Migratory Preseptal Cellulitis Secondary to Rhinosinusitis Complicated by Left Frontal Subdural Empyema in a Child: A Case Report

Abstract

Preseptal cellulitis is a common pediatric infection involving the eyelids and surrounding periocular tissues. It is typically benign and rarely progresses to intracranial complications, unlike orbital cellulitis. However, when secondary to rhinosinusitis, the infection may behave unpredictably and extend beyond expected anatomical boundaries. We report a rare case of migratory preseptal cellulitis in a 12-year-old boy, initially presenting with unilateral eyelid swelling, erythema, and fever. Despite prompt initiation of empirical intravenous antibiotics, the condition failed to improve and instead demonstrated an unusual migratory pattern, spreading superiorly to the forehead and crossing the midline to involve the contralateral eye. This atypical progression raised concern for deeper infection and prompted advanced imaging. Computed tomography and magnetic resonance imaging revealed maxillary sinusitis with intracranial extension, resulting in a left frontal subdural empyema. The patient underwent multiple surgical interventions, including incision and drainage of the eyelid, craniotomy for empyema evacuation, and functional endoscopic sinus surgery to address the underlying sinonasal source. Broad-spectrum intravenous antibiotics were continued, as there was no growth after 5 days of incubation. Following combined surgical and medical management, the patient made a full recovery within 20 days, with complete resolution of neurological and ocular symptoms. This favorable outcome underscores the importance of early recognition and aggressive treatment of intracranial complications arising from seemingly localized infections. This case highlights that intracranial extension can occur even in preseptal cellulitis, particularly when symptoms worsen or fail to respond to standard therapy. Migratory eyelid swelling should heighten clinical suspicion for atypical or progressive disease. Prompt imaging, identification of the primary infectious source, and timely multidisciplinary intervention are essential to prevent life-threatening complications.