¡¡¡¡DISCUSSION

¡¡¡¡Orbital abscesses caused by ethmoiditis are extremely rare in neonates[6]. The clinical picture, which includes the classical signs of cellulitis such as eyelid swelling, erythema, chemosis, proptosis, and ocular motility impairment, is highly suspicious of infection within the orbit[7]. However, the distinction between subperiosteal abscess and more benign preseptal disease is difficult to make especially in young child in whom ophthalmological evaluation is often difficult. To our knowledge, there are ten reported cases of neonatal orbital abscess up to date. In 2001, Cruz et al[6] has reported two cases of neonatal orbital abscess secondary to ethmoiditis and both cases were confirmed with CT scan findings. Both cases were totally cured after intravenous antibiotics treatment; one case had spontaneous drainage of abscess while the other case has surgical drainage through inferior transconjunctival orbitotomy.

¡¡¡¡Interestingly, all reported cases related to staphylococcal infection of the ethmoidal sinus. Neonatal staphylococcus infection of the ethmoidal labyrinth was postulated to result from the interaction of the three different factors: the embryology of ethmoidal cells, epidemiology of staphylococcal colonization after birth, and the defense mechanisms against staphylococcal infection operate in neonates. Usually, healthyª²term newborns become colonized with normal flora acquired from their mothers and environment within a few days after birth. Staphylococcus aureus colonization of skin and mucosal surfaces is common[8]. In our reported case the infant had history of upper respiratory tract infection prior to the presentation.Harris[9] reported that subperiosteal abscess in young children harbours single aerobe infections, commonly staphylococcus or streptococcus while beyond 9 years of age these infections become increasingly polymicrobial and aerobic in nature.

¡¡¡¡Computer tomography (CT) scanning is the imaging modality of choice in distinguishing preseptal cellulitis from postseptal infection of the orbit and for therapeutic decision in determining the initial treatment. The orbit is high contrast area and the infectious process can be easily localized to the preseptal area, the orbital muscle cone or the subperiosteal space[10]. On CT scan the abscess appeared as hypodense areas bounded within a convex, elevated periosteum and juxtaposed to an infected sinus.

¡¡¡¡Postseptal orbital cellulitis patients with favorable presentations (visual acuity normal or near normal, proptosis less than 2mm, good pupillary reflex, no history of immunodeficiency) were treated initially with intravenous
antibiotics. In addition, patients aged under 9 years are more likely to have single pathogen, and likely to cure with medical treatment alone. Ceftriaxone was started in our case because of good coverage of common respiratory pathogens and good penetration of blood brain barrier[11].

¡¡¡¡However, in neonates it is difficult to evaluate visual acuity and can progress to more sinister complications rapidly. Therefore surgical drainage is justified in our case. The common approach for drainage of subperiosteal abscess is through an external ethmoidectomy incision[12].

¡¡¡¡Endoscopic drainage of abscess is more favourable due to rapid resolution of periorbital inflammation, avoidance of facial scar and shortening of hospital stay[13]. This technique approaches the disease process from path of its origin within the ethmoidal sinus with the goal of establishing natural drainage back through the nose. The endoscopic technique can be used for medial disease, including some superior and inferior extension, but for the disease in the lateral half of the orbit. Endoscopic sinus surgery is more difficult in young children because of smaller anatomy of the sinuses, depending on the expertise and experience of the surgeon.

¡¡¡¡Staphylococcus ethmoiditis with concomitant orbital cellulitis in a neonate is a serious infection. Apart from causing ocular and central nervous system complications, it may result in septicemia[14]. Cruz et al[6] also reported, a case of neonatal abscess complicated with bilateral pneumothoraces with pleural effusion. They postulated due to immaturity of defense system in young infant against Staphylococcus aureus, which evolved to septicemia. Therefore it is important that any infant with orbital cellulitis should be carefully screened to rule out a systemic spread of the infection.

¡¡¡¡In conclusion, this is a rare presentation of neonatal orbital abscess due to ethmoidal sinusitis. Combined management between ophthalmologist, otorhinolaryngologist, pediatrician and radiologist is very important. Apart from intravenous antibiotics, surgical drainage is the treatment of choice to prevent further complications. Endoscopic approach is more favourable because of less ocular morbidity and cosmetically superior to the conventional surgical approach.

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Clin Immunol1992; 90: 552ª²554

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¡¡¡¡7 Ismaeel OM, Ibrahim M, Shaharuddin B. Orbital abscess secondary to frontal mucocele successfully treated by surgical drainage: a case report. Int J Ophthalmol (Guoji Yanke Zazhi)2007;7(5):1265ª²1267

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¡¡¡¡10 Spires JR, Smith RJ. Bacterial infections of the orbital and periorbital soft tissues in children. Laryngoscope1986;96: 763ª²767

¡¡¡¡11 Manning SC. Orbital cellulitis and abscess. In: Gates GA, editor. Current therapy in otolaryngologyª²head and neck surgery. 6th ed. St. Louis, MO: Mosbyª²Year Book Inc;1998:359ª²362

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¡¡¡¡13 Manning SC. Endoscopic drainage of subperiosteal orbital abscesses. Opera Tech Otolaryngol Head Neck Surg2002;13 (1):73ª²76

¡¡¡¡14 Kraus M. Tovi F. Central nervous system complications secondary to otorhinologic infections. An analysis of 39 pediatric cases. Int J Pediatr

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