Facial trauma aggravating paediatric orbital cellulitis

Abstract

We describe a case of paediatric orbital cellulitis with subperiosteal abscess following blunt facial trauma. Clinical features of orbital cellulitis developed on day 1 post-trauma. A subperiosteal collection subsequently formed lateral to the globe, causing significant ocular compromise. Surgical drainage and sinus washout were performed via external incisions, with satisfactory outcome. This case highlights how trauma may represent a non-sinogenic aggravating factor in orbital cellulitis. We describe how a subperiosteal abscess may vary depending on its aetiology, and how the surgical approach can be modified to locate and drain a laterally sited subperiosteal abscess.

Background

Periorbital cellulitis describes infection of the periorbital soft tissues, classified by Chandler in 1970 (table 1).¹

Table 1.

Summary of Chandler’s classification of orbital infections, as described in 1970 in his description of the pathogenesis of the orbital complications of acute sinusitis¹

Chandler’s class	Description
I	Preseptal cellulitis: inflammation of superficial structures anterior to the orbital septum
II	Orbital cellulitis: inflammation of orbital contents posterior to the orbital septum
III	Subperiosteal abscess: collection of pus between the lamina papyracea and its medial periosteum
IV	Intraorbital abscess: collection of pus within the orbital tissues
V	Cavernous sinus thrombosis

Preseptal cellulitis most commonly results from a breach in the skin barrier.² Orbital cellulitis is usually a complication of ethmoidal sinusitis with purulent exudate migrating through the ‘paper-thin’ lamina papyracea of the ethmoid bone, forming a subperiosteal abscess medially within the orbital space. Further complications can include blindness and intracranial spread of infection.³

We present a case of orbital cellulitis following blunt trauma. Trauma as a potential aetiological factor in orbital cellulitis is unusual and makes this case one of interest. We hypothesise that a post-traumatic haematoma formed laterally in the orbit and subsequently became infected, leading to abscess formation. This contrasts the usual aetiology of orbital cellulitis following acute sinusitis.

Case presentation

A 15-year-old girl presented to the emergency department with a painful, swollen right eye. 1 day prior she had presented in general practice with rhinorrhoea, postnasal drip and a frontal headache, the General Practicioner commenced an oral course of co-amoxiclav. Later that day she was assaulted; suffering blunt trauma to the right frontal and maxillary areas. There was no immediate swelling from the trauma, with her symptoms developing over the next 12 hours.

On examination there was oedema and erythema of the right upper eyelid and surrounding soft tissue. Right-sided conjunctival hyperaemia, chemosis and ophthalmoplegia in all directions were noted. Visual acuity of the right eye was 6/18 and 6/9 in the left. Paediatric Early Warning Score Parameters were all within normal limits and the patient was afebrile (temperature 36.0°C). Investigations showed raised inflammatory markers: white cell count of 13.1×10⁹/L (normal reference range 4–10×10⁹/L) and C-reactive protein of 140 mg/L (normal reference range <5 mg/L).

Initial management was with intravenous antibiotics as advised by the local microbiology team (ceftriaxone 2 g once daily, and metronidazole 300 mg three times a day), nasal decongestant (xylometalozine 0.1%: two sprays, three times a day) and nasal topical steroid (betamethasone 0.1%: two sprays, two times per day).

CT with contrast (galodinium) of the orbits and paranasal sinuses was undertaken, demonstrating gross oedema of the peri-orbital soft tissues but no clear subperiosteal abscess (figure 1). However, a thin-walled subcutaneous fluid collection lateral to the right orbit was noted.

Figure 1.

CT of the orbits with galodinium contrast on day 1 of admission, coronal view. There is gross oedema of the right eye periorbital soft tissues with a small fluid collection lateral to the orbit, as shown by the arrow.

After 36 hours of medical management, the chemosis and ophthalmoplegia became more severe with development of a right-sided proptosis.

Anterior ethmoidectomy via an external approach modified Lynch-Howarth incision was performed, as well as endoscopic uncinectomy, middle meatal anthrostomy and drainage of the right maxillary sinus. Approximately 5 ml of pus was drained from the maxillary sinus, but no periosteal collection was found. Following surgery, the patient’s condition improved initially. However, 36 hours later the right eye deteriorated again with worsening periorbital oedema, increasing chemosis, and deteriorating visual acuity (6/24) and colour vision. A repeated CT (figure 2) demonstrated a collection lateral to the superior rectus muscle, with inferior displacement of the globe with complete opacification of the right frontal, sphenoidal and maxillary sinuses.

Figure 2.

CT of the orbits with galodinium contrast day 2 after the initial operation, coronal view. There is an abscess in the region of the right superior rectus muscle (as indicated by the arrow) with inferior displacement of the orbit.

The patient was returned to theatre. An upper lid mid crease incision was made with submuscular dissection (orbicularis occuli) to the orbital rim. A subperiosteal plane was developed and followed posteriorly over the superior aspect of the orbit, releasing a collection of pus (approximately 5 ml) superolateral to the orbit. Maxillary sinus washout was performed. A corrugated drain was left in situ and intravenous antibiotic treatment continued.

Investigations

Microbiological test results returned no growth from the corneal swab, blood culture, maxillary sinus pus and pus from the subperiosteal abscess.

Outcome and follow-up

Following surgery, ocular motility, acuity and oedema continued to improve. Effective medical care was provided through close collaboration between the ENT, ophthalmology, microbiology, radiology and paediatric teams.

The mechanism of injury raised clear safeguarding concerns; the assault the patient had suffered was deliberate and targeted. A multidisciplinary team meeting was held which included representatives from the various medical specialities involved, social servies, the Police, the patient’s school, the patient and her parents. A hollistic approach was adopted in order to secure longer term safety for this child.

On day 4 postoperatively the patient was discharged with a further week of oral antibiotics (625 mg co-amoxiclav three times a day), topical antibiotic (1% chloramphenicol ointment to apply to the eye two times per day) and steroid nasal spray (betamethasone two sprays two times per day).

At 2-month ENT outpatient follow-up, the patient had mild residual right eye ptosis and numbness over the right side of her forehead (in the distribution of the supratrochlear nerve), which had resolved at 10-month follow-up. Scarring from the external incision was minimal.

Discussion

Orbital cellulitis is classically sinogenic.⁴ Infection spreads to the orbital cavity via the lamina papyracea. This case represents a different potential aetiology. We highlight trauma as a possible aggravating factor in orbital cellulitis.

The location of the abscess in the case described (supero-lateral to the orbit) suggests that although the patient had concurrent ipsilateral acute sinusitis, the aetiology of the pus collection was not purely sinogenic. The correlation between the preceding blunt trauma to the right orbital/frontal region, the initial radiological findings, and the resulting orbital abscess would suggest trauma as a potential propagating factor. We hypothesise that the laterally sited fluid collection within the orbit on day 1 of admission was trauma-related, and this subsequently became infected to form an abscess. The medial soft tissue thickening present on the initial CT scan likely represents an inflammatory response to trauma as well as the preceding sinusitis, though this did not develop into an abscess. Rare cases of non-traumatic subperiosteal haematoma associated with sinusitis have also been reported in the older population, which can undergo suppurative changes and become an orbital abscess.^{5 6}

While cases of penetrating trauma to the orbit (with and without foreign body) leading to orbital cellulitis are documented, reports of blunt trauma are less common.

A case series of orbital cellulitis following orbital blow-out fracture evaluates cases with similarities to this one,⁷ though our case does not involve any facial fracture. The four cases described involved blunt trauma with concurrent sinusitis prior to the development of orbital cellulitis. It is postulated that the presence of microbes, alongside bleeding into the sinuses and impaired blood supply of the orbital fat pad may propagate infection. This sequence of events is consistent with our case and offers a plausible explanation. A fluid collection (potentially a haematoma) initially formed laterally within the orbit (described in the report of the initial CT scan). In the presence of a current active infection with impaired blood supply due to local oedema, this then became infected and an abscess formed. Other case reports have outlined cases of blunt facial trauma and subsequent orbital cellulitis without concurrent sinusitis,^{8 9} though a mechanism for the infection is not proposed.

Learning points.

• We add to a body of case reports with orbital trauma as a potential aggravating factor in periorbital cellulitis, and we hypothesise the pathophysiology involved.

• The external Lynch-Howarth incision may be adapted to allow drainage of the collection depending on its variable location.

• The role of multidisciplinary assessment and management of cases such as this is integral to good clinical care.