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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 52  |  Issue : 2  |  Page : 60-62

Periorbital purulent drainage of resulting from bacterial pansinusitis


1 Department of Teaching, China Medical University Hospital, Taichung, Taiwan
2 Department of Plastic and Reconstructive Surgery, China Medical University Hospital; China Medical University, Taichung; Department of Cosmetics and Health Care, Chung-Jen Junior College of Nursing, Chiayi, Taiwan

Date of Submission21-Jul-2018
Date of Decision29-Aug-2018
Date of Acceptance06-Dec-2018
Date of Web Publication18-Apr-2019

Correspondence Address:
Dr. Pin-Keng Shih
Department of Plastic and Reconstructive Surgery, China Medical University Hospital, 2 Yuh Der Road, 404, Taichung
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_76_18

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  Abstract 

Periorbital cellulitis is much more common in younger children than in adolescents or adults, and most cases of uncomplicated periorbital cellulitis can be treated with antibiotics alone. Here, we report a case of a 53-year-old man with periorbital purulent discharge. Computed tomography imaging revealed pansinusitis. Pus culture isolated a pathogen of Streptococcus constellatus, but it was refractory to 2 weeks of antibiotic therapy with amoxicillin–clavulanate. The patient underwent debridement and functional endoscopic sinus surgery, followed by 10 days of hyperbaric oxygen treatment. The above antibiotic was changed to full-dose intravenous clindamycin. Two weeks after the surgery, the patient was discharged from the hospital. At 1-month follow-up, no purulent discharge was noted; however, mild left-eyelid contracture was observed. This study suggested that if conservative therapy for periorbital purulent discharge in an adult is not effective, progressive treatment, including surgery, should be considered.

Keywords: Periorbital cellulitis, sinusitis, Streptococcus constellatus


How to cite this article:
Lin CM, Shih PK. Periorbital purulent drainage of resulting from bacterial pansinusitis. Formos J Surg 2019;52:60-2

How to cite this URL:
Lin CM, Shih PK. Periorbital purulent drainage of resulting from bacterial pansinusitis. Formos J Surg [serial online] 2019 [cited 2019 Aug 25];52:60-2. Available from: http://www.e-fjs.org/text.asp?2019/52/2/60/256535


  Introduction Top


Periorbital cellulitis is much more common in young children than in adolescents or adults, and most cases of uncomplicated periorbital cellulitis can be treated with antibiotics alone. However, the conservative management of periorbital purulent discharge in adult patients is still controversial. For such patients who exhibit a poor-to-mild response to antibiotic treatment, especially those with accompanying bacterial sinusitis, surgical intervention may be essential. Here, we present a case of periorbital cellulitis with constant purulent discharge after antibiotic management for 2 weeks. Surgical interventions, including debridement and functional endoscopic sinus surgery (FESS), were performed, resulting in the discontinuation of purulent discharge.


  Case Report Top


A 53-year-old man was referred from the emergency department (ED) due to fever with painful, left side supraorbital swelling, and erythematous change. The patient denied systemic or underlying disease, nor recently traumatic event. The purulent discharge was observed at a lateral side of his left upper eyelid [Figure 1]a. The eyeball was orthophoric with no vision loss. He experienced no nasal obstruction or congestion causing breathing difficulty or yellow or greenish discharge from the nose. In the ED, initial vital signs were evaluated, including blood pressure: 146/100 mmHg, heart rate: 118/min, respiratory rate: 20/min, and body temperature: 39.7°C; additionally, he presented clear consciousness. His laboratory data reported the following: white blood cell count, 14,400/μl; neutrophilic segment percentage, 77.8%; high-sensitivity C-reactive protein, 21.18 mg/dL; and level of alanine transaminase, 59 IU/L; aspartate aminotransferase, 49 IU/L; blood urea nitrogen, 32 mg/dL; creatinine, 1.55 mg/dL; sodium, 129 mmol/L; and potassium, 3.0 mmol/L. Computed tomography (CT) imaging revealed pansinusitis (bil frontal, ethmoid, and maxillary sinus involved) and mucus retention with mucosal thickening in the left maxillary sinus with free air and fluid collection in the left eyelid and preseptal space [Figure 1]b and [Figure 1]c. Amoxicillin–clavulanate was prescribed as empirical antibiotics for periorbital purulent discharge and pansinusitis. Streptococcus constellatus was isolated from deep pus culture and demonstrated sensitivity to amoxicillin–clavulanate.
Figure 1: Purulent discharge at the lateral side of upper eyelid. (a) Computed tomography image showed pansinusitis and mucus retention with mucosal thickening in the left maxillary sinus with free air and fluid collection in the left eyelid and preseptal space (b and c)

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After 2 weeks of amoxicillin–clavulanate, the fever subsided, but the constant purulent discharge was still persistent. The patient underwent FESS and debridement, followed by 10 days of hyperbaric oxygen treatment. During FESS, the natural ostium of the left maxillary sinus was widened by removing anterior and inferior membranous and bony fontanel with backbiting forceps. The curved suction was probed through the ostium inferiorly to avoid penetrating the lamina papyracea and entering the orbit. The pathological mucosa was then partially eradicated by suction. Afterward, the left upper eyelid crease incision was done to expose to the preseptal area. Total debridement of the lateral upper eyelid soft tissue was performed. The wound was then closed by simple sure with Nylon 6-0. The antibiotic was changed from amoxicillin–clavulanate to full-dose intravenous clindamycin. Two weeks after the operation, the discharge had notably decreased, and a small open wound over left upper eyelid remained [Figure 2]a. Subsequently, the patient was discharged from the hospital. At the 1-month follow-up, no more discharge was noted, but mild left-eyelid contracture was observed. Scar contracture release was suggested, but the patient wished to receive conservative management [Figure 2]b and [Figure 2]c.
Figure 2: Discharge notably decreased; small open wound over left upper eyelid remained after functional endoscopic sinus surgery and debridement with 10-day hyperbaric oxygen treatment. (a) Mild left-eyelid contracture, without discharge, was found at 1-month follow-up (b and c)

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  Discussion Top


Periorbital cellulitis is more common in children than in adults, with approximately 80% of patients being <10 years old.[1] Antibiotic therapy seems to provide a good response in children with periorbital cellulitis, with few indications for surgery. Georgakopoulos et al. suggested that intravenous antibiotics alone offered effective management in most children, but a small proportion (6%) required surgical intervention.[2] Another study demonstrated that complete recovery was achieved in 109 of 110 children with periorbital cellulitis treated with intravenous antibiotics only.[3] For periorbital cellulitis in adults, there are fewer well-reported studies. Gavriel et al. suggested that most (30 of 37) adult patients respond well to antibiotic therapy, but 36.8% of patients required surgical intervention.[4]

According to the study by Georgakopoulos et al., the major predisposing factors in children with periorbital cellulitis were upper respiratory infection and the common pathogens Staphylococcus aureus, Streptococcus pneumoniae, and Staphylococcus epidermidis.[2] Intravenous antibiotic therapy with ceftriaxone + clindamycin for an average of 8.6 days effectively managed most patients with periorbital cellulitis. Flam et al. suggested that most pathogens in adults originate from the oral flora (56%) and respiratory tract (44%).[5] The common organisms were viridans group streptococci members (50%), S. aureus (31%), Eikenella corrodens (25%), and Prevotella species members (19%). Conservative therapy with amoxicillin–clavulanate resulted in good prognosis in most patients (63%).[4]

In our case, the patient initially received a full dose of amoxicillin–clavulanate for 2 weeks following the isolation of S. constellatus. CT findings suggested that periorbital purulent discharge resulted from pansinusitis. Although the fever subsided after the treatment, subcutaneous discharge was still observed. FESS and debridement were suggested to the patient, followed by 10 days of hyperbaric oxygen treatment. The debridement was not only for decompression but also drainage the pus and eradication of the necrotic tissue. Pus was identified in the maxillary sinus and was irrigated; maxillary sinus culture revealed the presence of S. constellatus. Subsequently, the antibiotic was changed to full-dose intravenous clindamycin. The discharge had notably reduced in 2 weeks, and the patient was discharged from the hospital. At the 1-month follow-up, no discharge was noted, but mild left eye contracture was observed. In conclusion, aggressive treatment including surgery may be suggested in case of poor response to conservative treatments in adults with periorbital purulent discharge.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Baring DE, Hilmi OJ. An evidence based review of periorbital cellulitis. Clin Otolaryngol 2011;36:57-64.  Back to cited text no. 1
    
2.
Georgakopoulos CD, Eliopoulou MI, Stasinos S, Exarchou A, Pharmakakis N, Varvarigou A. Periorbital and orbital cellulitis: A 10-year review of hospitalized children. Eur J Ophthalmol 2010;20:1066-72.  Back to cited text no. 2
    
3.
Gonçalves R, Menezes C, Machado R, Ribeiro I, Lemos JA. Periorbital cellulitis in children: Analysis of outcome of intravenous antibiotic therapy. Orbit 2016;35:175-80.  Back to cited text no. 3
    
4.
Gavriel H, Jabarin B, Israel O, Eviatar E. Conservative management for subperiosteal orbital abscess in adults: A 20-year experience. Ann Otol Rhinol Laryngol 2018;127:162-6.  Back to cited text no. 4
    
5.
Flam JO, Platt MP, Sobel R, Devaiah AK, Brook CD. Association of oral flora with orbital complications of acute sinusitis. Am J Rhinol Allergy 2016;30:257-60.  Back to cited text no. 5
    


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