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Case 3 - Orbital Cellulitis, Periorbital Abscess

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So this is a child who presented with left orbital inflammation

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and was being evaluated for the potential for orbital

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cellulitis. Again, the study is done post-contrast.

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As we scroll up from below, we come

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into our images of the orbit.

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We notice that there is swelling at the junction between the

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orbit and the nasal region and lots of edema on the left side.

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More importantly, however,

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is that the orbital fat on the left side and the medial

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aspect of the orbit has been infiltrated.

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So we've crossed the medial aspect of the nasal septum.

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So we're in the post-septal space and we see that there is

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indentation of the medial rectus muscle on the left side compared

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to the right side where it's been lifted

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away from the lamina papyracea.

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So this is a patient who has orbital cellulitis and more

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importantly there is this collection that is seen

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displacing the medial rectus muscle.

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This is what we refer to as a periorbital abscess.

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Now,

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it is true that this collection does not have a peripheral rim

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of enhancement that we typically look

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for in patients who have abscesses.

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Let's just say that in this particular location, you often do

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not see a peripheral rim of the wall of the abscess

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even though there is this inflammatory process.

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Now, some people might call this a phlegmon.

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A Phlegmon is an inflammatory collection that really doesn't

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have as good a wall around it as an

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abscess, but still has mass effect.

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And you can see that the source of this periorbital

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abscess is the ethmoid sinusitis.

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And this is very common in children that severe

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ethmoid sinusitis can lead to a periosteal abscess.

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Fortunately,

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whether or not this is a phlegmon or an abscess is not all that

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critical, because the treatment of this at this juncture is to

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administer at least 48 to 72 hours of intravenous antibiotics

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as a treatment for this, and to see whether

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the patient resolves the inflammation.

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If they improve, then the patient often will be discharged

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and given oral antibiotics to complete

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the course of the antibiotics. Going in

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to operate on this type of periosteal

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abscess is uncommon these days.

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If it is operated upon, it's usually not done with a medial

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canthotomy and drainage of the abscess.

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Usually what's done is that they go in endoscopically with

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no surgical marks on this child, you know, no external scarring.

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Instead they go in endoscopically and clear up the

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sinusitis because that is the source of the inflammation.

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So again,

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in these cases, including orbital cellulitis,

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generally treated with intravenous antibiotics at least

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for two days, and then converted to

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oral antibiotics with response.

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If they don't respond and or is a suggestion

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that the optic nerve may be in jeopardy,

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then they would do endoscopic surgery for treatment of the

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ethmoid sinusitis with the feeling or the philosophy

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that as soon as you get rid of the primary problem,

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the secondary abscess will resolve.

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Just want to point out a couple more

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findings on the coronal image.

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If we look at the medial rectus muscle

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on the affected left side,

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you see it's fatter and lower density than the

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medial rectus muscle on the right side.

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And I think on the coronal, you can better estimate

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the size of this collection.

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It's relatively small.

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And the communication of that collection

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with the diseased ethmoid sinusitis.

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As you go further posteriorly to look at the orbital apex,

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we see that the optic nerve has nice,

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clean fat around it and therefore is not in jeopardy of

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potentially being compressed or having

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an ischemic optic neuropathy.

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Occasionally, you will have inflammation that leads to a

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vasculitis of the veins that can lead to ischemic optic

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neuropathy without compression of the orbital apex.

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But that is an uncommon feature.

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Let's just take a quick look on the sagittal to see whether

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there's any benefit here on the sagittal scan.

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You see the inflammation along the

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medial aspect of the left eye.

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And you can also see on the axial scan that there's a little

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bit of proptosis with the left eye bulging

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out compared to the right side.

Report

Faculty

David M Yousem, MD, MBA

Professor of Radiology, Vice Chairman and Associate Dean

Johns Hopkins University

Tags

Neuroradiology

Head and Neck

Emergency

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