Orbit, 2015; 34(4): 183–185 ! Informa Healthcare USA, Inc. ISSN: 0167-6830 print / 1744-5108 online DOI: 10.3109/01676830.2015.1014517
ORIGINAL ARTICLE
Orbital Cellulitis of Odontogenic Origin William Yan1*, Rahul Chakrabarti2, Jessica Choong2, and Thomas Hardy2
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1
Faculty of Medicine, Nursing, Health Sciences, Monash University, Clayton, Australia and 2The Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
ABSTRACT Odontogenic orbital cellulitis, although uncommon, has the potential to cause severe vision loss if unsuspected and untreated. Compared to non-odontogenic bacteriology, odontogenic orbital abscesses typically feature a heavy mixed growth with anaerobic organisms. We review the literature and discuss the case of a 26-year-old male who presented with anaerobic orbital cellulitis for treatment. Keywords: Anaerobic, odontogenic, orbital cellulitis
CASE REPORT
right inferior fornix transconjunctival orbitotomy, drainage of the orbital abscess, and functional endoscopic sinus surgery for drainage of pus-filled right maxillary and ethmoid sinuses. The patient was treated post-operatively with intravenous ceftriaxone (2 g) daily, flucloxacillin (2 g) QID, and intravenous metronidazole (500 mg) BD for 5 days, in conjunction with regular sinus douches and intranasal steroids. Gram stain of the orbital collection revealed gramnegative rods, as well as gram-positive cocci and rods. Cultures from the orbital fluid grew heavy mixed anaerobic species and S. epidermidis. The maxillofacial team performed dental extractions at day 7 postprimary operation for two loose right upper molar teeth. In discussion with the infectious diseases unit the patient was discharged with oral clindamycin (600 mg) TDS and amoxicillin with clavulanic acid (875 mg/125 mg) for a total of one-month in duration. Upon review at one month the patient had full range of movements, no proptosis, and visual acuity of 6/6 in both eyes.
A 26-year-old Asian male presented two days prior to a regional hospital, preceded by dental pain and vomiting for three days. He was previously well with no history of trauma, sinusitis, or other infective symptoms. On admission he was afebrile, haemodynamically stable, with a visual acuity of 6/6 in both eyes, and no clinical evidence of optic neuropathy. There was complete restriction of movements of the right eye in all directions of gaze, with 6.5 mm of proptosis, and gross conjunctival chemosis. Tenderness over the right maxillary sinus and right upper molar teeth was elicited. Anterior and dilated posterior segment examinations of both eyes were unremarkable. CT of the head, sinuses and orbits revealed a right inferomedial orbital abscess with gas and soft tissue stranding. There was unilateral sinusitis involving the right maxillary and ethmoidal sinuses. Periapical lucency surrounding the roots of the first right upper molar was noted in keeping with a periodontal abscess, with evidence of direct communication with the floor of the maxillary sinus (Figure 1). The patient was empirically treated with a single dose of cefuroxime (1 g) prior to transfer. Upon arrival at our hospital he was treated with intravenous flucloxacillin, ceftriaxone, and metronidazole in emergency. He was taken to theatre the same day for a
DISCUSSION Approximately 2–5% of cases of orbital cellulitis are odontogenic.1,2 The roots of pre-molar and molars may communicate with the maxillary sinus floor directly, providing a passage for microorganisms.
Received 20 November 2014; Accepted 28 January 2015; Published online 7 May 2015 *Current affiliation: Monash Medical Centre, Monash Health, Clayton, Australia Correspondence: William Yan, Monash Medical Centre, Monash Health, Clayton 3168, Australia. E-mail: [email protected]
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184 W. Yan et al.
FIGURE 1. Sagittal CT section demonstrating apical lucency of the first right maxillary molar consistent with a periodontal abscess. The lucency appears to communicate directly with the right maxillary sinus, which is completely filled.
Odontogenic bacterial spread to the orbit is described across three routes: through the paranasal sinuses; premaxillary soft tissues; or from the infratemporal fossa and inferior orbital fissure.2 Cultures of odontogenic orbital cellulitis are typically polymicrobial, including anaerobic Bacteroides species, Peptostreptococcus, Prevotella, Fusobacterium and alpha-haemolytic Streptococcus. However, no statistically significant correlation has been reported between the type of bacterial infection (gram-positive aerobic vs. anaerobic) and vision loss.3 This suggests aetiology of gross bacterial propagation over pathogenicity alone. There is an increasing propensity for polymicrobial and anaerobic infections with increasing age.4 Predisposing risk factors include altered immune status, metabolic disorders, pregnancy, diabetes, intravenous drug use, and nephrotic syndrome.3 Clinical presentations typically follow a recent history of dental surgery or tooth infection and trismus.2,3,5 In the absence of this, identifying hallmark CT manifestations may be crucial to early diagnosis and treatment. These include peri-apical lucency, widening of the periodontal ligament space and asymmetrically severe sinus opacification ipsilateral to the infected orbit.2 Treatment should cover aerobic gram-positive, anaerobic and typical oral pathogens. Empirical intravenous cefuroxime or ceftriaxone with flucloxacillin is recommended. Additional anaerobic coverage with metronidazole may also warrant consideration, with subsequent therapy guided by
culture results.1,3 A high index of suspicion should remain for subsequent orbital abscess formation, despite initial antibiotic response.3–5 Surgical drainage is recommended if there is radiological evidence of an abscess, poor vision on initial presentation, or disease progression with antibiotics.3 If an odontegenic source is suspected, dental extraction and drainage of periodontal abscesses should be performed.2,3,5 In general, visual prognosis is dependent on the degree of vision loss at the time of presentation. Poor prognosis for improvement in vision is expected where presenting visual acuity is light perception or worse.3 Odontogenic orbital cellulitis, although uncommon, has the potential to cause severe vision loss if unsuspected and untreated. Clinicians should look to exclude a dental source particularly in the setting of recent dental pain, infection or dental procedures. Compared to non-odontogenic bacteriology, odontogenic orbital abscesses typically feature a heavy mixed growth with anaerobic organisms. Definitive treatment requires appropriate antibiotic coverage and prompt surgical drainage of dental and orbital abscesses.
DECLARATION OF INTEREST The author reports no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Orbit
Orbital Cellulitis of Odontogenic Source
REFERENCES
Orbit Downloaded from informahealthcare.com by University New South Wales on 08/17/15 For personal use only.
1. Ferguson MP, McNab AA. Current treatment and outcome in orbital cellulitis. Aust NZ J Ophthalmol 1999;27:375–379. 2. Caruso PA, Watkins LM, Suwansaard P, et al. Odontogenic orbital inflammation: clinical and CT findings – initial observations. Radiology 2006;239:187–194.
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3. Youssef OH, Stefanyszyn MA, Bilyk JR. Odontogenic orbital cellulitis. Ophthal Plast Reconstr Surg 2008;24:29–35. 4. Harris GJ. Subperiosteal abscess of the orbit. Age as a factor in the bacteriology and response to treatment. Ophthalmology 1994;101:585–595. 5. DeCroos FC, Liao JC, Ramey NA. Management of odontogenic orbital cellulitis. J Med Life 2011;4:314–317.
ORIGINAL ARTICLE
Orbital Cellulitis of Odontogenic Origin William Yan1*, Rahul Chakrabarti2, Jessica Choong2, and Thomas Hardy2
Orbit Downloaded from informahealthcare.com by University New South Wales on 08/17/15 For personal use only.
1
Faculty of Medicine, Nursing, Health Sciences, Monash University, Clayton, Australia and 2The Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
ABSTRACT Odontogenic orbital cellulitis, although uncommon, has the potential to cause severe vision loss if unsuspected and untreated. Compared to non-odontogenic bacteriology, odontogenic orbital abscesses typically feature a heavy mixed growth with anaerobic organisms. We review the literature and discuss the case of a 26-year-old male who presented with anaerobic orbital cellulitis for treatment. Keywords: Anaerobic, odontogenic, orbital cellulitis
CASE REPORT
right inferior fornix transconjunctival orbitotomy, drainage of the orbital abscess, and functional endoscopic sinus surgery for drainage of pus-filled right maxillary and ethmoid sinuses. The patient was treated post-operatively with intravenous ceftriaxone (2 g) daily, flucloxacillin (2 g) QID, and intravenous metronidazole (500 mg) BD for 5 days, in conjunction with regular sinus douches and intranasal steroids. Gram stain of the orbital collection revealed gramnegative rods, as well as gram-positive cocci and rods. Cultures from the orbital fluid grew heavy mixed anaerobic species and S. epidermidis. The maxillofacial team performed dental extractions at day 7 postprimary operation for two loose right upper molar teeth. In discussion with the infectious diseases unit the patient was discharged with oral clindamycin (600 mg) TDS and amoxicillin with clavulanic acid (875 mg/125 mg) for a total of one-month in duration. Upon review at one month the patient had full range of movements, no proptosis, and visual acuity of 6/6 in both eyes.
A 26-year-old Asian male presented two days prior to a regional hospital, preceded by dental pain and vomiting for three days. He was previously well with no history of trauma, sinusitis, or other infective symptoms. On admission he was afebrile, haemodynamically stable, with a visual acuity of 6/6 in both eyes, and no clinical evidence of optic neuropathy. There was complete restriction of movements of the right eye in all directions of gaze, with 6.5 mm of proptosis, and gross conjunctival chemosis. Tenderness over the right maxillary sinus and right upper molar teeth was elicited. Anterior and dilated posterior segment examinations of both eyes were unremarkable. CT of the head, sinuses and orbits revealed a right inferomedial orbital abscess with gas and soft tissue stranding. There was unilateral sinusitis involving the right maxillary and ethmoidal sinuses. Periapical lucency surrounding the roots of the first right upper molar was noted in keeping with a periodontal abscess, with evidence of direct communication with the floor of the maxillary sinus (Figure 1). The patient was empirically treated with a single dose of cefuroxime (1 g) prior to transfer. Upon arrival at our hospital he was treated with intravenous flucloxacillin, ceftriaxone, and metronidazole in emergency. He was taken to theatre the same day for a
DISCUSSION Approximately 2–5% of cases of orbital cellulitis are odontogenic.1,2 The roots of pre-molar and molars may communicate with the maxillary sinus floor directly, providing a passage for microorganisms.
Received 20 November 2014; Accepted 28 January 2015; Published online 7 May 2015 *Current affiliation: Monash Medical Centre, Monash Health, Clayton, Australia Correspondence: William Yan, Monash Medical Centre, Monash Health, Clayton 3168, Australia. E-mail: [email protected]
183
Orbit Downloaded from informahealthcare.com by University New South Wales on 08/17/15 For personal use only.
184 W. Yan et al.
FIGURE 1. Sagittal CT section demonstrating apical lucency of the first right maxillary molar consistent with a periodontal abscess. The lucency appears to communicate directly with the right maxillary sinus, which is completely filled.
Odontogenic bacterial spread to the orbit is described across three routes: through the paranasal sinuses; premaxillary soft tissues; or from the infratemporal fossa and inferior orbital fissure.2 Cultures of odontogenic orbital cellulitis are typically polymicrobial, including anaerobic Bacteroides species, Peptostreptococcus, Prevotella, Fusobacterium and alpha-haemolytic Streptococcus. However, no statistically significant correlation has been reported between the type of bacterial infection (gram-positive aerobic vs. anaerobic) and vision loss.3 This suggests aetiology of gross bacterial propagation over pathogenicity alone. There is an increasing propensity for polymicrobial and anaerobic infections with increasing age.4 Predisposing risk factors include altered immune status, metabolic disorders, pregnancy, diabetes, intravenous drug use, and nephrotic syndrome.3 Clinical presentations typically follow a recent history of dental surgery or tooth infection and trismus.2,3,5 In the absence of this, identifying hallmark CT manifestations may be crucial to early diagnosis and treatment. These include peri-apical lucency, widening of the periodontal ligament space and asymmetrically severe sinus opacification ipsilateral to the infected orbit.2 Treatment should cover aerobic gram-positive, anaerobic and typical oral pathogens. Empirical intravenous cefuroxime or ceftriaxone with flucloxacillin is recommended. Additional anaerobic coverage with metronidazole may also warrant consideration, with subsequent therapy guided by
culture results.1,3 A high index of suspicion should remain for subsequent orbital abscess formation, despite initial antibiotic response.3–5 Surgical drainage is recommended if there is radiological evidence of an abscess, poor vision on initial presentation, or disease progression with antibiotics.3 If an odontegenic source is suspected, dental extraction and drainage of periodontal abscesses should be performed.2,3,5 In general, visual prognosis is dependent on the degree of vision loss at the time of presentation. Poor prognosis for improvement in vision is expected where presenting visual acuity is light perception or worse.3 Odontogenic orbital cellulitis, although uncommon, has the potential to cause severe vision loss if unsuspected and untreated. Clinicians should look to exclude a dental source particularly in the setting of recent dental pain, infection or dental procedures. Compared to non-odontogenic bacteriology, odontogenic orbital abscesses typically feature a heavy mixed growth with anaerobic organisms. Definitive treatment requires appropriate antibiotic coverage and prompt surgical drainage of dental and orbital abscesses.
DECLARATION OF INTEREST The author reports no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Orbit
Orbital Cellulitis of Odontogenic Source
REFERENCES
Orbit Downloaded from informahealthcare.com by University New South Wales on 08/17/15 For personal use only.
1. Ferguson MP, McNab AA. Current treatment and outcome in orbital cellulitis. Aust NZ J Ophthalmol 1999;27:375–379. 2. Caruso PA, Watkins LM, Suwansaard P, et al. Odontogenic orbital inflammation: clinical and CT findings – initial observations. Radiology 2006;239:187–194.
!
2015 Informa Healthcare USA, Inc.
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3. Youssef OH, Stefanyszyn MA, Bilyk JR. Odontogenic orbital cellulitis. Ophthal Plast Reconstr Surg 2008;24:29–35. 4. Harris GJ. Subperiosteal abscess of the orbit. Age as a factor in the bacteriology and response to treatment. Ophthalmology 1994;101:585–595. 5. DeCroos FC, Liao JC, Ramey NA. Management of odontogenic orbital cellulitis. J Med Life 2011;4:314–317.
