Hospital-based study of causative organisms and clinical picture of orbital cellulitis secondary to sinusitis

Gihan M Shokier; Sara A Rabiea; Mahmoud M Soliman; Ahmed M EL Batawi; Rana Ahmed; Nermeen M Bahgat

doi:10.4103/ejos.ejos_78_22

ORIGINAL ARTICLE

Year : 2023 | Volume : 116 | Issue : 1 | Page : 1-6

Hospital-based study of causative organisms and clinical picture of orbital cellulitis secondary to sinusitis

Gihan M Shokier¹, Sara A Rabiea¹, Mahmoud M Soliman¹, Ahmed M EL Batawi², Rana Ahmed¹, Nermeen M Bahgat¹
¹ Department of Ophthalmology, Cairo University, Cairo, Egypt
² Department of ENT, Cairo University, Cairo, Egypt

Date of Submission	26-Oct-2022
Date of Decision	16-Nov-2022
Date of Acceptance	16-Nov-2022
Date of Web Publication	30-Mar-2023

Correspondence Address:
MD Nermeen M Bahgat
Department of Ophthalmology, Cairo University, Cairo 1234
Egypt

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/ejos.ejos_78_22

Abstract

Objectives The aim of this study was to assess the behavior of orbital cellulitis secondary to sinusitis and the detection of the causative organisms in patients presenting to Cairo University Hospitals.
Patients and methods This was a cohort study in which 43 cases diagnosed with orbital cellulitis secondary to sinusitis were admitted to hospital and were enrolled in the study. All patients underwent thorough ophthalmological examinations, ENT consultations, and systemic assessments. Coronal and axial computed tomography scans of orbit, paranasal sinuses, and brain were done for all patients. Some patients had specimen sent for culture and sensitivity from the drained pus either from sinuses or lid abscesses.
Results A total of 43 cases were involved in this study. The mean age was 23.93±19.38 years. Seven patients had systemic medical disorders. Six patients were diabetic. All patients received antimicrobial treatment, with seven (16.2%) patients needing addition of antifungal treatment and seven (16.2%) patients needing addition of steroids. A total of 20 (46.5%) patients needed surgical intervention. From these patients who had a specimen sent for culture and sensitivity, five (11.6%) had bacterial infections, seven (16.3%) had fungal infections, and eight (18.6%) showed no growth. A total of 39 (90.7%) patients responded clinically to treatment and four patients had recurrence within 6 months.
Conclusion Bacterial infection was the commonest cause of orbital cellulitis secondary to sinusitis in the current study. Diabetes mellitus was a predisposing factor to fungal infection, which had a poor prognosis, in which visual acuity reached no light perception.

Keywords: antibiotics, computed tomography, culture, orbital cellulitis, sinusitis

How to cite this article:
Shokier GM, Rabiea SA, Soliman MM, EL Batawi AM, Ahmed R, Bahgat NM. Hospital-based study of causative organisms and clinical picture of orbital cellulitis secondary to sinusitis. J Egypt Ophthalmol Soc 2023;116:1-6

How to cite this URL:
Shokier GM, Rabiea SA, Soliman MM, EL Batawi AM, Ahmed R, Bahgat NM. Hospital-based study of causative organisms and clinical picture of orbital cellulitis secondary to sinusitis. J Egypt Ophthalmol Soc [serial online] 2023 [cited 2023 May 30];116:1-6. Available from: http://www.jeos.eg.net/text.asp?2023/116/1/1/372946

Introduction

The orbital septum is a crucial anatomical separating landmark. Inflammation and infection anterior to it is known as preseptal cellulitis, which is handled differently than that which occurs posterior to it and known as orbital cellulitis [1],[2]. The bony orbit is a cavity with a pear shape that houses the eyeball and its adnexa. The orbit is bordered on the superior side by the frontal sinus, on the inferior side by the maxillary sinus, on the medial side by the ethmoid sinus, and on the posterior part by the sphenoid sinus [3],[4],[5].

All age groups may be affected by orbital cellulitis; however, children are more likely to develop it. The frequency in children is 1.6 per 100 000 of normal population, whereas in adults is 0.1 per 100 000 [6],[7]. The incidence of orbital cellulitis is highest in the early spring and winter and is minimal in the summer [6],[8],[9]. The patients commonly present with eyelid edema, pain, redness, tenderness, chemosis, and ocular motility limitation. In most patients, the emergence of the aforementioned clinical symptoms and signs along with a history of an upper respiratory infection may be enough to establish a diagnosis [9],[10],[11].

The age of the patient and the etiology of orbital cellulitis affect pathogens. The pathogen most frequently linked to sinus infections is Streptococcus pneumoniae, whereas infections brought on by local trauma are more commonly caused by Staphylococcus aureus and Streptococcus pyogenes. Owing to widespread vaccination, Haemophilus type B, which was once a prevalent cause, is now less frequent [2],[4],[6]. Fungi are remarkable pathogens, inducing orbital cellulitis in immunosuppressed or uncontrolled diabetes or diabetic ketoacidosis. Infection in children less than 9 years is usually with a single aerobic organism; with rising age, especially age greater than 15 years, infection is more usually polymicrobial with combined anaerobic and aerobic infections [10],[11],[12],[13].

This study’s aim was to assess the behavior of orbital cellulitis secondary to sinusitis as regarding the presentation, the response to treatment, and detect the causative organisms in a sample of patients presenting to Cairo University Hospitals.

Patients and methods

This was a prospective cohort study that was conducted on cases with orbital cellulitis secondary to sinusitis presenting to the Departments of Ophthalmic and ENT Emergency at Cairo University Hospital, from January 2019 until October 2019. The study was approved by the institutional review board of Cairo University (Cairo University Research Ethics Committee). All selected patients received an explanation of the study design and aims. An informed consent was obtained from all patients or their guardians. All patients with history of orbital surgery or trauma within 1 month before the starting of symptoms and signs of orbital cellulitis were excluded.

All participants underwent history taking, such as patient complaints, history of the present illness and past history of common cold and sinusitis, recurrent cellulitis, trauma, recent surgery, and medical diseases aiming for selection of cases of orbital cellulitis secondary to sinusitis. Full ophthalmological examination included evaluation of uncorrected and best-corrected visual acuity (VA) using Snellen’s chart; pupillary reaction to light; lid signs of orbital cellulitis such as redness, edema, or secondary ptosis; slit-lamp examination of anterior segment; Intraocular pressure (IOP) measurement using a Goldman applanation tonometer; fundus examination using slit-lamp biomicroscopy using +90 D lens; examination of extraocular muscle balance and motility in the six cardinal positions; and examination of proptosis using a Hertel exophthalmometer. ENT examination, erythrocyte sedimentation rate, complete blood count, and blood culture were done for all patients. All patients had a computed tomography scan of the orbit, paranasal sinuses, and brain using axial and coronal thin cuts with and without contrast to demonstrate the sinuses involved and to detect the size and location of potential subperiosteal abscess (SPA) or orbital abscess.

Patients were classified according to Chandler classification [12], as shown in [Figure 1].

Figure 1 Chandler classification of periorbital infections.

Click here to view

All patients were administered intravenous broad-spectrum empirical antibiotics on admission (Ampicillin and sulbactam 1 g every 12 h for adults, amoxicillin 50–80 mg/kg/day in children, cefotaxime 1 g every 12 h in adults and 30–75 mg/kg/d divided every 12 h in children, and metronidazole 500 mg every 8 h in adults and 7.5 mg/kg every 8 h in children) and continued on oral treatment for total duration of 10–14 days. Antibiotics were adjusted according to culture and sensitivity of pus obtained from those who needed surgical intervention. Antifungal therapy (Intravenous amphotericin 1 mg/kg/24 h or voriconazole 400 mg/12 h for 2 days and then 200 mg/12 h) was added if fungal infection was suspected as in immunocompromised patients or proved by culture and sensitivity. Oral prednisolone was added to patients showing partial response to accelerate recovery provided that the patients were immunocompetent or for children. It was started from day 4 to day 7 with tapering within the next 1–2 weeks. The initial dose was 1.5 mg/kg/day for 3 days followed by 1 mg/kg/day for further 3 days. Surgical drainage and functional endoscopic sinus surgery (FESS) were indicated in the following cases: deterioration of vision, no improvement within 48 h of treatment, development of superior SPA, fungal infection, and in adults. However, in children below the age of 9 years, medially located SPA may respond to intravenous antibiotics. In cases of severe mucormycosis with orbital involvement, exenteration is indicated. Retrobulbar amphotericin B injection is a new modality in recent publications, but it was not indicated in our cases [14].

Statistical analysis

The Statistical Package for the Social Sciences, version 26 was used to code and enter the data (IBM Corp., Armonk, New York, USA). Quantitative data were summarized employing the mean, SD, median, minimum, and maximum, and categorical data were described using relative frequency (%) and frequency (count). Comparisons between quantitative variables were performed using the nonparametric Kruskal–Wallis and Mann–Whitney tests. For contrasting categorical data, χ²/2 test was conducted. When the expected frequency is less than five, an exact test was used. The Spearman correlation coefficient was used to determine correlations between quantitative variables.

Results

A total of 43 patients were involved in this study, where 26 (60.5%) were males and 17 (39.5%) were females. The mean age was 23.93±19.38 years (ranging from 4 months to 70 years). Only seven (16.3%) patients had systemic medical disorders. Six (14.0%) patients were diabetic, whether being only diabetic or with associated other systemic diseases, as two (4.70%) of them had associated hypertension and one (2.3%) had associated ischemic heart disease. One patient had ischemic heart disease only.

A total of 30 (69.7%) patients had general symptoms of fever, headache, and malaise, and 40 (93%) patients had proptosis ([Figure 3]a). Six (14.0%) patients had a relative afferent pupillary defect. Fundus examination revealed that 34 (79.1%) patients had normal fundi, five (11.6%) patients had pale disc, one (2.3%) patient had central retinal artery occlusion, and three (7%) patients had no view for fundus. All (100%) patients had limited extraocular muscle motility.

Regarding VA, seven (16.3%) patients had VA of no perception of light (no PL), one (2.3%) patient had PL, one (2.3%) patient had VA of hand motion good projection, 6 (13.9%) patients had VA of 6/18-6/60, and 20 (46.5%) patients had VA of 6/6-6/12. VA could not be assessed in eight (18.6%) pediatric patients.

Two (4.7%) patients had endophthalmitis, 17 (39.6%) patients had SPA (detected by computed tomography), and none of the patients had intracranial complications. According to Chandler calcification, 26 (60.4%) patients were of grade II (orbital cellulitis) and 17 (39.6%) patients were of grade III (SPA). A total of 20 (46.6%) patients had affection of frontal, ethmiodal, and maxillary sinuses; four (9.3%) patients had ethmoido-maxillary sinus affection ([Figure 2]); and 19 (44.2%) patients had only ethmoidal sinus affection.

Figure 2 CT orbit and paranasal sinuses (coronal view) showing bilateral maxillary sinusitis and RT ethmoid sinusitis. CT, computed tomography.

Click here to view

A total of 20 (46.5%) patients had a specimen sent for culture and sensitivity from sinus and four of them had additional specimen from lid abscess. Both showed the same organisms as shown in [Table 1]. The culture and sensitivity were not correlated to the age or systemic diseases. However, two of the patients with mucormycosis were diabetic. They had black periorbital and nasal eschars.

Table 1 The results of culture and sensitivity of our patients

Click here to view

All (100%) patients received systemic intravenous antibiotics as empirical therapy, which were adjusted according to culture and sensitivity. Overall, seven (16.2%) patients needed antifungal treatment according to culture and sensitivity. Seven (16.2%) patients needed addition of steroids due to partial response. A total of 20 (46.5%) patients required FESS, which was indicated owing to the following: loss of vision (seven patients), no improvement within 48 h of treatment (four patients), and fungal infection for debridement and debulking (seven patients). Five patients had mucormycosis and two had aspergillosis, as shown in [Table 1]. A total of 17 patients needed drainage for SPA, which was done endoscopically in 11 patients who had medial SPA and by transorbital open approach in six patients who had superior SPA.

The mean duration of treatment was 2.51±1.22 weeks. It was not correlated to the age, sex, laterality, general conditions, severity of signs, or occurrence of complications (P values were 0.356, 0.852, 0.249, 0.181, 0.305, and 0.180, respectively).

A total of 39 (90.7%) patients improved clinically with resolution of all signs with treatment ([Figure 3]b). Causative organisms had insignificant effect on the response to treatment, as P value was 0.569. Four (9.3%) patients had recurrence within 6 months. The recurrence occurred in one case of aspergillus and one case of S. aureus infection. No recurrence occurred in diabetic patients. Recurrence was not correlated with the used treatments, whether systemic antimicrobial agent alone, FESS and systemic antimicrobial, or the group that needed the addition of steroids (P values of 0.181, 0.235, and 0.376, respectively).

The VA of the patients before and after treatment is demonstrated in [Table 2]. A total of five (11.63%) patients had improved vision after treatment, whereas the remaining had sustained VA, with seven patients had vision of no light perception. Four of the patients who had fungal infection showed VA of no PL, and this indicated the aggressive course of fungal infections.

Figure 3 (a) A 6-year-old child having right orbital cellulitis presented to our casualty with edema, erythema, and proptosis. (b) The same patient with total cure with only systemic antibiotics for 2 weeks with no need for surgical drainage.

Click here to view

Table 2 Visual acuity of our patients before and after treatment

Click here to view

Discussion

The causes of orbital cellulitis include direct contiguous spread (such as from the sinuses or teeth), exogenous (such as trauma or surgery), and endogenous (hematogenous). Numerous studies have demonstrated that the spread of infection from paranasal sinuses is a major cause of orbital cellulitis [6]. In this study, patients of orbital cellulitis secondary to sinusitis admitted to Cairo University Hospital over a 10-month period were evaluated for clinical presentations, pathogenic organisms, and therapeutic outcomes. Cairo University Hospital supplies tertiary service and medical emergency for millions from various areas in Egypt. A total of 43 patients who met the diagnostic criteria for orbital cellulitis secondary to sinusitis were recognized.

The mean age of presentation for all patients was 23.93 years (ranging from 4 months to 70 years), similar to the study in Minia University [10], as 60% of their patients were above 16 years and males. This was different from the study of the Pediatrics Department in University of Patras, Greece, with a periorbital or orbital cellulitis diagnosis throughout the 10-year period from January 1997 to December 2007, which was retrospectively studied as the mean age was 3.7±3.1 years [5]. This supports that all ages are susceptible to infection.

In our study, seven (16.3%) patients had systemic medical disorders, whereas the rest (83.7%) were medically free. Six (14.0%) of the seven patients were diabetics, either only diabetic or associated with other systemic diseases. This showed that DM was a major risk factor for orbital cellulitis. The majority of patients presented with general symptoms of fever, headache, anorexia, and malaise. Proptosis was the major presenting sign in 93% of patients. A total of 15 (34.9%) patients had lid edema, 20 (46.5%) patients had ciliary injection, six (14.0%) patients had a relative afferent pupillary defect, and the others had rounded regular reactive pupil. A total of 34 (79.1%) patients had normal fundi, five (11.6%) patients had pale disc, one patient had central retinal artery occlusion, and three patients had no view for fundus. All patients had limited EOM motility.

Compared with the results of our study, the Royal Victorian Eye and Ear Hospital study stated that the most frequent symptoms of orbital cellulitis were decreased VA compared with the noninvolved eye (54 patients, 69%), ophthalmoplegia (47 patients, 60%), elevated intraocular pressure (43 patients, 55%), and relative afferent pupillary defect (six patients, 8%) [14]. In Minia University Hospital study, all of the patients had periorbital edema, proptosis, and tenderness with ocular motility restriction [10]. Six (14.0%) patients had lid abscess, 11 (25.6%) had SPA, two (4.7%) had endophthalmitis, and seven (20.9%) had loss of vision only. No one had intracranial complications.

In our study, 20 (46.5%) patients had a specimen sent for culture and sensitivity from sinus and four of them had additional specimen from lid abscess; both showed the same organisms. The results showed five (11.6%) patients had bacterial infections, seven (16.3%) patients had fungal infections, and eight (18.6%) patients had no growth. Two patients who had mucormycosis and one patient who had S. aureus were diabetic. The other five patients had no associated condition. In our study, bacteria was the commonest cause of orbital cellulitis secondary to sinusitis, as five patients had bacterial infection according to culture and sensitivity, eight cases had no growth, which may be bacterial infection, and 23 patients who did not need FESS responded well to antibiotic treatment, so bacterial infection was the probable cause in 36 (83.7%) patients.

The negative results may be attributed to contamination of sample or prior use of antibiotics which made the isolation of the causative organisms from the sample difficult [15]. The results of several orbital abscess cultures are frequently negative, indicating that the abscess may mainly be an inflammatory spillover into the orbit rather than a true uncontrolled infection in the orbit [16]. The surgery’s risks and prospective complications can often be prevented as several patients respond well to medical treatment alone [17].In this study, all (100%) patients were administered broad-spectrum antibiotics covering gram-positive, gram-negative, and anaerobic bacteria as empirical therapy and only seven (16.2%) patients needed addition of steroids. Seven patients received antifungal according to culture and sensitivity. This is similar to other studies but different in the number of patients needed surgery. The surgical intervention in the form of FESS was indicated in 20 (46.5%) patients owing to deterioration of vision, no improvement within 48 h of treatment, occurrence of complications, or cases of fungal infection who needed debridement.

Clinically, 39 (90.7%) patients responded to treatment and four (9.3%) patients had recurrence within 6 months. In the Royal Victorian Eye and Ear Hospital study, two (3%) cases presented to the hospital with a recurrence of symptoms within 3 days of discharge. Neither underwent surgery as in patients throughout their initial hospitalization [14]. Recurrence of orbital infection happened in three (5.3%) cases in a 10-year retrospective review of 57 children hospitalized to the department of otolaryngology at Sant’ Orsola-Malpighi Hospital, University of Bologna [11].

The relation between the type of treatment and the response to treatment showed that 93.7% of patient who received only systemic antimicrobial agent responded to treatment and 6.3% had recurrence of infection, 85% of patients who received FESS and systemic antimicrobial agent responded to treatment, and 100% of patients who received additional steroid responded to treatment.

In our study, five (11.63%) patients had improved vision after treatment, whereas the remaining had sustained VA, with seven patients had vision of no light perception. Four of the patients who had fungal infection showed VA of no PL, and this indicated the aggressive course of fungal infections.

In conclusion, bacterial infections were the commonest cause of orbital cellulitis secondary to sinusitis in the current study. DM was a predisposing factor to fungal infection, which had a poor prognosis with VA reached no light perception.

Acknowledgment

All authors contributed in data collection, writing, and reviewing of the work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Amin N, Syed I, Osborne S. Assessment and management of orbital cellulitis. Br J Hosp Med 2016; 77:216–220.
2.	Abtahi SMB, Eghtedari M, Hosseini S, Shirvani M, Talebi A, Masihpoor N et al. Non-medial infectious orbital cellulitis: etiology, causative organisms, radiologic findings, management and complications. J Ophthalmic Inflamm Infect 2020; 10:22.
3.	Wald ER, Bordley WC, Darrow DH, Grimm KT, Gwaltney J, Marcy SM et al. Clinical practice guideline: management of sinusitis. In: Wald ER, Bordley WC, Darrow DH, editors. Cited from American Academy of Pediatrics. 5th ed. 2001. 108. 798–808.
4.	Babar TF, Zaman M, Khan MN, Khan MD. Risk factors of preseptal and orbital cellulitis, J Coll Physicians Surg Pak 2009; 19:39–42.
5.	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; 20:1066–1072.
6.	Mohd Ilham I, Muhd-Syafi AB, Khairy-Shamel ST, Shatriah I. Clinical characteristics and outcomes of pediatric orbital cellulitis in Hospital Universiti Sains Malaysia: a five-year review. Singapore Med J 2020; 61:312–319.
7.	Rodríguez Ferran L, Puigarnau Vallhonrat R, Fasheh Youssef W, Ribó Aristazábal J, Luaces Cubells C, Fernández JP. Orbital and periorbital cellulitis. Esp Pediatr 2000; 53:567–572.
8.	Chaudhry IA, Shamsi FA, Elzaridi E, Al-Rashed W, Al-Amri A, Al-Anezi F et al. Outcome of treated orbital cellulitis in a tertiary eye care center in the middle East. Ophthalmology 2007; 114:345–354.
9.	Wong SJ, Levi J. Management of pediatric orbital cellulitis. A systematic review. Int J Pediat Otorhinolaryngol 2018; 110:123–129.
10.	Elshafei AMK, Sayed MF, Abdallah RMA. Clinical profile and outcomes of management of orbital cellulitis in Upper Egypt. J Ophthalmic Inflamm Infect 2017; 7:8.
11.	Sciarretta V, Demattè M, Farneti P, Fornaciari M, Corsini I, Pic O. Management of orbital cellulitis and subperiosteal orbital abscess in pediatric patients: a ten-year review. Int J Pediatr Otorhinolaryngol 2017; 96:72–76.
12.	Chandler JR, Langenbrunner DJ, Stven ER. The pathogenesis of orbital complications in acute sinusitis. The Laryngoscope 1970; 80:1414–1428.
13.	Gonçalves R, Menezes C, Machado R, Ribeiro I, Lemos JA. Periorbital cellulitis in children: analysis of outcome of intravenous antibiotic therapy. Orbit 2016; 35:175–180.
14.	Potter NJ, Brown CL, Mcnab AA, Ting SY. Orbital cellulitis: Medical and Surgical Management. J Clin Exp Ophthalmol 2011; 90:100.
15.	Mathias MT, Horsley MB, Mawn LA, Laquis SJ, Cahill KV, Foster J et al. Atypical presentations of orbital cellulitis caused by methicillin resistant Staphylococcus aureus. In: Mathias MT, Horsley MB, Mawn LA, Laquis SJ, Cahill KV, Foster J editors. Cited from Ophthalmology. 6th ed. 2012. 119. 1238–1243.
16.	Boden JH, Ainbinder DJ. Methicillin resistant ascending facial and orbital cellulitis in an operation Iraqi Freedom troop population. Ophthal Plast Reconstr Surg 2007; 56 397–399.
17.	McKinley SH, Yen MT, Miller AM, Yen KG. Microbiology of pediatric orbital cellulitis. Am J Ophthalmol 2007; 144:497–501.