Orbital abscess and inflammation of odontogenic origin

Odontogenic infection of the paranasal sinuses and the orbit is a rare but ominous condition, as it may lead to disastrous complications such as blindness, cavernous sinus thrombosis, brain abscess or even death [1-12]. Odontogenic orbital infection appears as cellulitis but sometimes an abscess formation can be seen on radiologic examination. In 70-80 % of the cases, it results from the spread of odontogenic sinusitis caused by the extraction of maxillary teeth [13-14]. A smaller percentage is due to transduction of the infection from the eyelids, tonsils, middle ear, intracranial areas, or may be caused by a systemic disease [5, 15]. We present here a case of acute orbital infection of dental origin which had an unusually long course due to delayed diagnosis and which was further prolonged by the patient’s refusal to allow dental extractions.

A 33-year-old male with chemosis, exopthalmos, edema of the lower eyelid and pain in the infraorbital area presented to the emergency of the ophthalmology department. Pupil reflexes were normal but the patient had decreased ocular mobility, diplopia and moderate decrease in visual acuity (Vos=8/10). On admission, his temperature was 37.7 ⁰C and leukocyte count was 22,000 / mm³ with 92.9 % neutrophils. The patient was prescribed amoxicillin/clavulanic acid 626 mg, per os t.i.d.; despite treatment, his clinical condition deteriorated the following day, while edema and pain spread to the upper eyelid, the orbit and the periorbital region. Bacteroides stercoris was isolated from cultures obtained from the conjunctival sac and the patient’s antibiotic coverage was broadened to vancomycin 500 mg intravenously t.i.d., metronidazole 500 mg intravenously b.i.d. and ceftazidime 1000 mg intravenously t.i.d. However, there was no clinical improvement. Magnetic Resonance Imaging (MRI) of the face showed opacification of the left maxillary sinus, the anterior left ethmoid cells and the lower part of the left frontal sinus, proptosis of the left eyeball and fluid accumulation (characterized as swelling or pus) between the orbital roof and the superior and medial rectus and superior oblique muscles, extending to the medial orbital wall and affecting the optic nerve (Figure 1a). A maxillofacial surgeon was consulted and further dental history was obtained. The patient reported

endodontic treatment of upper left first and second premolar molar teeth by a private dentist (Figure 1b). The patient recalled a feeling of ”air blow” into his sinuses during irrigation of the root canals with sodium hypochlorite. On the day following tooth extraction, the patient developed swelling of his left facial area with pain and saw an ENT surgeon who diagnosed sinusitis of the maxillary sinus and prescribed cefuroxime axetil 500 mg b.i.d., metronidazole 500 mg b.i.d., anti-inflammatory drugs orally and decongestant nasal spray for eight days. The antibiotic regimen led to some improvement in the patient’s clinical picture and he was recommended to continue the endodontic therapy. Ten days after completion of the endodontic therapy, the patient presented to the ophthalmology emergency. After a detailed dental history and examination by the maxillofacial surgeon, teeth extractions and antrostomy were suggested. However, the patient refused to undergo dental extractions. In an effort to decompress the maxillary sinus, intranasal antrostomy under local anesthesia was performed by an ENT surgeon, and a silicone catheter was placed for drainage of pus and irrigation of the maxillary sinus. A new specimen was collected via the tube and sent for culture. The procedure offered temporary relief from the symptoms that lasted one day. There was further deterioration of clinical signs (worsening edema, erythema, proptosis, chemosis, and limitation of ocular mobility) and symptoms (diplopia and reduction of visual acuity on 4/10, Figure 1c). Patient underwent an urgent CT scan (Figure 1d) which confirmed the previous MRI findings; no involvement of the cavernous sinus or the cerebral parenchyma was recorded. The patient was taken to the operation theatre and underwent widening of existing antrostomy under general anesthesia by oral and maxillofacial surgeons. A copious flow of purulent material was