Visual Diagnosis Orbital Infection With Intracranial Involvement William J. Steele III MD, Rocky L. Chang BS, Sandi Lam MD * Department of Neurosurgery, Baylor College of Medicine/Texas Children’s Hospital, Houston, TX, USA A 9-year-old boy presented with 4 days of painful right eye swelling (Fig 1). He had fever and leukocytosis without focal neurological findings. Imaging revealed pansinusitis with superior orbital wall subperiosteal abscess and fron- toparietal subdural empyema. The patient had three serial washout operations with ophthalmology, otolaryngology, and neurosurgery (Fig 2) and four weeks of tailored intra- venous antibiotics for cultures positive for group C strep- tococcus, Streptococcus constellatus, Hemophilus influenza, and Prevotella. He recovered fully. Orbital cellulitis (postseptal cellulitis) typically arises in conjunction with acute rhinosinusitis. It is potentially life- threatening in the setting of intracranial involvement. Intracranial complications include epidural abscess, sub- dural empyema, meningitis, encephalitis, and dural sinus thrombophlebitis. Infection can propagate by septic thromboembolism or direct extension through diploic spaces and sinus wall osteomyelitis. 1 The orbit has para- nasal sinuses on three sides, separated from ethmoid air cells by the thin lamina papyracea with natural bony de- hiscences allowing ophthalmic vessels to supply the sinus. Diploic veins of the skull base penetrate the dura. The extensive valveless venous and lymphoid communications between the face, nasal cavity, pterygoid region, paranasal sinuses, cavernous sinus, and intracranial venous system allow flow in either direction. Because of this anatomy, intracranial involvement can be seen with orbital cellulitis and rhinosinusitis in up to 24% of cases. 1 In patients over six years of age treated for orbital complications of acute rhinosinusitis, there is a nearly 10% risk of concurrent intracranial infection. 2 If orbital surgery was required, this intracranial risk increases to 24%. Treat- ment of orbital cellulitis requires long-term culture-driven intravenous antibiotics, with surgery indicated for decreased visual acuity, disease progression, or failure to improve within 24 hours of medical therapy. 3 Surgical treatment includes orbitotomy and endoscopic sinus sur- gery; urgent craniotomy may be required for intracranial involvement. Cultures typically grow multiple organisms FIGURE 1. (Left) Preoperative photograph: eyelid swelling. (Right) Computed tomography of the orbits: subperiosteal abscess causing mass effect on the globe. (The color version of this figure is available in the online edition.) The authors have no financial disclosures. * Communications should be addressed to: Dr. Lam; Neurosurgery; Baylor College of Medicine/Texas Children’s Hospital; 6701 Fannin St CCC 1230.01; Houston, TX 77030. E-mail address: sklam@texaschildrens.org Contents lists available at ScienceDirect Pediatric Neurology journal homepage: www.elsevier.com/locate/pnu 0887-8994/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pediatrneurol.2015.09.001 Pediatric Neurology xxx (2015) 1e2