Dacryoadenitis

Dacryoadenitis, or inflammation of the lacrimal gland, is uncommon in childhood. It can occur with mumps (in which case it is usually acute and bilateral, subsiding in a few days or weeks) or with infectious mononucleosis. Staphylococcus aureus can produce a suppurative dacryoadenitis. Chronic dacryoadenitis is associated with certain systemic diseases, particularly sarcoidosis, tuberculosis, and syphilis. Some systemic diseases produce enlargement of the lacrimal and salivary glands (Mikulicz syndrome).

Dacryocystitis

Dacryocystitis is an infection of the lacrimal sac. Dacryocystitis generally requires obstruction of the nasolacrimal system to allow its development. Acute dacryocystitis manifests with redness and swelling over the region of the lacrimal sac. It is treated with warm compresses and systemic antibiotics. This will help to control the infection, but the obstruction usually requires definitive treatment to reduce the risk of recurrence.

Dacryocystitis can occur in newborns as a complication of a congenital dacryocystocele. Systemic antibiotics and digital pressure for decompression are recommended. The obstruction of the nasolacrimal system can resolve once the infection clears. If spontaneous resolution does not occur, probing should be considered within a short time. An intranasal cyst may be present in conjunction with the dacryocystocele. If this occurs, marsupialization of the cyst may be needed at the time of the probing.

Preseptal Cellulitis

Inflammation of the lids and periorbital tissues without signs of true orbital involvement (such as proptosis or limitation of eye movement) is generally referred to as periorbital or preseptal cellulitis and is a form of facial cellulitis. This is common in young children and may be caused by bacteremia, trauma, an infected wound, or an abscess of the lid or periorbital region (pyoderma, hordeolum, conjunctivitis, dacryocystitis, insect bite). Patients present with eyelid swelling; the edema may be so intense as to make it difficult to evaluate the globe. Prior to the Haemophilus influenzae type B vaccine, the most common cause of pediatric preseptal (facial) cellulitis was bacteremia due to H. influenzae type B. Group A streptococcal infection a common is cause. Clinical examination shows lack of proptosis, normal ocular movement, and normal pupil function. CT examination demonstrates edema of the lids and subcutaneous tissues anterior to the orbital septum (Fig. 626-1). Antibiotic therapy and careful monitoring for signs of sepsis and local progression are essential.

Figure 626-1 CT scan of a patient with preseptal cellulitis.

Orbital Cellulitis

Orbital cellulitis is a condition involving inflammation of the tissues of the orbit, with proptosis, limitation of movement of the eye, edema of the conjunctiva (chemosis), and inflammation and swelling of the eyelids with potentially decreased visual acuity. The mean age is about 7 yr but the range is 10 mo-18 yr. Patients often feel ill with general symptoms of toxicity, fever, and leukocytosis.

Orbital cellulitis can follow direct infection of the orbit from a wound, metastatic deposition of organisms during bacteremia, or more often direct extension or venous spread of infection from contiguous sites such as the lids, conjunctiva, globe, lacrimal gland, nasolacrimal sac, or more commonly the paranasal (ethmoid) sinuses (Table 626-1). In some cases, primary or metastatic tumor in the orbit can produce the clinical picture of orbital cellulitis. The most common cause of orbital cellulitis in children is paranasal sinusitis. The spread of infection to the orbit from the sinuses is more prevalent in children because of their thinner bony septa and sinus wall, greater porosity of bones, open suture lines, and larger vascular foramina. The spread of infection is also facilitated by the venous and lymphatic communication between the sinuses and surrounding structures, which allow flow in either direction, facilitating retrograde thrombophlebitis. Common pathogenic organisms include Staphylococcus species, including methicillin-resistant S. aureus (MRSA), Streptococcus species, and Haemophilus species.

Table 626-1 CHANDLER CLASSIFICATION OF ORBITAL COMPLICATIONS OF SINUSITIS, A CLINICAL DESCRIPTION

* The radiographic correlation of a subperiosteal or orbital abscess seen with CT is a contrast-enhancing mass in the extraconal or intraconal space, possibly with areas of cavitation, because purulence cannot be determined with CT scanning.

From Rudloe TF, Harper M, Prabhu SP, et al: Acute periorbital infections: who needs emergent imaging? Pediatrics 125:e719–e726, 2010.

The potential for complications is great. Vision loss can occur secondary to an increase in orbital pressure that causes retinal artery occlusion or optic neuritis. This is more likely to occur in the presence of an orbital abscess. Extension of infection from the orbit into the cranial cavity can lead to cavernous sinus thrombosis or meningitis, epidural or subdural empyema, or brain abscesses (see Table 626-1).

Orbital cellulitis must be recognized promptly and treated aggressively. Hospitalization and systemic antibiotic therapy are usually indicated. All patients require CT imaging of the orbit (including the surrounding CNS), preferably with intravenous contrast to detect a subperiosteal abscess, orbital abscess, or intracranial extension. Parenteral antibiotics must be started immediately. Antimicrobial agents that generally provide coverage for methicillin-sensitive S. aureus as well as aerobic and anaerobic sinus-derived bacteria include vancomycin and a third-generation cephalosporin (cefotaxime, ceftriaxone), and amoxicillin or ticarcillin combined with a β-lactamase inhibitor (clavulanic acid). Metronidazole may be administered in combination with an agent effective against aerobic or facultative streptococci and S. aureus if anaerobes are suspected or in the presence of intracranial extension. If there is no evidence of improvement or if there are signs of progression, sinus drainage may be required. An orbital or subperiosteal abscess (Fig. 626-2) can require urgent drainage of the orbit. The clinical presentation and course of each individual patient should dictate the need and timing of abscess drainage. The use of adjunctive corticosteroids and anticoagulation for cavernous venous thrombosis and or superior ophthalmic vein thrombosis is controversial.

Figure 626-2 CT scan demonstrating a subperiosteal abscess along the medial wall of the orbit.