Presentation
Left eye swelling for 1 day. History of uncontrolled diabetes mellitus.
Patient Data
Subperiosteal abscess anterior to the left maxilla, adjacent to a periapical radiolucency of the left maxillary canine suggestive of periapical abscess (ADA 11/FDI 23). This tooth has severe caries.
Left facial and preseptal/periorbital cellulitis, as evidenced by fat stranding and soft tissue swelling of the soft tissues of the left cheek, including canine space cellulitis.
Left orbital cellulitis, as evidenced by confluent edema/phlegmon in the postseptal extraconal fat inferiorly. The aforementioned subperiosteal abscess extends along the postseptal orbital floor, best seen on sagittal images. Left eye proptosis with straightening of the optic nerve.
Old left medial orbital wall blowout fracture. Mild mucosal thickening in the left maxillary sinus and left anterior ethmoid air cells. Multiple other teeth have caries, periodontal ligament space widening, and/or periapical lucencies.
Case Discussion
The imaging findings suggested orbital and periorbital/facial cellulitis with a dental source and complication of a premaxillary subperiosteal abscess. On further history, the patient had several days of left upper dental pain. Clinical exam findings, including decreased visual acuity and increased intraocular pressure, were concerning for an orbital compartment syndrome.
The patient received empiric antibiotics and underwent emergency surgery consisting of anterior orbitotomy, which relieved an accumulation of pus. Operative cultures grew multiple bacteria, including Parvimonas micra (often found in periodontitis), Streptococcus anginosus group, Atopobium species, and coagulase-negative Staphylococcus (S epidermidis), which were consistent with an oral source. The patient also received steroids and multiple topical medications addressing ocular hypertension. The following day, the patient underwent extraction of the left maxillary canine and first premolar teeth. Despite appropriate antibiotics and source control, the patient had a complicated hospital course that required additional returns to the operating room for repeat orbital debridement. Necrotic debris was found, consistent with necrotizing soft tissue infection. There was no culture or histopathologic evidence of angioinvasive fungal infection. Eventually, the infection resolved and vision improved to baseline.
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