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. 1999 Aug 21;319(7208):516. doi: 10.1136/bmj.319.7208.516a

Orbital trauma

Antibiotic prophylaxis needs to be given only in certain circumstances

Carrie Newlands 1,a, Peter Ramsay Baggs 1, Richard Kendrick 1
PMCID: PMC1116397  PMID: 10454413

Editor—In their lesson of the week Shuttleworth et al suggest that all patients with fractures involving the orbit should receive prophylactic antibiotics.1 These fractures are largely managed in maxillofacial surgery units, and the prescription of prophylactic antibiotics for all such cases is not routine.2 At least 500 patients with periorbital fractures are seen in our units in a year. Many more patients with undisplaced fractures of the periorbital region do not present to any medical practitioner, the fractures being self diagnosed as a bad black eye. In the past 25 years we have seen only two cases of orbital cellulitis following nose blowing after orbital fracture. This would give a maximum incidence of 1:6250. The true incidence will be lower.

Our practice is to give prophylactic antibiotics in only four circumstances: for fractures compound to skin; when surgical emphysema is present; when open reduction and internal fixation is performed; and in orbital grafting. Patients having conservative treatment or closed or indirect reductions of periorbital fractures are not prescribed antibiotics. The overuse of antibiotics has implications for adverse effects in individual patients and increasing antimicrobial resistance within the community.

Orbital cellulitis is serious but rare. The possible gains to the individual of antibiotic prophylaxis must be balanced against the potential losses, both to the individual and to the community. We believe that it is difficult to justify the routine prescription of prophylactic antibiotics but would agree that patients with diagnosed or suspected periorbital fractures should be advised about nose blowing and seeking help if signs of infection develop.

References

  • 1.Shuttleworth GN, David DB, Potts MJ, Bell CN, Guest PG. Orbital trauma: do not blow your nose. BMJ. 1999;318:1054–1055. doi: 10.1136/bmj.318.7190.1054. . (17 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Williams JL. Rowe and Williams’ maxillofacial injuries. 2nd ed. London: Churchill Livingstone; 1994. [Google Scholar]
BMJ. 1999 Aug 21;319(7208):516.

Authors’ reply

G N Shuttleworth 1,2,1-2002, D B David 1,2, M J Potts 1,2, C N Bell 1,2, P G Guest 1,2

Editor—We hoped to raise the awareness of medical staff dealing with orbital trauma of the potential sequelae of injuries such as the one we reported.

The incidence of orbital cellulitis after orbital trauma is unknown, and the figures provided by Newlands et al are interesting. In our experience, however, the incidence of orbital cellulitis after orbital trauma is considerably higher than the maximum incidence quoted (we have seen at least four cases in the past five years). In a retrospective review over 14 years Silver et al reported that a tenth (3/30) of all severe post-septal orbital infections occurred after orbital fractures from blunt trauma.1-1 These variations in incidence and clinical experience may in part relate to the prevalence of coexisting sinus disease in different communities as sinus disease will predispose to orbital infection in the presence of a fracture.

The absence of randomised control data means that it is difficult to balance the risks (both to the individual and to the community) associated with prophylactic antibiotic treatment against the risks and sequelae of infection. However, orbital trauma is uncommon, and the effects of orbital infection may be disastrous.

The use of prophylactic antibiotics after trauma to the orbit is controversial,1-2,1-3 but the potentially devastating nature of orbital infections has led several authors to suggest that they may be appropriate.1-1,1-4,1-5 In our experience orbital fractures usually result in a pathological communication between the paranasal sinuses and the orbit and should be regarded as compound fractures.

We conclude that the potential benefits of prophylactic treatment justify the risks and recommend that anyone sustaining orbital trauma with suspected fracture of the orbit and sinuses should receive prophylactic antibiotics.

References

  • 1-1.Silver HS, Fucci MJ, Flanagan JC. Severe orbital infection as a complication of orbital fracture. Arch Otolaryngol Head Neck Surg. 1992;118:845–848. doi: 10.1001/archotol.1992.01880080067015. [DOI] [PubMed] [Google Scholar]
  • 1-2.Paterson AW, Barnard NA, Irvine GH. Naso-orbital fracture leading to orbital cellulitis, and visual loss as a complication of chronic sinusitis. Br J Oral Maxillofac Surg. 1994;32:80–82. doi: 10.1016/0266-4356(94)90132-5. [DOI] [PubMed] [Google Scholar]
  • 1-3.Holds JB. Orbital infections and inflammatory disease. Curr Opin Ophthalmol. 1992;3:657–663. [Google Scholar]
  • 1-4.Westfall CT, Shore JW. Isolated fractures of the orbital floor: risk of infection and the role of antibiotic prophylaxis. Ophth Surg. 1991;22:409–411. [PubMed] [Google Scholar]
  • 1-5.Rumelt S, Rubin PA. Potential sources for orbital cellulitis. Int Ophthalmol Clin. 1996;36:207–221. doi: 10.1097/00004397-199603630-00019. [DOI] [PubMed] [Google Scholar]

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