Authors: Lara Ibrahim Ghannam, Rama Ahmad Abu Doush, Rita Kifah Yacoub, Zeina Amro, Jafer Ayyesh
Categories: Case Report, Subperiosteal Abscess, Orbital cellulitis, Modified lynch approach
Source: BMC Oral Health
Authors: Lara Ibrahim Ghannam, Rama Ahmad Abu Doush, Rita Kifah Yacoub, Zeina Amro, Jafer Ayyesh
Medial Subperiosteal Abscess is a rare but serious life-threatening complication of orbital cellulitis. Although it often results from a sinus infection, its association with odontogenic infection is rare and underreported. This article highlights the importance of recognizing dental origins in orbital infections to avoid delays in treatment.
This is a case of a 6-year-old female who presented with a rare Medial Subperiosteal Abscess due to an odontogenic infection. Symptoms began with toothache, headache, and progressive swelling around the right eye, which persisted despite initial antibiotic therapy. A CT scan revealed a Medial Subperiosteal Abscess that required urgent surgical intervention using the modified Lynch approach, followed by odontogenic surgery and antrostomy to extract the infected teeth and remove the antral polyps.
This case demonstrates one of the rare complications of dental infections in a paediatric patient, which highlights the importance of early diagnosis and prompt surgical intervention, as well as comprehensive multidisciplinary care, in order to prevent irreversible complications such as vision loss in paediatric orbital infections secondary to dental origin.
Orbital cellulitis is a serious infection that involves the muscles and fat of the orbit, but it doesn't involve the globe itself [1]. Infections of the orbit and periorbit are common but could be associated with many local and systemic complications. The stages of orbital infections described by (Chandler`s classification): 1. inflammatory edema associated with lid edema and erythema; 2. orbital cellulitis; 3. Subperiosteal abscess; 4. orbital abscess; and 5. cavernous sinus thrombosis [2]. Subperiosteal Abscess (SPA) is a rare but serious orbital condition of orbital cellulitis involving a collection of pus between the periosteum and the orbital bone. The orbit is a confined space containing the eye, muscles, nerves, and connective tissues; thus, any increase in pressure, like that caused by an abscess, can quickly lead to significant complications, including optic nerve compression ending with permanent vision loss [3].
Medial SPA in children is particularly concerning because of paediatric patients’ unique anatomical characteristics, making them more susceptible to rapid dissemination of infections through other organs such as orbit. Understanding this condition in children involves recognizing common causes, clinical presentations, and the challenges involved in managing paediatric cases [4].
The clinical signs of SPA in children may initially be subtle, but often progress rapidly. Common symptoms include proptosis, which is usually more notable in children owing to their smaller orbits. Also, children often present with severe pain, exacerbated by eye movement, which might become more restricted. Children might be more irritable and cry persistently compared to adults. Also, fever and systemic signs are more likely to present in children compared to adults [5]. Periorbital swelling and erythema commonly occur together, it might also be tender. Vision could be affected due to optic nerve compression or corneal exposure from severe proptosis. Additionally, The child may resist or lose the ability to move the affected eye due to the pain and mechanical restriction.
SPA frequently arises as a complication of infections in the areas surrounding the orbit. Sinus infections comprise the most common source of such complications, especially ethmoid, sphenoid and maxillary sinusitis. Additionally, bacteria can be introduced to the orbit or the adjacent facial structures via penetrating traumas. Interestingly, dental infections of the upper teeth, particularly those penetrating deep into the facial planes, are considered rare to cause orbital cellulitis, with only four cases reported in the literature in this regard [2]. Herein, we present a case of a 6-year-old female child who developed a SPA due to an odontogenic infection.
A 6-year-old female patient with an unremarkable medical, surgical, and dental history and no known drug allergies was in her usual state of health until four days prior to her presentation to a dentist, when she began experiencing a toothache, headache, swelling and edema around the periorbital region of the right eye. Her vision was grossly normal with limited abduction and elevation of her right eye. The pupil was rounded, regular and reactive to light. Her condition was accompanied by a high-grade fever of 40°C, which temporarily improved with antipyretics including IV Paracetamol (Acetaminophen) 15 mg/kg. The patient initially received four doses of Augmentin (amoxicillin/clavulanate potassium) at 35 mg/kg prescribed by her primary dentist, but her symptoms persisted. She subsequently developed non-bloody, non-mucoid two episodes of vomiting, accompanied by the gradual onset and progressive swelling of her right eye. At ER, she was evaluated by an ophthalmology team and she was admitted under the care of paediatric team, where she received IV Rocephin (Ceftriaxone) and IV Clindamycin (Cleoin). However, after three doses, IV Clindamycin (Cleoin) was discontinued, and IV Rocephin (Ceftriaxone) was increased to a meningeal dose (1150 mg every 12 h) for a total of four doses. Additionally, IV Flagyl (Metronidazole) (300 mg every 8 h) and IV Vancocin (Vancomycin) (340 mg every 6 h) were initiated. Laboratory tests revealed markedly elevated CRP, ESR, and D-dimer, but the coagulation profile was normal (Table 1). Table 1Summary of laboratory test resultsTestResultNormal Range (unit)C-Reactive Protein level (CRP)63 < 5.99 mg/LErythrocyte Sedimentation Rate (ESR)100 < 24.99 mm/hourD-Dimer548 < 500 µg/LRed Blood Cells (RBC)4.59(4.00–5.20) × 10^6/mm^3^Hemoglobin (HB)12.1(10.3- 14.9) g/dlWhite blood Cells (WBC)12.3(6.00–15.00) × 10^9/mm^3^ 10Leukocyte Count19.76–15 × 10^3/mm^3^Granulocytes Count7.68(2.00–7.80) × 10^9/mm^3^Lymphocyte count2.92(0.60–4.10) × 10^9/mm^3^Direct Fluorescent Antibody (DFA)negativenegativeUrine Routine Ketone + 3Prothrombin Time (PT)14.312.00–16.00
During her hospitalisation, her clinical condition deteriorated and was complicated with diplopia. A follow-up ophthalmological consult was done, and upon examination there was a right-sided orbital cellulitis with proptosis and restricted ocular mobility, which obscured the visualisation of the right fundus. Meanwhile, the patient was still on the previously prescribed IV antibiotics, she underwent a computed tomography (CT) scan of the brain and orbits. CT revealed right periorbital soft tissue and swelling with fat standing extending, and complete opacification of all the right paranasal sinuses with obliteration of the right osteomeatal complex and intact eye globes. Also, CT scan revealed a change in the integrity of maxillary sinus floor, ruling out a sinus abscess. There is no evidence of intracranial infection spread. This suspicion was ruled out based on the CT findings, and she was subsequently referred to the Oral and Maxillofacial Department for further management after the diagnosis of SPA. (Fig. 1a, b, c and d).Fig. 1Coronal (a), sagittal (b), and axial (c and d) computed tomography scan views revealing medial subperiosteal abscess with complete opacification of all the right paranasal sinuses
On presentation at the oral and maxillofacial department, the patient appeared ill but was fully orientated, without signs of dyspnea or pallor or any systemic symptoms. Her vital signs were stable, and an examination of her skin, hair, and nails revealed no abnormalities. Head, eyes, ears, nose, and throat (HEENT) examination showed significant findings. The patient had marked swelling, tenderness, warmth, and redness of the right eye, with restricted movement and mobility. Despite these findings, her right eye vision remained intact, though she exhibited photophobia. Additionally, there was a mild swelling of the left eye, but its movement was preserved. (Fig. 2).Fig. 2Clinical presentation of the patient showing periorbital swelling and erythema
Given the clinical and imaging findings, the diagnosis of Medial SPA of odontogenic origin was made, and the patient required urgent intervention. An urgent surgical intervention was planned following the diagnosis of an odontogenic Medial SPA, characterised by localized homogeneous or heterogeneous radiopaque masses with smooth margins and convexity toward the orbit [6]. As a subperiosteal orbital abscess. The procedure involved an incision and drainage through the modified Lynch approach, performed under general anesthesia. A Penrose drain was placed to facilitate ongoing drainage. During the surgery, a moderate amount of yellowish pus mixed with blood was evacuated through a needle aspiration of pus just below the right eyebrow (Fig. 3a and b). The procedure was completed without complications, and the patient was transferred to recovery in stable condition. Postoperatively, the patient remained on IV Flagyl (Metronidazole) 250 mg and IV Augmentin (Amoxicillin/clavulanate potassium) 300 mg for 3 days to manage the infection and prevent recurrence.Fig. 3Intra-operative photographs showing the surgical incision using the modified Lynch approach (a), and penrose drain was placed to facilitate ongoing drainage (b)
Seven days postoperatively, the patient underwent a right odontogenic surgery utilising the Caldwell-Luc technique. This procedure involved the removal of antral polyps and the extraction of the right deciduous first and second molars (54 and 55). Additionally, an antrostomy was performed to clear the sinus opening, ensuring proper drainage. The surgical site was then meticulously sutured in layers. The operation was completed without any complications, and the patient was transferred to recovery in stable condition. (Fig. 4a and b).Fig. 4Intra-operative photographs showing the removal of antral polyps and the extraction of the right deciduous molars using the Caldwell-Luc technique (a and b)
Laboratory results from the initial day of admission through the second surgical intervention demonstrated a progressive decrease in white blood cell count, ESR, and CRP levels. Postoperative follow-up revealed significant clinical improvement, as swelling, edema, proptosis, and redness had markedly reduced. Furthermore, the patient's eye movement and vision. (Fig. 5a, b and c) (Fig. 5d: Picture of the child 8 months after the operation).Fig. 5Follow-up images showing full recovery (a, b and c). (d) Eight-months follow-up after the operation
Orbital cellulitis can be defined as a rare but severe infection affecting the muscle and fat within the orbit, but not the globe itself. Also it can occur at any age, but it is more common in children [1]. In this age group, the most common predisposing factor of such condition is an upper respiratory tract infection or paranasal sinus infection especially in the ethmoid, sphenoid or maxillary sinuses, causing more than 90% of all orbital cellulitis cases, the rest of the cases are secondary to penetrating traumas or sinus injuries, hematogenous spread from bacteremia and dental infections [7]. Also, orbital infections were reported that can be caused by infections from adjacent structures, subacute bacterial endocarditis, and dental infections [3]. The reason behind this is that the infection spreads directly through naturally thin bony dehiscences, another method of rapid continuous spread of infection is through the veins,due to the valveless nature of the superior and inferior ophthalmic vein, these specific anatomic pathways facilitate the spread of pathogens, this highlights the importance of understanding these anatomical relationships in preventing delayed diagnosis and treatment [3, 8, 9].
Odontogenic orbital cellulitis represents only 2–5% of cases of orbital cellulitis [10]. Although it is uncommon, it is still considered serious [11]. Dental infections from maxillary teeth extend to the orbital spaces and tissues either from maxillary teeth, as it occurs in our case, or through other close structures [11]. This case describes a retrobulbar abscess secondary to an odontogenic sinusitis that was caused by the infection of maxillary teeth. Although overall occurrence of odontogenic sinusitis is quite low [12]. This emphasises the importance of early identification, monitoring cases, and prescribing proper antibiotic therapy, especially with children, to prevent or stop the spread of such infections to the orbits.
CT scan is the gold standard imaging modality for orbital cellulitis and abscess diagnosis, determining the extent of abscess from adjacent structures [8]. In this case, the CT scan showed a Medial SPA all along the medial wall of the right orbit; also, her ophthalmological examination identified swelling, proptosis, redness, warmth, tenderness, and limited ocular mobility due to accumulated pus in the right eye and mild swelling in the eyelids of the left one, which further directed us toward the diagnosis. The management of these cases, as reported in the literature, includes IV antibiotics with intensive monitoring of the systemic and visual functions depending on the severity of the signs. Also, urgent surgical drainage is required in the presence of any SPA. Nevertheless, now the use of IV antibiotics and monitoring of cases is sufficient, especially, in cases with normal visual function [2]. Hence, the treatment includes antibiotic therapy, with or without surgery [10]. According to the literature, as the SPA is a pus accumulation between the orbital bone and periorbita, this necessitates surgical intervention to relieve intraorbital pressure and avoid serious complications like blindness, septic cavernous sinus thrombosis, and superior orbital fissure syndrome [10]. Also, it necessitates the appropriate surgical approach based on the prompt identification of the odontogenic origin [10]. There are many surgical approaches to the medial orbit for the incision and drainage of SPA in cases of orbital cellulitis; transcutaneous- modified lynch approach to medial orbit is the safest approach staying superior to the canthal tendon medially and lacrimal apparatus. In the case present, a modified Lynch approach was indicated to access the medial orbital wall and extraperiosteal space for the drainage of SPA or to alleviate pressure on the medial orbital structures by removing or thinning portions of the bony Medial orbital wall. This approach is generally performed between the medial canthus and the nasal dorsum. The lacrimal sac can also be dissected away from its fossa to the level of the nasolacrimal duct. The nasolacrimal duct and trochlea limit exposure inferiorly and superiorly, respectively. This approach is used for extreme orbital swelling and limited visualization. There are other approaches that are deemed to be less superior to our case. This involves the transcaruncular approach, which is performed by first retracting the upper and lower eyelids, then the soft tissue surrounding the medial orbit is sharply dissected posteromedially to the posterior lacrimal crest, which can injure the globe, lacrimal apparatus, inferior and superior oblique muscles, and medial canthal tendon. Additionally, the endoscopic endosteal approach is another one, which is said to be the most suitable for access to the posterior inferomedial orbit and orbital apex without external scarring or injury of the eyelid and associated structures [13]. So, surgical drainage of the SPA was indicated using the modified Lynch approach, then surgical extraction of the first and second deciduous molars and antrostomies were indicated.
This condition of odontogenic infection is rare and difficult to distinguish, especially in its early stages. Dentists should be aware of it and its complications and able to prevent or stop it. Also, it is important to prevent these infections in children as these complications have an influence on their day-life activities, also causing pain and difficulty in ocular mobility. In this case, an infection arising from a deciduous tooth gave rise to a SPA. Dentists should be aware of such rare but aggressive infections, as well as the early signs and symptoms. As the early diagnosis is a critical step in preventing or stopping the spread of these infections. This emphasises the importance of dental care in children. Urgent surgical drainage via the Lynch approach, combined with aggressive antibiotic therapy, was essential for managing the case, as the antibiotics alone cannot fully eliminate the infection. This report highlights the need for multidisciplinary collaboration between general practitioners, oral and maxillofacial surgeons, ENT specialists, and ophthalmologists to prevent severe complications in paediatric odontogenic-orbital infections.
This case report highlights that dental infections, especially in paediatric patients, could result in Medial SPA due to their unique anatomical characteristics. The authors highlight the need for increased awareness among healthcare providers regarding the potential complications of dental infections, especially in children, and the need for comprehensive dental care to stop or reduce such complications.