45

CT of Orbital Infection and

Its Cerebral Complications

Robert A. Zimmerman1 Review of the clinical and radiologic findings in 1 8 patients with orbital infection
Larissa T. Bilaniuk1 revealed that computed tomography (CT) is a very informative method of evaluating
orbital infection. It is capable of demonstrating the presence, location, and extent of
subperiosteal abscesses, intraorbital foreign bodies, intraconic scarring, as well as the
cerebral complications of cerebritis, brain abscess, and epidural infection. In this group
of patients, the most common cause of orbital cellulitis was sinusitis (eight cases). The
second most common cause (seven cases) was trauma (orbital fractures or foreign
bodies).

In acute orbital infection, swelling of the eyelids due to reactive edema or

cellulitis often makes adequate physical examination of the eye difficult or
impossible [1 ]. Precise delineation of the extent and source of the infectious
disease are of paramount importance if correct treatment is to be instituted.
Treatment, whether it is surgical or medical, must be sufficient, timely, and
specific if vision is to be preserved and cerebral complications avoided [2].
Routine skull and sinus radiographs at times do not provide specific enough
information to be useful [3]. Free intraorbital air within a subperiosteal abscess
or an osteitis of the sinus wall are useful positive radiographic findings. However,
sinus opacification or mucosal thickening as the only findings do not necessarily
indicate that the involved sinus is the source of orbital infection.
Computed tomography (CT) is now an established radiographic method in
demonstrating intraorbital pathology [4, 5]. The ability of CT to demonstrate
minimal density differences in soft tissue and to display them in the transverse
and coronal planes [4, 5] has made CT the radiographic method of choice in the
evaluation of orbital infection. This paper presents CT findings in i 8 patients with
orbital and/or related cerebral infection; these findings are analyzed on the basis
of the current concepts of the pathogenesis of orbital infection and its compli-
cations.

Received March 6, 1 979; accepted after revi-

sion August 27, 1979. Subjects and Methods
Department of Radiology, Hospital of the Uni- During the 4 year period, 1 975-1 978, 1 8 patients were examined by CT for orbital
versity of Pennsylvania, 34th and Spruce Sts.,
infection and/or complicating cerebral infection. Trauma was a factor in seven patients
Philadelphia, PA 19104. Address reprint requests
to R. A. Zimmerman. and paranasal sinus infection in eight.
All patients were examined with either an EMI Mark I head scanner with water bag (160
AJR 134:45-50, January 1980
0361 -803X/80/ 1341-0045 $00.00 matrix), or with an EMI 5005 body scanner (160 or 320 matrix). When the EMI 5005
:; American Roentgen Ray Society scanner became available, coronal sections were done routinely in addition to the trans-
46 ZIMMERMAN AND BILANIUK AJR 134, January 1980

TABLE 1: Group 2: Patients with Orbital Trauma and Infectious Complications

Findings
Patient
clinical CT Operative

J. H. Papilledema, seizure 3 mos. after or- Frontal lobe abscess Cerebral abscess
bital fracture
P. L. Abscess orbit after fall on pencil Periscleritis, dense foreign body Orbital abscess, graphite foreign body
K. B. Proptosis, periorbital infection Periscleritis, medial rectus enlargement Wooden foreign body medial rectus
area
0. H. Multiple cranial & facial fractures, prop- Proptosis, retroglobar mass, intraorbital Subperiosteal intraorbital abscess,
tosis fever, meningismus bone fragment bony fragment
K. S. 2 years after foreign body Metallic foreign body, obliteration re- Foreign body removed
troorbital fat
A. B. 10 days after facial fractures Frontal mass with edema; 2 weeks Frontal lobe abscess
later, frontal abscess
H. P. Fracture orbital roof lntraorbital bony fragment, soft-tissue Orbital abscess, bony fragment
mass, proptosis

_c I
I’
. . -.
v4 #{149}
Fig. 1 .-Preseptal cellulitis (patient C. B.). Pre- Fig. 2.-Pre- and postseptal cellulitis (patient Fig 3 -Subperiosteal abscess secondary to
septal swelling of right eyelid (arrow). R. P.). Soft tissue swelling surrounds proptotic left acute ethmoid sinusitis (patient B. B.). Left prop-
globe posteriorly (postseptal, arrow) as well as tows, laterally displaced medial rectus (arrow-
anteriorly (preseptal, arrowheads). heads). gas within medial subperiosteal abscess
(arrow), and opacified ethmoid air cells.

verse sections. All patients were studied before and after the evaluation of orbital trauma complicated by orbital or cere-
injection of iodinated contrast medium. Patients received meglu- bral infection (table 1).
mine iothalmate (Conray 60) as an intravenous bolus in a dose of
1 00 ml for adults, and 2.2 mI/kg for children.
All patients were managed by one or more clinical services:
Group 1
otorhinolaryngology , ophthalmology, or neurosurgery. Cultures of
the periorbital soft tissues, nasopharynx, blood, and paranasal Group 1 consists of 1 1 patients: 1 0 children, aged 3-i 8
sinus contents (surgical) were performed for diagnostic purposes years, and one adult age 25. Eight were male and three
as each case indicated. Medical treatment consisted of deconges- female. In 1 0 of the i i patients, the orbital infectious disease
tants (sinusitis) and organism-specific antimicrobial therapy where
was of acute onset. In all of the patients (under age 1 8) with
possible. When cultures were sterile or initially unobtainable, mul-
acute symptoms, the reason for referral was lack of re-
tiple broad spectrum antibiotics as well as more specific antimicro-
sponse of the orbital infection to treatment and/or the
bial therapy were used, chosen on the basis of likelihood of a given
clinical picture.
possibility of complicating cerebral infection. Sinus opacifi-
In patients with acute infection in whom there was a lack of cation was demonstrated by both CT and sinus radiography
response to medical therapy, surgical treatment consisted of drain- in eight of 10 acutely symptomatic patients. The ethmoid
age of the involved paranasal sinuses. In patients with infection sinuses were involved in all eight, the maxillary sinuses in
related to trauma, surgical treatment consisted of abscess drainage. six, and the frontal sinuses in five. One acutely symptomatic
repair of dura mater, and foreign body removal. pediatric patient with negative sinus radiographs also had
sickle-cell disease. The only adult who was a drug addict,
did not have evidence of sinus disease.
Observations
In cases of acute infection the most common CT finding
The 1 8 patients in this series were divided into two groups: was swelling of the eyelids (1 0 of 1 0) (figs. 1 -4). Seven of
group 1 is patients referred with a clinical diagnosis of 10 cases had proptosis, a more significant finding, and six
periorbital cellulitis and group 2 is patients referred for of 10 had scleral thickening (figs. 2-4). Five cases (all
AJR:134, January 1980 CT OF ORBITAL INFECTION 47

Fig. 4.-Periorbital cellulitis with subperiosteal abscess (patient J. A.). A, Coronal scan. Right periorbital-temporal soft tissue swelling, gas (arrow) within
subperiosteal abscess, and opacification of left frontal sinus (arrowheads). B, Coronal scan further posterior. Subperiosteal intraorbital abscess membrane
enhancement (arrowheads). C, Transverse scan. Marked proptosis of right globe and periorbital soft tissue swelling.

Fig. 5.-Left periorbital cellulitis, left pansinusitis, and right frontal cerebritis (patient R. M.). A, Marked left periorbital soft tissue
swelling (arrowheads) and partial opacification of ethmoid and sphenoid sinuses. B, Higher scan. Abnormal right frontal intraparen-
chymal contrast enhancement (arrows) consistent with cerebritis. C, 2 weeks later after treatment with antibiotics. Normal after
contrast material inlection.

children) had subperiosteal abscesses (figs. 3 and 4), and Fig. 6.-Epidural inflammation
complicating orbital cellulitis (patient
one had infection of the peripheral surgical space. None N. K.). Initial examination normal for
had infection of the central surgical space. Cerebral com- brain (not shown). Scan 10 days
plications were demonstrated only in children: frontal lobe later, enhanced epidural membrane
(arrowheads) after contrast material
cerebritis in two (fig. 5) and epidural inflammation in one injection . Epidural infection con-
(fig. 6). One patient was examined 2 years after the clinical firmed by surgical exploration.

diagnosis and treatment of ‘ ‘ periorbital cellulitis’ ‘ ; his CT

examination demonstrated swollen eyelids, proptosis, per-
iscleritis, and obliteration of the retroorbital fat, recti, and
scleral soft tissue planes indicating scarring (fig. 7).
The offending bacterium was cultured in seven of 10
patients with acute infection (coagulase-positive Staphylo-
coccus in three, mixed organisms including Streptococcus
fecalis in two, fl-hemolytic Streptococcus in one, Pseudo-
monas aeruginosa in one). The inability to culture organisms
in the other three patients was attributed to preceding demonstrated intracranial abnormalities (cerebritis in two,
multiple antibiotic therapy. Four patients developed a eu- epidural inflammation in one). Surgical drainage of the in-
kocytosis in the cerebrospinal fluid associated with menin- fected sinuses and subperiosteal spaces was performed in
gitic or cerebral symptoms. In three of these patients, CT seven patients.
48 ZIMMERMAN AND BILANIUK AJR 134. January 1980

Fig. 7.-Inflammatory scarring

postorbital cellulitis (patient P. C.). After
contrast material injection. Enhanced
thickened soft tissues surrounding prop-
totic left globe, lateral rectus, and optic
nerve.

Fig. 8.-Graphite (pencil lead) for-

eign body (patient P. L.). Coronal scan.
Dense foreign body (arrow) and sur-
rounding soft tissue swelling (arrow-
heads). Foreign body successfully re-
moved.

7 8

Fig. 9.-Right frontal lobe ab-

osseous fragments from the frontal sinus floor and orbital
scess (patient J. H.). After contrast
I material injection. Enhanced right roof within the orbit.
frontal lobe abscess (arrowheads).
Nonclassifiable anaerobes grew
from pus drained from abscess.
Discussion

Bacterial inflammatory disease of the orbit is most often

due to sinus infection [6], bacteremia [7], skin infection
(secondary to trauma, insect bite, impetigo) [2], or foreign
body [8]. Superficial infection of the eyelids, and bacteremic
facial cellulitis (most often Haemophilus influenzae) in young
children [7] are confined initially to the preseptal portion of
the eyelids. The orbital septum, a periosteal reflection from
the anterior bony margin of the orbit, inserts on the tarsal
plates of the eyelids and acts as a barrier to the spread of
the infection into the orbit [3, 7].
The chief clinical manifestation of preseptal cellulitis is
swelling and redness of the eyelids. Edematous swelling of
Five of the 1 0 patients seen initially with acute infections the eyelids without infection can occur as a manifestation of
have suffered neurologic deficits or have developed other paranasal sinus infection [9]. Increased pressure within the
complications. Both patients who had cerebritis developed sinus cavity prevents the normal free access of venous
neurologic deficits: psychological in one case, aphasia and blood from the orbit into the venous system of the sinus
right hemiparesis in the other. The patient with endophthal- wall. Absence of valves in these veins [1 0] allows free
mitis ruptured the globe, after which the globe was removed communication among the facial, orbital, and paranasal
surgically. Two patients developed osteomyelitis of the sinus veins, and the cavernous sinus and pterygoid venous sys-
and orbital wall, which has required further treatment. tems. This permits the transmission of elevated pressure
from one part of the venous system to another [9]. Similarly,
Group 2 infection may spread through the venous intercommunica-
Group 2 consists of seven patients aged 3-55 years. Six tions (thrombophlebitis) [6]. Thus, eyelid edema may rapidly
of the seven were male. In three cases the infection was progress to preseptal cellulitis.
related to foreign bodies (one wooden fragment, one graph- Computed tomographic demonstration of swelling of the
ite pencil point, and one tip of an umbrella spoke). The eyelids is a nonspecific but frequent finding in patients with
graphite foreign body (fig. 8) and the umbrella spoke tip the clinical picture of orbital inflammatory disease (1 0 of 10
were well shown by CT; but in the case of the wooden acute cases in this series) (figs. 1 -4). However, it is not
fragment, only the inflammatory soft tissue changes were possible to differentiate between eyelid edema and cellulitis
demonstrated. on the basis of the CT appearance. The orbit becomes
Four patients suffered fractures that involved the orbit, its involved if the preseptal infection extends through the orbital
roof, and adjacent paranasal sinuses. In two patients with septum. Also, septic thrombophlebitis may extend to the
fractures, frontal lobe abscesses were demonstrated i -3 orbit proper, producing an orbital cellulitis [9].
months after trauma (fig. 9). In the other two patients with Infection within the orbit proper can be anatomically di-
fractures, one had a subperiosteal abscess and the other vided into: (1 ) intraconic (muscle cone)-within the central
had an intraconic abscess. In these two cases, CT revealed surgical space; (2) extraconic-within the peripheral surgi-
AJR:134, January 1980 CT OF ORBITAL INFECTION 49

cal space between the periosteum and the recti forming the carry a serious prognosis [6].
muscle cone; and (3) subperiosteal-between the orbital The orbital and paranasal sinus venous system commu-
wall and its periosteal covering [3]. Inflammation within the nicates with the intracerebral structures not only by the
fat of the central surgical space obliterates the normal soft- cavernous sinus but also by the cerebral emissary veins that
tissue planes between optic nerve, retroorbital fat, and the enter via the diploe and leptomeninges. Thus, septic throm-
recti as delineated by CT (fig. 7). Infection within this central bophlebitis may give rise to epidural infection (fig. 6) [31,
space forces the globe forward in axial proptosis and pro- subdural infection, and meningitis, cerebritis (fig. 5), and
duces chemosis (edema of the bulbar conjunctiva). brain abscess [3]. Direct extension of infection through the
Infections in the child or teenager occur most often in the posterior wall of the frontal sinus can involve structures from
ethmoid sinuses (fig. 3), and in the frontal sinus in the the epidural space through to the cerebral hemisphere
adolescent or young adult (fig. 4). These infections can (fig. 9)[i, 3].
involve the orbit by direct extension [i ]. Preexisting foram- Orbital infection as a consequence of sinusitis (60%) [9]
ma, congenital osseous dehiscences, and the normal thin- or other infection, is less frequent than it was in the prean-
ness of bone (especially the medial wall of the ethmoid tibiotic era. According to Britch-Hirschfield’s data (cited in
sinus, the lamina papyracea) may transmit infection directly [1 4], in the preantibiotic era, i 9% of those with intracranial
[i 0]. Infection may be transmitted through fenestrations due complications died. Of the survivors i 3% suffered some
to osteomyelitis, or as periphlebitic extensions along exist- degree of visual loss. However, Gans et al. [6] believes that
ing venous channels [9]. In the early stages periosteitis is despite antibiotics, 0.5%-3% of sinusitis cases still progress
characterized by pain and limitation of motion of the adja- to orbital involvement. Most authors believe that the mani-
cent rectus muscle [9]. Progression of the periosteitis leads festations of orbital infection today are often partially
to a subperiosteal abscess which arises between the in- masked by an early, but frequently inadequate, antibiotic
volved orbital wall and the periosteum (figs. 3 and 4) [9]. treatment so that the clinical findings are less apparent [8,
The orbital periosteum is loosely attached to the orbital 1 5].
wall except at the suture lines, where it is firmly adherent. The consequences of inadequate treatment remain poten-
With ethmoid sinusitis, typically the subperiosteal abscess tially catastrophic because blindness and death may result.
is found along the medial orbital wall, producing lateral Thus, it is imperative that the disease process be recognized
proptosis of the globe (fig. 3). With frontal sinusitis, the early, be treated aggressively, and operative drainage be
collection occupies the superior aspect of the orbit and the carried out whenever indicated [2]. In this matter CT plays
globe is displaced anteriorly and downward (fig. 4) [1]. an important role and contributes significantly to patient
Subperiosteal abscess appears as a mass lying between management. It demonstrates, frequently characterizes, and
the orbital wall and the displaced adjacent periosteum (figs. shows the extent of the orbital inflammation (figs. i -4). The
3 and 4). Gas may be found within the abscess (figs. 3 and presence of a foreign body as a source of infection is also
4), arising either from gas-forming bacilli or from communi- well shown by CT when the foreign body is of sufficient
cation of the abscess cavity with the adjacent paranasal density (Fig. 8).
sinus. Contrast enhancement can be used to define the Computed tomography is also capable of demonstrating
periosteal wall of the abscess (fig. 4). intracranial involvement of the epidural (fig. 6) and subdural
Once septic orbital thrombophlebitis exists, whether spaces, as well as involvement of the cerebral parenchyma
through orbital infection or by transmission of infection from by cerebritis (fig. 5) or an abscess
(fig. 9). An additional
a remote site such as the face, the danger of cavernous value of CT is that it can be used to monitor the response to
sinus involvement exists. The normal direction of venous treatment as in cerebritis (fig. 5), or the progression to brain
flow is from the orbital veins to the cavernous sinus. Due to abscess, or in case of the intraorbital infection to scar tissue
the free venous interconnections, the involvement of one formation (fig. 7).
cavernous
of the
conjunctiva,
other
sinus
[1
and
, , is usually
i 1 1 2]. Venous
eyelids;
rapidly

paresis
followed
engorgement
of the third,
by involvement
in the retina,
fourth, and
sixth cranial nerves; meningismus; and proptosis are the REFERENCES
usual hallmarks of septic cavernous sinus thrombosis [i].
In the one case of an orbital apex syndrome in this series, 1. Quick CA, Payne E. Complicated acute sinusitis. Laryngoscope
cavernous sinus thrombosis was clinically suspect. CT dem- 1972:82:1248-1263
onstrated a large subperiosteal abscess that explained the 2. Hawkins DB, Clark RW. Orbital involvement in acute sinusitis.
clinical findings that mimicked cavernous sinus thrombo- Clin Pediatr i977;16:464-471
sis. The clinical significance of septic cavernous sinus 3. Kaplan RJ. Neurological complications of infections ofthe head

thrombosis was better appreciated in the preantibiotic era and neck. Otolaryngol C/in North Am 1976;9:729-749
4. Tadmor R, New PFJ. Computed tomography of the orbit with
when cavernous sinus thrombophlebitis was more common;
special emphasis on coronal sections. I. Normal anatomy. J
the mortality approached 80%, and the morbidity in the
Comput Assist Tomogr 1978; 2: 24-34
other 20% was 75%. The sequelae were frequently signifi-
5. Tadmor R, New PFJ. Computed tomography of the orbit with
cant, including blindness or cranial nerve paresis [13]. Due special emphasis on coronal sections. II. Pathological anat-
to the availability of antibiotics, septic cavernous sinus omy. J Comput Assist Tomogr 1 978;2 :35-44
thrombosis is not as common now; however, it continues to 6. Gans H, Sekula J, Wlodyka J. Treatment of acute orbital
50 ZIMMERMAN AND BILANIUK AJR:134, January 1980

complications. Arch Otolaryngol 1974; 100:329-332 11. Kronschnabel EF. Orbital apex syndrome due to sinus infec-
7. Gellady AM, Shulman ST. Ayoub EM. Periorbital and orbital tion. Laryngoscope 1974;84 :353-371
cellulitis in children. Pediatrics 1978;6i :272-277 12. Bell WE, McCormick WF. Neurologic infections in children.
8. Haynes RE, Cramblett HG. Acute ethmoiditis. Am J Dis Child Philadelphia: Saunders, 1975:107-109
1967:114:261-267 13. Yarington CT. The progress and treatment of cavernous sinus
9. Chandler JR, Langenbrunner DJ, Stevens ER. The pathogen- thrombosis. Arch Otolaryngol 1967:86:205-209
esis of orbital complications in acute sinusitis. Laryngoscope 14. Duke-Elder S. The ocular adnexa. In: Textbook of Ophthal-
1970;80: 1414-1428 mology, vol 5. St. Louis: Mosby, 1952:5420-5443
10. Batson OV. Relationship of the eye to the paranasal sinuses. 15. Jarrett WH, Gutman FA. Ocular complications of infection in
Arch Ophthalmol 1936:16:322-328 the paranasal sinuses. Arch Ophthalmol 1969:81 :683-688