Keywords
abscess - orbit - pediatric - subperiosteal
Introduction
Orbital abscess secondary to an odontogenic cause is a rare, but dangerous complication
that can result in permanent vision loss. Timely recognition and management are paramount.
If untreated, this can lead to cavernous sinus thrombosis and/or a brain abscess resulting
in death.[1] This is the case of a 13-year-old male with a 2-day history of dental pain which
rapidly progressed to an abscess involving the periorbital tissues. Specialists were
consulted in a timely fashion by the pediatric emergency physician. A multidisciplinary
approach involving ophthalmology and oral and maxillofacial surgery specialists was
necessary to manage this infectious process surgically. The presentation, extent of
involvement, and surgical intervention are discussed in this case report.
Patient Presentation
A 13-year-old previously healthy male was brought to the emergency department for
a 2-day history of persistent right maxillary dental pain with associated swelling.
He had recently received a routine dental evaluation and cleaning, and was planned
for excavation and restoration of the dental caries within the month. One dose of
900 mg of intravenous clindamycin was administered at the outside hospital, and preseptal
cellulitis was identified on the computed tomography (CT) scan per the outside hospital
radiology written interpretation. The patient was transferred the same day to the
University of Illinois Medical Center for specialty evaluation. At that time, the
patient could not open his right eye due to swelling and reported blurry vision when
manually opening his eyelids. He endorsed right-sided facial pain and pain with eye
movement. He also presented with a 1-day history of subjective fevers and a recorded
fever at the outside hospital.
Clinical examination revealed severe right periorbital and midface edema. Mild emphysema
of the right upper eyelid was also noted. Ophthalmologic exam of the affected side
revealed 20/20 vision without evidence of optic nerve compromise, mild restriction
to adduction, and mildly elevated intraocular pressure. Intraorally, tooth 3 had a
large restoration with adjacent fluctuant vestibular swelling ([Fig. 1]). No active drainage was noted. The patient had a leukocytosis of 17.9, a neutrophilia
of 84.4%, and an absolute neutrophil count of 15.1. The patient was admitted and started
on 3,000 mg of intravenous ampicillin-sulbactam every 6 hours and 30 mg of intravenous
ketorolac every 6 hours as needed for pain. Other vital signs and laboratory values
were within normal limits.
Fig. 1 Panoramic radiograph demonstrating large restoration of tooth 3 with periapical radiolucency
and right maxillary sinusitis.
Review of the outside hospital CT scan by the ophthalmology and oral and maxillofacial
surgery services at our institution lead to the identification of a subperiosteal
abscess at the right lateral orbit ([Fig. 2]). The right canine space abscess emanated from the buccal roots of tooth 3. Continuity
of the fluid collection was noted extending from the right canine space superiorly
and posteriorly to the right lateral orbit. Right maxillary sinusitis was also apparent.
A panoramic radiograph revealed previously restored tooth 3 with a periapical radiolucency.
Intravenous antibiotics were continued and the patient was taken to the operating
room in a timely fashion for surgical drainage.
Fig. 2 Computed tomography scan coronal section displayed the right lateral orbit subperiosteal
abscess (black arrow) and right maxillary sinusitis.
The patient underwent surgical drainage of the involved abscesses, as well as extraction
of the associated molar, tooth 3. The anesthesia service provided general anesthesia
via an oral endotracheal tube. The ophthalmology service provided local anesthesia
via infiltration into right eye lids and right lateral canthal area using 1% lidocaine
with 1:100,000 epinephrine. Next, the service performed an intraorbital incision and
drainage through dissection of the preperiosteal plane along the lateral orbital rim,
opening the periosteum and dissecting along the subperiosteal plane into orbit ([Fig. 3]). The fluid and tissue were sent for culture. After copious irrigation and hemostasis,
the tissues were closed primarily. The oral and maxillofacial surgery service provided
local anesthesia via intraoral maxillary infiltration by administering 4 mL of 2%
lidocaine with 1:100,00 epinephrine. Next, the service performed an intraoral incision
and drainage of the right canine space abscess and extraction of tooth 3 using elevators
and forceps. A quarter-inch Penrose drain was placed into the canine space after copious
irrigation.
Fig. 3 Intraoperative photo showing the culture procurement via the lateral canthotomy.
The patient’s postoperative course was uncomplicated. Cultures were positive for Peptostreptococcus micros and Prevotella denticola from the right orbital tissue and Haemophilus parainfluenzae, Rothia mucilaginosa, and Streptococcus mitis/oralis from the right canine space. As an inpatient, the patient’s antibiotic regimen consisted
of 3,000 mg of intravenous ampicillin-sulbactam every 6 hours, 15 mL of 0.12% chlorhexidine
gluconate solution swish, and spit two times per day, and application of 0.5% erythromycin
ophthalmic ointment to the right eyelid four times per day. For pain control, the
patient continued utilizing 30 mg of intravenous ketorolac every 6 hours, and for
inflammation, the patient was given a single dose of 8 mg intravenous dexamethasone
at 9:00 on postoperative day 1. The patient was discharged the following day with
an antibiotic regimen consisting of oral 875 to 125 mg amoxicillin-clavulanic acid
taken two times per day for 5 days, 0.12% chlorhexidine gluconate solution swish and
spit two times per day for 7 days, and 0.5% erythromycin ophthalmic ointment applied
to the right eyelid four times per day for 7 days. For pain control, the patient was
prescribed 600 mg of oral ibuprofen taken every 6 hours for 7 days, and for inflammation,
the patient was prescribed 4 mg of Medrol dose pack taken as directed for 6 days.
The Penrose drain was removed on postoperative day 3, and the patient had notable
improvements at his follow-up appointments as an outpatient.
Discussion
Orbital abscess is an exceedingly rare complication arising from an odontogenic infection,
with reports of <5% incidence.[2] Orbital inflammation can quickly lead to permanent disability or even death.[3] The classification of periorbital and orbital inflammation is grouped into the following
categories: (1) inflammatory edema/preseptal cellulitis, (2) orbital cellulitis, (3)
subperiosteal abscess, (4) orbital abscess, and (5) cavernous sinus thrombosis. A
subperiosteal abscess results from purulent material collecting between the periorbital
and the orbital bones.[4] This may lead to orbital pressures quickly rising and cause visual impairment and
further progression of the infection.[5] Clinical signs of orbital involvement include limitation in extraocular motility,
symptomatic binocular diplopia, firmness to retropulsion, and evidence of relative
afferent pupillary defect.
Odontogenic infections follow the path of least resistance. The most common etiology
of orbital abscesses in the pediatric population is maxillary or ethmoidal sinusitis.[2] Infections of the maxillary teeth commonly involve the sinuses.[6] Odontogenic source only accounts for 1.3 to 2% of orbital infections, so this is
rarely seen.[7] In this case, the subperiosteal abscess resulted from the odontogenic infection
caused by the gross decay of tooth 3 traveling upward through the canine space and
maxillary sinus, and posteriorly to the subperiosteal region of the lateral orbit.
Direct extension of bacteria into the subperiosteal space is made possible by neurovascular
foramina, congenital and acquired bony dehiscence, and the valveless venous anastomoses.[8] Subperiosteal abscesses are typically polymicrobial with reports of both anaerobic
and aerobic bacteria.[9] The oral flora is usually the originating source.[10] Rapid expansion of the subperiosteal abscess can occur and this sits in a relatively
avascular zone, making it difficult for antibiotics to penetrate and suppress bacterial
growth.[8]
Patients with visual symptoms or severe periorbital edema with evidence of restriction
in extraocular motility should have immediate assessment by a specialist, and CT imaging
is indicated. Treatment of an orbital abscess with emergent drainage is suggested
any time patients report visual disturbance, and even those without.[11] Surgical intervention facilitates normalization of the orbital pressure and also
establishes aerobic conditions.[5] The Garcia-Harris criteria is used to help decide whether surgical intervention
is recommended. This is based on the age of the patient at presentation and the location
of the infection.[8] For a patient presenting with a subperiosteal orbital abscess, nonsurgical treatment
with close observation and intravenous antibiotics is recommended only if the patient
is less than 9 years of age, there is no intracranial involvement, no frontal sinus
involvement, no dental abscess, no vision loss or afferent pupillary defect, and the
medial wall abscess is of moderate or smaller size.[12] Close follow-up and administration of antimicrobial therapy is essential.[13] Surgery becomes indicated if the aforementioned criteria is not met, if the infection
involves the optic nerve, or if there is suspicion for an infection with anaerobic
bacteria.[12]
Conclusion
Orbital abscess secondary to an odontogenic cause is a rare, but dangerous complication
that can result in permanent vision loss. Dental pain is a common complaint among
pediatric patients presenting to emergency departments, dental offices, and primary
care providers. Periorbital edema and visual changes should alert the provider to
escalate care. Timely recognition and management are paramount. In the present case,
the patient had timely intervention resulting in resolution of symptoms and return
to function.
