications. The orbital septum is a periosteal reflection from the bony orbit which inserts into the eyelids and separates the lids from the orbital contents. This acts as a barrier to the spread of infection from the skin to the deeper structures 3,7,12. The more severe signs of proptosis, loss of visual acuity, chemosis, and ophthalmoplegia are more likely to occur with post-septal infection, and in situations where clinical examination is difficult. Computed tomography has been shown to be very useful in the differential diagnosis of pre- or post-septal cellulitis7,14. CT scans readily show edema or abscess formation in both preand post-septal regions and define any displacement of the muscle cone, globe, optic nerve, and localize pathologic processes for planning surgical drainage. In this case report, the CT scans defined a small abscess in a location outside the muscle conus related to a dehiscence in the right bony orbital floor. This allowed us to plan direct drainage of the post-septal abscess into the right maxillary sinus via the dehiscence in the orbital floor. While previous trauma may account for the orbital floor defect, it seems more likely that the defect re-

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sulted from bony erosion by the direct extension of the acute infection. Odontogenic infections can spread to the orbit through several routes (Fig.2). Infection from the maxillary premolar and molar teeth may perforate the maxillary buccal plate and spread posteriorly into the pterygopalatine and infratemporal fossae to reach the orbit via the inferior orbital fissure, or perforate the posterior maxillary wall to enter the maxillary sinus 1'2'12. Spread by perforation into the maxillary sinus and spread via the lymphatics into the orbit may also occur s. The maxillary anterior teeth may produce orbital cellulitis by retrograde spread through the valveless anterior facial, angular, and ophthalmic veins to the orbit 1,2,7,9, or by direct spread 1. Spread of infection of odontogenic origin via the maxillary sinus and traumatic fracture of the orbital floor has been described 1°, but no reports have been documented of the spread of odontogenic infection to the orbit via non-traumatic dehiscence of the orbitial floor as in the case presented. Congenital dehiscences do occur in the wall of the orbit ls,16, and this is another possible explanation in this case. The surgical approach to the drainage of this orbital abscess was unorthodox and deserves comment. The usual approach to an orbital abscess is by way of a skin incision. The decision to deviate from this method of choice was based on the information obtained from the C T scan, specifically that the orbital component of the process evolved by direct extension through the orbital floor, with its obvious defect, and confinement of the intra-orbital abscess to

the area immediately adjacent to this. That the maxillary sinus would require drainage for resolution of the infection also played a role in this decision. N o doubt had the C T scan not revealed the path and extent of the ascending process another approach would have been used. As it was, draining through the orbital floor into the maxillary sinus, and hence via a generous nasal antrostomy with the use of a free flowing irrigation drainage system was adequate and avoided the necessity of an external skin incision.

References

l. B1RNH. Spread of dental infections. Dent Pract Dent Rec 1972: 22:347 55. 2. BULLOCKJD, FLEISHMANJA. The spread of odontogenic infections to the orbit: diagnosis and management. J Oral Maxillofac Surg 1985: 43: 749-55. 3. CHANDLERJR, LANGENBRUNNERD J, STEVENS ER. The pathogenesis of orbital complications in acute sinusitis. Laryngoscope 1970: 80: 1414-28. 4. GREEN J. Management of orbital infections. Am J Ophthalmol 1931: 14: 196 201. 5. GOLD KS, SAGERE. Pansinusitis, orbital cellulitis, and blindness as a sequelae of delayed treatment of dental abscesses. J Oral Surg 1974: 32: 40-3. 6. GOLD SC, ARRIGG SG, HEDGES TR. Computerized tomograpby in the management of acute orbital cellulitis. Ophthalmic Surg 1987: 18: 753-6. 7. GOLDSBERGF, BERNEAS, OSK~FA. Differentiation of orbital cellulitis from preseptal cellulitis by computed tomography. Pediatrics 1978: 62: 1000-5. 8. HARBOUR RC, TROBE JD, BALLINGER WE. Septic cavernous sinus thrombosis

associated with gingivitis and parapharyngeal abscess. Arch Ophthalmol 1984: 102: 94-7. 9. HAYMARKERg . Fatal infections of the central nervous system and meninges after tooth extractions. Am J Orthod 1945: 31: 117-87. 10. HOVINGA J, CHRISTIAANSBJ.~'Odonto genic infection leading to orbital cellulitis as a complication of fracture of the zygomatic bone. J Cranio-Maxillofac Surg 1987: 15: 254-7. 11. JANAKARAJAHN, SUKUMARANK. Orbital cellulitis of dental origin: case report and review of the literature. Br J Oral Maxillofac Surg 1985: 23: 140-5. 12. KABANLB, McGIt:L T. Orbital cellulitis of dental origin: differential diagnosis and the use of computed tomography as a diagnostic acid. J Oral Surg 1980: 38: 682-5. 13. OGUNDIYADA, KE~THDA, MmOWSKIJ. Cavernous sinus thrombosis and blindness as a complication of an odontogenic infection. Report of case and review of literature. J Oral Maxillofac Surg 1989: 47: 1317-21. 14. TOWBIN R, HAN BK, KAUFMAN RA, BURKE M. Postseptal cellulitis: CT in diagnosis and management. Radiology 1986: 158:735 7. 15. WATTERS EC, WALKERPH, HILLS DA, MICHAELS RH. Acute orbital cellulitis. Ophthalmology 1976: 94: 785-8. 16. WILLIAMSON-NOBLEFA. Diseases of the orbit and its contents, secondary to pathological conditions of the nose and paranasal sinuses. Ann R Coil Surg Engl 1954: 15: 46-64. Address: Mark A. Egbert, DDS Harborview Med. Ctr. ZA-16 325 9th Ave. Seattle, Washington U.S.A. 98104

Orbital abscess of odontogenic origin. Case report and review of the literature.

A case is discussed of a patient with an orbital cellulitis and a post septal abscess secondary to infection from an upper molar tooth. Spread of infe...
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