43 A 9-year-old boy goes to the emergency room after awakening that morning with extensive left eye swelling. His recent medical history is significant for 8 days of an upper respiratory illness, with symptoms of nasal congestion, rhinorrhea, headache, and fever. He is otherwise in good health and his immunizations are up to date. Physical examination reveals a well-nourished though ill-appearing child with a normal ear examination, nasal congestion with purulent rhinorrhea bilaterally, 2+ tonsils that are not inflamed, and shotty lymphadenopathy. He is febrile to 101.9°F. He exhibits marked left peri-orbital edema that appears to be preseptal, with no apparent proptosis. Visual acuity is intact. His extraocular movements are intact. He has full flexion and extension of his neck. Based on his history and physical examination findings, a computed tomography (CT) scan of his sinuses and orbits is obtained. 1. Swelling of the upper and lower eyelids should lead the investigator to consider both intrinsic periorbital abnormalities as well as orbital extensions of periorbital processes. Furthermore, it is important to distinguish periorbital cellulitis from orbital cellulitis. 2. Periorbital cellulitis can result from a traumatic insult to the area, as from an insect bite, bacteremia, or spread from a regional infection such as bacterial conjunctivitis, dacrocystitis, or sinusitis. Typically the upper and lower eyelids are erythematous and swollen shut. However, examination of the eye reveals that visual acuity and extraocular movements are intact. 3. Decreased visual acuity and restricted movement of the globe, or ophthalmoplegia, are more indicative of orbital cellulitis, as are chemosis and proptosis. These signs indicate that the infection and inflammation have spread to postseptal muscle and fat tissue. These findings are of concern because of the possibility of spread of the infection to the optic nerve and intracranially. Permanent eye damage can result. This patient had no evidence of ophthalmoplegia, making a diagnosis of orbital cellulitis unlikely. 4. The most common cause of orbital and periorbital cellulitis in children is sinus disease, most notably ethmoid sinus infection. Both are more common in children than in adults and may respond to intravenous antibiotic therapy without the need for surgical intervention. Orbital cellulitis is more often associated with systemic signs, such as fever and malaise, and will usually require a more prolonged course of therapy. 5. Causative organisms in orbital cellulitis include mainly Staphylococcus and Streptococcus spp. Not surprisingly, Haemophilus influenzae spp. are also associated with these complications of sinus infection. 1. CT: A sinus CT scan with contrast is the study of choice to evaluate the paranasal sinuses and delineate the presence or absence of a subperiosteal phlegmon or abscess within the orbit (Fig. 43.1
Orbital Complications of Sinusitis
History
Differential Diagnosis—Key Points
Test Interpretation
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