A Young girl with previous history of repeated pain over medial canthus and chronic use of decongestants now presents with intense chills, rigors, and diplopia on lateral gaze. Examination shows optic disc congested. Most likely diagnosis would be:
C i.e. Cavernous Sinus Thrombosis Periostitis It is rare inflammation of periosteum mostly affecting orbital margin. Mostly d/t trauma, TB, syphilis or extension of inflammation from neightbouring tissue. Deep orbit involvement causes less definite signs. There may be pain of deep seated nature, proptosis with detion of direction of eye If apex of orbit is involved (orbital apex syndrome) various ocular motor palsies may develop with trigeminal anaesthesia & neuralgia and occasionly amaurosis d/t involvement of optic nerveQ. Orbital Cellulitis (OC) It is a purulent inflammation of cellular tissue of orbit. It is most common d/t extension of inflammation from neighbouring tissue esp nasal sinuses (mc. ethmoid). Other less common causes are penetrating injuries (esp with retained foreign body with in 72 hours), septic operations, posterior extension of suppurative infections of eyelids or eyeball eg panopthalmitis, facial erysipelas, or dacrocystitis, metastases in pyaemia Preseptal orbital cellulites involves structures anterior to orbital septum i.e. largely lids and presents as a swelling of lids, with erythema, chemosis and conjunctival discharge. But there is no proptosis, or restriction of ocular movements or visual function. However, orbital cellulites term is reserved for infections behind the orbital septum which may or may not spill over to lids. Bacterial OC is more common in children and fulminant infection (& ischemic infarction) with Mucor or Aspergillus typically affects patients with diabetes (esp ketoacidosis) and immunosuppression. Presentation is Extensive swelling of lids with chemosis often obscure proptosis (i.e. most commonly lateral & downwards). Proptosis with impaired mobility resulting in diplopia Pain is severe, increased by movement of eye or pressure Unilateral, tender, warm & red periorbital edema. Painful opthalmoplegia Rapid onset of severe malaise, fever, pain Vision may be impaired owing to retrobulbar optic neuritis or compression of otic nerve or its blood supply at the apex of orbit Fundus is difficult to examine; it may be normal or show engorgement of veins and optic neuritis developing later into optic atrophy. Orbit abscess usually pointing, towards skin of lid near orbital margin or conjunctival fornix is rare in sinus related but common in post traumatic or post operative cases. Panopthalmitis may supervene & there is grave danger of Meningitis, cerebral symptoms and cavernous sinus thrombosis, (CST). CST should be suspected when there is evidence of bilateral involvement, rapidly progressive proptosis, and congestion of facial, conjunctival and retinal veins. Additional features include abrupt progression of clinical signs a/w prostration, severe headache, nausea and vomittingQ. Cavernous Sinus Thrombosis Infection may occur obital veins, as in septic lesions of face, orbital cellulites, erysipelas, and infective conditions of mouth, pharynx, ear, nose and accessory sinuses, or as a metastasis in infectious diseases or septic condition. The patient presents with almost same features as in orbital cellulites, but with systemic symptoms such as fever, rigors, vomiting, headache, altered sensorium and severe cerebral symptomsQ. Another impoant diagnostic feature is transference of symptoms to the fellow eye 0, which occurs in 50% of cases where as bilateral orbital cellulitis is very rare. The first sign of other eye involvement is often paralysis of the opposite lateral rectus Q & this should be carefully watched for in any suspicious case of inflammatory unilateral proptosis. These is severe supra orbital pain d/t involvement of ophthalmic division of trigeminal nerve, and paresis of ocular motor nerves. In later stages pupil is dilated, eye immobilized and cornea anesthetic. Proptosis occurs in almost all cases, but is of late onset in cases of otic origin. Retinal veins may be greathy engorged and when this occurs it is usually accompanied by pronounced disc swelling (both indicating extensive implication of orbital veins) Bilateral (but more pronounced on the side of aural lesion), typical papilledema is most common in otitic cases & indicate meningitis or cerebral abscess Simultaneous bilateral CST, with proptosis and disc swelling, occurs in disease of sphenoid sinuses. Edema in the mastoid region behind the ear (d/t thrombosis of emissary vein) confirms the diagnosis. Feature Cavernous sinus thrombosis Orbital cellulites Panopthalmitis Leteralality Unilateral initially but very soon becomes bilateral Unilateral Unilateral Proptosis (degree) Moderate Marked Moderate Vison Initially not affected Initially not affected Complete loss from beginning Cornea & anterio chamber Initially clear Initially clear Hazy d/t corneal edem, Pus in anterior chamber Ocular movements Complete limitation to palsy Markedly limited Painful & limites Mastoid edema Present No No Systemic systems eg fever etc. Marked Mild Mild
Ethmoidal Sinusitis
Orbital Cellulitis
Cavernous Sinus Thrombosis
Orbital Apex syndrome