Orbital CellulitisOrbital Cellulitis

Orbit anatomyOrbit anatomy

Frontal

ZygomaMaxillary

NasalEthmoidLacrimal

Sphenoid

Orbital CellulitisOrbital CellulitisOrbital cellulitis is a dangerous infection withpotentially serious complications.It is usually caused by a bacterial infection fromthe sinuses (mainly ethmoid, accounting for morethan 90% of all cases) Other causes :a stye on the eyelid, recent traumato the eyelid including bug bites, or a foreignobject

ChildrenChildren

In children, orbital cellulitis is usually from asinus infection and due to the organism.Hemophilus influenza (decrease in incidenceafter vaccination program implantation). Other organisms are Staphylococcus aureus,Strep.pneumonia, and Beta. H streptococci

PathophysiologyPathophysiology

Extension of infection from the periorbital structures,most commonly from the paranasal sinuses, but alsofrom the face, globe, and lacrimal sac.Direct inoculation of the orbit from trauma or surgery(orbital decompression, DCR, eyelid surgery,strabismus surgery, retinal surgery, and intraocularsurgery, have been reported as the precipitating causeof orbital cellulitis) Hematogenous spread from bacteremia.

Orbital septumOrbital septumThe orbit is separated from the soft tissue of the eyelid bythe orbital septum. This is a facial plane that is continuouswith the periosteum of the facial bones. The orbital septum inserts into the tarsal plate of the upperand lower eyelids. The orbital septum usually proves to be an effective barrierthat prevents the spread of infection from the eyelidsposteriorly to the orbit. While preseptal cellulitis can occasionally spread to theorbital contents, it is generally a clinical entity that is distinctfrom orbital cellulitis

Orbital septumOrbital septum

Orbital vs. Preseptal CellulitisOrbital vs. Preseptal Cellulitis

Orbital cellulitis is infection of the soft tissuesof the orbit posterior to the orbital septum,differentiating it from preseptal cellulitis,which is infection of the soft tissue of theeyelids and periocular region anterior to theorbital septum DD: orbital pseudotumor (inflammatorycondition, responds to steroids)

Chandler ClassificationChandler Classification

Stage I Inflammatory edema-PreseptalStage II Orbital cellulitis - PostseptalStage III Subperiostal abscessStage IV Orbital abscessStage V Complication due to

posterior extension

SymptomsSymptoms

Fever, generally 39 degrees C or greater. Eyelid appears shiny and is red or purple in color. Infant or child is acutely ill or toxic. Eye pain especially with movement. Decreased vision proptosis Painful swelling of the eyelidsGeneral malaise. Restricted or painful eye movements

ComplicationsComplications

Subperiostal/Orbital abscess Cavernous sinus thrombosis Hearing loss SepticemiaMeningitis Optic nerve damage and blindness

A male with orbital cellulitis with proptosis, A male with orbital cellulitis with proptosis, ophthalmoplegia, eyelids edema and erythema .ophthalmoplegia, eyelids edema and erythema .

Non-surgical treatmentNon-surgical treatment

IV ABxAntifungal (if indicated)Nasal decongestants (open sinus ostia)Diuretics – DIAMOX (carbonic anhydraseinhibitor), manitol.

Surgical TreatmentSurgical TreatmentSurgical drainage if failed response to appropriateantibiotic within 48-72 h .Every case of subperiosteal or intraorbital abscessformation. Decrease V/A, RAPD. proptosis progresses despiteappropriate antibiotic therapyThe size of the abscess does not reduce on CT scanwithin 48-72 hours after appropriate antibiotics havebeen administered. If brain abscesses develop and do not respond toantibiotic therapy, craniotomy is indicated.

HowHow ? ?Superior orbit decompressionMedial orbit decompressionInferior orbit decompressionLateral orbit decompressionIntranasal approach

Superior Orbit DecompressionSuperior Orbit Decompression

Frontal cranioitomy –unroofing of superiorwall of orbitTitanium sheild placed tosupport the frontal lobeof the brainHigh morbidity, consideronly for severe cases

Medial Orbit DecompressionMedial Orbit DecompressionExternal ethmoidectomy incision or coronalforehead approachExternal ethmoidectomy- complete ethmoid sinusresection, then orbital fat herniated into sinus defectCoronal incision- ethmoidectomy via a superiorapproach, more risk for lacrimal sac and trochleainjury

Inferior Orbit DecompressionInferior Orbit DecompressionOrbital floor blow-out Fx ,but spares infraorbitalnerve.Subciliary eyelid incision or Caldwell-LucincisionCombined approach? Intraorbital fat herniates maxillary sinus

Lateral Orbit DecompressionLateral Orbit DecompressionLateral canthotomyRemoval of lat. orbital bone posterior to the rimOrbital fat protrudes the newly created space

An incision extending from the lateral canthus to the area just below the inferior punctum is created 4 mm to 5 mm below the lower border of the tarsal plate to avoid injury to the septum and the canaliculus

Intranasal approachIntranasal approachDecompression of medial and medioinferiorfloors of orbit.Endoscopic sinus surgery technique.Anterior EthmoidectomyMaxillary antrostomy