P0868 - A Unique Case of Orbital Cellulitis and Subperiosteal Orbital Abscess Secondary to Neonatal Tooth Infection in an Infant

Introduction:
Primary tooth eruption occurs at approximately six months of age. Neonatal teeth, defined as teeth that erupt within 30 days after birth, are uncommon, estimated to occur in 1:1,000 to 1:30,000 live births. Orbital infections in neonates are exceedingly rare. The small number of cases reported in the literature attribute ethmoid sinusitis as the underlying etiology of most neonatal orbital infections. This report describes orbital cellulitis and subperiosteal orbital abscess resulting from an infected neonatal tooth.

Case Description:
A 25-day-old, former full term, male presented with one day of fever and right eye swelling. Exam revealed right periorbital edema of the lower eyelid and proptosis. Nasopharyngoscopy showed no dacryocystocele or obstructing mass. Opthalmologic evaluation was showed normal intraocular pressures without optic nerve compromise. CT imaging revealed pre- and post-septal orbital cellulitis, maxillary and ethmoid sinus opacification, and inferior displacement of a maxillary molar tooth. Treatment began with intravenous linezolid and ceftazidime. After 24 hours, fever and purulent discharge resolved. Erythema and proptosis initially improved, but quickly recurred. Oral cavity bleeding was noted and a prematurely erupted right maxillary molar tooth was identified. An MRI with contrast demonstrated an area consistent with a multifocal subperiosteal abscess along with enhancement of a maxillary tooth follicle (Figure 1). The patient then underwent surgical extraction of the neonatal tooth (Figure 2) and drainage of the subperiosteal orbital abscess performed by pediatric otolaryngologists. Post-operatively, the patient’s periorbital edema, proptosis, and extraocular movements progressively improved. He was discharged on oral linezolid with follow-up in clinic, demonstrating continued improvement.

Discussion:
Orbital infections are extremely rare in neonates and infants and can progress to vision loss, fulminant sepsis, and occasionally death if not treated expeditiously with antibiotics and early surgical management. In children over one year of age, ethmoid sinusitis is responsible for 66-75% of orbital infections. Odontogenic infection of the orbit accounts for 1.3-2% of cases in patients of all ages and has not been reported in a neonate or infant secondary to a neonatal tooth. A 2014 systematic review over the preceding fifty years identified only eleven cases of subperiosteal orbital abscess in neonates or infants and were all attributed to ethmoiditis when a cause was recorded. There are 2 prior case reports in the literature describing neonatal toothbud infections leading to orbital cellulitis. To our knowledge, this is the first case of a neonatal tooth implicated in orbital cellulitis. Tooth extraction and abscess drainage resulted in resolution of infection.

Conclusion:
Orbital infections in children under one year of age are generally secondary to ethmoid sinusitis. However, an odontogenic source should be considered in neonates and infants with neonatal teeth given their close proximity. In our case, identifying the etiology was essential in facilitating treatment.