Abstract
Background
Pre- or retroseptal bacterial orbital cellulitis (pOC/rOC) is not an uncommon orbital disease. Treatment consists of antibiotics with or without surgical drainage. Several questions regarding course, complications and outcome of treatment are unanswered and the indication for surgery is not well defined. The aim of this study is to: 1. describe the outcome of orbital cellulitis (OC) in a large cohort, 2. assess the significance of Chandler’s classification, 3. assess the incidence of abscess formation in OC, and 4. redefine criteria for surgery.
Methods
Retrospective case series of patients with OC seen between 1-1-2007 and 1-1-2014 in a tertiary referral center.
Results
Sixty-eight patients presented with (presumed) bacterial pOC. Two out of these 68 developed rOC. All 68 patients had a full recovery. Forty-eight patients presented with rOC. Four out of 48 (8%) had intracranial extension of the infection at the time of admission. No admitted patient developed distant seeding. Only four (8%) patients with rOC had a true orbital abscess. In the other 92% we found a diffuse orbital inflammation or a subperiosteal empyema. Forty-four (92%) patients with rOC had a full recovery.
Conclusions
1. The prognosis of both pOC and rOC nowadays is generally favorable. 2. Chandler’s classification is of little use. 3. True abscess formation in OC is rare. 4. The indication for surgical intervention must be based on the clinical presentation and the assessment of true orbital abscess formation.
Highlights
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The prognosis of both pOC and rOC nowadays is generally favorable.
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Chandler’s classification is of little use.
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True abscess formation in OC is rare.
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The indication for surgery must be based on the clinical presentation and the assessment of true orbital abscess formation.
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Decreased visual functions, an unresponsive pupil or a densely packed orbit with a RAPD are indications for surgery
1
Introduction
Orbital cellulitis (OC) affects children and adults and has a reported incidence of 0.1–3.5/100.000 . Children are more commonly involved . OC is an infectious inflammation of the soft tissues of the orbit anterior and/or posterior to the orbital septum and can be caused by bacteria, viruses, fungi and protozoa, bacterial infection being the most common cause. OC most commonly results from paranasal sinus or eyelid pathology . Notorious for its bad outcome is cellulitis from orodental spread . Severe complications, including vision loss – for instance due to central retinal artery occlusion, cavernous sinus thrombosis, intracranial abscess formation, meningitis and death have been reported . Whereas the clinical presentation of pOC is limited to redness and swelling of the eyelids, rOC is characterized by pain, impaired motility, proptosis, optic neuropathy and loss of visual acuity.
In 1970, Chandler described five different stages of orbital cellulitis, as shown in Table 1 . This description suggests a chronologic succession of events and a tool for the approach and treatment of the affliction. Treatment of bacterial OC traditionally consists of antibiotics and surgical drainage . Oral antibiotics are given for milder presentations such as pOC and intravenously administered antibiotics for more severe presentations. Possibly based on the old surgical adagium: ‘Ubi pus, ibi evacua’, the common approach used to be surgical intervention once the diagnosis ‘abscess’ was made. Harris et al. already started to question this dogma in 1993 . Harris recommended a more conservative treatment consisting of intravenous antibiotics and close monitoring of patients who were less than 9 years old, with no visual changes, medium sized medial ‘abscess’ and no intracranial/frontal sinus disease. He based this treatment on the fact that in this subcategory of patients, the type of infection consisted of a uniform and less aggressive type of bacteria in contrast to the more multiform and more aggressive bacteria stems found in older patients. We wondered whether a less aggressive approach might be applicable to other subgroups of patients with OC as well and therefore studied the course of OC patients in a large cohort. In addition, we studied the occurrence of true orbital abscess formation in OC. Although the terms abscess and empyema are often used synonymously, they are in fact distinct entities. An abscess is a collection of pus and bacteria surrounded by a wall created by the bacteria through which antibiotics can hardly penetrate and therefore surgery is required to open the abscess and evacuate pus. In contrast, an empyema is a collection of pus and bacteria in a pre-existing anatomical space to which antibiotics can penetrate relatively easily. From a theoretical point of view, the approach of an orbital empyema therefore could be less invasive than treatment of an abscess. Knowledge of the incidence of a true abscess formation in bacterial orbital infection is thus mandatory to develop new guidelines for the treatment of OC.
