Question of the Week

A 5-year-old boy is brought to the emergency department with worsening right eye pain and blurred vision that began earlier today and did not improve with ibuprofen or warm compresses. He has a history of recurrent sinus infections, eczema, otitis media, and multiple dental caries. Two weeks ago, he sustained a scratch to his right upper eyelid while playing outside, for which his parents applied Neosporin, and it seemed to heal normally. Vitals show a temperature of 39.4 C (102.9 F), BP 100/70 mm Hg, pulse 120/min, and respirations 20/min. The patient appears uncomfortable. Visual acuity is 20/70 in the right eye and 20/10 in the left. Examination of the right eye reveals conjunctival injection, proptosis, periorbital edema and erythema, and a small, well-healed eyelid abrasion without drainage. Extraocular movements are painful with limited adduction of the right eye. Funduscopic examination is normal bilaterally. There is tenderness to palpation over the right cheek. Oral examination reveals a large malodorous dental caries involving the left lower second molar.

Which of the following predisposing factors is most likely responsible for this patient’s condition?

A. Eczema

B. Bacterial sinusitis

C. Dental abscess

D. Recent eyelid abrasion

E. Otitis media

Answer

The Correct answer is B.

This child has orbital cellulitis as indicated by: fever, proptosis, ophthalmoplegia, pain with extra ocular movements, and decreased visual acuity. The most common predisposing factor for orbital cellulitis in children is bacterial sinusitis, particularly involving the ethmoid sinus due to its thin medial orbital wall, which allows contiguous spread of infection into the orbit. The patient’s cheek tenderness further supports sinus involvement. Orbital cellulitis requires prompt imaging and intravenous antibiotics due to the risk of abscess formation and intracranial spread.

Choice A: Eczema may increase risk for superficial skin infections but is more commonly associated with preseptal cellulitis rather than orbital cellulitis.

Choice C: Dental infections can rarely spread into the orbit and particularly arise from maxillary teeth. However, this patient’s dental caries involves a mandibular molar on the contralateral side, making this less likely.

Choice D: Secondary bacterial infection from an eyelid abrasion can predispose to orbital or preseptal cellulitis through direct inoculation of bacteria into periocular tissues. However, this patient’s abrasion occurred two weeks earlier and reportedly healed without signs of infection, making it less likely than sinusitis in this scenario.

Choice E: Severe or untreated otitis media can progress to an invasive bacterial infection such as mastoiditis or meningitis. The orbits are not contiguous with the middle ear, making orbital cellulitis an unlikely sequela.