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Orbital cellulitis of dental origin: Case report and review of the literature
British Journal of Oral and Maxillofacial Surgery (1985) 23, 14S-145 0 1985 The British Association of Oral and Maxillofacial Surgeons
ORBITAL CELLULITIS
OF DENTAL ORIGIN: CASE REPORT AND REVIEW OF THE LITERATURE
N. JANAKARAJAH, M.D.s.,F.D.s.R.c.s.,”
andK.
SUKUMARAN, M.B., B.S., D.O.R.C.P.S.
Departments of Oral Surgery and Ophthalmology, Lumpur, Malaysia
University Hospital, Kuala
Summary.Orbital cellulitis is a rare condition. which usually develops as a complication of the infection of paranasal sinuses, namely ethmoidal, frontal and occasionally the maxillary sinuses. Maxillary sinusitis could result from dental infection. A case is presented illustrating how dental infection can proceed to maxillary sinusitis and orbital cellulitis. The clinical presentation and treatment are described. Possible complications are discussed.
Introduction Orbital cellulitis comprises diffuse oedema of the orbital contents with infiltration of the adipose tissue with inflammatory cells, and bacteria; however, there is no discrete abscess formation. It originates from neighbouring sinuses in 70-80 per cent of cases. In the adult, bacterial frontal sinusitis is the most frequent cause whereas in childhood, spread from ethmoidal sinuses is more common (Sorsby, 1963). Other causes include scarlet fever, trauma to neighbouring tissues, dental abscess, middle ear infections and intracranial infections. With the advent of antibiotics, there are now fewer cases than formerly, but orbital cellulitis is still due usually to infection of neighbouring para-nasal sinuses (Williamson, 1954). About 10 per cent of cases of maxillary sinusitis are of dental origin (Killey, 1975). Thus, it is important for oral and dental surgeons to be aware that infection originating from dental caries in the upper jaw can give rise to orbital cellulitis. Once this stage is reached, it can lead to orbital abscess, optic neuritis, cavernous sinus thrombosis, blindness and death (Jarrett, 1969). The aim of this paper is to present a case of orbital cellulitis of dental origin. Case Report A 14 year-old Indian boy was seen in the oral surgery clinic, with a history of four days’ swelling of the right side of the face following a toothache involving the upper right molar tooth. On examination, the patient was thin and undernourished, but was alert, well orientated and co-operative. The swelling around the eye was firm, tender and diffuse, extending to the right temporal and infra-orbital regions. The right eye was partially closed with severe restriction of ocular movements. The lower and upper eyelids were markedly oedematous (Figs. 1 and 2). The right submandibular lymph node was enlarged and tender. Tenderness of the right infra-orbital region was worse on bending the head down. There was slight trismus, erythema and swelling of the right cheek, upper lip and maxillary buccal sulcus, but ‘Reprint
requests
to N. Janakarajah, (Received
206. Rembrance
20 March
Road,
Willenhall.
1984; accepted 27 April
140
1984)
Coventry,
ORBITAL
~
P
Fig. Figure
l-Frontal
view.
141
CELLULITIS
.,a
Fig.
; Note
the brawny swelling, oedema and proptosis. showing prolapsed chemotic conjunctiva.
2 Figure
2-Lateral
view
no fluctuation. Oral hygiene was poor. All teeth were present except the third molars. 6/ was carious and tender to percussion. OrthoDantomograuh and occipitofintal radiographs revealed periabical radiolucency of the m&id-buccal root of 6/ and complete opacification of the right maxillary antrum (Figs. 3 and 4).
Fig. Figure
Fig. 4
3
3-Orthopantomograph Occipitomental
showing caries with view revealing the cloudy
periapical radiolucency. right maxillary antrum.
Figure
4-
142
BRITISH
JOURNAL
OF
ORAL
& MAXILLOFACIAL
SURGERY
He was referred to the Ophthalmologist who confirmed that the right upper and lower eye lids were moderately oedematous with brawny induration upon palpation. There was. marked proptosis, moderate conjunctival oedema and prolapse of the lateral portion of the chemotic conjunctiva. The right pupil was partially dilated and reacted sluggishly to light. The right fundus was normal and the cornea was bright. Ocular movements were severely restricted on the affected side with diplopia in right gaze. His vision was 619 corrected to 616 with pin hole. He was admitted to hospital with a diagnosis of right orbital cellulitis secondary to dento-alveolar abscess with maxillary sinusitis. On admission the temperature was 38.9”C and the white blood cell count was 12,000 per cu. mm. A course of Ampicillin 500 mg and Metronidazole 400 mg intravenously every six hours was started. On admission nasal decongestants (Ephedrine nasal drops 1 per cent) and Bacitracin eye oitnment were started as prophylaxis against exposure keratitis. Hot compresses were applied to the swollen orbit. On the following day, $1 was extracted under local anaesthesia. Copious amounts of pus drained from the maxillary antrum through the socket, which when cultured, grew coagulase-negative Staphylococcus albus sensitive to Ampicillin. Antral irrigation was performed daily via the communication. On the third day, the temperature dropped to 37.4”C and the swelling started to subside. The proptosis improved and there was less chemosis. The pupils were reactive on the fourth day and ocular movements returned on the fifth day. Visual acuity was normal by the seventh day. The left eye remained completely normal throughout this period. By the tenth day there was complete resolution of the infection. The systemic and local
Fig. 5 Figure
5-Patient
with
complete
Fig. 6 resolution. Figure 6-Follow up radiograph resolution of maxillary sinusitis.
showing
complete
ORBITAL
143
CELLULITIS
antibiotic therapy was discontinued and two days later, he was discharged home. Follow-up examinations two months later showed that the patient was fully recovered. (Figs. 5 and 6). There was no residual oro-antral communication. Discussion Though maxillary sinus infections are common, complications from these infections have greatly decreased since the advent of antibiotics. Orbital cellulitis due to bacterial infection of dental origin is a very rare condition. The bony orbit is in close relation with the frontal sinus superiorly, ethmoid sinus medially and the maxillary sinus inferiorly. These partitions are rather thin and do not provide an effective barrier against the spread of infection (Fig. 7). Congenital or other dehiscences in the bony walls of the orbit may expose the orbital contents to direct extension of sinus infections. The most likely and certainly the most common mechanism is due to interference with the venous drainage of the orbital contents (Chandler, 1970). The superior and inferior ophthalmic veins having no valves allow extensive two way communications between the face, nasal cavity, pterygoid region and sinuses. Both veins have communications with the cavernous sinus, the superior ophthalmic vein through the angular vein and the inferior ophthalmic vein
Fig. Figure
7-Diagramatic
representation
of path premolar
7
of spread of odontogenic and molars.
infection
from
maxillary
144
BRITISH
JOURNAL
OF
ORAL
&
MAXILLOFACIAL
SURGERY
through the pterygoid venous plexus. Thus dental infection may propagate through the orbit and can give rise to cavernous sinus thrombosis (Limongelli et al., 1977). Blindness may be another tragic sequel. This serious complication may occur in treated as well as in untreated patients (Gold, 1972). The loss of vision usually follows extreme congestion and oedema within the orbit together with proptosis of the eye due to obstruction of the blood flow through the retinal artery brought about by compression and constriction of this artery by external congestion and oedema (Donahue, 1946). Haymaker (1945) studied fatal intracranial complications from dental infections and concluded that direct spread was more often caused by maxillary than mandibular teeth whereas in haematogenous infection, the reverse was the case. Maxillary molar infection may spread laterally from the roots into the buccal sulcus or into the soft tissues of cheek depending on the level of attachment of buccinator muscle. Because of the close proximity of the teeth to the floor of the maxillary sinus, dental infection may produce maxillary sinusitis. In the series of acute orbital infections presented by Healy & Strong (1972), periorbital extension of infection from the maxillary sinus resulted from one patient’s failure to return for removal of an antral pack and in another from a silastic implant used to repair a previous ‘blowout’ fracture. From the maxillary sinus, it can spread along the venous system as periphlebitis or thrombophlebitis resulting in a purulent infection of the orbital tissues, or directly through the thin bone of the orbit. Dental sepsis may also spread backwards, into the pterygopalatine and infra-temporal fossae and then reach the orbit via the inferior orbital fissure (Kaban, 1980). Inflammatory cells and bacteria may infiltrate the orbit retrogradely and cause cellulitis (Chandler, et al., 1970; Goldberg, 1978). The diagnosis of orbital cellulitis and its sequelae is mainly clinical although radiographs and CT. Scan may be of diagnostic aid (Kaban & McGill, 1980). These conditions may be difficult to distinguish in their early stages, especially Table I
Orbital cellulitis of dental origin Onset
Orbital
Origin
Sides
affected
Signs and symptoms Limitation of extra ocular movement Additional features
cellulitis
Cavernous thrombosis
sinus
acute
orbital
fissure
gradual
acute
Infection from paranasal sinuses, eyelids, tonsils, middle ear and teeth, spread directly or by veins Unilateral
Infection spreading via ophthalmic, facial or pterygoid plexus of veins
Narrowing or compression of the fissure by cellulitis
Initially unilateral rapidly progressing bilaterally Oedema of eyelids, ptosis, proptosis and chemosis Due to involvement of III, IV & VI nerves Meningitis or meningeal irritation
Unilateral
Oedema of eyelids, ptosis, proptosis and chemosis Due to congestion or oedema May also present with optic neuritis, atrophy or blindness
and rapid
Superior, syndrome
and rapid
Motor and sensory changes of III, IV and VI nerves III. IV and VI nerve damage Optic nerve is consistently spared. Loss of cornea1 reflex
ORBITAL
CELLULITIS
145
where there is only unilateral involvement. Septic cavernous sinus thrombosis and superior orbital fissure syndrome should be considered in the differential diagnosis (Table I). Positive diagnosis may not be possible until after resolution of the acute process and even then may not be conclusive. A definitive diagnosis, however, is not essential for proper treatment, which consists of massive intravenous antibiotic therapy (Limongelli et al., 1977), but there are certain features that should be closely monitored. Failure of the temperature to drop steadily and rapidly to normal, decrease in visual acuity and any impairment in ocular mobility after the institution of treatment are definite indications for surgical intervention (Chandler et al., 1970). Duke-Elder (1952) has emphasised the difficulties of making the decision to operate and its proper timing. Surgery which is too hasty may spread a localised infection throughout the orbital tissues. If surgery is too late, infection may spread to the cavernous sinus or to the meninges, with disastrous results (Jarrett & Gutman, 1969). In their series, Welsh and Welsh (1974) observed that with advancing age, zmtibiotic therapy is less successful and must be supported with a surgical procedure such as frontal trephine or external ethmoidectomy in conjunction with drainage of any orbital abscess or intra nasal antrostomy in maxillary sinus involvement. Oral surgeons should understand the close anatomical relationship of the orbit and the adjacent structures to establish the early diagnosis and start vigorous treatment of this severe progressive and dangerous condition that can originate from dental infection to prevent the unfortunate complications described. Acknowledgements We are very grateful to Miss T. C. Yap for her secretarial preparing the illustrations.
assistance
and Encik Razali for his help in
References Chandler, .I. R. Langenbrunner, D. J. & Stevens, E. R. (1970). The pathogenesis of orbital complications in Acute Sinusitis. Laryngoscope, 80, 1414. Donahue, H. C. (1946). Orbital cellulitis followed by total blindness. American Journal of Ophthalmology, 29, 1574. Duke-Elder, S. (1952). Textbook of Ophthalmology 1st ed. St. Louis, C. V. Mosby Co.. 5428-5444. Gold, R. S. Br Strong, M. S. (1972). Acute periorbital swelling. Laryngoscope, 82, 1491. Goldberg, F. (1978). Differentiation of orbital cellulitis from preseptal cellulitis by computed tomography. Paediatrics, 62, 1000. Haymaker, W. (1945). Fatal infections of the central nervous system and meninges after tooth extractions. American Journal of Orthodontics, 31, 117. Healy. G. B. & Strong. M. S. (1972). Acute periorbital swelling. Laryngoscope, 82, 1491. Jarrett, W. H. & Gutman, F. A. (1969). Ocular complications of infections in the paranasal sinuses. Archives of Ophthalmology, 81, 6X3. Kaban, L. B. & McGill. T. (1980). Orbital cellulitis of dental origin: differential diagnosis and the use of computed tomography as a diagnostic aid. Journal of Oral Surgery, 38, 682. Killey, H. C. & Kay L. W. (1975). The maxillary sinus and its dental implications. 1st ed. Bristol. John Wright and Sons: 18-24. Limongelli, W. A., Clark, M. S. & Williams, A. C. (1977). Panfaciaicellulitis with contralateral orbital cellulitis and blindness after tooth extraction. Journal of Oral Surgery, 35, 38. Sorsby, A. (1963). Modern Ophthalmology. Vol. 2. London. Butterworth. 598-600. Welsh, L. W. 8r Welsh, J. J. (1974). Orbital complications of sinus disease. Laryngoscope, 84, 848. Williamson-Noble, F.A. (1954). Diseases of the orbit and its contents secondary to pathological conditions of the nose and paranasal sinuses. Annals of the Royal College of Surgeonsof England, 15, 46.
ORBITAL CELLULITIS
OF DENTAL ORIGIN: CASE REPORT AND REVIEW OF THE LITERATURE
N. JANAKARAJAH, M.D.s.,F.D.s.R.c.s.,”
andK.
SUKUMARAN, M.B., B.S., D.O.R.C.P.S.
Departments of Oral Surgery and Ophthalmology, Lumpur, Malaysia
University Hospital, Kuala
Summary.Orbital cellulitis is a rare condition. which usually develops as a complication of the infection of paranasal sinuses, namely ethmoidal, frontal and occasionally the maxillary sinuses. Maxillary sinusitis could result from dental infection. A case is presented illustrating how dental infection can proceed to maxillary sinusitis and orbital cellulitis. The clinical presentation and treatment are described. Possible complications are discussed.
Introduction Orbital cellulitis comprises diffuse oedema of the orbital contents with infiltration of the adipose tissue with inflammatory cells, and bacteria; however, there is no discrete abscess formation. It originates from neighbouring sinuses in 70-80 per cent of cases. In the adult, bacterial frontal sinusitis is the most frequent cause whereas in childhood, spread from ethmoidal sinuses is more common (Sorsby, 1963). Other causes include scarlet fever, trauma to neighbouring tissues, dental abscess, middle ear infections and intracranial infections. With the advent of antibiotics, there are now fewer cases than formerly, but orbital cellulitis is still due usually to infection of neighbouring para-nasal sinuses (Williamson, 1954). About 10 per cent of cases of maxillary sinusitis are of dental origin (Killey, 1975). Thus, it is important for oral and dental surgeons to be aware that infection originating from dental caries in the upper jaw can give rise to orbital cellulitis. Once this stage is reached, it can lead to orbital abscess, optic neuritis, cavernous sinus thrombosis, blindness and death (Jarrett, 1969). The aim of this paper is to present a case of orbital cellulitis of dental origin. Case Report A 14 year-old Indian boy was seen in the oral surgery clinic, with a history of four days’ swelling of the right side of the face following a toothache involving the upper right molar tooth. On examination, the patient was thin and undernourished, but was alert, well orientated and co-operative. The swelling around the eye was firm, tender and diffuse, extending to the right temporal and infra-orbital regions. The right eye was partially closed with severe restriction of ocular movements. The lower and upper eyelids were markedly oedematous (Figs. 1 and 2). The right submandibular lymph node was enlarged and tender. Tenderness of the right infra-orbital region was worse on bending the head down. There was slight trismus, erythema and swelling of the right cheek, upper lip and maxillary buccal sulcus, but ‘Reprint
requests
to N. Janakarajah, (Received
206. Rembrance
20 March
Road,
Willenhall.
1984; accepted 27 April
140
1984)
Coventry,
ORBITAL
~
P
Fig. Figure
l-Frontal
view.
141
CELLULITIS
.,a
Fig.
; Note
the brawny swelling, oedema and proptosis. showing prolapsed chemotic conjunctiva.
2 Figure
2-Lateral
view
no fluctuation. Oral hygiene was poor. All teeth were present except the third molars. 6/ was carious and tender to percussion. OrthoDantomograuh and occipitofintal radiographs revealed periabical radiolucency of the m&id-buccal root of 6/ and complete opacification of the right maxillary antrum (Figs. 3 and 4).
Fig. Figure
Fig. 4
3
3-Orthopantomograph Occipitomental
showing caries with view revealing the cloudy
periapical radiolucency. right maxillary antrum.
Figure
4-
142
BRITISH
JOURNAL
OF
ORAL
& MAXILLOFACIAL
SURGERY
He was referred to the Ophthalmologist who confirmed that the right upper and lower eye lids were moderately oedematous with brawny induration upon palpation. There was. marked proptosis, moderate conjunctival oedema and prolapse of the lateral portion of the chemotic conjunctiva. The right pupil was partially dilated and reacted sluggishly to light. The right fundus was normal and the cornea was bright. Ocular movements were severely restricted on the affected side with diplopia in right gaze. His vision was 619 corrected to 616 with pin hole. He was admitted to hospital with a diagnosis of right orbital cellulitis secondary to dento-alveolar abscess with maxillary sinusitis. On admission the temperature was 38.9”C and the white blood cell count was 12,000 per cu. mm. A course of Ampicillin 500 mg and Metronidazole 400 mg intravenously every six hours was started. On admission nasal decongestants (Ephedrine nasal drops 1 per cent) and Bacitracin eye oitnment were started as prophylaxis against exposure keratitis. Hot compresses were applied to the swollen orbit. On the following day, $1 was extracted under local anaesthesia. Copious amounts of pus drained from the maxillary antrum through the socket, which when cultured, grew coagulase-negative Staphylococcus albus sensitive to Ampicillin. Antral irrigation was performed daily via the communication. On the third day, the temperature dropped to 37.4”C and the swelling started to subside. The proptosis improved and there was less chemosis. The pupils were reactive on the fourth day and ocular movements returned on the fifth day. Visual acuity was normal by the seventh day. The left eye remained completely normal throughout this period. By the tenth day there was complete resolution of the infection. The systemic and local
Fig. 5 Figure
5-Patient
with
complete
Fig. 6 resolution. Figure 6-Follow up radiograph resolution of maxillary sinusitis.
showing
complete
ORBITAL
143
CELLULITIS
antibiotic therapy was discontinued and two days later, he was discharged home. Follow-up examinations two months later showed that the patient was fully recovered. (Figs. 5 and 6). There was no residual oro-antral communication. Discussion Though maxillary sinus infections are common, complications from these infections have greatly decreased since the advent of antibiotics. Orbital cellulitis due to bacterial infection of dental origin is a very rare condition. The bony orbit is in close relation with the frontal sinus superiorly, ethmoid sinus medially and the maxillary sinus inferiorly. These partitions are rather thin and do not provide an effective barrier against the spread of infection (Fig. 7). Congenital or other dehiscences in the bony walls of the orbit may expose the orbital contents to direct extension of sinus infections. The most likely and certainly the most common mechanism is due to interference with the venous drainage of the orbital contents (Chandler, 1970). The superior and inferior ophthalmic veins having no valves allow extensive two way communications between the face, nasal cavity, pterygoid region and sinuses. Both veins have communications with the cavernous sinus, the superior ophthalmic vein through the angular vein and the inferior ophthalmic vein
Fig. Figure
7-Diagramatic
representation
of path premolar
7
of spread of odontogenic and molars.
infection
from
maxillary
144
BRITISH
JOURNAL
OF
ORAL
&
MAXILLOFACIAL
SURGERY
through the pterygoid venous plexus. Thus dental infection may propagate through the orbit and can give rise to cavernous sinus thrombosis (Limongelli et al., 1977). Blindness may be another tragic sequel. This serious complication may occur in treated as well as in untreated patients (Gold, 1972). The loss of vision usually follows extreme congestion and oedema within the orbit together with proptosis of the eye due to obstruction of the blood flow through the retinal artery brought about by compression and constriction of this artery by external congestion and oedema (Donahue, 1946). Haymaker (1945) studied fatal intracranial complications from dental infections and concluded that direct spread was more often caused by maxillary than mandibular teeth whereas in haematogenous infection, the reverse was the case. Maxillary molar infection may spread laterally from the roots into the buccal sulcus or into the soft tissues of cheek depending on the level of attachment of buccinator muscle. Because of the close proximity of the teeth to the floor of the maxillary sinus, dental infection may produce maxillary sinusitis. In the series of acute orbital infections presented by Healy & Strong (1972), periorbital extension of infection from the maxillary sinus resulted from one patient’s failure to return for removal of an antral pack and in another from a silastic implant used to repair a previous ‘blowout’ fracture. From the maxillary sinus, it can spread along the venous system as periphlebitis or thrombophlebitis resulting in a purulent infection of the orbital tissues, or directly through the thin bone of the orbit. Dental sepsis may also spread backwards, into the pterygopalatine and infra-temporal fossae and then reach the orbit via the inferior orbital fissure (Kaban, 1980). Inflammatory cells and bacteria may infiltrate the orbit retrogradely and cause cellulitis (Chandler, et al., 1970; Goldberg, 1978). The diagnosis of orbital cellulitis and its sequelae is mainly clinical although radiographs and CT. Scan may be of diagnostic aid (Kaban & McGill, 1980). These conditions may be difficult to distinguish in their early stages, especially Table I
Orbital cellulitis of dental origin Onset
Orbital
Origin
Sides
affected
Signs and symptoms Limitation of extra ocular movement Additional features
cellulitis
Cavernous thrombosis
sinus
acute
orbital
fissure
gradual
acute
Infection from paranasal sinuses, eyelids, tonsils, middle ear and teeth, spread directly or by veins Unilateral
Infection spreading via ophthalmic, facial or pterygoid plexus of veins
Narrowing or compression of the fissure by cellulitis
Initially unilateral rapidly progressing bilaterally Oedema of eyelids, ptosis, proptosis and chemosis Due to involvement of III, IV & VI nerves Meningitis or meningeal irritation
Unilateral
Oedema of eyelids, ptosis, proptosis and chemosis Due to congestion or oedema May also present with optic neuritis, atrophy or blindness
and rapid
Superior, syndrome
and rapid
Motor and sensory changes of III, IV and VI nerves III. IV and VI nerve damage Optic nerve is consistently spared. Loss of cornea1 reflex
ORBITAL
CELLULITIS
145
where there is only unilateral involvement. Septic cavernous sinus thrombosis and superior orbital fissure syndrome should be considered in the differential diagnosis (Table I). Positive diagnosis may not be possible until after resolution of the acute process and even then may not be conclusive. A definitive diagnosis, however, is not essential for proper treatment, which consists of massive intravenous antibiotic therapy (Limongelli et al., 1977), but there are certain features that should be closely monitored. Failure of the temperature to drop steadily and rapidly to normal, decrease in visual acuity and any impairment in ocular mobility after the institution of treatment are definite indications for surgical intervention (Chandler et al., 1970). Duke-Elder (1952) has emphasised the difficulties of making the decision to operate and its proper timing. Surgery which is too hasty may spread a localised infection throughout the orbital tissues. If surgery is too late, infection may spread to the cavernous sinus or to the meninges, with disastrous results (Jarrett & Gutman, 1969). In their series, Welsh and Welsh (1974) observed that with advancing age, zmtibiotic therapy is less successful and must be supported with a surgical procedure such as frontal trephine or external ethmoidectomy in conjunction with drainage of any orbital abscess or intra nasal antrostomy in maxillary sinus involvement. Oral surgeons should understand the close anatomical relationship of the orbit and the adjacent structures to establish the early diagnosis and start vigorous treatment of this severe progressive and dangerous condition that can originate from dental infection to prevent the unfortunate complications described. Acknowledgements We are very grateful to Miss T. C. Yap for her secretarial preparing the illustrations.
assistance
and Encik Razali for his help in
References Chandler, .I. R. Langenbrunner, D. J. & Stevens, E. R. (1970). The pathogenesis of orbital complications in Acute Sinusitis. Laryngoscope, 80, 1414. Donahue, H. C. (1946). Orbital cellulitis followed by total blindness. American Journal of Ophthalmology, 29, 1574. Duke-Elder, S. (1952). Textbook of Ophthalmology 1st ed. St. Louis, C. V. Mosby Co.. 5428-5444. Gold, R. S. Br Strong, M. S. (1972). Acute periorbital swelling. Laryngoscope, 82, 1491. Goldberg, F. (1978). Differentiation of orbital cellulitis from preseptal cellulitis by computed tomography. Paediatrics, 62, 1000. Haymaker, W. (1945). Fatal infections of the central nervous system and meninges after tooth extractions. American Journal of Orthodontics, 31, 117. Healy. G. B. & Strong. M. S. (1972). Acute periorbital swelling. Laryngoscope, 82, 1491. Jarrett, W. H. & Gutman, F. A. (1969). Ocular complications of infections in the paranasal sinuses. Archives of Ophthalmology, 81, 6X3. Kaban, L. B. & McGill. T. (1980). Orbital cellulitis of dental origin: differential diagnosis and the use of computed tomography as a diagnostic aid. Journal of Oral Surgery, 38, 682. Killey, H. C. & Kay L. W. (1975). The maxillary sinus and its dental implications. 1st ed. Bristol. John Wright and Sons: 18-24. Limongelli, W. A., Clark, M. S. & Williams, A. C. (1977). Panfaciaicellulitis with contralateral orbital cellulitis and blindness after tooth extraction. Journal of Oral Surgery, 35, 38. Sorsby, A. (1963). Modern Ophthalmology. Vol. 2. London. Butterworth. 598-600. Welsh, L. W. 8r Welsh, J. J. (1974). Orbital complications of sinus disease. Laryngoscope, 84, 848. Williamson-Noble, F.A. (1954). Diseases of the orbit and its contents secondary to pathological conditions of the nose and paranasal sinuses. Annals of the Royal College of Surgeonsof England, 15, 46.