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A Case of Odontogenic OrbitalCellulitis Causing Blindness: ACase ReportDelhi J Ophthalmol 2013; 24 (2): 102-105

Orbital cellulitis is a life threatening infection of the soft tissues behind the orbital septum.1 It is an ocular emergency that not only threatens vision but also can lead to life-threatening complications such as cavernous sinus thrombosis, meningitis, and brain abscess.2,3 It must be distinguished from preseptal cellulitis (sometimes called periorbital cellulitis), which is an infection of the anterior portion of the eyelid. Neither infection involves the globe itself. Although preseptal and orbital cellutis may be confused with one another because both can cause ocular pain and eyelid swelling and erythema, they have very different clinical implications. Preseptal cellulitis is generally a mild condition that rarely leads to serious complications, whereas orbital cellulitis may cause loss of vision and even loss of life. Orbital cellulitis can usually be distinguished from preseptal celulitis by its clinical features (ophthalmoplegia, pain with eye movements and proptosis) and by imaging studies; in cases in which the distinction is not clear, clinicians should

treat patients as though they have orbital cellulitis. Both conditions are more common in children than in adults, and preseptal cellulitis is much more common than orbital cellulitis.4

The major causes of orbital cellulitis are sinusitis (58%), lid or face infection (28%), foreign body (11%), and hematogenous (4%), odontogenic 2-5%. Staphylococcus and Streptococcus are the most common causative organisms in adults, Haemophilus influenzae in children. Less common organisms are Pseudomonas and Esterichia coli.5,6

The warning signs of orbital cellulitis are a dilated pupil, marked ophthalmoplegia, loss of vision, afferent papillary defect, papilledema, perivasculitis, and violaceous lids.5

Case ReportA 30 years old male presented to

the eye OPD chief complaint of loss of vision of right eye with swelling, redness of right eye associated with swelling of right sided temporal region for 10 days. He had a history of dental

Keywords : orbital cellulitis • periodontal abscess • odontogenic • blindness

Aim: To report a case of odontogenic orbital cellulitis causing blindness in young male

Methods: We report a rare case of odontogenic orbital cellulitis secondary to periodontal abscess, due to which a young male lost his sight.

Results: After extensive clinical examination and investigations diagnosis of odontogenic orbital cellulitis. Patient took incomplete treatment and showed negligence while taking treatment for recurrent periodontal abscess. As a result he developed orbital cellulitis and temporal fossa abscess, which ultimately caused blindness in his right eye.

Discussion: Orbital Cellulitis is the infection of the soft tissues behind the orbital septum. Orbital cellulitis is a life threatening infection. It is an ocular emergency that not only threatens vision but also can lead to life-threatening complications such as cavernous sinus thrombosis, meningitis, and brain abscess. The major causes of orbital cellulitis are sinusitis (58%), lid or face infection (28%), foreign body (11%), and hematogenous (4%), odontogenic 2-5%. Odontogenic i.e tooth related causes of orbital cellulitis are very less.

Vimlesh Sharma, Laltanpuia Chhangte, Vijay Joshi, Swati Gupta, Kalpana Department of ophthalmologyGovernment Medical College, Haldwani,Uttarakhand, India

Laltanpuia Chhangte (MS)

Department of ophthalmologyGovernment Medical College, Haldwani, Uttarakhand, IndiaEmail id: drtpchhangte18@gmail.com

*Address for correspondence

DOI: http://dx.doi.org/10.7869/djo.2013.22

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Case Report

abscess with fistula in the right upper jaw 14 days back, pus can be extruded out of the fistula when pressing the upper jaw and right temporal regions, following which he started complaining of loss of vision and swelling of right eye. He denied any history of nasal obstruction or discharge or ear problem. He gave a history of on off dental pain for last 1 year. He took incomplete treatment due to negligence every episode. His general physical examination was within normal limits except for right side temporal swelling and tenderness.

His right eye was swollen, erythematous, and tender to palpation and very mild proptosis (Figure 1a). His right pupil was mid dilated and non-reacting. The right conjunctiva was erythematous and chemosed associated with lid edema and moderate restriction of eyeball movement (Figure 1b). His dental examination shows a fistula present in the upper jaw opposite right premolar tooth with expression of pus through the fistula on pressing the upper jaw region (Figure 1b) suggesting periodontal abscess. At the time of presentation, his Snellen’s visual acquity was no perception of light in the right eye and 6/6 in the left eye. On fundoscopy, nasal blurring of optic disc margin and hyperaemic disc was seen, rest was within normal limits.

After hospital admission, a MRI SCAN of the cranium and orbits revealed cellulitis involving abscess involving right temporalis muscle and upper masseter muscle, also

cellulitis involving preseptal and intraorbital compartments of the right orbit, more on the lateral aspect. (Figure 2). These findings were consistent with right orbital cellulitis.The patient’s past medical history was not significant but his habit of drinking was. He used to drink in excess 40-60 units of alcohol every day for the past 8 years and smoked 10-20 cigarettes per day, chew paan occasionally. He had no history of drug abuse.

Sharma V et al

Figure 1 (a): Of the face showing mild swelling of right cheek and periorbital area involving eyelid, and mild proptosis of the right eye

Figure 2 (a): MRI of cranium and orbit showing cellulitis involving right temporal fossa, preseptal and intraorbital compartments of the right orbit

Figure 2 (b): MRI of cranium and orbit showing decreased Intensity of the optic nerve is with mild proptosis in RE

Figure 1 (b): Showing a fistula opposite the root of premolar tooth

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1(b)

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Case ReportA Case of Odontogenic Orbital Cellulitis Causing Blindness: A Case Report

Figure 3: Extracted premolar tooth caries causing periodontal abscess

Ceftriaxone, amikacin and metronidazole were started empirically. About eight hours later, the patient underwent ENT evaluation and incision and drainage of the temporal abscess. Gram’s stain of material from surgery revealed moderate neutrophils and moderate gram positive cocci in clusters. But on Zieh Nielsen staining, no acid fast bacilli was found. Cultures yielded predominant growth of Staphyloccus aureus(> 100000 colonies/ml grown). Drug Sensitivity test shows sensitivity against the drugs we were currently administering the patient and also against ampicillin, cefixime, cefotaxime, cephalexin, ciprofloxacin, erythromycin, levofloxacin, ofloxacin, tetracycline, trimethoprim/sulfamethoxazole and gentamicin, and resistance against ceftazidime.

The patient was discharged after completing the 7-day course of injectable antibiotics and extraction of the right premolar tooth for prevention of further attack (Figure 3). All Signs and symptoms subsided at the time of discharge except that the vision could not be restored due to negligence of seeking medical advice at the most crucial time.

DiscussionThe most important element in the care of patients with

preseptal cellulitis and orbital cellulitis is differentiating the two infections. Preseptal cellulitis is much more common than orbital cellulitis, and patients with preseptal cellulitis can be treated as outpatients with oral antibiotics. If the globe can be examined and the patient has full gaze without pain, CT imaging can be deferred. Red flags for the more worrisome diagnosis of orbital cellulitis or abscess include proptosis and decreased extraocular movements. These signs warrant hospitalization, parenteral antibiotics that include coverage for H. Influenzae, CT, and surgical specialty consultation. The inability to completely examine the globe for intact vision and extraocular movements also necessitates CT scanning.

Treatment in both preseptal and orbital cellulitis should include coverage of Haemophilus species as well as skin

and sinus flora (Staphylococcus and Streptococcus species).Orbital cellulitis or subperiosteal abscess from

odontogenic causes are relatively rare complications and these can occur along several pathways due to specific anatomic structure of facial bone. The first pathway is the most common one via the sinus because the roots of molar and premolar tooth are adjacent to the base of maxillary sinus; the infection of a tooth invades the maxillary sinus directly. Then the inflammation or infection of the sinus spreads into the orbit through bone erosion between the orbit and the maxillary sinus or through ethmoid sinus or infraorbital canals.7,8 The second pathway is the one through the facial soft tissue over buccal cortical plate, spreading to periorbital tissues. The third pathway is the one that infection of a molar or premolar tooth invades the infratemporal and pterygopalatine fossa, spreading into the orbit through the inferior orbital fissure.8-10 Infection of a tooth can also spread into the orbit along the facial vein and the ophthalmic vein by hematogeneous regurgitation because the veins of the face, eyes, nasal cavity and sinus are all connected without valves.8 With regard to our patient, it is thought that the findings of invasion of cheek area and temporal fossa demonstrate the correspondence with the second and third pathways. There are normal floras such as Staphylococcus epidermidies, S. aureus, Streptococcus salivarius, S. mutans, Lactobacillus sp., Eubacterium sp., and Bacteroides gingivalis in the mouth which can cause infection.12-13 As S. aureus had been identified from the microbiologic culture of the patient, it was highly suspected that this complication was induced by odontogenic infection.

There are some case reports which described a visual loss from an odontogenic complication14, but the cases had not shown typical findings of tension orbit and eyeball deformation caused by severe proptosis and optic nerve traction. The direct dissemination of infection to the optic nerve may be considered the possible cause of visual loss that occurred in our patient.15

Administration of high dose steroid in the patient with infection can be controversial. But some authors reported that active administration of steroid at an early stage may be helpful for faster symptomatic improvement.16,17 Although co-administration of high dose steroid along with antibiotics did not aid in the recovery of vision in our patient, it is considered somewhat helpful for blocking further aggravation of inflammation. Complications of untreated infections include periosteal and orbital abscesses, loss of vision, cavernous sinus thrombosis, and brain abscesses.

Odontogenic orbital cellulitis is a relatively rare complication, but it can cause blindness via rapidly progressing tension orbit in spite of antibiotic treatment or by direct dissemination. Therefore even the simplest dental problems require careful attention.

Financial & competing interest disclosureThe authors do not have any competing interests in any product/

procedure mentioned in this study. The authors do not have any financial interests in any product / procedure mentioned in this study

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References

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TD. Ed. Clinical ophthalmology. New York; Harper and Row. 1976; 4:chapter 25.

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4. Botting AM, McIntosh D, Mahadevan M. Paediatric pre- and post-septal peri-orbital infections are different diseases. A retrospective review of 262 cases. Int J Pediatr Otorhinolaryngol 2008; 72:377.

5. Yanoff and Duker Ophthalmology, 3rd Edition, Section 3: Orbital and Lacrimal gland, page

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7. Brook I. Sinusitis of odontogenic origin. Otolaryngol Head Neck Surg 2006; 135:349-55.

8. Thakar M, Thakar A. Odontogenic orbital cellulitis. Report of a case and consideration on route of spread. Acta Ophthalmol Scand 1995; 73:470-1

9. Poon TL, Lee WY, Ho WS, Pang KY, Wong CK. Odontogenic subperiosteal abscess of orbit: a case report. J Clin Neurosci 2001; 8:469-71.

10. Bullock JD, Fleishman JA. Orbital cellulitis following dental extraction. Trans Am Ophthalmol Soc 1984; 82:111-33.

11. Brook I. Microbiology of acute and chronic maxillary sinusitis associated with an odontogenic origin. Laryngoscope 2005; 115: 823-5.

12. Nash D, Wald E. Sinusitis. Pediatr Rev 2001; 22:111-7.13. Brook I. Microbiology of acute sinusitis of odontogenic origin

presenting with periorbital cellulitis in children. Ann Otol Rhinol Laryngol 2007; 116:386-8.

14. Cho HS, Kwon JW, Ahn HS. Central reinal artery occlusion and orbital abscess following dental abscess. J Korean Ophthalmol Soc 2003; 44:750-4.

15. Dolman PJ, Glazer LC, Harris GJ, Beatty RL, Massaro BM. Mechanisms of visual loss in severe proptosis. Ophthal Plast Reconstr Surg 1991; 7:256-60.

16. Chang KC. Orbital cellulitis with subperiosteal abscess secondary to dental extraction. J Korean Ophthalmol Soc 2008; 49:1845-9.

17. Cheon HC, Park JM, Lee JH, Ahn HB. Effect of corticosteroids in the treat¬ment of orbital cellulitis with subperiosteal abscess. J Korean Ophthalmol Soc 2006; 47:2030-4.

Case Report Sharma V et al

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