Infections of the orbit, cavernous sinus thrombosis

Acute suppurative infection is common near the eye, especially in children. It can occur in front of or behind the orbital septum. This is a sheet of fibrous tissue which stretches from the edges of the orbit into the eyelids, and divides the periorbital region from the orbit. Infections of both these regions usually start acutely with erythema and oedema of the eyelids; distinguish between them as described below. The danger with any infection in this region is that infection may occasionally kill the patient by spreading to his cavernous sinus or his meninges.

Periorbital cellulitis occurs in front of the orbital septum, is more common than orbital cellulitis and occurs in younger children. It can be primary, or secondary to: (1) Local trauma. (2) Skin sepsis. (3) A recent upper respiratory infection; H. influenzae is commonly responsible for the latter, and the child may be bacteraemic.

Orbital cellulitis occurs behind the orbital septum, and is less common but more serious. It is usually due to spread from the paranasal sinuses, commonly from the frontal or ethmoid sinuses

Subperiosteal abscesses may form when bacteria spread from the adjacent sinuses.

Cavernous sinus thrombosis can be: (1) Occasionally, aseptic as result of trauma, tumours, or marasmus. (2) More commonly, it is septic as the result of the spread of infection from the nose (a nasal furuncle is the commonest source), face, mouth, teeth, sphenoid or ethmoid sinuses, the middle ear, or the internal jugular vein. A cord of thrombus spreads from the site of the infection to the cavernous sinus, and sometimes to the cerebral veins and meninges to cause: (1) A rise in pressure in the veins draining the eye, resulting in severe oedema and proptosis. (2) Paralysis of the 3rd, 4th, 6th (commonly) and the first two branches of the 5th cranial nerves. (3) Meningeal irritation. In the days before antibiotics the patient almost always died; now he should not. If you treat him late, he may be left with visual impairment, ocular palsies, and hemiplegia.

Don't be frightened of operating in the orbit. Because of the danger of cavernous sinus thrombosis you must drain pus early. A negative exploration will not harm him, and you are very unlikely to damage his globe.

RANGIT (60 years) was admitted with a history of septic teeth for many years. Recently he had had fever, headache, rigors, and gradual swelling of his mandible. He was ill, dehydrated, shocked, jaundiced, and confused. Pus discharged from his mouth, his submental glands were enlarged, his neck was stiff, and Kernig's test was positive. Both his globes were proptosed, particularly the left, which was fixed; his forehead and cheek were oedematous, and his CSF turbid. Despite vigorous penicillin treatment he died. Postmortem examination revealed left dental and mandibular abscesses; his left orbit and cavernous sinus were full of pus. LESSONS (1) This is a very dangerous condition. (2) Proptosis in the presence of facial sepsis is a dangerous sign. (3) The organisms responsible are often penicillin-resistant. D'arbella PG, Cavernous sinus thrombosis. East African Medical Journal 1964;41:551[nd]9[-3] Anonymous. Orbital cellulitis [Editorial] Lancet 1986;ii:497. Fig. 5-5 CAVERNOUS SINUS THROMBOSIS. A, orbital oedema and proptosis may be associated with paralysis of the 3rd, 4th, 6th (commonly), and the first two branches of the 5th cranial nerves, and also with meningeal irritation. B, infection may spread to the cavernous sinus from the eyes, nose, teeth, middle ear, or the paranasal sinuses.

INFECTIONS OF THE ORBIT For the general method, see Section 5.2. Gently separate the patient's lids. Examine for induration and tenderness of his lids, chemosis (subconjunctival oedema), proptosis (his globe is pushed forwards), limitation of ocular movement, and loss of visual acuity. If you find these, suspect orbital cellulitis, take blood cultures and start parenteral antibiotics immediately!

CAUTION ! (1) Oedema and erythema of the lids are common to both orbital and periorbital cellulitis. (2) If the treatment of orbital cellulitis is delayed or incorrect, cavernous sinus thrombosis may follow.

X-RAYS. Infection may have spread from his paranasal sinuses, so consider X-raying them (if this is possible), to see if you can find a loss of translucency on the affected side. The films will be difficult to interpret, especially in children in whom the sinuses are small.

TREATMENT. Give him penicillin with cloxacillin. Or, give him cephradine alone (2.9). Or, give him penicillin and chloramphenicol.

DIFFICULTIES [s7]WITH ORBITAL SEPSIS If the patient's GLOBE IS DISPLACED BY AN INFLAMMATORY SWELLING, and its movement impaired, perhaps accompanied by loss of visual acuity, suspect that he has a subperiosteal abscess of his orbit. For example, an abscess above his eye will displace it downwards. Try aspirating the pus from the roof of the abscess with a needle. His eye may go back into place. Then incise and evacuate his abscess through a conjunctival fornix[md]his inferior fornix if swelling is maximal inferiorly, and his superior fornix if it is maximal superiorly. Pus will probably be coming from a paranasal sinus and you may find a track through to it. Insert a drain.

If he has an inflammatory SWELLING IN THE UPPER, OUTER PART OF HIS ORBIT, involving the outer third of his upper lid, suspect that his lachrymal gland is infected (DACRYOADENITIS). Incise the abscess through the upper fornix of his conjunctiva, or through his eyelid.

If he has an inflammatory SWELLING BELOW THE MEDIAL ASPECT OF HIS LOWER LID, suspect that he has an abscess in his lachrymal gland (DACRYOCYSTITIS). Press it, pus may exude through the punctum. If it suppurates, incise it through the skin of his lower lid. When the infection has subsided, refer him for a dacryocystorhinostomy, which will usually re-establish the flow of his tears.

If his conjunctiva becomes increasingly congested, his globes proptose, his OCULAR MOVEMENTS BECOME PROGRESSIVELY IMPAIRED, his accommodation paralysed, his pupil fixed and dilated, and his cornea anaesthetic, he has CAVERNOUS SINUS THROMBOSIS. It will probably involve both his eyes. Early vigorous chemotherapy may save him (2.9). Give him penicillin and cephradine, or chloramphenicol.

Fig. 5-6 TWO ABSCESSES IN THE THROAT. A, the danger with a retropharyngeal abscess is that an unconscious child may inhale pus and get bronchopneumonia. Avoid this by incising it while his head is hanging over the end of a table. B, a peritonsillar abscess occasionally follows tonsillitis, and needs draining. Do both these incisions with a guarded knife that cannot cut too deeply.