Orbital cellulitis is an important and frequent complication of rhinosinusitis. If not treated adequately and timely, it can lead to loss of vision and life threatening complications. We describe three peculiar cases of orbital cellulitis with favorable outcome. An endoscopic approach is favored if orbital cellulitis is arising as a complication of rhinosinusitis. The nasal endoscopic approach is safe and quick way of addressing severe sub-periosteal abscess as well as sinus infections especially in the immunocompromised patients with poor general health conditions. Medial orbital decompression is achieved by removal of lamina papyracea, part of superolateral wall of sphenoid sinus wall and inferiomedial wall of the orbit so that orbital contents can be decompressed.
Keywords:Bacterial Orbital Cellulitis, Endoscopic orbital decompression, CSF repair, HIV; Diabetes
The pre and post septal cellulitis, subperiosteal and orbital abscess are important and serious complications of rhinosinusitis. If not treated adequately and timely, they can lead to loss of vision and life threatening complications. We describe four cases of acute orbital cellulitis who all presented with short duration of proptosis and vision loss. The early intervention in the form of endoscopic sinus clearance and medial orbital decompression along with targeted antibiotics can bring the favorable outcomes in such patients.
A 45 years old female, known case of HIV, not on antiretroviral therapy, presented with complaints of painful swelling left eye and rapidly progressive loss of vision for past 07 days.
Examination: Left eye: Proptosis, restricted ocular movements and decreased vision (perception of light) was noted on examination. The pupillary reflex was sluggish. Necrotizing fasciitis of lower eyelid was also present. Right eye was essentially normal. Nasal endoscopy revealed frank purulent discharge was seen originating from the spheno-ethmoid recess.
Imaging: Contrast Enhanced Computed Tomography (CECT) scan was suggestive of left maxillary sinusitis with evidence of subperiosteal collection in the orbit. Magnetic resonance imaging (MRI) orbit, brain and paranasal sinuses revealed proptosis of left eye with peri-orbital soft tissue swelling associated with inflammatory mucosal thickening in the left side paranasal sinuses.
Bacteriology (Nasal Swab): Swab of the discharge was taken. Culture and sensitivity showed Pseudomonas aeruginosa which was resistant to Amoxicillin-Clavulanic acid, Piperacillin-Tazobactam, Ticaracillin-Sulbactum, First and second generation Cephalosporins, Carbapenems, Aminoglycosides, Fluoroquinolones, Colistin, Trimethoprim- Sulfamethoxazole.
Viral markers: The serology was positive for HIV- 1.
Medical management: Parenteral antibiotic cover was given with Ceftazidime, Imipenem, Clindamycin and Metronidazole.
Surgical management: Urgent endonasal endoscopic sinus surgery was done with clearance of maxillary, ethmoidal, frontal and sphenoidal sinuses and involving removal of medial orbital wall. The orbit was opened and decompressed removing the orbital fat till medial rectus muscle. The entire lamina papyracea and medial part of roof of maxillary sinus was removed. Sphenoid sinus was opened widely upto the orbital apex and optic nervewas decompressed by opening its sheath. Also, lower eyelid
wound debridement along with lateral cantholysis was done.
The patient’s vision improved postoperatively to 6/24 and she
underwent staged tarsorrhaphy later.
A 73 years old male, known case of uncontrolled diabetes
mellitus presented with complaints of painful swelling around
right eye and complete loss of vision of 20 days duration.
Examination: Proptosis, complete ophthalmoplegia and
no perception of light in right eye. Nasal endoscopy showed
mucopus in right middle meatus and in spheno-ethmoidal
Imaging:olvement of sphenoid,
maxillary and ethmoidal sinuses bilaterally with intra-orbital
extension of infection in right orbit with thickening of right optic
Bacteriology (Nasal Swab): Staphylococcus aureus
Medical management: Antibiotic cover with Linezolid,
Clindamycin, Cefoperazone and Metronidazole was given.
Surgical management: Urgent endonasal endoscopic
sinus surgery and clearance of all paranasal sinuses and
decompression of the right orbit into nasal cavity was done.
The optic nerve was decompressed by opening its sheath
along the length near the orbital apex. Intraoperatively,
anterior cranial base dura was detected to be unhealthy with
The unhealthy dura with granulation tissue was excised
which resulted in an iatrogenic cerebrospinal fluid (CSF) leak.The CSF leak was repaired by ‘sandwich technique’ using two
layers of nasal septal bone and one layer of septal cartilage.
These layers were reinforced with fibrin tissue sealant. The
defect was covered with pedicled middle turbinate mucosal flap.
Postoperatively, the patient had partial return of upper eyelid
movements and perception of light in his operated eye. He had
no signs of any CSF leak and serial nasal endoscopy showed good
healing and mucosalization of nasal cavity.
A 6 years old girl with no known co-morbidities presented
with painful swelling around left eye and diminution of vision
(left eye) and left frontal sinus tenderness with erythema of skin
over left frontal region of 10 days’ duration.
Examination: Revealed proptosis left eye. Vision was
reduced to 6/60. There was no restriction of eye movements.
Nasal endoscopy showed frankpus in middle meatus.
Imaging: Contrast enhanced CT scan showed extensive
mucosal involvement of maxillary and ethmoidal sinuses on
left with intra-orbital extension of infection displacing the
Bacteriology: Staphylococcus aureus.
Medical management:Antibiotic cover with Linezolid,
Clindamycin and Metronidazole was given.
Surgical management- Urgent endonasal endoscopic sinus
surgery and clearance of all sinuses and Draf2 procedure for
frontal sinus on left side was done. The orbital decompression
was done by removing the infero-medial part of floor of
the orbit as well as the medial wall upto the medial rectus
muscle. Post-operative, the patient’s vision improved to 6/6
and she made an uneventful recovery.
A 51 years old lady, old case of Type II Diabetes Mellitus,
presented with complaints of diminution of vision, swelling and
proptosis of Left eye of 10 days duration.
Examination: Left eye: Vision was reduced (Perception of
light present) and proptosis present. Pupils were fixed and
dilated and eye movements were restricted. Nasal endoscopy
revealed purulent discharge from middle meatus and frontal
Imaging: NCCT PNS showed the presence of soft tissue
density contents in Left frontal, maxillary, sphenoidal,
anterior and posterior ethmoidal air cells and erosion of
lamina papyracea on left side.
Bacteriology: Serratia marcescens, E coli
Management: The patient was started on Injectable Insulin
and taken for Endoscopic Sinus Surgery and medial orbital
decompression. Purulent discharge was found in Left
frontal, maxillary, anterior ethmoidal, sphenoidal sinuses
and Right posterior ethmoidal sinus. Lamina papyracea was
found partially necrosed and its remnant was removed. Postoperative
antibiotic cover was given with Inj Piperacillintazobactam
and Inj Imipenem. Post-operative, the patient
continued to have diminished vision (Perception of light
present, inaccurate projection of rays). Ophthalmological
consultation revealed Central Retinal Artery Occlusion (Lt)
and Palsy of 6th cranial nerve (Table 1).
Post septal orbital cellulitis is an acute inflammatory process
with infection of orbital contents posterior to orbital septum.
This is differentiated from pre septal cellulitis which involves
infection of the eyelids and peri-orbital soft tissue anterior to
the orbital septum. The orbital cellulitis may occur in following
possible situations :
Extension of the infection from peri-orbital structures
(Paranasal sinuses, lacrimal sac).
Direct inoculation due to surgery or trauma.
Haematogenous spread from bacteremia. Orbital
cellulitis is the most common and frequent complication of
ethmoid rhinosinusitis in all age groups.
The predisposing factor in development of orbital cellulitis
is sinus infection followed by trauma, orbital surgery/ implant,
dacrocystitis, retained foreign body and dentalinfections .
Immunocompromised individuals generally have higher rates of
complications and an overall poor outcome [3,4]. An increased
incidence of orbital cellulitis is seen in winters because of
increased incidence of rhinosinusitis. An increase has been
noted in the frequency of orbital cellulitis caused by community
acquired methicillin resistant Staphylococcus aureus infections
[5,6]. Orbital cellulitis is seen more commonly in children than
The most common underlying factor for its development
is preceding rhinosinusitis, commonly involving ethmoid
sinuses, with microbiology reflecting the association .
As the medial wall oforbit is very thin and porous, owing to
the neurovascular channels, infections can easily extend to
the neighbouring structures . The pathogens commonly
associated with orbital cellulitis are aerobic, non-spore forming
bacteria like Streptococcus pneumoniae, Staphylococcus aureus,
Streptococcus pyogenes and Haemophilus influenzae (mainly
found in children). Pseudomonas, Klebsiella and enterococcus
are less common etiological agents. Fungal infections are often
seen in immune-compromised patients (Figures 1 & 2).
Differentiation between preseptal and postseptal cellulitis is
often difficult at the initial presentation . Orbital cellulitis
may present as unilateral swelling of lids and conjunctiva,
proptosis, painful ocular movements, diminution of vision,
diplopia, sluggish pupillary reflexes, associated with fever and
other toxemic features. Loss of vision in chronic rhinosinusitis
can occur as a result of orbital complications such as central
retinal artery occlusion, optic neuritis, corneal ulceration and
pan-ophthalmitis . Various imaging modality including
ultrasonography and CT scan can be used for diagnosis. Although
USG is quick and non-invasive but CT scan may be required to
assess the evidence of rhinosinusinusitis and orbital involvement
and remains investigation of choice. MRI is of limited value as it
does not show the bony landmarks required for surgery [12,13].
Medical management includes parenteral antibiotic therapy.
Bacteriological culture from conjunctiva and preseptal tissue
might not be representative. In majority of cases surgical
intervention is required. Surgery is indicated where there is
evidence of orbital collection, in cases refractory to medical
therapy, cases with compromised vision, where there is an
atypical picture which warrants a diagnostic biopsy and in
cases with complications (Table 2). Surgery often warrants
a concurrent drainage of the infected sinuses . Urgent
endonasal endoscopic drainage with wide decompression of
medial wall of orbit is indicated in patients who present with
signs and symptoms of vision loss .
Any child with proptosis, reduced or painful eye movement
(ophthalmoplegia), or decreased visual acuity (initially
manifesting itself with reduced green/red colour discrimination)
should be evaluated with a CECT scan of the sinuses with orbital
detail to distinguish between orbital cellulitis and intraorbital or
subperiosteal abscess. In cases where an associated intracranial
complication is suspected or in case of uncertainty, MRI can
provide valuable additional information. All three conditions
(orbital cellulitis, subperiosteal and intraorbital abscess) cause
proptosis and limited ocular movement. Evidence of an abscess
on the CT scan, worsening of orbital findings and impairment
of vision (especially colour vision) after initial intravenous
antibiotic therapy are indications for orbital exploration and
drainage. Repeated ophthalmologic examinations of visual
acuity should be done. Intravenous antibiotic therapy may be
converted into oral when the patient has been a febrile for 48
hours and the ophthalmologic symptoms and signs are resolving
(Figures 3 & 4).
An endoscopic approach is favored if orbital cellulitis is
arising as a complication of sinus disease. The nasal endoscopic
approach is safe and quick way of addressing the severe subperiosteal
abscess as well as sinus infections especially in
the immunocompromised patients with poor general health
conditions. The medial decompression is achieved by removal
of lamina papyracea; part of superolateral part of sphenoid
sinus wall and inferomedial wall of the orbit so that orbital
contents can be decompressed into nasal cavity. The other
advantages of endonasal endoscopic approach are that optic
nerve decompression and repair of skull base or CSF leaks can
be done simultaneously. However, in presence of intracranial
complications, a combined approach is recommended. There
have been a number of recent studies showing good outcomes
with intravenous antibiotics in small children with subperiosteal
abscesses. In such cases there can be an argument for withholding
surgical drainage, provided there is:
Clear clinical improvement within 24-48 hours,
No decrease in visual acuity,
Small (<0.5-1 ml in volume) medially located
No significant systemic involvement
Patient’s age is less than 2-4 years.
Complications: 15 - 63% patients report diplopia due to
iatrogenic damage to extraocular muscles. Other complications
can be postoperative bleeding, which has to be managed
intraoperatively by cauterization of bleeder. Rare complications
include CSF rhinorrhoea and blindness.
Follow up: Loss of vision in rhinosinusitis can result from
central retinal artery occlusion, corneal ulceration, optic
neuritis or panophthalmitis.
Summary: Orbital cellulitis in adults, as opposed to in
children, is a relatively rare condition. A prompt diagnosis
and treatment is necessary to avoid complications and
death. The present case series is highlighted to emphasize
on aggressive medical and surgical management with an
aim to preserve the vision and prevent life threatening