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MANAGING PERIORBITAL SPACE ABSCESS. SECONDARY TO DENTOALVEOLAR ABSCESS
ARTICLE 2
CASE REPORT
MANAGING PERIORBITAL SPACE ABSCESS
SECO NDARY TO DENTOALVEO LAR ABSCESS ERIC H. MILLER, D.D.S.; DENISE K. KASSEBAUM, D.D.S., M.S.
Q xtension of dental infections to the orbital spaces and tissues surrounding the eye presents a serious problem with the potential for causing significant impairment. Damage to neurovascular, muscular and soft tissues often results in permanent sequelae such as loss of vision, restricted eye movement and drooping eyelids. Abscesses that extend to the posterior orbital space can even be lifethreatening, as the infection may spread through the optic canal and ophthalmic veins to
the meninges and brain.1`7 Early detection and aggressive management of dentoalveolar infections both are critical in preventing subsequent orbital space abscesses. This article reports a case of an orbital space abscess resulting from the spread of an acute dentoalveolar abscess. CASE REPORT
A 21-year-old woman sought treatment at a hospital emergency room complaining of facial pain and swelling on the left side, which had begun two days earlier. Over the previous week, she had developed dental pain involving the left maxilla and had seen a dentist 24 hours before coming to the emergency room. At that time, the dentist removed decay from the mesial
Although orbital space Infections are a relatively rare sequela of
dentoalveolar infections, such cases have been reported. This case report describes the
management of an abscess
Involving the left eye that originated as a dental abscess.
surface of the upper left first molar and placed an amalgam restoration. The distal surface of the first molar, upper left second molar and third molar were not addressed. The patient reported no other information about her medical history that would have contributed to this condition. The patient had a temperature of 100.7 F. Her pulse was slightly elevated at 80 beats/minute; her other vital signs were within normal limits. With the exception of significant redness around the left eye and swelling involving the left orbit and left canine space, the patient's head appeared normal with no signs of trauma. The swelling was firm and warm to the touch with marked edema involving the upper eyelid. The patient was able to
open her eyes 5 to 6 millimeters and reported that eye movement was extremely uncomfortable. The cranial nerves were grossly intact. The patient's pupillary reflexes were normal, but the vision in her left eye was impaired. Dental radiographs, including a panoramic film and periapical radiographs, revealed a clouded left sinus and gross dental caries involving the upper left first and second molars. These teeth were extremely sensitive to percussion and palpation and were slightly mobile. We noted no appreciable intraoral swelling on examination. With the patient under local anesthesia, we removed the upper left first and second molars, and drained a copious amount of exudate from the extraction socket of the upper left first molar. The patient was then admitted to the hospital and placed on 2 million units of intravenous penicillinG potassium. Cultures were sent to the microbiology lab for gram-stain testing, culture and sensitivity. On examination eight hours later, the patient's condition appeared to be worsening: a marked increase in periorbital swelling, a further decrease in her vision, a loss of her ability to move her left eye. Her pupils JADA, Vol. 126, April 1995 469
CLINICAL PRACTICE remained reactive, and examination of the retina was unremarkable. Gram-stain testing revealed gram-positive cocci, gram-positive rods and gramnegative rods. We ordered computed tomography scans of the sinuses and orbits, and on consultation with the ophthalmology service, we placed the patient on intravenous gentamicin sulfate and nafcillin sodium. The CT scans revealed extensive disease of the left sinus, 9 mm of displacement of the left eye from its normal position, and the presence of an abscess along the medial surface of the left eye. Twenty-four hours after admission, the patient underwent removal of the left ethmoid sinus and exploration of the left orbit under general anesthesia. Exudate was encountered in the sinuses and the left medial orbital space; it was sent to microbiology for culture and sensitivity testing. Two surgical drains were placed to promote further drainage. The patient's condition did not improve immediately, and extrusion of the eye worsened over the following 24 hours. A repeat CT scan of the sinuses and orbits revealed an increase in forward displacement of the eye from 9 mm to 12 mm and the appearance of an abscess lateral to the left eye. In addition, the forward displacement of the eye by the abscess began to cause a thinning of the optic nerve. Forty-eight hours after the patient's admission, we performed a second surgical exploration of the eye and placed additional surgical drains to encourage further drainage. The exudate cultures revealed Streptococcus viridans, mixed anaerobic flora, He470 JADA, Vol. 126, April 1995
mophilus species and Neisseria species. The patient improved significantly after the second surgery and after being placed on an intravenous regimen of a sulbactam/ampicillin combination (Unasyn, Roerig), gentamicin sulfate and clindamycin phosphate. The surgical drains were removed four days later, after the patient's condition showed marked improvement. The patient was discharged 11 days after admission and received follow-up care through the dental, ophthalmological and otolaryngology clinics as an outpatient. At the time of discharge, the patient's tem-
visits, redness and swelling of the conjunctiva had decreased and vision had increased. Furthermore, the intraoral drainage site was well-healed with no apparent signs of infection in the left maxillary sinus. Three months after discharge the patient's visual acuity improved to 20/15 in the left eye, although she still had notable drooping of the eyelid and double vision when looking to the right. Her eye movements were normal,
perature was normal, and her vision and ability to move her left eye had greatly improvFigure 1. The p atient's appearance 12 hours after ed. By subseher admission tto the hospital. Note the significant quent follow-up periorbital and preseptal swelling of the left orbit.
Figure 2. Periapical radiograph of the upper left maxilla revealing dental caries in the first and second maxillary molars.
-CLINICAL PRACTICE-
Figure 3. CT scan taken on the third day after admission. Note the 12mm displacement of the left eyeball and the involvement of the periorbital sinuses (radiodense pattems in the left sinus are surgical packing).
orbital abscess. Early diagnosis and treatment is demanded due to the unique architecture and the potential for significant morbidity and even
mortality. Allan and colleagues6 reported that while 70 perFigure 4. Photograph of the patient tthree months after discharge. Note the ptosis of ti ie left eyelid.
and she reported only occasional eye pain and fullness in her left sinus. DISCUSSION
The "closed-box" anatomy of the orbit and surrounding structures predisposes these tissues to serious sequelae when infection spreads to the area. The lack of lymphatic drainage and numerous soft-tissue spaces potentiate the establishment and extension of preseptal and peri-
cent to 80 percent of orbital
infections develop as a complication of infection of the paranasal sinuses, 30 percent are spread from the eyelids, tonsils, middle ear or dento- or intra-alveolar areas or via the lymphatic and vascular channels. Although orbital space infections are a relatively rare sequela of dentoalveolar infections, such cases have been reported. Bullock and Fleishman' reported four cases of the spread of odontogenic infections to the eye, one of
which ended in death from subdural empyema. All four patients had undergone extraction of a maxillary molar with intervals between extraction and the development of orbital symptoms ranging from two hours to 13 days. All patients had an elevated temperature and elevated leukocyte counts, as well as radiologic evidence of paranasal sinus infection. In our case, the patient did not undergo an extraction before the onset of orbital swelling. She had been treated with a dental amalgam on tooth no. 14, and her periapical and sinus symptoms were not addressed. As with the cases described by Bullock and Fleishman,' our patient's leukocyte count and temperature were elevated, and we detected radiologic evidence of sinus infection. Dentoalveolar abscesses may spread via direct extension from the maxillary and ethmoid sinuses, hematogenously or more superficially by way of the facial spaces. Often, aerobic and anaerobic oral flora and upper respiratory tract flora are isolated in cultures from orbital space abscesses.'-4 True orbital space abscesses often will affect the extraocular muscles, thus influencing extraocular eye movements, and significant retrobulbar abscesses will result in proptosis, or extrusion of the eye, and a narrowing in diameter of the optic nerve. If the infection continues to spread along the optic nerve or the ophthalmic vein, abscesses may form in the brain. The signs of orbital infection include swelling, chemosis (conjunctival edema) and, often, limitation of extraocular movements.23 Displacement of the eyeball and decreasing visual JADA, Vol. 126, April 1995 471
CUINICAL PRACTICE acuity signal the formation of periorbital and retrobulbar space abscesses. These symptoms and involvement of the contralateral eye (loss of visual acuity) are characteristic of cavernous sinus thrombosis. Cavernous sinus thrombosis, cerebral abscess, meningitis and blindness are rare, but potential, complications in the extension of peniorbital abscesses.2w Once recognized, orbital space abscesses require aggressive treatment. Appropriate antibiotic therapy includes multiple drug regimens to ensure adequate coverage. Bullock and Fleishman2 recommend including a penicillinase-resistant penicillin in the regimen. Intravenous antibiotic therapy using nafcillin
Dr. Miller Is an a_ssitant
CONCLUSION
clincalrprofesor
and director, General
Practice Rsesdency Program, Unbverait of Colorado, School of Dentity, 4200
Eat 9th Avenue, Box No.
C284, Denver
8022. Address repnrit requests to Dr. MNier.
sodium, oxacillin sodium, gentamicin sulfate, vancomycin hydrochloride or cindamycin phosphate is indicated based on gram-stain testing and the suspected etiology of the abscess. Antibiotic therapy alone may not be sufficient in managing orbital space abscesses. Surgical drainage often is indicated to prevent or minimize sequelae. In cases of dentoalveolar abscess extension, the removal of the abscessed tooth or teeth is indicated, with the establishment of adequate intraoral drainage whenever possible. Janakarajah and Sukumaran7 report that if surgical intervention is late or inadequate, the abscess may spread to the cavernous sinus or meninges. Relapse reportedly can occur even several days after apparent resolution with initial antibiotic therapy,2 underscoring the importance of follow-up care and antibiotic therapy.
Dr. Kassebaum Is an
eprofessor and chair, Oral Diagnoals, Oral Medicine and Oral Radiology, Unhvelty of Colorado, School of Detiby, Denver.
472 JADA, Vol. 126, April 1995
This case demonstrates the potential morbidity associated with maxillary dentoalveolar infections, and the need for early diagnosis and institution of multidisciplinary management, involving dentists, ophthal-
mologists, otolaryngologists and oral and maxillofacial surgeons, using aggressive treatment once an orbital space abscess is recognized. It also establishes the importance of the assessment of orbital signs in patients with periorbital swelling, and demonstrates the close anatomic relationship between the oral cavity, sinuses and orbits. . The opinions expressed or implied are strictly those of the authors and do not necessarily reflect the opinion or official policies of the American Dental Association or its subsidiaries. 1. Topazian RG, Goldberg MH. Oral and maxillofacial infections. 2nd ed. Philadelphia: Saunders; 1987. 2. Bullock JD, Fleishman JA. The spread of odontogenic infections to the orbit: diagnosis and management. J Oral Maxillofac Surg 1985;43(10):749-55. 3. Krohel GB, Krauss HR, Winnick J. Orbital abscess: diagnosis, therapy and sequelae. Ophthalmology 1982;89(5):492-8. 4. Schramm VL Jr., Curtin HD, Kennerdell JS. Evaluation of orbital cellulitis and results of treatment. Laryngoscope 1982;92(7 Pt 1):732-8. 5. DelBalso AM. Maxillofacial imaging. Philadelphia: Saunders; 1990. 6. Allan BP, Egbert MA, Myall RW. Orbital abscess of odontogenic origin. Case report and review of the literature. Int J Oral Maxillofac Surg 1991;20(5):268-70. 7. Janakarajah N, Sukumaran K Orbital cellulitis of dental origin: case report and review of the literature. Br J Oral Maxillofac Surg 1985;23(2):140-5. 8. Limongelli WA, Clark MS, Williams AC. Panfacial cellulitis with contralateral orbital cellulitis and blindness after tooth extraction. J Oral Surg 1977;35(1):38-43.
CASE REPORT
MANAGING PERIORBITAL SPACE ABSCESS
SECO NDARY TO DENTOALVEO LAR ABSCESS ERIC H. MILLER, D.D.S.; DENISE K. KASSEBAUM, D.D.S., M.S.
Q xtension of dental infections to the orbital spaces and tissues surrounding the eye presents a serious problem with the potential for causing significant impairment. Damage to neurovascular, muscular and soft tissues often results in permanent sequelae such as loss of vision, restricted eye movement and drooping eyelids. Abscesses that extend to the posterior orbital space can even be lifethreatening, as the infection may spread through the optic canal and ophthalmic veins to
the meninges and brain.1`7 Early detection and aggressive management of dentoalveolar infections both are critical in preventing subsequent orbital space abscesses. This article reports a case of an orbital space abscess resulting from the spread of an acute dentoalveolar abscess. CASE REPORT
A 21-year-old woman sought treatment at a hospital emergency room complaining of facial pain and swelling on the left side, which had begun two days earlier. Over the previous week, she had developed dental pain involving the left maxilla and had seen a dentist 24 hours before coming to the emergency room. At that time, the dentist removed decay from the mesial
Although orbital space Infections are a relatively rare sequela of
dentoalveolar infections, such cases have been reported. This case report describes the
management of an abscess
Involving the left eye that originated as a dental abscess.
surface of the upper left first molar and placed an amalgam restoration. The distal surface of the first molar, upper left second molar and third molar were not addressed. The patient reported no other information about her medical history that would have contributed to this condition. The patient had a temperature of 100.7 F. Her pulse was slightly elevated at 80 beats/minute; her other vital signs were within normal limits. With the exception of significant redness around the left eye and swelling involving the left orbit and left canine space, the patient's head appeared normal with no signs of trauma. The swelling was firm and warm to the touch with marked edema involving the upper eyelid. The patient was able to
open her eyes 5 to 6 millimeters and reported that eye movement was extremely uncomfortable. The cranial nerves were grossly intact. The patient's pupillary reflexes were normal, but the vision in her left eye was impaired. Dental radiographs, including a panoramic film and periapical radiographs, revealed a clouded left sinus and gross dental caries involving the upper left first and second molars. These teeth were extremely sensitive to percussion and palpation and were slightly mobile. We noted no appreciable intraoral swelling on examination. With the patient under local anesthesia, we removed the upper left first and second molars, and drained a copious amount of exudate from the extraction socket of the upper left first molar. The patient was then admitted to the hospital and placed on 2 million units of intravenous penicillinG potassium. Cultures were sent to the microbiology lab for gram-stain testing, culture and sensitivity. On examination eight hours later, the patient's condition appeared to be worsening: a marked increase in periorbital swelling, a further decrease in her vision, a loss of her ability to move her left eye. Her pupils JADA, Vol. 126, April 1995 469
CLINICAL PRACTICE remained reactive, and examination of the retina was unremarkable. Gram-stain testing revealed gram-positive cocci, gram-positive rods and gramnegative rods. We ordered computed tomography scans of the sinuses and orbits, and on consultation with the ophthalmology service, we placed the patient on intravenous gentamicin sulfate and nafcillin sodium. The CT scans revealed extensive disease of the left sinus, 9 mm of displacement of the left eye from its normal position, and the presence of an abscess along the medial surface of the left eye. Twenty-four hours after admission, the patient underwent removal of the left ethmoid sinus and exploration of the left orbit under general anesthesia. Exudate was encountered in the sinuses and the left medial orbital space; it was sent to microbiology for culture and sensitivity testing. Two surgical drains were placed to promote further drainage. The patient's condition did not improve immediately, and extrusion of the eye worsened over the following 24 hours. A repeat CT scan of the sinuses and orbits revealed an increase in forward displacement of the eye from 9 mm to 12 mm and the appearance of an abscess lateral to the left eye. In addition, the forward displacement of the eye by the abscess began to cause a thinning of the optic nerve. Forty-eight hours after the patient's admission, we performed a second surgical exploration of the eye and placed additional surgical drains to encourage further drainage. The exudate cultures revealed Streptococcus viridans, mixed anaerobic flora, He470 JADA, Vol. 126, April 1995
mophilus species and Neisseria species. The patient improved significantly after the second surgery and after being placed on an intravenous regimen of a sulbactam/ampicillin combination (Unasyn, Roerig), gentamicin sulfate and clindamycin phosphate. The surgical drains were removed four days later, after the patient's condition showed marked improvement. The patient was discharged 11 days after admission and received follow-up care through the dental, ophthalmological and otolaryngology clinics as an outpatient. At the time of discharge, the patient's tem-
visits, redness and swelling of the conjunctiva had decreased and vision had increased. Furthermore, the intraoral drainage site was well-healed with no apparent signs of infection in the left maxillary sinus. Three months after discharge the patient's visual acuity improved to 20/15 in the left eye, although she still had notable drooping of the eyelid and double vision when looking to the right. Her eye movements were normal,
perature was normal, and her vision and ability to move her left eye had greatly improvFigure 1. The p atient's appearance 12 hours after ed. By subseher admission tto the hospital. Note the significant quent follow-up periorbital and preseptal swelling of the left orbit.
Figure 2. Periapical radiograph of the upper left maxilla revealing dental caries in the first and second maxillary molars.
-CLINICAL PRACTICE-
Figure 3. CT scan taken on the third day after admission. Note the 12mm displacement of the left eyeball and the involvement of the periorbital sinuses (radiodense pattems in the left sinus are surgical packing).
orbital abscess. Early diagnosis and treatment is demanded due to the unique architecture and the potential for significant morbidity and even
mortality. Allan and colleagues6 reported that while 70 perFigure 4. Photograph of the patient tthree months after discharge. Note the ptosis of ti ie left eyelid.
and she reported only occasional eye pain and fullness in her left sinus. DISCUSSION
The "closed-box" anatomy of the orbit and surrounding structures predisposes these tissues to serious sequelae when infection spreads to the area. The lack of lymphatic drainage and numerous soft-tissue spaces potentiate the establishment and extension of preseptal and peri-
cent to 80 percent of orbital
infections develop as a complication of infection of the paranasal sinuses, 30 percent are spread from the eyelids, tonsils, middle ear or dento- or intra-alveolar areas or via the lymphatic and vascular channels. Although orbital space infections are a relatively rare sequela of dentoalveolar infections, such cases have been reported. Bullock and Fleishman' reported four cases of the spread of odontogenic infections to the eye, one of
which ended in death from subdural empyema. All four patients had undergone extraction of a maxillary molar with intervals between extraction and the development of orbital symptoms ranging from two hours to 13 days. All patients had an elevated temperature and elevated leukocyte counts, as well as radiologic evidence of paranasal sinus infection. In our case, the patient did not undergo an extraction before the onset of orbital swelling. She had been treated with a dental amalgam on tooth no. 14, and her periapical and sinus symptoms were not addressed. As with the cases described by Bullock and Fleishman,' our patient's leukocyte count and temperature were elevated, and we detected radiologic evidence of sinus infection. Dentoalveolar abscesses may spread via direct extension from the maxillary and ethmoid sinuses, hematogenously or more superficially by way of the facial spaces. Often, aerobic and anaerobic oral flora and upper respiratory tract flora are isolated in cultures from orbital space abscesses.'-4 True orbital space abscesses often will affect the extraocular muscles, thus influencing extraocular eye movements, and significant retrobulbar abscesses will result in proptosis, or extrusion of the eye, and a narrowing in diameter of the optic nerve. If the infection continues to spread along the optic nerve or the ophthalmic vein, abscesses may form in the brain. The signs of orbital infection include swelling, chemosis (conjunctival edema) and, often, limitation of extraocular movements.23 Displacement of the eyeball and decreasing visual JADA, Vol. 126, April 1995 471
CUINICAL PRACTICE acuity signal the formation of periorbital and retrobulbar space abscesses. These symptoms and involvement of the contralateral eye (loss of visual acuity) are characteristic of cavernous sinus thrombosis. Cavernous sinus thrombosis, cerebral abscess, meningitis and blindness are rare, but potential, complications in the extension of peniorbital abscesses.2w Once recognized, orbital space abscesses require aggressive treatment. Appropriate antibiotic therapy includes multiple drug regimens to ensure adequate coverage. Bullock and Fleishman2 recommend including a penicillinase-resistant penicillin in the regimen. Intravenous antibiotic therapy using nafcillin
Dr. Miller Is an a_ssitant
CONCLUSION
clincalrprofesor
and director, General
Practice Rsesdency Program, Unbverait of Colorado, School of Dentity, 4200
Eat 9th Avenue, Box No.
C284, Denver
8022. Address repnrit requests to Dr. MNier.
sodium, oxacillin sodium, gentamicin sulfate, vancomycin hydrochloride or cindamycin phosphate is indicated based on gram-stain testing and the suspected etiology of the abscess. Antibiotic therapy alone may not be sufficient in managing orbital space abscesses. Surgical drainage often is indicated to prevent or minimize sequelae. In cases of dentoalveolar abscess extension, the removal of the abscessed tooth or teeth is indicated, with the establishment of adequate intraoral drainage whenever possible. Janakarajah and Sukumaran7 report that if surgical intervention is late or inadequate, the abscess may spread to the cavernous sinus or meninges. Relapse reportedly can occur even several days after apparent resolution with initial antibiotic therapy,2 underscoring the importance of follow-up care and antibiotic therapy.
Dr. Kassebaum Is an
eprofessor and chair, Oral Diagnoals, Oral Medicine and Oral Radiology, Unhvelty of Colorado, School of Detiby, Denver.
472 JADA, Vol. 126, April 1995
This case demonstrates the potential morbidity associated with maxillary dentoalveolar infections, and the need for early diagnosis and institution of multidisciplinary management, involving dentists, ophthal-
mologists, otolaryngologists and oral and maxillofacial surgeons, using aggressive treatment once an orbital space abscess is recognized. It also establishes the importance of the assessment of orbital signs in patients with periorbital swelling, and demonstrates the close anatomic relationship between the oral cavity, sinuses and orbits. . The opinions expressed or implied are strictly those of the authors and do not necessarily reflect the opinion or official policies of the American Dental Association or its subsidiaries. 1. Topazian RG, Goldberg MH. Oral and maxillofacial infections. 2nd ed. Philadelphia: Saunders; 1987. 2. Bullock JD, Fleishman JA. The spread of odontogenic infections to the orbit: diagnosis and management. J Oral Maxillofac Surg 1985;43(10):749-55. 3. Krohel GB, Krauss HR, Winnick J. Orbital abscess: diagnosis, therapy and sequelae. Ophthalmology 1982;89(5):492-8. 4. Schramm VL Jr., Curtin HD, Kennerdell JS. Evaluation of orbital cellulitis and results of treatment. Laryngoscope 1982;92(7 Pt 1):732-8. 5. DelBalso AM. Maxillofacial imaging. Philadelphia: Saunders; 1990. 6. Allan BP, Egbert MA, Myall RW. Orbital abscess of odontogenic origin. Case report and review of the literature. Int J Oral Maxillofac Surg 1991;20(5):268-70. 7. Janakarajah N, Sukumaran K Orbital cellulitis of dental origin: case report and review of the literature. Br J Oral Maxillofac Surg 1985;23(2):140-5. 8. Limongelli WA, Clark MS, Williams AC. Panfacial cellulitis with contralateral orbital cellulitis and blindness after tooth extraction. J Oral Surg 1977;35(1):38-43.