|Year : 2016 | Volume
| Issue : 2 | Page : 65-68
Combined surgical approach in a late case of orbital cellulitis
Misra Somen, Bhandari Akshay, Pratik Gogri, Neeta Misra
Department of Ophthalmology, Rural Medical College, Pravara Institute of Medical Sciences, Loni, Ahmednagar, Maharashtra, India
|Date of Web Publication||17-Jan-2017|
Department of Ophthalmology, Pravara Institute of Medical Sciences and Rural Medical College, Loni - 413 736, Ahmednagar, Maharashtra
Source of Support: None, Conflict of Interest: None
Orbital cellulitis refers to infection of the ocular adnexal structures posterior to the orbital septum. The infection most commonly originates from the sinuses. Mucopyoceles are infected cysts of mucous content that affect the paranasal sinuses most commonly the frontal sinus. Many of these lesions have an intraorbital extension causing vision-threatening ocular complications such as orbital cellulitis and intracranial extension causing life-threatening neurological complication like meningitis. We treated a 12-year-old female patient of acute orbital cellulitis secondary to frontoethmoidal mucopyocele with combined surgical approach - transnasal endoscopic and open surgical drainage.
Keywords: Anterior orbitotomy, endoscopic marsupialization, orbital cellulitis
|How to cite this article:|
Somen M, Akshay B, Gogri P, Misra N. Combined surgical approach in a late case of orbital cellulitis. Sudanese J Ophthalmol 2016;8:65-8
|How to cite this URL:|
Somen M, Akshay B, Gogri P, Misra N. Combined surgical approach in a late case of orbital cellulitis. Sudanese J Ophthalmol [serial online] 2016 [cited 2022 Dec 2];8:65-8. Available from: https://www.sjopthal.net/text.asp?2016/8/2/65/198543
| Introduction|| |
Orbital cellulitis is a potentially life-threatening but uncommon ophthalmic emergency characterized by the infection of the soft tissues behind the orbital septum.  As such, rapid diagnosis and prompt initiation of therapy, medical and/or surgical, are important to minimize complications and optimize outcomes. Mucocele is a chronic, expanding, mucosa-lined lesion of the paranasal sinus characterized by mucous retention that can become infected forming a mucopyocele.  A mucopyocele when extends into the orbit, can present as acute orbital cellulitis, as was the case in our patient. 
The management of orbital cellulitis is primarily medical with prompt initiation of intravenous antibiotics. Surgical intervention should be considered in patients who fail to respond or deteriorate on medical therapy, display worsening visual function/pupillary changes, or develop an orbital abscess, particularly in those cases in which the primary cause requires surgery too. However, it is recommended that the treatment approach should be case based.  We describe a case of late presentation of acute orbital cellulitis subsequent to a frontoethmoidal mucopyocele extending into the orbit treated with a combined conventional external orbitotomy and newer endoscopic approach.
| Case Report|| |
A 12-year-old female patient presented with progressive left eyelids swelling for 1 week. There was associated acute pain, redness along with downward and outward protrusion of the left eyeball. The patient complained of diplopia and mild diminution of vision in the left eye. In addition, there was history of fever with chills for 10 days and intermittent frontal headache for the last 2 years. There was no history of projectile vomiting, nasal discharge, or toothache. On local examination, there was fluctuant, erythematous, nonpulsatile, tender swelling in the upper eyelid of the left eye along with ptosis. The left eyeball was pushed inferiorly and laterally causing a proptosis of 26 mm [Figure 1]. The vision was 6/12 in the left eye, and ocular movements were painful and restricted in all gazes. On fundus examination, there was blurring of disc margins along with venous dilatation and tortuosity in the left eye. All the findings in the right eye were within normal limits. There was history of left-sided endoscopic frontal sinus surgery 3 months back. A clinical diagnosis of acute orbital cellulitis was made.
|Figure 1: Clinical photograph of the patient showing left eyelid swelling, erythema, ptosis, and left eye downward outward proptosis|
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On contrast-enhanced computed tomography scan, there was a large, expansile, cystic lesion arising from the left frontal and ethmoid air cells extending into the left retrobulbar space destroying the lamina papyracea, posterior wall of frontal sinus, and eroding the floor of the anterior cranial fossa [Figure 2]. Magnetic resonance imaging scan suggested that the lesion was biloculated, the medial one in close proximity with the left frontal lobe of the brain, and the lateral loculus extending into the orbit causing proptosis of the left eyeball [Figure 3].
|Figure 2: Computed tomography scan images showing homogenous isodense well-defined cystic lesion eroding the lamina papyracea, posterior frontal sinus wall extending into the left retrobulbar space|
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|Figure 3: Magnetic resonance imaging orbit suggestive of a biloculated lesion which is iso-hypointense on T1-weighted images and hyperintense on T2-weighted images with characteristic rim enhancement on postcontrast study. The mass is seen eroding the superomedial wall of the left orbit displacing the eyeball laterally and downwards and extending to anterior cranial fossa|
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We started the patient on intravenous amoxicillin and clavulanate potassium combination, amikacin, and metronidazole along with anti-inflammatory and pain killers. In spite of starting, the patient on intravenous antibiotics and anti-inflammatory, her visual acuity deteriorated to 6/36 in the left eye, and there was color vision defect on testing with Ishihara's charts. There was worsening of proptosis to Hertel value of 30 mm. Fundoscopy revealed choroidal folds and indentation of the superior hemisphere of the retina. The patient was planned for surgery. First, endoscopic drainage of the medial loculus of the mucocele was done along with marsupialization by the axillary flap technique. Subsequently, the external orbitotomy was done using the Benedict incision for complete drainage and removal of the lateral orbital loculus along with the mucosa. A Rains frontal sinus stent was used for stenting the frontal sinus during marsupialization, and silicon drains were placed in the external orbitotomy incision. Both were removed subsequently after 12 weeks and 1 week, respectively. Postoperatively, the patient received intravenous antibiotics to which she responded very well with steady decrease in proptosis, swelling, and fever over the next 7 days. Eyelid edema subsided fully after the 2 weeks of treatment [Figure 4] with free and full movement of eyeball in all directions of gaze and normal color vision along with normal visual acuity in the left eye. There were no choroidal folds on fundoscopy.
|Figure 4: Subsidence of eyelid edema, proptosis, and ptosis 2 weeks after surgery|
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| Discussion|| |
Orbital cellulitis describes infections that involve the tissues posterior to the orbital septum within the bony orbit.  Orbital cellulitis affects all age groups but is more common in the adolescent population. The most frequent cause of orbital cellulitis is secondary extension of infection from the paranasal sinuses, particularly from the ethmoid sinus given the thin medial orbital wall. Other notable causes of orbital cellulitis include trauma with associated orbital fracture or foreign body, dacryocystitis, dental infections, and untreated preseptal cellulitis. 
Mucoceles of the paranasal sinus are slowly expanding lesions which consist of accumulation of mucus and epithelial debris in the mucosa of the sinus subsequent to obstruction of the ostium of the sinus. They affect most commonly the frontal sinus. If there is acute infection of mucocele, leading to mucopyocele, there is higher likelihood of complications mainly orbital or intracranial.  In our case, the frontoethmoidal mucopyocele had extended into the orbit causing acute orbital cellulitis and abscess formation. The globe itself was compressed superomedially, resulting in the development of chorioretinal striae. A progressive optic neuropathy from compression of the orbital portion of the optic nerve occurred as the mucocele expanded posteriorly to compress posterior orbital structures. 
Given, the potential for significant complications, intravenous antibiotics should be started promptly for all cases of orbital cellulitis.  Surgical drainage is considered in case of nonresponse to medical treatment, subperiosteal or orbital abscess formation, or presence of signs of optic neuropathy. The surgical drainage can be endoscopic alone, open drainage or combination of open and endoscopic drainage.  In our case, there were two abscess cavities with one abscess extending medially upward toward the roof of the orbit and the other one spreading laterally and posteriorly into the retrobulbar space. In addition, there was history of the previous sinus surgery. Because of the failure to medical therapy, worsening visual function, and the presence of two large orbital abscesses, surgical intervention was done in our patient. We used the combined external and endoscopic approach to get a wide drainage of marsupialization of the medial abscess via the transnasal endoscopic approach and adequate excision of the lateral abscess via the external orbitotomy approach. The combined approach gave us an added advantage of treating the sinus pathology along with the abscess drainage, thus, reducing the chances of recurrence.
Ours is a case of very late presentation of acute orbital cellulitis having two separate orbital abscesses subsequent to frontoethmoidal mucopyocele. The nasal abscess was easily accessible through the nasal endoscopic method, but the temporal one could not be drained through that route as it was a thick encapsulated loculus which was beyond the reach of the endoscopic approach. The uniqueness of this case is very late presentation, two separate abscess loculi which were treated successfully with two simultaneous different surgical approaches - transnasal endoscopic and external orbitotomy, resulting in complete recovery. In spite of being a relatively uncommon late presentation of frontoethmoidal mucopyocele, orbital cellulitis remains a potentially sight and life-threatening infection that requires careful examination and prompt treatment. Through this article, we are laying emphasis on the fact that orbital abscess can have varied presentations depending on the extent and complexity of the lesion, and hence, conventional preferred surgical approaches cannot be applied in all such cases. An individualized therapeutic approach should be undertaken for each case.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]