Left Periorbital Swelling Research Articles

A Severe Case of Septic Cavernous Sinus Thrombosis Caused by a Rare Pathogen

SESSION TITLE: Student/Resident Case Report Poster - Critical Care IV SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Cavernous Sinus Thrombosis (CST) is thrombophlebitis in the cavernous sinuses. Before the availability of antibiotics, this dramatic and lethal illness carried a 100% mortality, therefore, the onus is on the clinician to have early recognition of this disease and treatment options, which include antibiotics, anticoagulation, and surgery. Although there have been case reports of CST as a complication of paranasal sinusitis, otitis media, and pharyngitis in pediatric population, literature review reveals few cases of CST in adults causing multi-organ impairment similar to our patient. We report a case of CST causing cranial nerve palsy and internal carotid artery narrowing from ethmoid and sphenoid sinusitis secondary to Group C, Beta Hemolytic Streptococcus. This is a common flora of upper airways and skin and bacteremia is almost always seen in immunocompromised individuals and rarely seen in an immunocompetent patient like ours. CASE PRESENTATION: 36 year old female with no significant past medical history presented to the ED with a three day history of left sided headaches, subjective fevers, diplopia and left periorbital swelling. On exam, she was febrile with left eye proptosis and left lateral gaze palsy. Labs revealed significant leukocytosis with left shift and elevated inflammatory markers. CTA head and neck showed left cavernous sinus thrombosis/thrombophlebitis as well as narrowing of left internal carotid artery with MRI/MRV confirming these findings. Imaging also revealed bilateral complete opacification of sphenoid and ethmoid cells suggestive of severe sphenoiditis and ethmoiditis. She was admitted to ICU and her course was complicated by septic shock and acute hypoxemic respiratory failure requiring pressors and mechanical ventilation as per ARDS protocol. Further septic workup revealed the patient to have beta hemolytic, group C strep bacteremia with nasal culture showing the same speciation. She was started on IV antibiotics and heparin drip in ICU and was later discharged home on oral warfarin and IV ceftriaxone. DISCUSSION: The likely mechanism in our patient is that she initially had ethmoiditis causing orbital inflammation and thrombophlebitis of the ophthalmic vein, which extended posteriorly to cause septic CST. Literature review shows that S. aureus encompasses two-thirds of the cases followed by streptococci, especially pneumococci, but there have been no cases, to our knowledge, of group C beta hemolytic strep causing CST. CONCLUSIONS: Aggressive multidisciplinary approach to management remains key in these patients due to high mortality if there is a delay in early and proper diagnosis. Sinusitis and ethmoiditis are relatively common and a physician should be aware of the potential adverse consequences, especially in the setting of ptosis, proptosis, and external opthalmoplegia. Reference #1: Hiroshi Sakaida, Masayoshi Kabayashi, Ai Ito. Cavernous Sinus Thrombosis: linking a swollen red eye and headache. Lancet 2014: 384: 928 DISCLOSURE: The following authors have nothing to disclose: Hemal Mehta, Anthony Saleh, Ravish Singhal No Product/Research Disclosure Information

Orbital emphysema after nose blowing

A 33-year-old male presented with a sudden onset of left periorbital swelling and painless erythema over left lower eyelid after vigorous nose blowing (Figure 1a). There was no history of paranasal sinusitis, no trauma to the nose or face and no history of facial or nose surgery. Ophthalmologic examination revealed mild left congested conjunctiva with normal extraocular movements and visual acuity. Flexible fiberoptic rhinoscopy was unremarkable. Computed tomography (CT) scan showed orbital …

An Aggressive Primary Orbital Natural Killer/T-Cell Lymphoma Case

Natural killer/T-cell lymphoma (NKTCL) and its presentation with extranodal orbital involvement as a single lesion are extremely rare. The aim of this article was to describe the presentation, diagnosis, and systemic treatment of a primary orbital NKTCL. A 67-year-old Caucasian woman presented with left exophthalmos, pain, periorbital swelling, and limited extrinsic ocular motility. Orbital cellulitis was suspected, but finally orbital biopsy was performed due to no response to initial antibiotic and anti-inflammatory standard treatment. The pathologic diagnosis was NKTCL. Systemic evaluations were negative. CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) chemotherapy was initiated, but after 2 cycles of treatment, tumoral progression was observed. SMILE (dexamethasone, methotrexate, ifosfamide, L-asparaginase, etoposide) rescue chemotherapy was then administered. Lymphoma progression was inevitable. She died 10 months later. Although more nasal NKTCL cases have been described, the nonnasal primary orbital NKTCL is an uncommon neoplasm with high mortality rate, despite the recent use of more potent chemotherapy regimens.

Rosai dorfman syndrome with extranodal presentation

Rosai-Dorfman disease (RDD) also known as sinus histiocytosis with massive lymphadenopathy is a rare idiopathic and non-neoplastic disorder of histiocytes, resembling the sinus histiocytes of lymph nodes. The most common presentation of RDD is painless cervical lymphadenopathy in a young patient. The typical clinical features of this disease include bilateral painless lymphadenopathy, fever, and polyclonal hyperglobulinemia. However, in about 25% of cases there is no lymph node involvement and the disease presents as a mass in skin, soft-tissue, nasal cavity, eye, bone, or in other extranodal sites (extranodal type). The condition may present with extranodal involvement in 43% of cases, and cutaneous lesions are the most common form of extranodal disease. This can pose a diagnostic challenge if RDD is not considered in differential diagnoses. Isolated extranodal RDD is relatively uncommon. We report this rare case of extranodal RDD in a 32-year-old female who presented with erythematous tender subcutaneous plaques on lower extremities with left periorbital swelling. Histopathological examination demonstrated lymphophagocytosis (emperipolesis) consistent with a diagnosis of RDD.

Utility of 18F-FDG PET/CT in Diagnosis and Management of Mucormycosis

(18)F-FDG PET/CT on a 23-year-old woman with aplastic anemia and left periorbital swelling showed FDG-avid lesions in the head and neck. The lesions were confirmed to be mucormycosis histologically after (18)F-FDG PET/CT-guided biopsy. Antifungal therapy was adjusted with serial follow-up (18)F-FDG PET/CT until complete patient recovery. (18)F-FDG PET/CT is valuable in the diagnosis and management of mucormycosis.

Collagenous Fibroma (Desmoplastic Fibroblastoma) of the Orbital Rim

A 40-year-old woman with left periorbital swelling for 1 month presented without diplopia or change in vision. Imaging studies revealed a 1-cm mass at the frontozygomatic junction at the orbital rim with slight bony erosion and spiculation. The lesion was applied to the periosteum and was excised along with a portion of the bony orbital rim. Histopathology revealed elongated and stellate fibroblasts within a dense collagenous matrix. Vimentin and Masson trichrome staining was consistent with a collagenous fibroma, a rare tumor that has, only once before, been reported in the orbit in the lacrimal fossa region. The current collagenous fibroma arose from the periosteum to grow exophytically, causing minimal bone changes. A literature review shows that this condition predominantly affects middle-aged and older adults rather than children.

Antibiotic-Refractory Sinusitis

A 64-YEAR-OLD MAN WITH A HISTORY OF CHRONIC SINUSITIS PRESENTS WITH left periorbital swelling and subtle left ptosis (FIGURE 1). His past medical history is otherwise unremarkable. He was treated with amoxicillinclavulanate, 875 mg/125 mg, twice per day for 10 days for presumed sinusitis. He experienced mild temporary improvement. Symptoms recurred within a month, and he was given a second course of amoxicillin. Physical examination reveals worsening left periorbital swelling, unilateral nasal blockade, and persistent subtle left ptosis. The neurological examination results are normal, and ptosis is thought to be secondary to palpebral swelling. Lymphadenopathy and hepatosplenomegaly are absent. Laboratory test results are unremarkable. What Would You Do Next?

CT and Orbital Ultrasound Findings in a Case of Castleman Disease

A 53-year-old man with a 2-month history of left periorbital swelling was found to have a large solid intraconal mass on CT scan. Orbital ultrasound showed that the lesion had a cavernous pattern of internal reflectivity. Histopathology revealed hyaline-vascular type Castleman disease (CD). This article represents the first reported orbital ultrasound findings in CD. The findings of CT scan and ultrasound may be useful in the preoperative evaluation of orbital hyaline-vascular type CD.

Posterior scleritis mimicking orbital cellulitis

In 2008, an 88-year-old woman with a background of well controlled systemic hypertension and high myopia presented to an emergency department with a 5-day history of left periorbital swelling, erythema and mild discomfort, without visual loss. She was seen in the ophthalmology clinic on the same day. Her visual acuity was 6/12 in each eye. She was afebrile, with left upper and lower lid erythema, oedema closing the palpebral fissure, and conjunctival and scleral injection. Slit-lamp biomicroscopy revealed normal anterior chambers; clear, well centred intraocular lens implants from previous uncomplicated cataract surgery; and posterior staphylomata (an incidental finding of bulging of the globe seen in some highly myopic patients). A computed tomography (CT) scan revealed left periorbital soft tissue thickening, with stranding confined to the preseptal area.

A Case of Simultaneous Orbital Cellulitis and Intracranial Complication

Purpose: To report a case of simultaneous orbital cellulitis and intracranial complications of acute sinusitis in a young patient. Case summary: The 11-year-old male presented with a one-day history of left periorbital erythematous swelling, fever and headache. He was diagnosed with acute sinusitis at the department of otorhinolaryngology, and endoscopic sinus drainage of pus was performed. However, the patient's symptoms did not improve. The next day, a subdural abscess was found on brain computed tomography. He was treated by external drainage of the periosteal abscess via a subbrow incision and systemic antibiotics, as well as anticonvulsant medication. Conclusions: Twenty days after external drainage and beginning systemic antibiotics and anticonvulsant treatment, he was discharged with improved orbital cellulitis symptoms and a resolved subdural abscess.

A Case of Periocular Necrotizing Fasciitis of Odontogenic Origin

Purpose: We report a case of periocular necrotizing fasciitis originating from dontogenic infection. Case summary: A 53-year-old man, who had suffered from severe periodontitis one week prior, visited our clinic due to a 2-day history of rapidly progressing left mandibular and periorbital swelling and pain. By the time of his visit, he had lost vision in the left eye and had moderate swelling, expression of pus, and skin explosion with necrotizing discoloration of the left lid and lower facial area. MRI of the orbits revealed soft tissue necrosis, gas accumulation, and subperiosteal abscess formation of the left orbit. We administered systemic antibiotics and surgically excised the left periorbital necrotic tissue. A constant expression of pus material was also achieved, decreasing painful swelling. We considered exenteration of the left eye to block the spread of necrosis to adjacent intact tissue; however, the left eye was fairly well-preserved with the exception of mild lagophthalmos developed by the excision of necrotic skin. Streptoccocal species was observed in microbiologic cultures of pus and necrotic tissue and ‘necrotizing inflammation’ was described on tissue biopsy, with the findings consistent with necrotizing fasciitis. Conclusions: Through the diagnosis of necrotizing fasciitis originating from an odontogenic infection, the proper administration of antibiotics and surgical management were achieved. As a result, we were able to preserve the eye. J Korean Ophthalmol Soc 49(6):993-999, 2008

Preseptal cellulitis caused by community acquired methicillin resistant Staphylococcus aureus (CAMRSA)

Infections with methicillin resistant Staphylococcus aureus (MRSA) usually occur in individuals with well established risk factors such as a recent hospital admission, multiple antibiotic treatment, or chronic illness. We report...

Thyroid Eye Disease Presenting After Cosmetic Botulinum Toxin Injections

A 53-year-old woman with left periorbital swelling 4 days after botulinum toxin injection in the lateral canthal area presented after noticing left eye prominence. Physical examination demonstrated proptosis and eyelid retraction. Computed tomography of the orbits confirmed extraocular muscle enlargement consistent with thyroid eye disease. In this case, the patient had development of proptosis after receiving botulinum toxin injections. Although the proptosis may represent progression of the patients' thyroid eye disease, it is worthwhile to consider incitation by botulinum toxin as a possible cause given its widespread use.

M. obliquus-inferior-Nekrose mit Rekonstruktion bei intraorbitalem Holzfremdkörper

A 39-year-old patient presented 3 days after a bicycle accident with a progressive left periorbital inflammatory swelling and diplopia in upgaze. On the day of the accident, a cranial x-ray did not reveal a fracture or an orbital foreign body, and the 2.5 cm skin wound on the left lower eyelid was sutured. For further evaluation, computer tomography) was performed. This did not show a radio-opaque, orbital foreign body. An explorative orbitotomy was carried out and revealed a 3.7 cm long wooden fragment medial to the inferior oblique muscle (OI). The extraconal portion of OI was found to be necrotic. Complete reconstruction of the OI was not possible due to the extent of the necrosis. The residual muscle was fixated to the orbital septum. Recovery was good and the diplopia resolved after 6 months. This case emphasizes the importance of a meticulous inspection of skin wounds with a high risk of remaining wooden foreign bodies and shows the possibility of functional recovery of extraocular muscles following partial reconstruction.

Orbital Metastasis from Squamous Cell Carcinoma of the Esophagus

To describe a rare case of orbital metastasis from squamous cell carcinoma of the esophagus. A 63-year-old man presented with intermittent left-sided headache. This was initially attributed to angle-closure glaucoma and bilateral peripheral laser iridotomies were performed. One month later, he developed left periorbital swelling. On reviewing the history, it was noted that he had undergone surgery for esophageal carcinoma. CT scan revealed a soft tissue mass in the left orbit, which on biopsy showed histologic features of metastatic squamous cell carcinoma. The patient died before palliative radiotherapy could be completed. Orbital metastasis from esophageal carcinoma is rare. In this case, the possibility of metastasis was overlooked at initial presentation, as there were no clinical signs to suggest it. Regardless of the primary tumor, the prognosis following orbital metastasis is poor. It is important to consider radiologic investigation when patients with systemic malignancy present with unexplained headache.

Orbital Peripheral T-Cell Lymphoma in a Child

A 6-year-old boy with known peripheral T-cell lymphoma had progressive left periorbital swelling and CT findings consistent with abscess or necrosis. Biopsy revealed peripheral T-cell lymphoma and associated necrosis involving the lacrimal gland and surrounding orbital tissue. Immunohistochemical and T-cell receptor gene rearrangement studies confirmed the diagnosis. The patient responded to local radiation and systemic chemotherapy. This is the first pathologically confirmed case of orbital peripheral T-cell lymphoma with subpanniculitic features.

Pfählungsverletzung der Orbita

A 71-year-old female patient fell in her garden, inducing a skin wound on the temporal left eyebrow. Skin disinfection and wound closure were performed elsewhere, an X-ray image did not reveal a foreign body. She was referred to our service three days later with a progressive left periorbital swelling. Clinical inspection demonstrated a painfully, fluctuant swelling around the wound with an inflammatory pseudoptosis of the left eye. Vision was reduced on the left eye; anterior and posterior segments of both eyes were unharmed. After opening the wound sutures a purulent liquid was drained and a wooden fragment was found, measuring 22 x 0.5 mm. Because of restriction of abduction of the left eye, magnetic resonance imaging (MRI) was performed, detecting another organic intraorbital foreign body and a fracture of the left medial orbital wall. Anterior orbitotomy was performed and a wooden fragment was removed, measuring 47 x 0.6 mm. Under administration of intravenous antibiotics vision and ocular motility recovered uneventfully. This case emphasizes the value of MRI in the diagnostics of retained wooden foreign bodies as well as the importance of a soigneuse inspection of skin wounds with a high risk for remaining foreign bodies.

Rapidly growing periodontal enlargement

CLINICAL PRESENTATION A 26-year-old white man came to the dental clinic with a complaint of rapid, progressive loosening of his upper teeth. Clinical examination showed Class III mobility in the right posterior maxillary teeth, without detectable mucosal or alveolar abnormalities. Periapical radiographs demonstrated irregular bone around the roots of the maxillary right second and third molars (Fig 1), a feature that was not apparent from bite-wing radiographs taken during a routine dental exam 1 month before his current presentation. Although the clinical course and radiographic findings were considered unusual, a working diagnosis of rapidly progressive adult-onset periodontitis was made, and the patient was appointed for extraction of the right maxillary second and third molars. The extractions were accomplished without difficulty; however, no hard or soft tissue was submitted for histopathologic examination. A follow-up appointment 1 week later showed normal postoperative healing. Two months after the extractions, the patient presented with right maxillary and left periorbital swelling, as well as complaints of decreased left visual acuity, jaw pain, and fever. Left-sided proptosis and decreased function of

The resident's page.

PATHOLOGIC QUIZ CASE 1 R. D. Anderson, MD, and K. D. Devine, MD, Rochester, Minn A 60-year-old white woman consulted her local otolaryngologist about a nasal obstruction of three to four months duration. She had also had three episodes of epistaxis, sneezing, nasal itching, and anterior and posterior rhinorrhea. On examination a very large red pedunculated polyp was noted on the right side. The remainder of the examination was negative and sinus x-ray films were clear. Excision of the polyp was accomplished and the patient was referred to the Mayo Clinic. With cocainization, a gray boggy granulation-like area was noted at the posterior end of the middle turbinate and sphenoethmoid recess area. PATHOLOGIC QUIZ CASE 2 Edward J. Glinski, MD, and Daniel D. Rabuzzi, MD, Syracuse, NY A 76-year-old white man had a one-month history of left periorbital swelling, left nasal and postnasal mucopurulent discharge, and left-sided facial pain.