Abordagem cirúrgica a abscesso orbitário subperiosteal associado à fratura de órbita Surgical approach of orbital subperiosteal abscess associated with the orbital fracture

1Course of Study of Odontology, Universidade Federal de Alagoas, Maceió, AL, Brazil. 2Multidisciplinary Residency in Surgery and Oral and Maxillofacial Traumatology, Hospital Universitário Oswaldo Cruz, Universidade de Pernambuco, Camaragibe, PE, Brazil. 3Masters Program, Faculdade de Odontologia de Pernambuco, Camaragibe, PE, Brazil. 4Faculdade de Odontologia de Pernambuco, Camaragibe, PE, Brazil. ABSTRACT


T
he orbital content is closely related to the paranasal sinuses.Because of this anatomical relationship, the most common etiological factor for orbital infections is sinusitis, particularly ethmoid sinusitis.They may also result from the extension of periorbital infection and direct inoculation by trauma or anachoresis.][3] The orbital abscess is clinically presented in most cases with local pain, edema, lid erythema and fever.The main findings are visual changes such as diplopia, ophthalmoplegia, central retinal artery occlusion, increased intraorbital pressure, proptosis, optic nerve neuropathy, ocular dystopia and vision loss (blindness).
If not promptly diagnosed and treated they can develop to severe complications such as bone involvement, cavernous sinus thrombosis, brain abscess, meningitis, septic embolism, neurological sequelae and death. 4reatment usually requires hospitalization, multidisciplinary assessment and broad-spectrum intravenous antibiotic therapy.The surgical indication is essential in cases of abscess in patients with visual impairment and who do not respond to the initial medical treatment. 5

OBJECTIVE
Report a case of orbital infection in a pediatric patient treated at the General Hospital of the State of Alagoas.

CASE REPORT
Male patient, 11 years old, victim of sports accident presenting trauma in the face resulting in linear fracture of the upper orbital rim.Upon hospital admission 4 days after the trauma, he was in fever, pain complaints in the left orbital region, strong eye proptosis, eyelid ptosis, ophthalmoplegia, chemosis and decreased visual acuity.(Figures 1-A e 1-B).He reported previous history of chronic sinusitis.
A CT scan (Figure 2 AD) was requested, where there were hyperdense images in the left sinus spaces suggesting thereby that the infection affected the paranasal sinuses (ethmoid and maxillary), which was consistent with the patient's history of  Based on clinical, laboratory and CT findings, the subperiosteal orbital abscess was diagnosed.The initial antibiotic therapy started empirically with Ampicillin associated to Sulbactan and Clindamycin.The laboratory tests showed leukocytosis with left deviation and substantial increase in the number of neutrophils and lymphocytes.Although the culture was held through conjunctival smears, it would not be feasible to wait for the results to decide upon the surgery due to the imminent risk of severe complications and development of the disease.After three days of drug treatment and without involution of the condition, the patient underwent a surgical procedure to treat the infection.After five days, the culture of conjunctival smears showed high colonization of Streptococcus sp and Staphylococcus sp.
Under general anesthesia, drainage and orbital decompression were made via superciliary incision and divulsion blunt of the tissues to gain access to the subperiosteal region of the orbital roof with abundant drainage of the purulent exudate (Figure 3A).
The fracture line in this rim line was evident during surgery (Figure 3B), without the need for treatment due to be properly

DISCUSSION
Nasosinusal infections are highly prevalent clinical entities, and may develop with potentially severe complications.Acute complications have higher incidence in children due to common anatomical factors and frequent infections of the upper respiratory tract.The orbital impairment secondary to rhinosinusitis is due to the direct extension of the infection by ophthalmic vein thrombophlebitis, facilitated by the absence of valves in this venous system, the weakness of separation between the orbital contents and the ethmoidal labyrinth, the presence of Rev Bras Oftalmol.2015; 74 (5): 315-8

A B C D
aligned and without mobility.The drainage of the maxillary sinus was performed with a Cadwell Luc access, and abundant irrigation with saline solution (Figure 3D).Postoperatively, broad-spectrum antibiotics were given: ampicillin associated to Sulbactan, clindamycin and oxacillin.
The patient recovered well after the drainage and orbit decompression, with almost complete remission of the clinical profile within a period of 10 days.Clinical exams showed that the patient presented transient reversal of amaurosis.Preoperatively, he did not respond to the test of counting fingers, and only showed light perception.A thorough assessment of visual acuity was impaired due to the edema.Ten days after surgery the patient already showed normal visual acuity (20/20).Referring to the ocular motility tests performed, a regression of motor function of the affected eyeball was found, without diplopia or visual sequelae.In 90-day follow-up the patient showed no visual and oculomotor deficits.No sequelae were observed, except a slight scar on the upper eyelid region.6][7] In the present case the patient was affected by a trauma resulting in orbital fracture with subsequent hematoma formation in the region, and due to anatomical peculiarities of the patient it was colonized by microorganisms of the previously infected sinuses.
A literature search showed the Haemophilus influenza type B as the microorganism most commonly found in blood culture.Staphylococcus sp was the pathogen most commonly found in the maxillary sinus aspirated secretion.The microorganisms most commonly found in orbital infections are species of Streptococcus and Staphylococcus, all susceptible to clindamycin or vancomycin.However, due to the indiscriminate use of antibiotics, the development of resistance, and the constant changes in the profile of these micro-organisms, there is a growing need for studies on the microbiological changes present in these infections.In this case the culture results were consistent with the literature, and treatment followed preconized protocols. 8omputed tomography has 78 to 92% of detection sensitivity, with absolute request indication when in suspicion of Figure 2. A-D: Face CT in the axial, coronal and sagittal cuts, where there is exophthalmos of the left eyeball, opacification of paranasal sinuses and hyperdense image in the upper left part of the orbit suggestive of content arising from infection and thickening of the muscles of the ocular motility.

Figures 1 -
Figures1-A e 1-B: He reported previous history of chronic sinusitis.

Figure 3 A
Figure 3 A -Soon after obtaining access to the subperiosteal region of the upper wall of the orbit was the drainage onset of abundant purulent exudate.Figure 3 B -Linear fracture in the upper orbital rim. Figure 3 C -Immediate post-surgical with drain installed for drainage of remnants and disorganization of the infectious content.Figure 3 D -Suture held after draining through Cadwell Luc access of the left maxillary sinus.

Figure 3 D
Figure 3 A -Soon after obtaining access to the subperiosteal region of the upper wall of the orbit was the drainage onset of abundant purulent exudate.Figure 3 B -Linear fracture in the upper orbital rim. Figure 3 C -Immediate post-surgical with drain installed for drainage of remnants and disorganization of the infectious content.Figure 3 D -Suture held after draining through Cadwell Luc access of the left maxillary sinus.

Figure 4A :
Figure 4A: Front aspect, 90 days after surgery, with a slight scar on left eyebrow region.Figure 4 B, C and D: Movements of the eyeball showing remission of ophthalmoplegia and preservation of eye motilidadde with visual acuity preserved without motor and visual deficits.