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Recurrent periorbital cellulitis in a child
International Journal of Pediatric Otorhinolaryngology (2004) 68, 1529—1532
www.elsevier.com/locate/ijporl
CASE REPORT
Recurrent periorbital cellulitis in a child A random event or an underlying anatomical abnormality? P.D. Karkosa,1, Y. Karagamaa, A. Karkanevatosb, V. Srinivasanb,* a
Department of Otolaryngology, The Freeman Hospital, Newcastle Upon Tyne, UK Arrowe Park Hospital, Upton, Wirral CH49 5PE, UK
b
Received 4 February 2004; received in revised form 11 June 2004; accepted 25 June 2004
KEYWORDS Periorbital cellulites; Recurrent; Child; Ethmoidal sinuses; Rhinosinusitis
Summary We present a case of recurrent periorbital cellulitis in a child. From the age of 2 years the child was admitted with periorbital cellulitis a total of six times with the first five episodes responding to conservative management with intravenous antibiotics. On the sixth admission endoscopic surgical treatment was carried out. Two abnormalities were noted: an anatomically abnormal uncinate process and an isolated abscess in an ethmoidal cell. It is believed that the abnormal uncinate process caused obstruction of the osteomeatal area, predisposing to recurrent periorbital cellulitis. We discuss the importance of early imaging and surgery in recurrent periorbital cellulitis. # 2004 Elsevier Ireland Ltd. All rights reserved.
1. Case report A 5-year-old girl presented to the pediatric department with a spontaneous recurrent left periorbital swelling (6 times) since the age of 2 years. The first episode was following a cold. On each of the occasions the clinical examination of the eye was unremarkable with the visual acuity, visual fields and red reflexes all being normal. Although the nose was * Corresponding author. E-mail addresses: [email protected] (P.D. Karkos), [email protected] (V. Srinivasan). 1 Present address: 3 Douglas Court, Walnut Str. Residences, Walnut Str., Leicester, LE27GJ Wirral, UK.
noted to be crusty, no tenderness or erythema was noted over the frontal, ethmoid and maxillary sinuses. On all occasions the patient was treated by the pediatricians with intravenous antibiotics and intranasal ephedrine drops and the swelling and temperature resolved within 48 h. An ENT opinion was not sought during any of these previous episodes. Three years following the first admission, the patient developed another episode of left periorbital swelling (Fig. 1) with swinging pyrexia. This time an ENT opinion was sought soon after the admission because of the acute presentation and progression of her symptoms and signs. The patient was commenced on intravenous antibiotics and intranasal ephedrine drops. Forty-eight hours later,
0165-5876/$ — see front matter # 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2004.06.013
1530
P.D. Karkos et al.
resolved almost completely after 24 h (Fig. 3) during which time the patient became apyrexial. She was discharged home 48 h postoperatively. Culture of the pus from the ethmoidal abscess did not grow any pathogens. The child has been followed up regularly since the operation and at 18 months she has been asymptomatic, without getting any further attacks of peri-orbital cellulitis.
2. Discussion
Fig. 1
Marked left periorbital swelling.
the child was still pyrexial and the swelling was not improving and, therefore CT Scan of the paranasal sinuses was requested. The scan showed extensive anterior and posterior ethmoid sinusitis with subperiosteal cellulitis on the left side displacing the rectus muscle laterally but with no infiltration of the peri-orbital fat (Fig. 2). It was decided to explore the ethmoid surgically in case a sub-perisoteal abscess was forming. During informed consent it was explained to the parents that surgery would be undertaken by the endoscopic route but if necessary, an external approach would also be used. During endoscopic sinus surgery two abnormalities were seen. The uncinate process was abnormally long and curved causing osteomeatal complex obstruction. There was a well-circumscribed nonpulsatile sac-like structure in one of the anterior ethmoidal air cells. On its incision a large amount of pus was released. Uncinectomy, middle meatal antrostomy and anterior ethmoidectomy were performed endoscopically. The lamina papyracea was removed but no pus was found in the sub-periosteal plane. No congenital perforation of the lamina papyracea was identified. The periorbital cellulitis
In this case report there are three important focusing points: firstly, the recurrent nature of the periorbital cellulitis, secondly, the age of the patient (a child) and finally, the unusual findings at surgery. Rhinosinusitis in children is rarely a surgical disease and ‘‘watchful waiting’’ is usually recommended. There are two exceptions to this rule: nasal polyps, with a possibility of cystic fibrosis and periorbital cellulitis [2]. What we found intraoperatively was an isolated cell with pus collection which might have been the predisposing trigger factor for the periorbital cellulitis. Acute infection of the paranasal sinuses is a rather frequent pathology in children. On the contrary, local orbital complications are rare [4]. Kanra et al. [3] reviewed 69 children with periorbital cellulitis and found that sinusitis was the most important cause in 43% of cases. Other causes were trauma, odontogenic infection, external ocular infection and local skin inflammations. The terms perioorbital and orbital cellulitis are often used interchangeably, obscuring important differences in their pathogenesis, aetiology and appropriate treatment [6]. Periorbital cellulitis is a process limited to the eyelids in the preseptal region and has a good prognosis under appropriate antibiotic therapy. It is important to distinguish this disease from the less common orbital (retroseptal) cellulitis, a potentially lethal process involving the contents of the orbit and associated with marked proptosis and opthalmoplegia [1]. Early opthalmological assessment, parenteral antibiotics and CT scanning of the paranasal sinuses-orbit with drainage of any pus are indicated if there is suspicion, clinical or radiological, of orbital involvement. This child had been having recurrent episodes of preseptal cellulitis from the age of 2 years, which were responding to antibiotics until the last episode. Although periorbital cellulitis secondary to ethmoiditis in a child has been described before [5], recurrent nature of such a complication of rhinosinusitis in a child has not been reported so
Recurrent periorbital cellulitis in a child
1531
Fig. 2 Extensive anterior and posterior ethmoid sinusitis with sub-periosteal flegmun/abscess formation on the left displacing the rectus muscle laterally but with no infiltration of the peri-orbital fat.
far. We cannot be sure about the cause of this recurrence, but we believe it is most likely due to the anatomical abnormality of the uncinate process. The abnormal uncinate process has probably acted as a triggering factor as it can compromise the muco-ciliary drainage mechanism at the osteo-
Fig. 3
meatal area, especially during acute inflammatory events, such as rhinitis. This has perhaps led to the development of an isolated pyocoele in the ethmoidal air cell system. It is probably the combination of the abnormal uncinate process and the activation of the ethmoidal pyocole that have led to the development of peri-orbital cellulitis on a recurrent
Postoperative improvement.
1532
basis. Once these triggering factors were removed by surgery, there was no further recurrence of the infective complication. This case report highlights the fact that the surgeon should think of underlying anatomical abnormalities in the osteo-meatal complex area in cases of recurrent peri-orbital cellulitis. Surgical intervention should also be considered in such recurrent cases, though the timing of the surgery can be debatable. It would be preferable to operate electively, in between attacks of periorbital cellulits, provided the orbital complication responds to medical treatment. In our case, we had to undertake surgery during an attack of periorbital cellulitis, because there was no significant improvement even after a reasonable period of intravenous antibiotics.
P.D. Karkos et al.
References [1] K. Jackson, S.R. Baker, Periorbital cellulitis, Head Neck Surg. 9 (4) (1987) 227—234. [2] N.S. Jones, Current concepts in the management of paediatric rhinosinusitis, J. Laryngol. Otol. 113 (1) (1999) 1—9. [3] G. Kanra, G. Secmeer, E.N. Gone, M. Ceyhan, Z. Ecevit, Periorbital cellulitis: a comparison of different treatment regimes, Acta Paediatr. Jpn. 38 (4) (1996) 339—342. [4] M. Magnano, V. Ferrero, B. Morra, M. Bussi, Orbital and endocranial complications in acute sinusitis in childhood, Acta Otorhinolaryngol. Ital. 12 (6) (1992) 565—573. [5] A. Murray, L. Albanasawy, M.S. Morrisey, Periorbital cellulitis secondary to ethmoiditis in a 5-week-old child, Int. J. Pediatr. Otorhinolaryngol. 52 (1) (2000) 101—103. [6] E.D. Shapiro, E.R. Walker, B.A. Brozanski, Periorbital cellulitis and paranasal sinusitis: a reappraisal, Pediatr. Infect. Dis. 1 (2) (1982) 91—94.
www.elsevier.com/locate/ijporl
CASE REPORT
Recurrent periorbital cellulitis in a child A random event or an underlying anatomical abnormality? P.D. Karkosa,1, Y. Karagamaa, A. Karkanevatosb, V. Srinivasanb,* a
Department of Otolaryngology, The Freeman Hospital, Newcastle Upon Tyne, UK Arrowe Park Hospital, Upton, Wirral CH49 5PE, UK
b
Received 4 February 2004; received in revised form 11 June 2004; accepted 25 June 2004
KEYWORDS Periorbital cellulites; Recurrent; Child; Ethmoidal sinuses; Rhinosinusitis
Summary We present a case of recurrent periorbital cellulitis in a child. From the age of 2 years the child was admitted with periorbital cellulitis a total of six times with the first five episodes responding to conservative management with intravenous antibiotics. On the sixth admission endoscopic surgical treatment was carried out. Two abnormalities were noted: an anatomically abnormal uncinate process and an isolated abscess in an ethmoidal cell. It is believed that the abnormal uncinate process caused obstruction of the osteomeatal area, predisposing to recurrent periorbital cellulitis. We discuss the importance of early imaging and surgery in recurrent periorbital cellulitis. # 2004 Elsevier Ireland Ltd. All rights reserved.
1. Case report A 5-year-old girl presented to the pediatric department with a spontaneous recurrent left periorbital swelling (6 times) since the age of 2 years. The first episode was following a cold. On each of the occasions the clinical examination of the eye was unremarkable with the visual acuity, visual fields and red reflexes all being normal. Although the nose was * Corresponding author. E-mail addresses: [email protected] (P.D. Karkos), [email protected] (V. Srinivasan). 1 Present address: 3 Douglas Court, Walnut Str. Residences, Walnut Str., Leicester, LE27GJ Wirral, UK.
noted to be crusty, no tenderness or erythema was noted over the frontal, ethmoid and maxillary sinuses. On all occasions the patient was treated by the pediatricians with intravenous antibiotics and intranasal ephedrine drops and the swelling and temperature resolved within 48 h. An ENT opinion was not sought during any of these previous episodes. Three years following the first admission, the patient developed another episode of left periorbital swelling (Fig. 1) with swinging pyrexia. This time an ENT opinion was sought soon after the admission because of the acute presentation and progression of her symptoms and signs. The patient was commenced on intravenous antibiotics and intranasal ephedrine drops. Forty-eight hours later,
0165-5876/$ — see front matter # 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2004.06.013
1530
P.D. Karkos et al.
resolved almost completely after 24 h (Fig. 3) during which time the patient became apyrexial. She was discharged home 48 h postoperatively. Culture of the pus from the ethmoidal abscess did not grow any pathogens. The child has been followed up regularly since the operation and at 18 months she has been asymptomatic, without getting any further attacks of peri-orbital cellulitis.
2. Discussion
Fig. 1
Marked left periorbital swelling.
the child was still pyrexial and the swelling was not improving and, therefore CT Scan of the paranasal sinuses was requested. The scan showed extensive anterior and posterior ethmoid sinusitis with subperiosteal cellulitis on the left side displacing the rectus muscle laterally but with no infiltration of the peri-orbital fat (Fig. 2). It was decided to explore the ethmoid surgically in case a sub-perisoteal abscess was forming. During informed consent it was explained to the parents that surgery would be undertaken by the endoscopic route but if necessary, an external approach would also be used. During endoscopic sinus surgery two abnormalities were seen. The uncinate process was abnormally long and curved causing osteomeatal complex obstruction. There was a well-circumscribed nonpulsatile sac-like structure in one of the anterior ethmoidal air cells. On its incision a large amount of pus was released. Uncinectomy, middle meatal antrostomy and anterior ethmoidectomy were performed endoscopically. The lamina papyracea was removed but no pus was found in the sub-periosteal plane. No congenital perforation of the lamina papyracea was identified. The periorbital cellulitis
In this case report there are three important focusing points: firstly, the recurrent nature of the periorbital cellulitis, secondly, the age of the patient (a child) and finally, the unusual findings at surgery. Rhinosinusitis in children is rarely a surgical disease and ‘‘watchful waiting’’ is usually recommended. There are two exceptions to this rule: nasal polyps, with a possibility of cystic fibrosis and periorbital cellulitis [2]. What we found intraoperatively was an isolated cell with pus collection which might have been the predisposing trigger factor for the periorbital cellulitis. Acute infection of the paranasal sinuses is a rather frequent pathology in children. On the contrary, local orbital complications are rare [4]. Kanra et al. [3] reviewed 69 children with periorbital cellulitis and found that sinusitis was the most important cause in 43% of cases. Other causes were trauma, odontogenic infection, external ocular infection and local skin inflammations. The terms perioorbital and orbital cellulitis are often used interchangeably, obscuring important differences in their pathogenesis, aetiology and appropriate treatment [6]. Periorbital cellulitis is a process limited to the eyelids in the preseptal region and has a good prognosis under appropriate antibiotic therapy. It is important to distinguish this disease from the less common orbital (retroseptal) cellulitis, a potentially lethal process involving the contents of the orbit and associated with marked proptosis and opthalmoplegia [1]. Early opthalmological assessment, parenteral antibiotics and CT scanning of the paranasal sinuses-orbit with drainage of any pus are indicated if there is suspicion, clinical or radiological, of orbital involvement. This child had been having recurrent episodes of preseptal cellulitis from the age of 2 years, which were responding to antibiotics until the last episode. Although periorbital cellulitis secondary to ethmoiditis in a child has been described before [5], recurrent nature of such a complication of rhinosinusitis in a child has not been reported so
Recurrent periorbital cellulitis in a child
1531
Fig. 2 Extensive anterior and posterior ethmoid sinusitis with sub-periosteal flegmun/abscess formation on the left displacing the rectus muscle laterally but with no infiltration of the peri-orbital fat.
far. We cannot be sure about the cause of this recurrence, but we believe it is most likely due to the anatomical abnormality of the uncinate process. The abnormal uncinate process has probably acted as a triggering factor as it can compromise the muco-ciliary drainage mechanism at the osteo-
Fig. 3
meatal area, especially during acute inflammatory events, such as rhinitis. This has perhaps led to the development of an isolated pyocoele in the ethmoidal air cell system. It is probably the combination of the abnormal uncinate process and the activation of the ethmoidal pyocole that have led to the development of peri-orbital cellulitis on a recurrent
Postoperative improvement.
1532
basis. Once these triggering factors were removed by surgery, there was no further recurrence of the infective complication. This case report highlights the fact that the surgeon should think of underlying anatomical abnormalities in the osteo-meatal complex area in cases of recurrent peri-orbital cellulitis. Surgical intervention should also be considered in such recurrent cases, though the timing of the surgery can be debatable. It would be preferable to operate electively, in between attacks of periorbital cellulits, provided the orbital complication responds to medical treatment. In our case, we had to undertake surgery during an attack of periorbital cellulitis, because there was no significant improvement even after a reasonable period of intravenous antibiotics.
P.D. Karkos et al.
References [1] K. Jackson, S.R. Baker, Periorbital cellulitis, Head Neck Surg. 9 (4) (1987) 227—234. [2] N.S. Jones, Current concepts in the management of paediatric rhinosinusitis, J. Laryngol. Otol. 113 (1) (1999) 1—9. [3] G. Kanra, G. Secmeer, E.N. Gone, M. Ceyhan, Z. Ecevit, Periorbital cellulitis: a comparison of different treatment regimes, Acta Paediatr. Jpn. 38 (4) (1996) 339—342. [4] M. Magnano, V. Ferrero, B. Morra, M. Bussi, Orbital and endocranial complications in acute sinusitis in childhood, Acta Otorhinolaryngol. Ital. 12 (6) (1992) 565—573. [5] A. Murray, L. Albanasawy, M.S. Morrisey, Periorbital cellulitis secondary to ethmoiditis in a 5-week-old child, Int. J. Pediatr. Otorhinolaryngol. 52 (1) (2000) 101—103. [6] E.D. Shapiro, E.R. Walker, B.A. Brozanski, Periorbital cellulitis and paranasal sinusitis: a reappraisal, Pediatr. Infect. Dis. 1 (2) (1982) 91—94.