Post on 19-May-2020
Orbital myositiscomplicating sinusitis
Joe S Dylewski FRCPC1, Robert Drummond MDCM
1, Tiffany Townsend MDCM2
Orbital myositis is an idiopathic inflammation of the extrao-
cular muscles (EOMs) in the absence of thyroid disease
(1-3). The clinical presentation is acute orbital pain worsened by
eye movements, and the diagnosis is confirmed by demonstrat-
ing enlargement of one or more EOMs by echography and/or a
computed tomography (CT) scan (4,5). Various infectious and
noninfectious conditions have been associated with orbital
myositis, and treatment with corticosteroids can hasten recov-
ery (1). Recurrences and chronicity have also been described.
The present article describes a case of orbital myositis in a pa-
tient with subclinical sinusitis that appeared to respond to anti-
biotic therapy. The literature on this topic is also reviewed.
CASE PRESENTATIONA previously healthy, 38-year-old female was seen in the
emergency department with a two-day history of right ocular
pain. The pain was described as severe, dull and worse with
eye movements. There was photophobia and nausea with
vomiting. She denied trauma, fever, diplopia or sinus pain. On
examination, she was in obvious pain but afebrile. The right
eye was mildly proptotic with chemosis and periorbital ery-
thema. Visual acuity was 20/25 bilaterally (uncorrected), and
the pupils were equal and reactive. The slit lamp examination
was unremarkable, and the intraocular pressure was normal.
Laboratory investigations showed a white blood cell count of
17�109/L with predominant neutrophilia and an erythrocyte
sedimentation rate of 47. The working diagnosis was a retro-
orbital abscess, and a CT scan of the head and orbit was
performed. The CT scan of the head showed air fluid levels in
both the ethmoid and in the anterior sphenoid sinuses. The CT
scan of the orbit completed with contrast revealed marked fo-
cal swelling of the right medial rectus muscle with an oval
central, nonperfused lucency (Figure 1). The ethmoid plate ad-
jacent to the medial rectus muscle was intact.
Can J Infect Dis Vol 12 No 1 January/February 2001 51
CASE REPORT
1St Mary’s Hospital, 2McGill University Medical School, Montreal, Quebec
Correspondence: Dr Joe Dylewski, St Mary’s Hospital, 3830 Lacombe Street, Montreal, Quebec H3T 1M5. Telephone 514-345-3511 ext 3075,
fax 514-734-2607, e-mail joedylewski@hotmail.com
Received for publication November 12, 1999. Accepted February 23, 2000
Dylewski JS, Drummond R, Townsend T. Orbital myositis complicating sinusitis: Case report and review.Can J Infect Dis 2001;12(1):51-53.
Orbital myositis is a common cause of extraocular muscle enlargement. It is characterized by nonspecific inflammationof one or more extraocular muscles. Although often idiopathic in origin, orbital myositis has been associated withvarious noninfectious diseases. Several cases have also been reported as occurring after upper respiratory tractinfections. The present report describes a case of orbital myositis together with subclinical sinusitis and its rapidresolution after antibiotic treatment. The literature on this clinical entity is also reviewed.
Key Words: Myositis; Ocular muscle infection; Sinusitis
Myosite orbitale comme complication de la sinusite
RÉSUMÉ : La myosite orbitale est une cause fréquente d’hypertrophie du muscle extraoculaire. Elle se caractérisepar une inflammation non spécifique de l’un ou de plusieurs des muscles extraoculaires. Bien que souvent d’ori-gine idiopathique, la myosite orbitale a été associée à diverses maladies non infectieuses. Plusieurs cas ont en ou-tre été signalés après des infections des voies respiratoires supérieures. Le présent rapport décrit un cas demyosite orbitale associée à une sinusite subclinique et sa résolution rapide après l’antibiothérapie. La littératuresur cette entité clinique est également passée en revue.
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A diagnosis of orbital myositis with a possible abscess was
made, and the patient was transferred to a tertiary care centre
where she received intravenous piperacillin/tazobactam for
five days. An orbital ultrasound performed two days before
discharge showed an enlarged right medial rectus muscle with
diffuse soft tissue swelling. The reflectivity of the muscle was
low median and irregular. The central lucency seen by the CT
scan was not identified. The patient improved dramatically,
with a return of her white blood cell count to normal, and she
was asymptomatic on discharge. A follow-up CT scan of the or-
bit (Figure 2) showed marked improvement in the previously
enlarged right medial rectus muscle. She remained well six
months after her hospitalization.
Orbital myositis was first reported in 1903, after several pa-
tients with proptosis and presumed orbital tumours had spon-
taneous improvement, whereas others who underwent surgical
exenteration were found to have benign inflammation (6). Be-
fore modern imaging techniques, a diagnosis could only be es-
tablished by surgery. Now the diagnosis refers to a nonspecific
orbital disease in which one or more EOMs is infiltrated by an
inflammatory process. Orbital myositis appears to affect pre-
dominantly females over a wide range of ages (three to 84
years). The mean age for reported patients is 37.0 years (1).
Cases have been reported in association with giant cell myocar-
ditis (7), systemic lupus erythematosis (8), Crohn’s disease
(9,10) and cancer (11). Infectious causes for orbital myositis in-
clude herpes zoster (12), Lyme disease (13) and cystercercosis
(14). Recent upper respiratory tract infections have also been
associated with the development of orbital myositis (15).
The major clinical presentation of orbital myositis is pain
worsened by eye movements. Patient have diplopia, proptosis,
chemosis, periorbital and eyelid edema, conjunctival injec-
tion, blepharoptosis and, occasionally, a palpable mass. Vis-
ual acuity is normal, and the affected muscle may be paretic in
the acute stage. More than one EOM may be involved, and
rarely are both eyes affected. The most frequently involved
muscle is the medial rectus, followed by the superior rectus,
lateral rectus, superior oblique, inferior rectus and inferior
oblique muscles (16). Imaging of affected muscles by CT scan
or magnetic resonance imaging reveals enlarged muscle bel-
lies with thickened tendons and low internal reflectivity on
A-scan echography (4-5,16).
Orbital myositis appears to be an immune-mediated disease.
There are reports of new onset disease being associated with in-
creased activity of Crohn’s disease and resolving following
bowel resection (10). Cases of orbital myositis have occurred
one or more weeks after respiratory tract infections (15). There
has been one previous case of sinusitis associated with orbital
myositis reported, but no details were given on the patient’s
presentation or response to therapy (17). Our patient did not
have clinically evident sinusitis, but the CT scan was diagnos-
tic. Of note in our patient, the ethmoid plate was intact, which
is an argument against direct infection of the medial rectus
muscle, although spread through penetrating veins was not
ruled out. As in other cases, the diagnosis was delayed while
our patient received antibiotics (17). In that report, the patients
did not improve until treatment with corticosteroids were given
(17). Resolution of symptoms took three to six weeks, unlike the
rapid clinical response seen in this case. It is possible that an im-
mune reaction directed at the medial rectus muscle was precipi-
tated by the sinusitis and that antibiotic treatment targeted at
that infection resulted in a diminished antigenic stimulus. How-
ever, spontaneous resolution is also a possible explanation (17).
Acute orbital myositis will often respond to systemic corti-
costeroids at doses of 60 to 120 mg prednisone/day for two
weeks, with subsequent tapering over weeks to months (18).
Prompt treatment is associated with dramatic improvement in
symptoms, and a reduced risk of muscle fibrosis and recur-
rence. Treatment with nonsteroidal anti-inflammatory drugs
has also had some success, but these drugs are not considered
52 Can J Infect Dis Vol 12 No 1 January/February 2001
Dylewski et al
Figure 1) A computed tomography scan of the orbit, showing marked
swelling of the right medial rectus muscle with an oval central lucency
(arrow)
Figure 2) The follow-up computed tomography scan of the orbit two
months later, showing resolution of the swelling in the right medial
rectus muscle (arrow)
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as effective as corticosteroids. Recurrent disease is not un-
usual; also, some cases have proven refractory to steroids, and
orbital radiation has been tried with mixed results (17,18).
There are also cases of treatment with immunosuppressive
drugs, but too few case reports make recommendations on
their utility (19).
Acute orbital myositis is an acute inflammatory process in-
volving EOMs that can easily be confused with a primary infec-
tious disease. Clinicians should be familiar with the diagnostic
and therapeutic modalities that concern this condition.
REFERENCES1. Scott IU, Siatkowski RM. Idiopathic orbital myositis.
Curr Opin Rheumatol 1997;9:504-12.2. Rootman J, Nugent R. The classification and management of
acute orbital pseudotumors. Ophthalmology1982;89:1040-8.
3. Kennerdell JS, Dresner SC. The nonspecific orbital inflammatorysyndromes. Surv Ophthalmol 1984;29:93-103.
4. Byrne SP, Green RL. Ultrasound of the Eye and Orbit. St Louis:CV Mosby, 1992:353-92.
5. Trokel SL, Hilal SK. Recognition and differential diagnosis ofenlarged extraocular muscles in computed tomography.Am J Ophthalmol 1979;87:503-12.
6. Gleason JE. Idiopathic myositis involving the extraocularmuscles. Ophthalmic Rec 1903;12:471-8.
7. Stevens AW, Grossman ME, Barr ML. Orbital myositis, vitiligo,
and giant cell myocarditis. J Am Acad Dermatol1996;35:310-2.
8. Serop S, Vianna RN, Claeys M, DeLaey JJ. Orbitalmyositis secondary to systemic lupus erythematosus.Acta Ophalmologica (Copenh) 1994;72:520-3.
9. Squires RH Jr, Zweiner RJ, Kennedy RH. Orbital myositis andCrohn’s disease. J Pediatr Gastroenterol Nutr 1992;15:448-51.
10. Young RS, Hodes BL, Cruse RP, Koch KL, Garovoy MR. Orbitalpseudotumor and Crohn’s disease. J Pediatr 1981;99:250-2.
11. Harris GJ, Murphy ML, Schmidt EW, Hanson GA, Dotson RM.Orbital myositis as a paraneoplastic syndrome. Arch Ophthalmol1994;112:380-6.
12. Volpe NJ, Shore JW. Orbital myositis asociated with herpeszoster. Arch Ophtalmol 1991;109:471-2.
13. Seidenberg KB, Leib ML. Orbital myositis with Lyme disease.Am J Ophthalmol 1990;109:13-6.
14. Stewart CR, Salmon JF, Murray AD, Sperryn C. Cystercercosisas a cause of severe medial rectus muscle myositis.Am J Ophthalmol 1993;116:510-1.
15. Purcell JJ Jr, Taulbee WA. Orbital myositis after upper respiratorytract infection. Arch Ophthalmol 1981;99:437-8.
16. Siatkowski RM, Capo H, Byrne SF, et al. Clinical and echographicfindings in idiopathic orbital myositis. Am J Ophthalmol1994;118:349-50.
17. Hankey GJ, Silbert PL, Edis RH, Nicoll AM. Orbital myositis:a study of six cases. Aust N Z J Med 1987;17:585-91.
18. Mombaerts I, Koornneef L. Current status in the treatment oforbital myositis. Ophthalmology 1997;104:402-8.
19. Sanchez-Roman J, Varela-Aguilar JM, Bravo-Ferrer J. Idiopathicorbital myositis: treatment with cyclosporin. Ann Rheum Dis1993;52:84-5.
Can J Infect Dis Vol 12 No 1 January/February 2001 53
Orbital myositis complicating sinusitis
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