Volume 1, Issue 1 , Pages 5-8, March 2006
Bilateral lacrimal gland abscesses
Article Outline
Summary
Dacryoadenitis is an unusual orbital infection that rarely involves acute suppuration. We describe what to our knowledge is the first reported case of bilateral lacrimal gland abscesses: a 9-year-old girl who presented with painful periorbital swelling and fever. The child was diagnosed with the abscesses by CT scan of the orbits with contrast, which was obtained when the patient's periorbital swelling progressed despite intravenous antibiotics. Despite early drainage of the abscesses, the patient sustained a complicated hospital course with epidural and cerebral abscesses. The causes of dacryoadenitis as well as the mechanisms of infectious spread into the orbit are reviewed. This case as well as a review of the literature suggest that superolaterally located orbital abscesses are associated with an increased risk of intracranial infection and should be managed aggressively.
Keywords: Dacryoadenitis, Lacrimal gland, Orbital, Periorbital, Sinusitis, Epidural abscess
1. Introduction
Periorbital swelling is a common presenting complaint in the pediatric population. It is important to distinguish infectious and non-infectious etiologies. Of those caused by bacterial infections, it is important to determine whether an abscess has formed that may require surgical intervention and puts the patient at risk for ophthalmic and neurological complications. Abscesses within the lacrimal gland are rare and potentially dangerous infections of the orbit.
2. Case report
A 9-year-old girl presented with a two-day history of painful periorbital swelling and fever. On examination, she had bilateral periorbital swelling with erythema of the upper eyelids. Her visual acuity was normal and there was no ophthalmoplegia, proptosis or chemosis. A CT scan of the orbits and paranasal sinuses was performed and demonstrated edema in the pre-septal orbit, however, there was no collection or retrobulbar involvement noted. Diffuse mucosal thickening of the paranasal sinuses was noted, with complete opacification of the left maxillary sinus. Several days of intravenous ampicillin-sulbactam were administered. The patient was without symptomatic improvement, therefore, a CT scan with contrast was repeated. The scan demonstrated the interval formation of bilateral rim-enchancing hypodensities in the lacrimal glands, which were consistent with abscesses (Fig. 1). An incision and drainage of both lacrimal gland abscesses was performed in the operating room. Purulent secretions were recovered from the lacrimal glands. Drains were placed and slowly withdrawn. The drained collections yielded a polymicrobial infection and the patient's antibiotic coverage was broadened to vancomycin, cefotaxime, and metronidazole.
Fig. 1.
Axial (A) and coronal (B) CT scans of the orbits with intravenous contrast demonstrate symmetric, bilateral rim-enhancing hypodense collections in the supero-lateral orbit consistent with abscesses of the lacrimal gland. Also seen is opacification of the frontal and anterior ethmoid sinuses and of the left maxillary sinus.
Over the following days, the periorbital swelling improved, but the patient developed a focal tender swelling of her scalp concerning for an abscess. Another CT scan, followed by an MRI of the head, demonstrated a subcutaneous abscess as well as bilateral frontal epidural abscesses (Fig. 2). The patient was taken back to the operating room where bifrontal craniotomies were performed with drainage of the abscesses. Concurrently, bilateral endoscopic maxillary antrostomies and anterior ethmoidectomies were performed with purulent secretions noted only from the left maxillary sinus. None of these collections yielded microorganisms on culture. Furthermore, frontal sinus trephinations demonstrated only mucosal disease without purulent secretions. The patient continued to have a complicated post-operative course with persistent fevers, focal seizures and a small cerebral abscess, which was managed medically. She eventually defervesced and returned to her neurological baseline. She was discharged from the hospital with a peripherally-inserted central line to complete six weeks of intravenous antibiotics. At three-month follow-up she was doing well and a surveillance CT scan of the head and sinuses was unremarkable.
Fig. 2.
Axial CT scan with contrast (A) and T2-weighted MRI (B) of the head demonstrate a large subcutaneous fluid collection in the left scalp and several bilateral epidural fluid collections.
3. Discussion
To our knowledge, this is the first reported case of bilateral lacrimal gland abscesses in the English literature. Periorbital swelling and pain were the most prominent features of this unusual infection. The diagnosis was made by imaging with a CT scan of the orbit with intravenous contrast, which clearly demonstrated the abscesses within the lacrimal glands. Aggressive management with broad-spectrum intravenous antibiotics and early incision and drainage of the abscess was successful in resolving the orbital manifestations and preventing loss of vision; however, the interventions did not prevent further complications, namely intracranial extension of the infection which required a craniotomy.
Dacryoadenitis refers to an inflammatory condition of the lacrimal gland and has a variety of acute and chronic causes. Viral infection is most common and can involve the mumps virus, Epstein-Barr virus, cytomegalovirus, and Coxsackievirus A. Inflammatory conditions that affect the lacrimal glands are Sjögren's syndrome, sarcoidosis, and Grave's disease. Fungal infections may present in immunocompromised patients. Bacterial infections are typically Gram-positive, but also can involve mycobacteria, gonorrhea, chlamydia, and syphilis [1]. Acute suppurative infection of the lacrimal gland is rare and has only been reported a few times [2], [3], [4], [5]. The exact mechanism of spread of bacterial infection to the lacrimal gland is not known. Tears are conveyed from the lacrimal gland to the conjunctival sac by small lacrimal ducts and these may act as a route for an ascending infection. Infection may also spread hematogenously from sites on the face or within the paranasal sinuses due to retrograde flow through an extensive valveless venous network that connects to the cavernous sinus via the ophthalmic veins. Finally, infection can spread directly from the sinuses to the orbit through the thin bony orbital walls, especially at the medial orbital wall [6], [7]. In a classification system still in use today, Chandler described a progression of orbital infection (specifically secondary to sinus disease) in 1970 by defining five groups or stages of infection: I. pre-septal cellulitis; II. orbital cellulitis; III. subperiosteal abscess; IV. orbital abscess; and V. cavernous sinus thrombosis [8]. The lacrimal gland abscess would be considered a group III infection since it is in the pre-septal orbit. While this classification system is helpful in conceptualizing the potential orbital complications of sinusitis, its prognostic significance has not been demonstrated. Also, orbital infection does not always progress through the steps outlined.
The etiology of this child's disease is unclear. The presence on imaging of mucosal thickening within the paranasal sinuses and opacification of the left maxillary sinus raised the possibility that the patient's lacrimal gland abscesses represented an orbital extension of rhinosinusitis. However, most subperiosteal abscesses are located along the medial orbital wall and are related to ethmoid sinusitis. A superolateral abscess could potentially be caused by frontal sinusitis. During surgical exploration in this patient, suppurative infection was only identified in one maxillary sinus. The formation of bilaterally symmetric infections of the lacrimal glands, given their location in the superolateral orbit, would be an unusual complication of unilateral maxillary sinusitis. The etiology of this patient's condition is potentially a primary infection of the lacrimal gland. A probable mechanism would involve a viral upper respiratory infection with viral dacryoadenitis and subsequent bacterial super-infection with concomitant rhinosinusitis as a result of the viral infection.
The development of intracranial infection further complicated this patient's clinical course. Herrmann and Forsen [9] retrospectively reviewed children who presented with simultaneous intracranial and orbital complications of sinusitis. They reported that all of these patients had superiorly or superolaterally located orbital abscesses. While causation cannot be implied, this study suggests that patients with abscesses at these locations are at increased risk for intracranial complications. Imaging of the orbits and paranasal sinuses by CT with contrast or MRI should be obtained in all patients who present with periorbital swelling. The lacrimal glands should be carefully examined as an unusual but possible site of infection. A low threshold for re-evaluation and repeat scans should prevail in these patients given the potential for intracranial extension of the infection. Patients should be managed aggressively with an interdisciplinary approach involving the otolaryngologist and ophthalmologist, and when indicated, neurosurgery.
References
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PII: S1871-4048(05)00003-1
doi:10.1016/j.pedex.2005.09.001
© 2005 Elsevier Ireland Ltd. All rights reserved.
Volume 1, Issue 1 , Pages 5-8, March 2006
