Paediatric pre- and post-septal peri-orbital infections are different diseases: A retrospective review of 262 cases

https://doi.org/10.1016/j.ijporl.2007.11.013Get rights and content

Summary

Objective

Peri-orbital infections can be classified as pre-septal or post-septal depending upon the location of the focus of infection. The ability to differentiate between these two is frequently difficult at the initial presentation, with marked orbital edema and pain limiting the ophthalmic examination. Hence, it is important to identify all the features at presentation that will lead to an accurate and rapid diagnosis and treatment. Our retrospective review of peri-orbital infections identifies contrasting features between these two groups that will aid the clinician in the subsequent management of these infections.

Design and setting

A retrospective review over an 11-year period of children admitted to a tertiary children's hospital for the treatment of peri-orbital cellulitis was undertaken. The two subgroups were identified, those suffering from a pre-septal infection and those with a post-septal infection. The groups were compared with respect to their presentation, clinical findings, findings on CT and surgical intervention.

Results

Two hundred and sixty-two children were identified with peri-orbital infections, 227 pre-septal, and 35 post-septal. There were statistically significant differences between the pre- and post-septal groups with regards to the following: age (3.9 vs. 7.5 years, p < 0.001), medical co-morbidities (19% vs. 0%, p < 0.01), a history of trauma (40% vs. 11% of cases, p < 0.003), clinical diagnosis of acute sinusitis (9% vs. 91% of cases, p < 0.001), and fever (47% vs. 94%, p < 0.001). Ophthalmologic examination identified diplopia (p < 0.001), opthalmoplegia (p < 0.001) and proptosis (p < 0.001) as significant features of a post-septal infection. Intravenous antibiotics were successful in treating the majority of cases, with 5% of pre-septal, and 25% of post-septal infections requiring surgery.

Conclusion

When considering the management of a child with a peri-orbital infection, features from the history and examination such as trauma, medical co-morbidities and ophthalmic signs will guide management and delineate the indications for early CT imaging. In the absence of acute visual compromise or other signs of disease progression, initial management with intravenous antibiotics for 48 h to cover Staphylococcal aureus and Streptococcal pyogenes with nasal decongestant should be considered before surgical intervention is contemplated. A multi team approach is essential in obtaining the best outcome for the child.

Introduction

Orbital infections pose a serious risk to a patient's vision or life, with a 20% morbidity rate quoted in the pre-antibiotic era [1]. Even with modern diagnostic and therapeutic tools, an emergence of resistance organisms or a delay in management can result in a poor outcome with a mortality rate still above 1% [2]. A commonly used classification system to describe peri-orbital infections is that proposed by Chandler [3] in the 1970s (see Table 1).

The pathophysiology of the disease presentation is related to local anatomical structures, especially the orbital septum and the lamina papyracea. The orbital septum delineates peri-orbital infections into pre-septal and post-septal. This septum is a condensation of loose areolar tissue, arising from the periosteum of the orbital rim. In the upper lid it descends to insert into the levator palpabrae superioris, and in the lower lid it attaches to the lower edge of the tarsal plate. Lacking lymphatic channels, this forms a barrier to the spread of infection from superficial tissue into the orbit.

The lamina papyracea is a very thin bone and has numerous natural dehiscences as well as being perforated by numerous vessels and nerves. These natural defects facilitate communication between the ethmoid air cells and the subperiosteal space on the medial wall of the orbit, the most common location of orbital abscess formation [4]. Within the orbit, valveless veins allow for the intracranial retrograde spread of infection to the cavernous sinus.

Differentiation between the pre-septal and post-septal infection may be difficult. An accurate diagnosis of the anatomical location of the infective process is crucial, and is aided by thorough history taking and physical examination, including an ophthalmologic evaluation. Contrast enhanced CT scanning (saggital, coronal and axial slices of orbit and sinuses) is required in difficult cases and in advanced disease.

In this article, we describe our experience with the diagnosis and treatment of peri-orbital infections, which we have classified into pre-septal and post-septal in their location.

Section snippets

Patients and methods

Ethics approval has been granted from the Northern Regional Ethics Committee, Auckland. A retrospective review was conducted from electronic medical records of all paediatric patients (age < 15 years) discharged from Starship Children's Hospital, Auckland, New Zealand from June 1995 through June 2006. A search was made for ICD-9 and ICD-10 codes of sinusitis, orbital or peri-orbital cellulitis or abscess and facial cellulitis (682, 373.13, 376.01, 360, 461, 473, L03.2, L03.2 + H00.0, H05.0, H44.0,

Results

From the broad search, 2105 patients were reviewed with 262 patients being identified with peri-orbital infections. There were 35 cases with post-septal and 227 with pre-septal infections. The number of post-septal cases presenting over the past 4 years has increased by a factor of eight, which is greater than that expected from population growth alone (see Fig. 1).

Discussion

A classification for orbital infections was introduced in the 1970s by Chandler [3], and is still widely used today. A similar approach characterises the infection as either pre-septal or post-septal with the dividing anatomical landmark being the orbital septum. The correct anatomical location of the infectious process is difficult in some cases, with examination often limited by peri-orbital oedema and the patient's pain. A skilled Ophthalmologic examination will overcome such difficulties.

Summary

A child with a peri-orbital infection is often difficult to assess. This is an acute condition, usually not in the context of preexisting chronic sinus disease. Our data provides criteria that will aid the clinician to identify those children with post-septal infections. The value of an accurate ophthalmologic examination is highlighted. Urgent CT imaging can then be arranged as a component of the management plan. At least 48 h treatment with nasal decongestant and intravenous antibiotics

Acknowledgment

We would like to thank Katrina Poppe of Waitemata District Health Board for her help with statistical analysis.

References (12)

There are more references available in the full text version of this article.

Cited by (114)

  • Role of Acute Rhinosinusitis in Periorbital Infections in Children

    2024, International Journal of Pediatric Otorhinolaryngology
  • High risk and low prevalence diseases: Orbital cellulitis

    2023, American Journal of Emergency Medicine
  • Role of systemic corticosteroids in orbital cellulitis: a meta-analysis and literature review

    2022, Brazilian Journal of Otorhinolaryngology
    Citation Excerpt :

    A previous retrospective study on this issue reported 50% of systemic steroid use in pediatric orbital cellulitis with subperiosteal abscess.6 Other retrospective studies did not report the use of steroids.17–19 A steroid is like a double-edged sword.

View all citing articles on Scopus
View full text