Retroorbital infection

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An 11 yo child with nasal stuffiness presents with right eye swelling. On examination, there is pain when moving the left eye and blurry vision. Diagnosis?

Answer:

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Acute sinusitits complicated by retroorbital abscess

Maxillarys sinusitis can spread upwards to the globe via the thin inferior orbital floor. Alternatively, it may also spread to other sinuses and from other sinuses go to eyes.

Acute sinusitis

  • Most are viral, so antibiotics are not routinely indicated.
  • Viral vs bacterial is always hard and cannot be reliably differentiated.
  • Bacterial sinusitis is likely if there isz
    Onset of severe symptoms (eg high fever with purulent nasal discharge)
    Persistence of the symptoms at least 10 days (I would say if after 5 days or so if sinusitis does not improve parents will take children come and it is appropriate to give antibiotics)
    Worsening of the symptoms (fever, pain)
  • The organisms involved are respiratory organisms
    – Influenza, parainfluenza virus
    – S.pneumonia, M.catarrhalis, H.influenzae (increasing prevalence of H.influenzae)
  • Abx: based on increasing prevalence of H.influenzae
    – 1st line: augmentin (better than amoxicillin alone due to rise in beta-lactamase producing strains)
    – 2nd line: doxycycline, resp.quinolones
    ** macrolides and cephalosporins are not recommended due to documented rise in resistance
    – In child 2 weeks, in adult 1 week

Retro-orbital infection

  • Emergency as it can lead to blindness
  • Broad spectrum antibiotics that can cover anaerobic infections is needed.
  • Who needs surgical drainage?
    – Opthalmoplegia
    – Impaired visual acuity
    Large proptosis (>5 cmm)

References:

  1. Anthony W. Chow, MD. Diagnosing and Treating Rhinosinusitis: New Guidelines.
  2. Rose M. Chasm, MD; Zachary D. W. Dezman, MD, MS. Images in Emergency Medicine. Annals of Emergency Medicine, 2015:66(4)
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