Orbital complications in children: differential diagnosis of a challenging disease

Abstract

Orbital swelling in children presents diagnostic and therapeutic challenges. Most are associated with acute sinusitis with complicating factors possibly including: amaurosis, meningitis, intracranial abscess or even cavernous sinus thrombosis. However not all acute orbital swelling is associated with acute sinusitis. A careful evaluation is critical prior to initiating therapy. Clinical records of 49 children (27 girls, 22 boys, with an average age of 11.8 years) were retrospectively reviewed. Historical data evaluated included all available information from parents and previous treating physicians. All patients underwent intensive pediatric, ophthalmologic, and otorhinolaryngologic examinations. Computed tomography (CT scans) were additionally performed in 40 % of children. The results of any examinations were also evaluated. Eighteen of the 49 patients had an orbital complication due to acute sinusitis. All 18 had elevated body temperature, C-Reactive Protein (CRP) values and white blood cell counts. Endoscopy of the nose revealed pus in the middle meatus in each case. According to Chandlers' classification, ten children presented with a preseptal, and eight children had a postseptal orbital cellulitis. All patients were admitted to the hospital and treated with intravenous antibiotics. CT scans further demonstrated signs of subperiostal abscess in four children. Functional endoscopic sinus surgery (FESS) was required in six children, including all patients with subperiostal abscess. Twenty children experienced orbital swelling unrelated to acute sinusitis, i.e. atheroma, inflammed insect stings, dental related abscess, conjunctivitis, and Herpes simplex associated superinfection. In three children, acute orbital swelling was caused by an orbital tumor. Orbital complications of an acute sinusitis occur often in the pediatric patient group, and most of these patients can be treated conservative with intravenous antibiotics. Indications for FESS include failure to improve or worsening of clinical symptoms during 24 h of therapy, signs for subperiostal abscess in CT scan, and/or vision loss. Patients with infectous orbital complications had fever, elevated CRP and white blood cell counts. This symptom complex is key in making the correct diagnosis. Interestingly, 61 % of patients in this study demonstrated non-sinusitis related diseases leading to acute orbital swelling, which also required prompt recognition and appropriate therapy.

Sinonasal-Related Orbital Infections in Children: A Clinical and Therapeutic Overview

“…Laboratory tests, including assessment of white blood cell counts and serum C-reactive protein levels may be useful, as inflammatory markers are generally higher in children with SROIs than in those with peri-orbital cellulitis unrelated to complicated rhinosinusitis; it has also been reported that the presence of fever, a white blood cell count of >11,100 per microlitre, and proptosis are independent predictors of SPA or OA [31].…”

Diagnosis, management and treatment of orbital and periorbital cellulitis in children

“…Differential diagnosis Inflammation of the tissues around the eye is a common feature of various conditions (Welkoborsky et al 2015). Orbital cellulitis, in which orbital inflammation is a sign, is uncommon but can be life threatening.…”

A Rare Complication of Orbital Cellulitis in a Diabetic Case: Cavernous Sinus Thrombosis

“…[8] It can be a long-term complication of midfacial or paranasal sinus infections and has high mortality and morbidity rates. Staphylococcus aureus is the responsible pathogen in 70% of cases, while Streptoccocus pneumoniae, gramnegative bacilli, anaerobes, and fungi such as Aspergillus sp.…”