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    Zunaina Embong, Shatriah Ismail, Asokumaran Thanaraj, Adil Hussein

    Department of OphthalmologySchool of Medical Sciences, Universiti Sains Malaysia, Health Campus

    16150 Kubang Kerian, Kelantan, Malaysia

    A 43 year-old man presented with pain on the right tooth for three days duration.Computed tomography showed left orbital cellulitis and right parapharyngealabscess. There was also evidence suggestive of a dental abscess over right upperalveolar region. Magnetic resonance imaging revealed left superior ophthalmicvein thrombosis. Emergency drainage of the right parapharyngeal abscess wasperformed. Right maxillary molar extraction revealed periapical abscess. Left eyeproptosis markedly reduced after initiating heparin.

    Key words : Maxillary molar abscess, cavernous sinus thrombosis, superior ophthalmic vein thrombosis.


    Dental infection may cause sinusitis, orbitalcellulitis, parapharyngeal abscess, mediastinitis andpericarditis (1, 2). However, maxillary molar abscesswith contralateral orbital cellulitis and superiorophthalmic vein thrombosis is an unusualpresentation.

    Case Report

    A 43 year-old Malay man presented with ahistory of pain on his right tooth for three daysduration. He also experienced pain over the rightjaw which was associated with low-grade fever.However, he reported no facial pain or pain over

    Submitted-20-02-2005, Accepted-03-12-06

    Malaysian Journal of Medical Sciences, Vol. 14, No. 2, July 2007 (62-66)


    Figure 1: Appearance of the left eye at presentation

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    the maxillary region. Two days after having righttoothache, he developed a left orbital swelling, whichwas progressively increase in size and associatedwith pain. The left eye was red with marked tearing.The vision of the left eye was progressively gettingworse. The left orbital swelling was not associatedwith discharge, difficulty in swallowing, neck painor fits. There was no history of trauma and nosignificant past medical or surgical history.

    Eye examination showed visual acuity in theright eye was 6/6. Visual acuity in the left eye wasperception to light. There was relative afferentpupillary defect in the left eye. The left eyelid wasswollen and partially covered the eye. There was 6mm proptosis of the left eye with no obvious massof the orbit seen. The conjunctiva was chemotic andinjected with clear cornea (Figure 1). The eye waswarm and tender. The proptosed eye was non-pulsatile and elicited no bruit. There was painfulophthalmoplegia. The anterior chamber examinationwas normal and the intraocular pressure hadincreased to 29mm Hg. Fundoscopy showedchoroidal striae at the posterior pole with normalpink disc. The retinal vessels were normal.

    The right eye was normal and not proptosed.The anterior segment and the fundus were alsonormal. Maxillary and frontal area was normal andnon-tender. General examination revealed an ill-looking patient who was afebrile with stable vitalsigns. However, he was conscious and alert. There

    was no neck stiffness or weakness of both upperand lower limbs. Systemic examination wasunremarkable.

    Diagnosis and Treatment

    A diagnosis of left eye orbital cellulitis wasmade. The patient was immediately started onintravenous ceftazidime one gram 12 hourly andintravenous vancomycin one gram 12 hourly aftertaking blood for culture and sensitivity. Guttaeciprofloxacin every 2 hourly and topical timolol0.5% every 12 hourly was instilled to the left eye.

    Urgent computed tomography finding wascompatible with left orbital cellulitis (Figure 2) andrevealed right parapharyngeal abscess (Figure 3).There was also evidence suggestive of tooth abscessover right upper alveolar region with bilateralmaxillary and posterior ethmoidal sinusitis.However, the cavernous sinus area was not clearlyvisible.

    An emergency drainage of the rightparapharyngeal abscess and bilateral antral washoutwas performed by an otorhinolaryngologist. Rightmaxillary molar extraction was done by the dentalteam revealing a periapical abscess. Culture fromthe drainage and blood showed scanty mixed growth.Intravenous metronidazole 500mg was subsequentlyadded to give a better coverage of the anaerobes.


    Figure 2: Computed tomography showing left eyeproptosis with orbital cellulitis

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    Magnetic resonance imaging revealedcavernous sinus thrombosis with left superiorophthalmic vein thrombosis (Figure 4). The patientwas then started on subcutaneous heparin 5000 unit12 hourly after reviewed by a neurologist. Two daysafter initiating heparin, the proptosis was markedlyreduced with regression of the lid oedema. However,the visual acuity has not improved. Patient wasdischarged after having completed two weeks ofintravenous antibiotics and was placed on long-termwarfarin for one year.


    Infection of maxillary molar may become life-threatening through airway compromise orthreatened vision by rapid spread involving theorbital area.

    Parapharyngeal space is a critical area in theneck which may be easily infected by a dentalinfection (3, 4). Infection of the maxillary molar mayspread through local tissue planes or venous channelto involve parapharyngeal space; resulting in thedevelopment of a parapharyngeal abscess. Adangerous complication of parapharyngeal abscessincludes airway obstruction due to medial bulgingof the pharyngeal wall and supraglottic oedema.

    Other complications of maxillary molarinfection include maxillary sinusitis, pansinusitis,

    orbital cellulitis, and cavernous sinus thrombosis (5,6). Maxillary sinusitis may result from extension ofmaxillary molar infection or from perforation of thesinus floor during extraction of diseased maxillaryteeth (6). This is because the root of the molar teethin the upper jaw lies close to the floor of themaxillary antrum and may even protrude into it.

    Maxillary sinusitis may lead to cavernoussinus thrombosis (7) via thrombophlebitis ofinfraorbital vein. Dental infection is a well-reportedcause of cavernous sinus thrombosis and it isbelieved that the most frequent route of spread isthrough the pterygoid plexus (4). Cavernous sinusthrombosis also can occur following acuteethmoiditis (7, 8). The spread of infection throughvalveless superior ophthalmic vein reaches thecavernous sinus (9).

    Involvement of the contralateral eye, indicatesspread from the original side of infection throughthe intercavernous sinuses to the opposite cavernoussinus (7, 8, 10). The infection presumably gainedaccess to the contralateral eye through valvelessvenous channels in a retrograde fashion. Otherpossible explanation for the presentation ofcontralateral orbital cellulitis in this patient is thatthe infection may spread from the ethmoidal sinussince this patient has bilateral ethmoidal sinusitis.Orbital complications are usually secondary toethmoiditis (8, 11, 12) especially in children (13).

    Zunaina Embong, Shatriah Ismail et. al

    Figure 3 : Computed tomography showing rightparapharyngeal abscess and right upperalveolar abscess

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    Reddy reported that orbital cellulitis secondary toethmoiditis in 25%, maxillary sinusitis in 10% andethmoid and maxillary sinusitis in 30% of patient(10). The thin lamina papyracea divides the orbitfrom the ethmoidal sinus and permits infection tospread with relative ease. Infection may erodethrough the bone or pass through the numerous smallvalveless veins that perforate the bone (10, 12).

    Superior ophthalmic vein thrombosis isgenerally noted as a thickening of the superiorophthalmic vein as compared with the contralateralnormal side. Thickening of the superior ophthalmicvein should be looked for as an importantradiological marker of impending orbitalcomplications (9).

    Orbital cellulitis can lead to seriouscomplication include blindness, intracranialcomplications (1, 9, 10), and death (4). Optic nervedamage can occur either due to vascular compromiseto the optic nerve, compressive optic neuropathy ordue to inflammatory optic neuropathy (12).

    The most common bacteria isolated in orbitalinfection is Staphylococcus aureus (10, 14) andStreptococcus pneumoniae (14). Haemophilusinfluenza is a very commonly isolated pathogen inchildren (15). Streptococcus anginosus was reportedas one of the virulent pathogens that causenecrotising orbital cellulitis (16). Bacteroidesmelaninogenicus is a pathogen implicated in neckabscess of dental origin (6). There was no organismisolated in this patient. One possible explanation is

    that the patient was started on antibiotics by theprimary physicians before initial referral (13).

    Computed tomography is the diagnosticmodality of choice for demonstrating cavernoussinus thrombosis. However, even with intravenouscontrast, computed tomography often fails todemonstrate occlusion of the cavernous sinus (8).Magnetic resonance venogram, using presaturationto eliminate arterial signal is a more sensitive methodfor revealing cavernous sinus thrombosis (17).

    Optimal therapy for septic cavernous sinusthrombosis may include antibiotics, anticoagulant,corticosteroids and surgery. In general, apenicillinase-resistent penicillin, often with a thirdgeneration cephalosporin, is appropriate empirictherapy. Metronidazole may be added to the regimeto optimize anaerobic coverage, especially when theprocess originates from a dental or otorhinologicprocess. When there is rapid progression of septiccavernous sinus thrombosis, initial therapy includingvancomycin should be immediately administered(8).

    Early anticoagulant therapy was shown toreduce mor