94 orbit ac cellulitis
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Orbital Cellulitis
Tal Marom, M.D.
September 2004
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Orbit anatomy
Frontal
Zygoma
Maxillary
NasalEthmoid
Lacrimal
Sphenoid
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Orbital Cellulitis
Orbital cellulitis is a dangerous infection withpotentially serious complications
It is usually caused by a bacterial infection fromthe sinuses (mainly ethmoid, accounting formore than 90% of all cases)
Other causes :a stye on the eyelid, recent trauma
to the eyelid including bug bites, or a foreignobject
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Children
In children, orbital cellulitis is usually from a
sinus infection and due to the organism
Hemophilus influenzae (decrease in incidenceafter vaccination program implentation).
Other organisms are Staphlococcus aureus,
Streptococcus pneumoniae, andBetahemolytic streptococci
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Pathophysiology
extension of infection from the periorbital structures,
most commonly from the paranasal sinuses, but also
from the face, globe, and lacrimal sac direct inoculation of the orbit from trauma or surgery
(orbital decompression, dacryocystorhinostomy,
eyelid surgery, strabismus surgery, retinal surgery,
and intraocular surgery, have been reported as theprecipitating cause of orbital cellulitis)
hematogenous spread from bacteremia
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Orbital septum
The orbit is separated from the soft tissue of the eyelid bythe orbital septum. This is a fascial plane that is continuouswith the periosteum of the facial bones.
The orbital septum inserts into the tarsal plate of the upperand lower eyelids.
The orbital septum usually proves to be an effective barrierthat prevents the spread of infection from the eyelids
posteriorly to the orbit.
While preseptal cellulitis can occasionally spread to theorbital contents, it is generally a clinical entity that isdistinct from orbital cellulitis
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Orbital septum
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Orbital vs. Preseptal Cellulitis
Orbital cellulitis is infection of the soft
tissues of the orbit posterior to the orbital
septum, differentiating it from preseptalcellulitis, which is infection of the soft
tissue of the eyelids and periocular region
anterior to the orbital septum DD: orbital pseudotumor (inflammatory
condition, responds to steroids)
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Chandler Classification
Stage I Inflammatory edema-Preseptal
Stage II Orbital cellulitis - Postseptal
Stage III Subperiostal abscess
Stage IV Orbital abscessStage V Complication due to posterior
extension
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Symptoms
Fever, generally 102 degrees F or greater.
Painful swelling of upper and lower lids (upper is usuallygreater).
Eyelid appears shiny and is red or purple in color.
Infant or child is acutely ill or toxic.
Eye pain especially with movement.
Decreased vision (because the lid is swollen over the eye).
Eye bulging (forward displacement of the eye). Swelling of the eyelids
General malaise.
Restricted or painful eye movements
http://www.nlm.nih.gov/medlineplus/ency/article/003090.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003103.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003032.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003029.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003033.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003089.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003089.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003033.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003029.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003032.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003103.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003090.htm -
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Complications
Subperiostal/Orbital abscess (Chandler III-IV)
Cavernous sinus thrombosis
Hearing loss
Septicemia or blood infection
Meningitis Optic nerve damage and blindeness
http://www.nlm.nih.gov/medlineplus/ency/article/001628.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003044.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/001355.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000680.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000680.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/001355.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003044.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/001628.htmhttp://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/oph/images/Large/230_1small.jpg&template=izoom2 -
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A male with orbital cellulitis with proptosis,
ophthalmoplegia, and edema and erythema of the eyelids
http://www.emedicine.com/cgi-bin/foxweb.exe/makezoom@/em/makezoom?picture=/websites/emedicine/oph/images/Large/230_1small.jpg&template=izoom2 -
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Non-surgical treatment
IV ABx
Antifungals (if indicated)
Nasal decongestants (open sinus ostia)
DureticsDIAMOX (carbonic anhydrase
inhibitor), mannitol (reduce IOP)
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Surgical Treatment1. Surgical drainage if the response to appropriate antibiotic
therapy is poor within 48-72 hours or if the CT scan showsthe sinuses to be completely opacified.
2. Consider orbital surgery, with or without sinusotomy, inevery case of subperiosteal or intraorbital abscessformation.
3. Surgical drainage of an orbital abscess is indicated if anyof the following occurs: decrease in vision, An afferent
pupillary defect. proptosis progresses despite appropriateantibiotic therapy
4. The size of the abscess does not reduce on CT scan within48-72 hours after appropriate antibiotics have beenadministered.
5. If brain abscesses develop and do not respond to antibiotictherapy, craniotomy is indicated.
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How?
Superior orbit decompression
Medial orbit decompression
Inferior orbit decompression
Lateral orbit decompression
Intranasal approach
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Superior Orbit Decompression
Frontal cranioitomy
unroofing of superior
wall of orbit Titanium sheild placed
to support the frontal
lobe of the brain
High morbidity,
consider only for
severe cases
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Medial Orbit Decompression
External ethmoidectomy incision or coronal
forehead approach
External ethmoidectomy- complete ethmoid sinus
resection, then orbital fat herniates into sinus defect
Coronal incision- ethmoidectomy via a superior
approach, more risk for lacrimal sac and trochlea
injury
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Inferior Orbit Decompression
Orbital floor blow-out fracture , but spares
infraorbital nerve
Subcilliary eyelid incision or Caldwell-Lucincision
Combined approach?
Intraorbital fat herniates maxillary sinus
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Lateral Orbit Decompression
Lateral canthotomy
Removal of lateral orbital bone posterior to the
rim Orbital fat protrudes the newly created space
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An incision extending from the lateral canthus to the
area just below the inferior punctum is created 4 mm to
5 mm below the lower border of the tarsal plate to avoid
injury to the septum and the canaliculus
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Intranasal approach
Decompression of medial anf medioinferior
floors of orbit
Endoscopic sinus surgery technique Anterior Ethmoidectomy
Maxillary antrostomy
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