Orbital Infection Imaging - Overview, Computed Tomography, Magnetic Resonance Imaging

6/27/2016
OrbitalInfectionImaging:Overview,ComputedTomography,MagneticResonanceImaging
OrbitalInfectionImaging
Author:ClaudiaFEKirsch,MDChiefEditor:JamesGSmirniotopoulos,MDmore...
Updated:Oct07,2015
Overview
Whendiscussingorbitalinfections,understandingtheclinicaldifferencesbetween
anocularversusanorbitalinfectionisimportant. [1,2]Theorbitincludesthebone,
periorbita,ocularmuscles,retroseptalfat,andopticnerveandisconsidered
separatelyfromtheglobe.Theglobeiscontainedbythescleraandlieswithinthe
fascialenvelopeoftheTenoncapsule.Orbitalcellulitis,anorbitalinfectionresulting
fromasinusinfection,isseenintheimagebelow.
Axialcomputedtomographyscanoforbitalandfacialcellulitis.
Anocularinfectionisdefinedasbeinglimitedtotheglobeorintraoculartissue.
Oculardisease,suchasinfectiousscleritis,endophthalmitis,cytomegalovirus(CMV)
retinitis,andsyphiliticchorioretinitis,istypicallydiagnosedusingdirect
ophthalmologicexamination.Radiographicevaluationusingcomputedtomography
(CT)scanningandmagneticresonanceimaging(MRI)haslimitedusefulnessinthe
assessmentofthesediseaseentities,althoughdedicatedophthalmic
ultrasonographymaybeausefuladjuvant. [3]
CTscanningandMRImaybehelpfulindistinguishinganendophthalmitiswith
limitedsecondaryextraocularinflammationfromatruepanophthalmitiswith
infectedorbitaltissue.Inaddition,diffusionweightedimaging(DWI)inMRIshows
utilityinassessingtheopticnervesfordevelopingischemiaorinfarction,whichmay
occurduringorbitalinfections. [4,5]
Classificationoforbitalinfections
Althoughtheorbitalcomplicationsofsinusinfectionsareusuallyclassifiedasorbital
cellulitis,treatmentofthisdiseaserequiresamorecompletedescription. [6]Chandler
etaldefinedthefollowingcategoriesoforbitalinfections(imagesofwhichare
presentedbelow)[7]:
Inflammationwithedema
Orbitalcellulitis
Subperiostealabscess(SPA)
Orbitalabscess
Cavernoussinusthrombosis
Coronalcomputedtomographyscaninapediatricpatientwithsinusitisaswellasan
orbitalandsubperiostealabscess.
http://emedicine.medscape.com/article/383902overview
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AxialcomputedtomographyscaninapatientwithaninfectioncausedbyStreptococcus
pneumoniaeandasuperiororbitalsubperiostealabscessthatresultedinblindness.
Coronalcomputedtomographyscaninapediatricpatientwithsinusitisandorbital
abscess.
Oneofthemostimportantclinicalandradiographicquestionsregardingthese
categoriesiswhethertheorbitalinfectionispreseptalorpostseptal.
SeebelowforaseriesofCTscansandMRIsfromacase.
AxialpostcontrastCTscanofa56yearoldwomanwithconcernfororbitalinfection.Notethe
leftorbitalproptosistherearebothpreseptalandpostseptalinflammatorychanges,with
strandingoftheleftintraconalfatplanes.Inthispatient,thediagnosiswasmucormycosisand
washighlyworrisomeforangioinvasivespreadtothecavernoussinus,whichcanleadto
cavernoussinusthrombosis.
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Samepatientasintheaxialimage(56yearoldwomanwithconcernformucormycosis)
correspondingpostcontrastcoronalCTscanwithfindingsworrisomeforcavernoussinus
thrombosis.
MRI(1.5Tesla)ofthesamepatient(56yearoldwomanwithconcernfororbitalinfection)
obtained2daysafteraleftorbitalexenteration.Abnormalenhancementcanbenotedalongthe
courseofthecisternalsegmentofthelefttrigeminalnerve,associatedwithrestricteddiffusion,
withincreasedfluidattenuatedinversionrecovery(FLAIR)signalalongtheleftlateralpons.
Redemonstrationofaleftcavernoussinusthrombosiscanbeseen.Thefindingsareworrisome
forcontinuedangioinvasivespreadofthemucormycosisintotheleftlateralpons.
obtained2daysafteraleftorbitalexenteration.Abnormalenhancementcanbeseenalongthe
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obtained2daysafteraleftorbitalexenteration.Abnormalenhancementcanbeseenalongthe
obtained1weekafterthepriorMRIcontinuedabnormalenhancementisseenalongthecourse
ofthecisternalsegmentofthelefttrigeminalnerve,withprogressionoftheassociatedrestricted
diffusion,withincreasedfluidattenuatedinversionrecovery(FLAIR)signalalongtheleftlateral
pons.Redemonstrationofaleftcavernoussinusthrombosisisseen.Newabnormalfociof
restricteddiffusionarenownotedalongtheleftmedialtemporallobe,whichareworrisomefor
continuedprogressionofdiseaseandthedevelopmentofnewareasofischemicchange.
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Recentstudies
SepahdarietalreportedontheroleofDWIindetectingorbitalabscessasa
complicationoforbitalcellulitis.Theauthorsalsoassessedwhetherabscesscanbe
diagnosedwithacombinationofconventionalunenhancedsequencesandwhole
brainDWIwithparallelacquisition.
Inthestudy,DWIimproveddiagnosticconfidenceinnearlyallcasesoforbital
abscesswhenusedinconjunctionwithcontrastenhancedimaging.Inaddition,DWI
confirmedabscessinamajorityofcases,withoutcontrastenhancedimaging
(indicatingthatDWIalonecanbediagnosticallyeffectivewhentheuseofcontrast
materialiscontraindicated). [8]
KapuretalidentifiedtheroleofDWIindifferentiatingorbitalinflammatory
syndrome,orbitallymphoidlesions,andorbitalcellulitis.Theauthorsfounda
significantdifferencebetweentheseconditionsinDWIintensities,apparent
diffusioncoefficients(ADCs),andADCratios.
Inthestudy,Kapuretalnotedthatlymphoidlesionsweresignificantlybrighterthan
orbitalinflammatorysyndromeandthatorbitalinflammatorysyndromelesionswere
significantlybrighterthancellulitis.Inaddition,lymphoidlesionsshowedlowerADC
thanorbitalinflammatorysyndromeandcellulitis,andatrendwasseentoward
lowerADCinorbitalinflammatorysyndromethanincellulitis. [9]
Preferredexamination
CTscanningisoftenthefirstimagingmodalitythatisusedbecauseofitseaseand
availabilityatmostmedicalinstitutions. [10,11,12]
OnCTscans,apreseptalcellulitismayappearasanareaofincreaseddensity,with
swellingoftheanteriororbitaltissuesandobliterationoftheadjacentfatplanes.
Whentheinfectionprogresses,anincreaseinthedensityoftheorbitalfatmay
occurwithgradualdevelopmentofmorediscretedensitiesthat,inturn,may
progresstoformationofanorbitalabscess.
Iftheinfectionissecondarytoanunderlyingsinusitis,thismaymanifestasan
SPA.CTscanningisalsousuallythefirstimagingmodalityofchoicetoidentifyan
SPA,whichmaybelocatedjustlateraltothelaminapapyracea.
Inpediatricpatients,ophthalmicultrasonography,inskilledhands,maybeauseful
adjuvantfortherapidevaluationofpreseptalversuspostseptalinvolvement,aswell
asausefulmodalityforafollowupexamination.However,ultrasonographyis
limitedinitsabilitytoassessintracranialextension,theorbitalapex,andparanasal
sinuses. [3]
MRI,especiallypostgadoliniumenhanced,fatsuppressedsequences,isusefulfor
thedetectionofearlyinflammatorychangeswithintheorbit.OnMRI,anorbital
cellulitisappearshypointenseonT1weightedsequencesandhyperintenseonT2
weightedsequences.(Seetheimagesbelow.)[13]
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CoronalT1weighted,postgadolinium,fatsaturatedmagneticresonanceimageinapatientwith
allergicfungalsinusitis,withextensionintotheorbit.
CoronalT2weightedmagneticresonanceimageofapatientwithallergicfungalsinusitisand
extensionintotheorbit.
MRIisalsousefulforassessingintracranialextensionoftheinfectionintothe
cavernoussinusandforevaluatingcavernoussinusthrombosis.DWIinMRIcan
helpintheassessmentoftheopticnervesfordevelopingischemiaorinfarction,
whichcanoccursecondarilyfromorbitalinfections. [4,5]
MRImaybeusefulforevaluatingimmunocompromisedpatientswhohaveviral
infections.Becauseherpeszosterophthalmicus(HZO)andcytomegalovirus(CMV)
mayleadtoacuteretinalnecrosis(ARN)andretrobulbaropticneuritis(RBON),MRI
ismoresensitiveforevaluatingpathophysiologyinthesofttissuesoftheoptic
nervesandradiations,andthismodalitymaydemonstrateT2weighted
hyperintensityandcontrastenhancementthatextendsalongtheopticnerves,optic
tracts,lateralgeniculatebodies,opticradiations,andopticcortex. [10]
Plainfilmshavelimitedusefulnessinthediagnosisoforbitalinfections,especially
withtheadventofCTscanning.
Adjacenttissuemaybeinvolvedeitherprimarilyorsecondarilyinorbitalinfections,
suchasthelacrimalgland,resultingindacryoadenitis(seenintheimagesbelow),
orthelacrimalductorsac,resultingindacryocystitis.
Coronalcomputedtomographyscanofapatientwhowasonsteroidsandhadmultiple
myeloma.Inaddition,thepatienthadinfectiousdacryoadenitiswithStaphylococcusaureus
infectionandanabscesscollection.
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CoronalcomputedtomographyscanofapatientwithdacryoadenitisandStaphylococcusaureus
infection,resultinginanabscess.
Adiagnosisofdacryocystitisismadeclinicallyunlessadjacentperiorbitalcellulitisis
present,limitingtheophthalmologicevaluation.Becausethelacrimalsacisa
preseptalstructure,radiographicimaginginpatientswithperiorbitalcellulitisisa
helpfuladjuvant.Ifonlythelacrimalglandisinfectedandinflamed,thetreatmentis
nonsurgicalbecauseofthepreseptallocation.However,extensionintothe
postseptalspacewitharesultantabscessmayrequiresurgicaltreatment. [14,15]
CTscanningalsoallowsforcarefulevaluationofthelacrimalsacandnasolacrimal
ductstoexcludethepossibilityofadacryolith,which,althoughrare,canleadto
obstructionofthenasolacrimalductsandtoaresultantdacryocystitisandorbital
infection.
Limitationsoftechniques
LimitationsofMRIincludethelengthoftimethatisneededtoobtaintheimages
andtheissueofmotionartifacts,whichmaybecriticalfactorsinpatientswhoare
extremelyillwithcerebralinvolvement.Metallicforeignbodiesandtheinabilityto
performMRIinpatientswithpacemakers,nonapprovedaneurysmclips,orother
devicesthatarenotapprovedforplacementintheMRIscannerareadditional
limitations.
AlthoughCTscanningisuseful,repeatedscanscanbedamagingtothelens.Thus,
imagingstudiesshouldbetailoredappropriately.
Forexcellentpatienteducationresources,visiteMedicineHealth'sEyeandVision
Center.Also,seeeMedicineHealth'spatienteducationarticlesEyelidInflammation
(Blepharitis),Sty,andForeignBody,Eye.
ComputedTomography
CTscanningisanextremelyusefulimagingmodalityinthesettingoforbital
infections,especiallyindetectingSPAs.Orbitalcellulitisisusuallywellvisualized
becauseofthelowdensityoffatontheimages.OrbitalcellulitisandSPAsare
seenintheimagesbelow.
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Coronalcomputedtomographyscaninapediatricpatientwithsinusitisaswellasanorbitaland
subperiostealabscess.
pneumoniaeandasuperiororbitalsubperiostealabscessthatresultedinblindness.
pneumoniaeandasuperiororbitalsubperiostealabscess.
OnCTscans,preseptalcellulitismayappearasanareaofincreaseddensitywithin
thelowdensityorbitalfat.Thismayrepresentthefirstsignofinfection,inwhich
thereisobliterationofthenormalfatplanesandswellingoftheanteriororbitalsoft
tissues.
Asthecellulitisprogresses,morediscretedensitieswithintheorbitalfatmay
appear.Cellulitisisusuallyconfinedtotheextraconalspacehowever,ifthe
infectionisallowedtoprogress,itcanenterthemusclecone,resultinginan
intraconalinfectionandabscessformation.
SinusdiseasefromtheethmoidsinusesmayextendintotheorbitasanSPA,
whichisseenonCTexaminationasathinlayerofhighdensityimmediatelylateral
tothelaminapapyracea. [16]
Degreeofconfidence
AlthoughCTscanningisanexcellentimagingmodalityforidentifyingpreseptal
cellulitis,SPAs,defectswithinthelaminapapyracea,anddehiscenceofthebony
marginsoftheethmoidsinus,thistechniqueisnotasefficaciousinevaluatingthe
orbitalapexbecauseofthesurroundingbonystructuresthatmaycreateartifactsin
theregion. [16,11]
Falsepositives/negatives
Hematomainthesubperiostealspace(seenintheimagebelow)canmimicthe
appearanceofasubperiostealabscess.
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Coronalcomputedtomographyscaninapatientwithsicklecelldisease.Inthisimage,the
patienthasasubperiostealbleedthatmimicstheappearanceofaninfectioussubperiosteal
abscess.
MagneticResonanceImaging
MRIiscommonlyusedtoassessorbitalandsofttissuedisease[17]andhas
advantagesoverCTscanninginthisregionbecauseoftheosseousnatureofthe
orbitalapexanditslackofsignalintensity.Inaddition,MRImaybeadvantageous
inevaluatinganyinfectiousprocessthatextendsfromtheorbitalapextothe
cavernoussinus.Thesuperiorophthalmicveinandcavernoussinusmaybe
assessednoninvasivelybyevaluatingthevascularflowviagradientechoimaging.
[13]
OnMRI,anorbitalcellulitisappearshypointenseonT1weightedimagesand
hyperintenseonT2weightedimages.
AlthoughT1weightedimagesdemonstratethenormalfindingsofhighsignal
intensityoforbitalfatwithdarkinflammatorychanges,andalthoughT2weighted
imagesdemonstratethenormalfindingsofdarkorbitalfatwithincreasedhigh
signalintensityinflammatorychanges,themostsensitivetechniqueforevaluating
anorbitalinfectionmaybepostgadolinium,fatsuppressedimaging. [18]
MRIisespeciallyusefulinpatientswhohaveanaggressivefungalsinusitis,suchas
mucormycosisandaspergillosis,whichhasapropensityforextensionintotheorbit,
cavernoussinus,andneurovascularstructures.(Fungalsinusitisisexhibitedinthe
MRIscansbelow.)Mucormycosisismarkedlyangioinvasivethefungusgrowsinto
theinternalelasticmembraneofthebloodvessels.Thefungalhyphaemaythen
extendintoandoccludetheluminaofthebloodvesselstheyhaveinvaded.
CoronalT1weighted,postgadolinium,fatsaturatedmagneticresonanceimageinapatientwith
allergicfungalsinusitis,withextensionintotheorbit.
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CoronalT2weightedmagneticresonanceimageofapatientwithallergicfungalsinusitisand
extensionintotheorbit.
AxialT1weighted,postgadoliniummagneticresonanceimageinapatientwithsinoorbitaland
cavernoussinusmucormycosis.
DWIinMRIhasshownutilityinassessingtheopticnervesforadeveloping
ischemiaorinfarction,whichmayoccurduringorbitalinfections. [4,5]
Gadoliniumbasedcontrastagentshavebeenlinkedtothedevelopmentof
nephrogenicsystemicfibrosis(NSF)ornephrogenicfibrosingdermopathy(NFD).
NSF/NFDhasoccurredinpatientswithmoderatetoendstagerenaldiseaseafter
beinggivenagadoliniumbasedcontrastagenttoenhanceMRIorMRAscans.
NSF/NFDisadebilitatingandsometimesfataldisease.Characteristicsincludered
ordarkpatchesontheskinburning,itching,swelling,hardening,andtighteningof
theskinyellowspotsonthewhitesoftheeyesjointstiffnesswithtroublemoving
orstraighteningthearms,hands,legs,orfeetpaindeepinthehipbonesorribs
andmuscleweakness.
Ultrasonography
Ultrasonographyisusuallyperformedinophthalmologypracticesbytrained
techniciansusingahighfrequency10MHzprobe.Theprobeisappliedovera
closedeyelid,withthegloveinaneutralpositionandwithgentleeyemotionsfrom
lefttoright.
Toassesstheposterioraspectoftheglobe,thegainsettingsareadjustedto
dampennearfieldechoes.Toassessthevitreousandcentralportionoftheglobe,
thenearfieldgainisincreased.
Thecenterofthelensisanechoic,whereasthemidportionsoftheanteriorandthe
posteriorpartsofthelensreflecttheultrasonographicbeam,withtheirisseenasan
echogeniclineoneitherside.
Thevitreoushumorisanechoic,andtheposteriorechogeniclimitoftheglobeisthe
retina.
Posteriortotheglobe,theretrobulbarfatisechogenic,withtheopticnerveseenas
ahypoechoicstructurethatextendsdorsallyawayfromtheposteriormarginofthe
globe. [19]
Degreeofconfidence
Ultrasonographyrequiresadedicatedophthalmologictechnicianandmaynotallow
importantvisualizationsofthecavernoussinusandtheintracranialextensionof
infections.
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NuclearImaging
Nuclearmedicineimagesthatusetechnetium99m(99m Tc)labeledleukocytes
havebeenusefulinthediagnosisoforbitalimplantinfectionsinpatientsinwhom
CTscansfailedtorevealradiographicabnormalities. [20]
ContributorInformationandDisclosures
Author
ClaudiaFEKirsch,MDAssociateProfessorofNeuroradiologyandOtolaryngology,DepartmentofRadiology,
SectionChiefforHeadandNeckImaging,Director,RadiologyMedicalStudentTeaching,WexnerMedical
Center,TheOhioStateUniversityCollegeofMedicine
ClaudiaFEKirsch,MDisamemberofthefollowingmedicalsocieties:AmericanAssociationforWomen
Radiologists,AmericanCollegeofRadiology,AmericanRoentgenRaySociety,AmericanSocietyofFunctional
Neuroradiology,AmericanSocietyofHeadandNeckRadiology,AmericanSocietyofNeuroradiology,Association
ofEducatorsinImagingandRadiologicSciences,AssociationofUniversityRadiologists,BritishSocietyofHead
andNeckImaging,EasternNeuroradiologicalSociety,EuropeanSocietyofHeadandNeckRadiology,NewYork
AcademyofSciences,RadiologicalSocietyofNorthAmerica,RoyalCollegeofRadiologists,Western
NeuroradiologicalSociety
Disclosure:ReceivedconsultingfeefromPrimalPictures,forconsultingReceivedgrant/researchfundsfrom
AdenoidCysticCarcinomaResearchFoundationforother.
Coauthor(s)
RogerTurbin,MDConsultingStaff,DepartmentofOphthalmology,RutgersNewJerseyMedicalSchool
Disclosure:Nothingtodisclose.
DevangGor,MDStaffPhysician,DepartmentofRadiology,UniversityofMedicineandDentistryofNewJersey
SpecialtyEditorBoard
BernardDCoombs,MB,ChB,PhDConsultingStaff,DepartmentofSpecialistRehabilitationServices,Hutt
ValleyDistrictHealthBoard,NewZealand
CDouglasPhillips,MD,FACRDirectorofHeadandNeckImaging,DivisionofNeuroradiology,NewYork
PresbyterianHospitalProfessorofRadiology,WeillCornellMedicalCollege
CDouglasPhillips,MD,FACRisamemberofthefollowingmedicalsocieties:AmericanCollegeofRadiology,
AmericanMedicalAssociation,AmericanSocietyofHeadandNeckRadiology,AmericanSocietyof
Neuroradiology,AssociationofUniversityRadiologists,RadiologicalSocietyofNorthAmerica
ChiefEditor
JamesGSmirniotopoulos,MDProfessorofRadiology,Neurology,andBiomedicalInformatics,Program
Director,DiagnosticImagingProgram,CenterforNeuroscienceandRegenerativeMedicine(CNRM),Uniformed
ServicesUniversityoftheHealthSciences
JamesGSmirniotopoulos,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofRadiology,
AmericanRoentgenRaySociety,AmericanSocietyofHeadandNeckRadiology,AmericanSocietyof
Neuroradiology,AssociationofUniversityRadiologists,RadiologicalSocietyofNorthAmerica,AmericanSociety
ofPediatricNeuroradiology
AdditionalContributors
BartonFBranstetter,IV,MDProfessorofRadiology,Otolaryngology,andBiomedicalInformatics,Universityof
PittsburghSchoolofMedicineChiefofNeuroradiology,UniversityofPittsburghMedicalCenter
BartonFBranstetter,IV,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofRadiology,
AmericanMedicalAssociation,AmericanRoentgenRaySociety,AmericanSocietyofHeadandNeckRadiology,
AmericanSocietyofNeuroradiology,PennsylvaniaMedicalSociety,RadiologicalSocietyofNorthAmerica
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