Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 25  |  Issue : 2  |  Page : 141-145

Orbital cellulitis in a tertiary institution in Nigeria: Improving outcomes


1 Department of Ophthalmology, LAUTECH Teaching Hospital, Nigeria
2 Department of Ophthalmology, LAUTECH Teaching Hospital; Department of Surgery, Osun State University, Nigeria
3 Department of Surgery, Osun State University; Department of Otorhinolaryngology (ORL), LAUTECH Teaching Hospital, Osogbo, Osun State, Nigeria

Date of Web Publication22-Feb-2018

Correspondence Address:
Dr. Michaeline A Isawumi
Department of Surgery, Osun State University, PMB 4494 Osogbo, Osun State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njo.njo_42_16

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  Abstract 


Background: Orbital infections could have untowards associated ocular and systemic morbidity. There is a need to reduce these complications to the barest minimum. Objectives: To improve outcomes of orbital cellulitis in Osogbo and suggest how to prevent complications. Materials and Methods: A 10-year retrospective study was conducted between 2003 and 2013 on cases admitted to the eye wards of LAUTECH Teaching Hospital, Osogbo, Nigeria. Clinical and sociodemographic data were extracted from the case notes. Data were entered into and analyzed with SPSS version 17 using descriptive statistics. Result: Of the 31 patients admitted for the treatment of orbital cellulitis, 20 (64.52%) were males and 11 (35.48%) were females. The age ranged between 2 and 85 years with a mean of 18.4 + 9.21 years, with 18 (56.06%) aged less than 20 years. The predisposing factors were mainly sinogenic, 18 (58.06%). Maxillary sinus constituted six (33.3%) whereas trauma and local spread constituted six (19.1%) each. Staphylococcus aureus was the only organism cultured in three (42.86%) whereas the remaining (57.14%) showed no growth. Complications recorded were orbital abscess in four and three each of panophthalmitis and optic atrophy. No death was recorded. Commonest surgery performed was bilateral intranasal anthrostomy in eight (25.8%) and drainage of orbital abscess. Visual acuity improved in four cases after treatment from blindness and visual impairment category to normal vision. Conclusion: The commonest cause of orbital infections was from adjacent sinus-related diseases. The problem of negative cultures still persists possibly due to indiscriminate use of antibiotics by the patients. Early presentation, effective antibiotics, and comanagement with other specialists improved outcome. No mortality was recorded.

Keywords: Comanagement, early presentation, orbital cellulitis, prevention, tertiary hospital


How to cite this article:
Adeoti CO, Adejumo OO, Isawumi MA, Kolawole OO, Haastrup AA. Orbital cellulitis in a tertiary institution in Nigeria: Improving outcomes . Niger J Ophthalmol 2017;25:141-5

How to cite this URL:
Adeoti CO, Adejumo OO, Isawumi MA, Kolawole OO, Haastrup AA. Orbital cellulitis in a tertiary institution in Nigeria: Improving outcomes . Niger J Ophthalmol [serial online] 2017 [cited 2018 May 28];25:141-5. Available from: http://www.nigerianjournalofophthalmology.com/text.asp?2017/25/2/141/226006




  Introduction Top


Orbital cellulitis is an infection of the orbital soft tissues posterior to the orbital septum which can threaten not only vision but also life. It is a medical as well as an ocular emergency.

Orbital cellulitis is mostly a disease of childhood but could occur at any age.[1],[2],[3] It occurs more commonly in males.[2]

It most commonly occurs as an acute spread of infection into the orbit from adjacent structures such as sinuses. It could also be from the extension of preseptal cellulitis, local spread, hematogenous, posttraumatic, and postsurgical.[1],[2]

The orbit is prone to contagious spread of infection from the sinuses due to their close relationship to the orbit. As it is surrounded by these paired air-containing spaces, infection is usually a direct extension through the thin bone in the lateral wall of ethmoid most times[2] but could also be through the floor of the frontal sinus, roof of maxillary sinus, or infection from thrombophlebitis along the valveless veins.[2] This sinus relation has been found to be the commonest cause of orbital infection from previous studies.[2],[3],[4],[5]

Previous studies found Staphylococcus aureus as the commonest isolated organisms.[1],[4],[5],[6]

Complications from orbital cellulitis are found in 25 to 41% of cases.[3],[7] Ocular complications could include panophthalmitis, exposure keratopathy, raised intraocular pressure, central retinal artery or vein occlusion, endophthalmitis, and optic neuropathy. Intracranial complications which are rare but could be life-threatening include meningitis, brain abscess, and cavernous sinus thrombosis.[3],[7]

With the advent of antibiotics, the incidence of orbital cellulitis has significantly reduced especially in the developed world. However, significant morbidity and mortality is still seen in developing countries like Nigeria.[3],[5],[7] Early presentation, prompt treatment using multidisciplinary approach can lead to reduction in serious complications. These disciplines include, ophthalmology, paediatrics, internal medicine, infectious disease, otorhinolaryngology, and neurologist as indicated.

The aim of this study is to show that visual outcome can be improved by early presentation and prompt treatment using multidisciplinary approach which will prevent or reduce morbidity or mortality from this disease.

It is hoped that this study would further improve awareness on the management of orbital cellulitis and reduce the associated complications.


  Materials and methods Top


All patients diagnosed to have orbital cellulitis and admitted into the eye ward of LAUTECH Teaching Hospital, Osogbo, Nigeria during the period of October 2003 to September 2013 were recruited into the study. We studied retrospectively the case files of these patients. Information retrieved from patients’ records included age, sex, visual acuity of affected eyes at presentation and discharge, underlying causes, radiological findings, microscopic, culture and sensitivity findings, treatment modalities, multidisciplinary management, and associated complications. Excluded were patients whose records could not be located.

Number of blind eyes and visually impaired using WHO classification at presentation and discharge were identified.

Diagnosis was based on clinical presentation including proptosis and painful ophthalmoplegia. X-rays of the paranasal sinuses were ordered for. None of the patients had computerized tomography done.

Results of blood specimen for microscopy, culture and sensitivity, and full blood count were obtained.

High-dose intravenous broad spectrum antibiotics were usually given. The common drugs used included intravenous metronidazole and ceftriazone.

Appropriate surgical intervention such as orbital or lid abscess drainages (ophthalmic) and/or otorhinolaryngological procedures were carried out as necessary. The Neurologists co-managed the cases of meningitis and cavernous sinus thrombosis with no surgical intervention done. Adjuvant therapies in form of anti-inflammatory, corticosteroids together with occasional physiotherapy when necessary were offered to patients.

Data management

The data were entered into a spread sheet. Statistical analysis was done using Statistical Package for Social Sciences for windows, version 17 (SPSS Inc, Chicago, Illinois, USA). Data were presented in simple descriptive terms as proportions, mean, standard deviation, and 95% confidence interval.


  Results Top


Of the 31 patients admitted for the treatment of orbital cellulitis, 20 (64.52%) were male and 11 (35.48%) were female. The age range was between 2 and 85 years with a mean of 18.4 + 9.21 years. Eighteen (56.06%) were aged less than 20 years and 13 (41.94%) were aged 20 years and above. The visual acuity at presentation and after discharge is shown in [Table 1].
Table 1: Distribution of visual acuity at presentation and discharge

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The duration of symptoms from onset till the admission ranged between 1 day and 4 weeks with 24 (77%) presenting within the first 1 week, four (13%) within 2 weeks while three (10%) presented after 2 weeks of onset.

The right eye was affected in 14 (45.16%), left eye in 10 (32.26%) while both eyes were involved in seven (22.58%) patients.

A predisposing cause could be determined in all patients. Majority [18 (58.06%)] of the causes were sinogenic as shown in [Table 2].
Table 2: Distribution of the predisposing factors for orbital cellulitis

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Of the 18 patients who were sinogenic in origin, six had maxillary sinus infection, two from the frontal sinus, one from ethmoidal sinus, and one from fronto-ethmoidal while the remaining eight were secondary to pansinusitis.

Only seven patients did microscopy, culture, and sensitivity tests. S. aureus was the only organism isolated from the culture results in three (42. 86%) whereas the remaining four (57.14%) showed no growth. Two patients did full blood count showing neutrophilia with leukocytosis while two other patients did not carry out any of their laboratory investigations.

Multidisciplinary management of patients revealed that appropriate surgical intervention was carried out as necessary on 14 patients as shown in [Table 3]. Some of the surgeries done included incision and drainage of orbital abscesses, and eviscerations by the ophthalmologists. High-dose intravenous ceftriazone and metronidazole were administered pre- and postoperatively. The ear, nose and throat (ENT) surgeons did anthrostomies for severe orbital cellulitis and fronto-ethmoidectomies for those that had extension of abscesses into the fronto-ethmoid paranasal sinuses with antibiotics compliments pre- and postoperatively.
Table 3: Distribution of the types of surgery performed for orbital infections

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Combined or interdisciplinary approach between the ophthalmologists and the otorhinolaryngologists was used in the management of 20 cases while the neurologists and neurosurgeons were involved in the management of four cases.

Other complications [Table 4] were managed according to the area involved. The neurosurgeons managed the brain abscess while the neurologists managed the cavernous sinus thrombosis and meningitis. These cases were all managed with intravenous antibiotics, antiinflammatory, and analgesics. Physiotherapy was also prescribed to complement and assist the physical recovery of motor functions of affected limbs.
Table 4: Frequency distribution of complications from orbital cellulitis

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Visual outcome showed that 14 patients remained blind after treatment [Table 1]. Fifteen patients recovered fully whereas complications were noted in 16 patients. Orbital abscess was the commonest type of complication [Table 4]. No death was recorded.


  Discussion Top


Orbital cellulitis is a serious and major infection of orbital tissues. It is a known fact that some of its complications could be sight and life-threatening.[8] It however appears to be a problem much more seen in the lower income countries such as Asia and Africa[2],[3],[4],[5] than among the higher income countries such as France and other western countries.[8] Murphy et al.[9] in Scotland decided to carry out an incidence study due to dearth of literature in that part of the world to further show how uncommon this condition is in the higher income level countries. In this study, the mean age was 18.4 + 9.21 years and 18 (56.06%) were aged less than 20 years. Previous studies have documented the frequency of this disease in children. For example, Nwaorgu et al.[2] found (84%) of their cases to be under 20 years of age. In Scotland, it was also seen that 75% of the incident cases were children.[9] This is not unexpected because sinuses are thinner walled in children and so predispose them to a higher rate of orbital infections.[2],[3],[4],[5] A male preponderance and left orbit predilection was also seen in this study similar to the Ibadan study.[2]

Most of the patients (77%) presented in the first week of onset which may be responsible for the improvement in the visual outcome. At presentation, four patients (13%) were blind while five (15%) improved to normal vision after treatment. This was reflected in the number of patients in the blind group which was seen to have decreased at discharge whereas the number in the normal vision group increased [Table 1]. Those who remained blind were as a result of conditions that could not be reversed even after surgeries were carried out such as those who had trauma and evisceration. This also tends to further support that early presentation and appropriate management could result in improved visual outcome and reduction in mortality (death).

Sinus infections were the commonest cause of orbital cellulitis in this study (58.1%). This trend had similarly been noticed in other studies in the Middle East, India, and Nigeria[7],[10],[11] where sinus infections were documented to constitute the highest proportions. Chaudhry et al.[10] in a 15-year clinical review of patients with a diagnosis of orbital cellulitis referred to a tertiary eye hospital in Riyadh found that untreated sinusitis and orbital trauma were the common risk factors for developing orbital cellulitis which is very similar to our study.

Orbital cellulitis can occur as a result of bacterial infection from various causative organisms. The only organism cultured in this study was S. aureus as seen in three out of seven cases whereas in four there was no growth of organism seen. These may be due to abuse or misuse of antibiotics before presentation. In this environment, getting drugs over the counter is easy and so there is usually antibiotics abuse due to self-medication as documented by Fasina and Ubah.[12] This finding of S. aureus being commonly isolated may indicate the need for immediate treatment of cases with S. aureus-sensitive agents like vancomycin, clindamycin, and doxycycline in addition to cephalosporins before results of laboratory tests are out.

Chavan et al. reported in India that S. aureus in 16 (80%) patients was the commonest organism found following culture of the exudate drained from the orbit. This was followed by B hemolytic streptococci, Mycobacterium tuberculosis, and Aspergillus species, respectively.[11] It however appears that Staphylococcus organism is the commonest cultured organism in Asia and Africa. Comparatively, Streptococcus pneumoniae and hemolytic streptococcus were seen as the common causes in drained orbital abscesses among children in Scotland. On the other hand, trauma and immune suppression were seen as risks factors for orbital cellulitis among adults.[9]

The only radiological investigations carried out were X-rays as either orbital or paranasal sinuses. Ultrasonographic scans, computerized tomogragpic scans, or magnetic resonance imaging (MRI) were not done. The reasons may not be unconnected with the nonavailability of these equipment and or financial constraints so that these advanced radiologic investigations could not be carried out. Modernpractice involves carrying out high-tech radiological investigations. Orbital ultrasound investigations are thought to have a nonspecific role in identifying features of orbital cellulitis such as nonspecific thickening of the orbital wall or edema along the anterior aspect of the orbit as well as early or hidden changes of abscess formation in the head and cavernous sinus.[13] This does not preclude using advanced imaging techniques such as computerized tomography and MRI that could confirm the cause or site of inflammation or complications by using sagittal sections.[13] This would lead to early intervention and reduce the rate of complications such as cavernous sinus thrombosis.[14] It is important to note that all the radiological diagnostic methods complement each other in the diagnosis of orbital diseases.[15]

Medical treatment alone has been found to be satisfactory, if patients report early and are promptly and effectively given evidence-based treatment. This has been documented in times past by Harris[16] up to recent times when Taubenslag et al.[17] recorded that 93% of his patients with frontal sinusitis associated with medial subperiosteal abscesses were successfully managed with medical therapy alone. In this study, 77% of the patients presented in the first week and were promptly treated with intravenous ceftriaxone and metronidazole. Thirteen of the 14 patients who needed surgical intervention had it for drainage of orbital abscesses and sinuses as this was the most common type of surgical intervention carried out.

Complications following orbital cellulitis in this study reveal that orbital abscess followed by panophthalmitis were the commonest types occurring. Similar complications were also recorded by Balogun et al. in Lagos with five cases of orbital abscess, four blind patients, and one exposure keratopathy.[5] However, cases of optic atrophy and meningitis were not seen in their study. Other complications that did not require surgical intervention were meningitis and cavernous sinus thrombosis. Co-magement with the neurosurgeon and neurologists assisted in complete healing with no visual or mortality sequelae. The cases of brain abscesses and meningitis were treated with potent broad spectrum intravenous antibiotics. Other supportive therapies like antiinflammatory drugs (dexamethasone and/or corticosteroids) were also used. Physiotherapy was administered to the patients when necessary until complete recovery. Anticoagulants and antithrombolytics were not used in management by the neurologists. This was mainly due to its nonavailability. It is also important to note that the use of anticoagulants is controversial. It has been found to improve clinical conditions in some cases by reducing mortality; therefore, its use can be advocated, while in some cases, clot was propagated during the course of cavernous sinus thrombosis management.[18] Its use has been advocated because of its life-saving tendency; This scenario has therefore highlighted the importance of comanagement in attaining improved outcomes associated with vision and life.

Comparatively, Shrinivas et al. found no cases of cavernous sinus thrombosis and brain abscess. This could have been attributed to surgical intervention of the complications in all (100%) of their cases requiring surgery. Localization of site by radiological studies such as computerized tomography most likely assisted in the success of surgical treatment coupled with the administration of potent antibiotic. Uhumwangho and Kayoma[19] suggested that patients who presented early were very likely to develop less complications. This study seems to have proven Uhumwangho and Kayoma[19] true since it appeared that our cases with early presentation (77% within a week) assisted in the reduction of complications and thus improved visual outcome as compared to the mean duration of presenting complaints of 15.5 ± 31.6 days by Uhumwangho and Kayoma.[19]

Sinogenic factors were the most common predisposing factor to orbital cellulitis occurring in this study as they contributed to more than 50% of the predisposing factors. Other studies have revealed similar findings.[20] Anthrostomies performed for severe cases of orbital cellulitis aimed at reducing the sinus reservoir of infections and also promote drainage and aeration via the natural ostia, thus reversing the inflammation with subsequent resolution of the orbital cellulitis.

Most patients improved on the administration of appropriate antibiotics or surgical intervention. Only one patient had evisceration and there was also no case of death. Effective co-management with other disciplines supported this.

Early presentation, intervention, and multidisciplinary approach are important in the management of orbital cellulitis. This would reduce morbidity and also prevent death.


  Conclusion Top


Most patients presented early. Therefore, prognosis will be good if orbital cellulitis, though a serious and dangerous infection of orbital tissues, is seen early and effectively treated using multidisciplinary approach. There is also need for health education to avoid over-the-counter drugs, treat predisposing problems such as sinusitis, dental infection, and periorbital infections promptly to prevent orbital cellulitis. Provision of necessary equipment will also go a long way in attaining a good treatment outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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