True abscess formation is rare in bacterial orbital cellulitis; consequences for treatment

High risk and low prevalence diseases: Cavernous sinus thrombosis

INTRODUCTION

Cavernous sinus thrombosis (CST) is a serious condition that carries with it a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of CST, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

CST is a potentially deadly thrombophlebitic disease involving the cavernous sinuses. The most common underlying etiology is sinusitis or other facial infection several days prior to development of CST, though other causes include maxillofacial trauma or surgery, thrombophilia, dehydration, or medications. Staphylococcus aureus, streptococcal species, oral anaerobic species, and gram-negative bacilli are the most frequent bacterial etiologies. The most prevalent presenting signs and symptoms are fever, headache, and ocular manifestations (chemosis, periorbital edema, ptosis, ophthalmoplegia, vision changes). Cranial nerve (CN) VI is the most commonly affected CN, resulting in lateral rectus palsy. Other CNs that may be affected include III, IV, and V. The disease may also affect the pulmonary and central nervous systems. Laboratory testing typically reveals elevated inflammatory markers, and blood cultures are positive in up to 70% of cases. Computed tomography of the head and orbits with intravenous contrast delayed phase imaging is recommended in the ED setting, though magnetic resonance venography demonstrates the highest sensitivity. Management includes resuscitation, antibiotics, and anticoagulation with specialist consultation.

CONCLUSION

An understanding of CST can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Subperiosteal and Orbital Abscesses: A Comparison of Clinical Features, Management, and Outcomes

PURPOSE

To compare the clinical features, management, and outcomes between orbital cellulitis patients with subperiosteal abscess (SPA) and those with orbital abscess (OA).

METHODS

A retrospective study was conducted at a tertiary care center through medical record search to identify patients with orbital cellulitis from January 1, 2000 to December 31, 2022. Charts were screened for those with radiographic evidence of SPA or OA. Demographic data and presenting clinical features were compared between the 2 cohorts. Primary outcomes compared included rates of surgical intervention, reoperation, and readmission; and length of hospital stay and final vision.

RESULTS

A total of 189 patients, 162 with SPA and 27 with OA, met the criteria. The OA group (mean 46.5 ± 18.6 years) was older than the SPA group (mean 19.1 ± 21.4 years). Comorbid sinusitis was significantly more common in the SPA cohort (95.7% SPA; 70.4% OA; p < 0.001), while OA was more likely to occur with orbital trauma (29.6% vs. 8.0%; p = 0.003), implanted hardware (11.1% vs. 0.6%; p = 0.005), and comorbid diabetes (22.2% vs. 4.3%; p = 0.001). OA patients more often presented with a relative afferent pupillary defect (21.7% vs. 3.9%; p = 0.005), vision worse than 20 of 50 (42.3% vs. 16.2%; p = 0.005), and methicillin-resistant Staphylococcus aureus infection (20.8% vs. 5.8%; p = 0.036). OA was associated with a higher reoperation rate (47.8% vs. 21.3%; p = 0.019), readmission rate (18.5% vs. 5.6%, p = 0.047), and limited extraocular motility at follow-up (4.3% vs. 25%; p = 0.013); while mean length of hospital stay and final visual acuity were similar.

CONCLUSION

OA may affect an older population with a divergent risk factor profile compared with SPA. OA may cause more severe functional impairment on presentation, warranting more aggressive management to achieve visual outcomes similar to SPA.

Staphylococcus aureus Orbital Abscess With Impending Compressive Optic Neuropathy in an Immunocompetent Individual With Subclinical Bacteriuria: A Case Report

This is a case of an orbital abscess evidenced radiologically in a 41-year-old female with no comorbidities. She was healthy and had no history of trauma or infection of the adjacent structures. She denied having symptoms of upper or lower respiratory and urinary tract infections. The decision for surgical drainage was made following a slow response to antimicrobial agents after 24 hours, a progressive painful erythematous eyelid swelling, and further deterioration of vision. Her clinical condition and visual acuity improved following cutaneous incision and drainage. Culture and sensitivity results for urine and orbital abscess were positive for Staphylococcus (S.) aureus. The patient regained full visual recovery without any sequelae. In conclusion, an orbital abscess is a blinding and life-threatening condition that rarely occurs in immunocompetent individuals and uncommonly arises from distant sources. A high index of suspicion, early institution of appropriate diagnostic imaging, and aggressive medical and surgical treatment are necessary for a favorable visual outcome in orbital abscess cases.

Fusobacterium necrophorum Orbital Cellulitis With Intraconal Abscess

A 19-year-old male presented to the emergency department with progressive right eye proptosis and was subsequently diagnosed with bacterial orbital cellulitis and acute on chronic allergic fungal sinusitis. He experienced brief symptomatic improvement after endoscopic sinus surgery, initiation of antibiotics, and steroid treatment; however, he re-presented five days after discharge with significantly worsened symptoms and no light perception in the right eye. Cultures resulted in Aspergillus and Fusobacterium necrophorum, a rare, aggressive etiology of bacterial orbital cellulitis. He developed an intraconal abscess requiring multiple orbitotomies for decompression and abscess drainage. To our knowledge, only eight prior cases of F. necrophorum orbital cellulitis have been reported in the literature (excluding the present case) and our patient is the first case of this organism causing an intraconal abscess. The authors discuss the importance of early recognition and close follow-up of F. necrophorum orbital infections.

[Children's rhinosinusitis orbital complications]

The number of cases of children's sinogenic orbital complications does not reduce in spite of the advanced methods of paranasal sinuses visualization, wide use of antibacterial therapy against sinusitis, and preventive vaccination against pneumococcal disease. Orbital complications are more common with children than with adults, the basic reason of their development being ethmoiditis. The prevailing classification of orbital complications proposed by J. Chandler et al. divides these into preceptal and postceptal forms and gives description to 5 development stages of orbital complications in the order of their increasing severity. At an early age preceptal and orbital cellulites prevail, and these commonly need conservative treatment only. In case of orbital cellulitis, the major treatment method is endovenous antibiotic therapy in which the chosen antibiotic is to cover the whole spectrum of aerobic and anaerobic microbes often extracted in such cases. At small subperiostal abscesses (<0.5-1 ml), conservative treatment during 24-48 hours is possible. If there is no positive dynamics, or abscess grows in size, or eye symptoms progress, abscess and affected sinuses drain is recommended. Orbital abscess is to be given surgical treatment; at the same time endoscopic management of paranasal sinuses might by complemented with external surgical approaches (lateral and medial orbitotomy).

Misdirection of a nasopharyngeal SARS-CoV-2 swab: An unexpected complication

Background

The diagnosis of coronavirus disease (COVID-19) is based on detecting viral RNA of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the nasal cavities and the nasopharynx. Millions of nasopharyngeal swab tests are currently performed daily worldwide; complications of the procedure are uncommon, but occasionally they occur.

Case report

We describe the case of a 79-year-old man who developed right orbital cellulitis after a nasopharyngeal swab test for SARS-CoV-2. He underwent two surgeries for nasal polyposis 20 and 15 years prior, that probably caused an easy pathway to the medial wall of the orbit. At hospital admission he presented right visual loss, proptosis, palpebral edema, conjunctival chemosis, and limitations in eye movements. Computed tomography showed violation of the lamina papyracea, which appeared related to misdirection of the nasopharyngeal swab. He received intensive antibiotic treatment and achieved complete resolution of the orbital infection. To our knowledge this is the first case report concerning this dangerous complication.

Conclusion

Orbital cellulitis is a serious condition that requires prompt diagnosis and treatment, as it may result in permanent visual loss or life-threatening complications, such as intracranial abscess and cavernous sinus thrombosis, if inadequately treated. This case highlights the importance of providing adequate instruction about nasal anatomy to health care professionals performing nasopharyngeal swab tests to avoid misdirections leading to potentially dangerous complications.

A rapid review of the red eye

ABSTRACT

The red eye is a common presenting complaint among patients. Although assessment may seem intimidating, clinicians who are mindful of the patient's anticipated history and physical examination findings should be able to accurately diagnose and manage common conditions, identify ocular emergencies, and expedite care.

Septic cavernous sinus thrombosis: A review

Septic cavernous sinus thrombosis (SCST) is a rare, yet severe, process typically arising from infections of the paranasal sinuses (predominately ethmoid and/or sphenoid sinusitis) and less commonly, otogenic, odontogenic, and pharyngeal sources. Clinical symptoms of SCST arise from obstruction of venous drainage from the orbit and compression of the cranial nerves within the cavernous sinus. In the preantibiotic era SCST was considered universally fatal (80-100%); however, with the introduction of antibiotics the overall incidence, morbidity, and mortality of SCST have greatly declined. In spite of dramatic improvements, morbidity and mortality remain high, with the majority of patients experiencing neurological sequalae, highlighting the severity of the disease and the need for prompt recognition, diagnosis, and treatment. Here we review of the literature on SCST with a focus on the current recommendations and recent evidence for diagnostic and medical management of this condition.

Orbital Abscess—Two Case Reports with Review

Periorbital infections lead to severe condition of the orbital abscess, and eventually to sight loss, and even death. Current study aims in reviewing the literature regarding orbital abscess in adult patients and presenting 2 original cases. A surgical intervention to drain the abscess and a revision of the orbital was required. A review of literature is also reported focusing on aetiology and treatment options dealing with an orbital abscess.

Ocular bacterial infections: Pathogenesis and diagnosis

The human eye is a rigid asymmetric structure with unique defence system. Despite considerable resident microbiota, eye is exposed to external environment where a range of microorganisms also inhabits. Opportunistically, some of these microorganisms could associate with eye pathogen that could contact incidentally, leading to destructive visual consequences. Among such microbiota, bacteria form the major proportion concerning ocular complications worldwide. The succession of genome based approach through 16S rRNA gene based identification tremendously augmented the knowledge on diversity of ocular surface bacteria. Such evidence suggests that while few bacteria contribute towards normal ocular functions, considerable number of bacteria play active role in pathophysiology of ocular diseases. Thus, understanding the complexity of ocular microflora not only throw light on their critical role towards normal function of the eye, but also enlighten on certain visual exigencies. Under these circumstances, development of a rapid, reliable and cost effective method is essential that eventually evolve as a routine diagnostic protocol. Such precise prognostic modalities facilitate ophthalmologists to formulate pioneering therapeutics towards challenging ocular diseases.

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.].

Surgical Treatment of Rhinosinusitis-Related Orbital Complications: Factors Affecting Irreversible Blindness

If left untreated, rhinosinusitis can rarely cause a devastating complication irreversible blindness (IB). Despite new technologies in endoscopic sinus surgery and use of new broad-spectrum antibiotics, IB outcome is still a problem for surgically treated orbital complication of paranasal sinus infection (OCPSI) patients, and factors leading to IB outcome are not actually known. The aim of this study was to assess the factors leading to the IB outcome for surgically treated OCPSI patients. Results of 25 surgically treated OCPSI patients in our clinic were combined with surgically treated OCPSI patients reported through the PubMed database search from the year 2007. Patients were divided into 2 groups: IB group and recovery group. Patients having at least 1 immune status-related additional risk factor (ARF) were more common in the IB group, having an at least 1 ARF had 1.683 risk value of IB outcome (RR: 1.683, P = 0.006). IB patients had statistically significant higher mean (21.87 ± 40.35, P = 0.005) time interval (days) (TI) between onset of ophthalmological symptoms and surgical intervention compared to recovery group patients (2.92 ± 2.53). ROC curve analysis for an estimation of IB outcome according to the TI value demonstrated that a cut-off value of ≥2.5 days had the ideal sensitivity (87.5%) and specificity (71.9%) that resulted in IB outcome. (80.5% power, P = 0.008) IB and recovery group patients did not differ according to orbital complication type according to Chandler's classification (P = 0.492) and white blood cell count status (P = 0.584). In conclusion, OCPSI patients with ARFs and delayed admission after onset of orbital symptoms have a higher risk of IB outcome. These patients deserve prompt evaluation and early surgical intervention to prevent blindness. With future studies, new surgical criteria, including the ARF status and onset of ophthalmological symptoms (≥2.5 days) may be added to classical surgical criteria to prevent IB for OCPSI cases.

Prognosis of septic cavernous sinus thrombosis remarkably improved: a case series of 12 patients and literature review

Purpose

Septic cavernous sinus thrombosis (CST) is a rare complication of infections in the head and neck area. CST is notorious for its bad prognosis, with high mortality and morbidity rates described in literature. However, these rates are based on old series. We question whether the prognosis of CST is currently still as devastating. The primary purpose of this study is to assess the mortality and morbidity of CST.

Methods

Using the databases of all relevant specialties in our tertiary referral hospital, we collected all the patients treated for CST in the period 2005–2017. In addition, a PubMed search, using the mesh term ‘cavernous sinus thrombosis’, was performed.

Results

We found 12 patients with CST in the study period. Of the 12 patients, 11 survived and 9 recovered without any permanent deficits. Seven patients were treated with anticoagulation, and in none of the patients we saw hemorrhagic complications. In literature, older articles describe higher mortality rates (14–80%), but more recent articles report mortality and morbidity rates similar to our results.

Conclusions

The prognosis of CST nowadays is more favorable than previously described. Anticoagulation seems to be a safe addition to antibiotic and surgical treatment, at least in patients without central nervous system infection.

Early signs and symptoms of intracranial complications of otitis media in pediatric and adult patients: A different presentation?

OBJECTIVES

The aim of this study was to review the clinical presentation and early signs and symptoms of otogenic intracranial complications (OIC) in children and adults.

METHODS

retrospective chart review. The medical records of all children and adults admitted in our center with OIC during the period 2008-2017 were reviewed. Data concerning clinical presentation, treatment and outcomes were reviewed and analyzed.

RESULTS

We included 47 patients with OIC: 21 children (range 1-13 years) and 26 adults (range 22-71 years). We included more patients with acute otitis media than with chronic otitis media (children 5% adults 19%, all with cholesteatoma). In children; the most common OIC was central cerebral venous thrombosis. In both children and adults; otogenic symptoms such as otalgia and otorrhea were present. Children presented more frequently with headache and nausea. Adults presented more frequently with decreased consciousness. Hearing loss was the most common long-term sequel. Three adults died.

CONCLUSIONS

In our series, we found that OIC in children present as 'mimicking meningitis' (e.g. nausea and vomiting). Adults on the other hand have a clinical presentation 'mimicking stroke' (e.g. neurological deficits and decreased level of consciousness). In children, sinus thrombosis was observed more frequently than in adults. Despite the low mortality rate, death still occurs. Long -term sequelae most frequently include hearing loss in children as well as in adults.