Trauma and sinusitis induce orbital cellulitis in an 11-year-old boy

Background We conducted a literature review and found that the most common causes of orbital cellulitis susceptibility in children are infections in adjacent areas (such as sinusitis, dental disease, upper respiratory tract infections, and facial skin infections), recent trauma/surgery, foreign bodies, and insect bites. This article aims to discuss the differential diagnosis and treatment of orbital cellulitis in children. Case presentation: Here we present a report of a case of orbital cellulitis with intra-frame abscess induced by trauma and sinusitis, and a review of the relevant literature. An 11-year-old boy with a history of orbital trauma one year earlier had had fever, pain in the right eye, periorbital swelling, restricted extraocular movement, protruding eyes, and decreased vision for six days before admission. The initial treatment with intravenous Rocephin and linezolid was unsuccessful. MRI showed sinusitis and orbital abscess. Endoscopic sinus surgery was then performed to clean up the purulent secretions in the orbit, which relieved his orbital symptoms. Here, we report a case of sinusitis and trauma-induced orbital cellulitis in an 11-year-old boy. The use of intravenous antibiotics and further treatment with orbital incision and decompression led to clinical improvement. Children with orbital complications of sinusitis have complex clinical manifestations and rapid disease progression. Our literature review ndings suggest that broad-spectrum antibiotics are the main empirical treatment, and abscesses are not Therefore, consultations, and In the present article, we introduce a case of orbital cellulitis and intra-frame abscess induced by trauma and sinusitis. Additionally, we have performed a literature review and have discussed the clinical features, diagnosis, treatment options, and prognosis of orbital cellulitis in children.

The symptoms of the child did not improve signi cantly despite the change in the antibiotic therapy to meropenem and linezolid, and the continued administration of eye drops and symptomatic treatment of sinusitis. Three days later, head CT re-examination showed cellulitis of the right orbit and increased in ammation of the ethmoid, sphenoid, and maxillary sinuses. We added voriconazole since fungal infections were not ruled out. Due to the Spring Festival Holiday, MRI was not performed until the 5th day of conservative treatment. During this period, the appointed Ophthalmology Clinic personnel conducted dynamic evaluations every day maintaining close contact with the Otolaryngology Department staff. MRI revealed cellulitis of the right orbit with local abscess and in ammation of the ethmoid, sphenoid, and maxillary sinuses ( Figure 1).
Due to the lack of signi cant improvement after the implementation of conservative treatment and the MRI ndings of abscess formation, on the 5th day of the conservative therapy, we performed surgery of the right maxillary, ethmoid, sphenoid, and frontal sinuses by nasal endoscopy + orbital lesion resection + orbital incision decompression. Endoscopy showed obvious deviation of the nasal septum to the right side. Nasal stenosis and abundant purulent secretions were found in the middle nasal passage. Next, we opened the right maxillary sinus and observed excessive purulent secretion in the right maxillary sinus. We further collected a sample of the purulent secretion for culture by excision of a small part the orbital fascia. And we cleaned up the purulent secretions in the orbit thoroughly. Next, a large amount of normal saline was ushed through the operation cavity. Intensive anti-in ammatory and anti-swelling treatments were administered postoperatively. The patient recovered well, and the pain in the right eye disappeared.
The following physical examination results were obtained: VOD 0.3, VOS 0.3; the swelling of the right eyelid had disappeared, the protrusion of the right eye was eliminated, and the conjunctiva showed no obvious congestion. Our treatment achieved complete resolution of the orbital in ammation, and his extraocular motility returned to normal (Figures 1 and 2).

Discussion And Conclusions
Orbital cellulitis in this child might have been induced by trauma and sinusitis. However, this case was characterized by certain speci c features: the child had no history of sinusitis, whereas a history of orbital trauma one year earlier was present. This condition is not consistent with previous reports indicating that trauma-induced orbital cellulitis usually occurs within a few days post-trauma [4]. We, therefore, speculated that the damage of the local orbital structures caused by the trauma could easily induce orbital cellulitis in a later period of life. Moreover, no orbital abscess was detected by the repeated CT examinations in this patient, which is consistent with the existing literature evidence. Notably, MRI can improve the diagnosis rate of patients with orbital abscess [5]. In this patient, broadspectrum antibiotics were rst used as empirical treatment after suspected orbital cellulitis. Additionally, close contact was maintained with ophthalmology and otolaryngology departments. During the conservative treatment, the visual acuity and imaging conditions were dynamically evaluated. Due to the absence of considerable improvement, surgical treatment was considered and applied, followed by hormone anti-in ammatory agent administration until the child was nally cured.
In this study, we also conducted a literature review on PubMed using the terms "orbital cellulitis" and collected data associated with children reported in the past ve years. We then analyzed and summarized its clinical features, treatment, and differential diagnosis. Interestingly, we found that most of the studied children had unilateral eye disease. The most common predisposing etiologies were infection of the adjacent area (such as sinusitis, dental disease, upper respiratory tract infection, and facial skin infection), recent trauma/surgery, foreign body, and insect bites. Staphylococcus aureus and non-hemolytic streptococci were the major pathogens [6]. Fungal infections should be considered as part of the initial workup in each patient diagnosed with preseptal/septal cellulitis unresponsive to empirical broad-spectrum antibiotic therapy, high CRP levels, and severe proptosis [7]. A high index of suspicion for fungal infection should also be taken into consideration after surgical intervention with insertion of prosthetic materials [5]. In our case, the child was diagnosed with sinusitis and trauma-induced orbital cellulitis (Table S1). Acute sinusitis is infectious or non-infectious in ammation of the nasal cavity and sinus mucosa. However, due to the thinner sinus bone walls and weaker immune system in children than those in adults, this disease leads to a higher incidence of nasal orbital complications and more extensive progression of the disease into the adjacent tissues. Acute sinusitis complications can be divided into peripheral soft tissue infections, osteitis, and intraorbital and intracranial complications. Intraorbital complications are most common, accounting for approximately 80% of all complications. Importantly, these complications have a rapid onset and progression, and, if not timely treated, they can cause optic neuritis, cavernous sinus thrombophlebitis, and can even lead to life-endangering intracranial infection [1,2].
The clinical manifestations of the orbital complications of acute sinusitis include acute sinusitis, fever, headache, red and swollen eyelids, bulging eyeballs, restricted movement, eyeball tenderness, bulbar conjunctival edema, ptosis (in severe cases), and even loss of vision. The blood test in our case showed an increase in the white blood cell count (mainly that of neutrophils). Our patient initially had a fever, headache, eyelid swelling, but then gradually developed bulging eyes, restricted movement, and vision decline. It is noteworthy that in the literature review we performed, the main symptoms reported were eyelid redness and swelling.
CT examination is of considerable value in the diagnosis and treatment of orbital cellulitis. It can not only facilitate the diagnosis, but can also clarify the extent of the lesion, the involvement of adjacent bone walls and extraocular muscles, the degree of sinusitis and its relationship with orbital infection, showing the formation of abscesses and their locations. Therefore, timely incision and drainage should be implemented. MRI should be routinely applied for examinations in patients with suspected intracranial complications. Additionally, DWI (diffusion-weighted imaging) can improve the diagnosis rate in almost all patients with orbital abscess by the concurrent use of enhanced scan images [22]. In the present case, the orbital abscess was found only through MRI. Most patients with orbital cellulitis are cured by active treatment. However, acute periorbital swelling in some children can be misdiagnosed as orbital cellulitis. Hence, disease diagnosis is to be performed based on the assessment of infection indicators, clinical presentation, imaging features, the feedback on the effect of antibiotic treatment, and even of histopathology results.
A history of sinusitis, high temperature, leukocytosis, and a normal pupil and fundus are usually present in children with true orbital cellulitis [20]. Importantly, timely diagnosis and treatment are essential for the prevention of potential irreversible visual loss [9], which highlights the importance of differential diagnosis of acute periorbital swelling in children. Nevertheless, most cases in which correct treatment has been implemented will be resolved without adverse residual effects (Table 1).  [21] No consensus guideline for the treatment of children with orbital cellulitis exists. The main empirical treatment for periorbital infection is the application of broad-spectrum antibiotics. Early diagnosis and appropriate antibiotic treatment are essential for the prevention of life-threatening complications. An empirical treatment is generally recommended that is directed against at least 90% of the possible pathogen microorganisms. It is critical that all patients should be treated against Streptococcus pneumoniae, Streptococcus pyogenes, Streptococcus viridans, Staphylococcus aureus, Haemophilus representatives, and anaerobes. In areas with a low incidence of MRSA, the administration of ampicillin/sulbactam, followed by amoxicillin/clavulanic acid, is the best monotherapy. In case of concerns regarding cerebrospinal uid penetration or suspected or con rmed allergy to penicillin, ceftriaxone can be considered as part of an empirical treatment plan. However, the therapy in patients with severe illness is usually combined with the implementation of metronidazole and vancomycin. Additionally, in patients with mild illness or in areas with high rates of clindamycin susceptibility, it can be considered for use. signs of clinical and laboratory improvement are present, a transition from initial intravenous treatment to oral treatment can be considered. The total treatment duration of these infections has decreased considerably in recent years to approximately two weeks, even in cases of orbital or subperiosteal infections [23][24][25][26]. After CT examination for diagnosis con rmation, children with orbital honeycomb in ammation combined with sinusitis are usually treated with systemic antibiotics, nasal glucocorticoids, nasal cavity washing, agents promoting mucosal dissolution, negative pressure to attract nasal secretions, etc. After the exclusion of tumors and systemic immune system diseases, 3-5-day corticosteroid therapy can be applied systemically, with a dexamethasone dosage of 0.1-0.2 mg/kg. This treatment is to be terminated after the symptoms have signi cantly improved. The use of systemic steroids as an adjunct to the systemic antibiotic treatment of orbital cellulitis can reduce orbital in ammation while diminishing the risk of infection aggravation [27,28]. Due to the present lack of guidelines for corticosteroid dosage in children with orbital cellulitis, CRP levels can be used as an effective indicator for determination of the need for corticosteroid application in orbital cellulitis [29]. In an earlier study, IV dexamethasone was administered on admission concurrently with broad spectrum IV antibiotics. The dosing regimen selected was based on the standard pediatric IV dosing of dexamethasone for the treatment of in ammation (0.3 mg/kg/d divided every 6 hours) [30]. Antibiotics with high sensitivity can be replaced depending on the speci c drug sensitivity results. Importantly, surgical incision and pus drainage are to be performed in cases of incorrect or missed orbital cellulitis diagnosis, as well as when the applied antibiotics therapy has been ineffective, the imaging has shown abscess formation, or after vision loss + persistent high fever despite intravenous antibiotics administration for 24-48 hours and worsening clinical symptoms. The rates of surgery in most studies are within the range of 0-11% [31]. Importantly, subperiosteal abscess is not an absolute indication for immediate surgery (Figure 3) [32].
Here, we present our analysis and summary of the initial treatment process features in a case of an orbital mass detected in children. The following information was collected: a history of trauma or eye surgery, presence of eyelid edema, extraocular movement, abnormal changes in visual acuity, exophthalmos, diplopia, fever, headache, and other clinical manifestations. Routine blood test + CRP + blood culture + CT examination results were also required. CT scans were necessary for the following conditions in patients with orbital cellulitis: inability to perform a complete eye evaluation, exophthalmos, ophthalmoplegia, and pain in external eye movements, decreased vision, or central symptoms (seizures, focal neurological de cits, or a change in the mental state). In clinical cases of intracranial complications or cavernous sinus thrombosis or such suspected on the basis of CT ndings, such as changes in the mental status, persistent fever after appropriate treatment, or CT ndings suggesting intracranial expansion, MRI should be considered [25,31]. When the clinical manifestations support orbital cellulitis, but the CT examination results are normal, MRI examination is recommended to be performed to facilitate the diagnosis [33]. In case of intracranial symptoms, MRI examination is to be performed. If orbital cellulitis is diagnosed, conservative treatment can be initially administered, including the application of topical quinolone-containing eye drops on the eyelids, levo oxacin eye drops, and gati oxacin eye ointment in combination with systemic broad-spectrum antibiotic therapy ( Figure 3).
Brie y, in cases of orbital swelling, we recommend that multidisciplinary consultation should be performed, considering all infectious and non-infectious causative factors. Ineffective three-day conservative treatment should be followed by CT/MRI examination for diagnosis and treatment facilitation. However, surgery is to be considered in cases of persistent or progressive symptoms.
Declarations Figure 1 Swelling of the right eye before treatment and image scan within hospitalization 02-14 02-17CT and 02-18MRI performed prior to surgery showing a signi cant right eye proptosis, cellulitis and sinusitis. Postoperative MRI (02- 24) showed no cellulitis of the right orbit.