Guidelines for the management of periorbital cellulitis/abscess

Evaluation of moderate periorbital cellulitis and home-based therapy in children (EPOCH study, Part 2): A prospective single centre cohort study

BACKGROUND

Paediatric periorbital cellulitis, a common eye condition, typically requires inpatient admission for intravenous antibiotics due to concerns about orbital spread. This study aimed to assess the safety and effectiveness of ambulatory management for children with moderate periorbital cellulitis.

METHODS

Over a 24-month period, we prospectively enrolled 84 children aged 1 to 16 years who presented with moderate periorbital cellulitis to the emergency department. Demographic and clinical data were collected. Following a guideline-based decision tree, eligible children received intravenous antibiotics and were discharged with a peripheral cannula for follow-up in ambulatory care and ophthalmology clinics. Descriptive statistics were used for data presentation.

RESULTS

Among the 84 children, 62 (73.8%) were managed through the ambulatory care model. Within the category of moderate POC, those who were admitted to the hospital did not have higher CRP or White Cell counts and received IV antibiotics for the same length of time. The ambulatory care clinic provided a total of 132 daily doses of intravenous antibiotics. Two children treated on this pathway required inpatient admission due to clinical deterioration, one of whom required ophthalmic surgical intervention. There was no mortality or sight-threatening complications in this study.

CONCLUSIONS

Implementing a directed ambulatory care pathway for children with moderate periorbital cellulitis proved to be an effective and safe management strategy. This approach reduces the strain on hospital bed occupancy while promoting community-based patient care.

Ocular Manifestations of Pediatric Rhinosinusitis: A Comprehensive Review

Background: Rhinosinusitis is a common childhood illness that may result in a number of ocular problems. The goal of this thorough analysis is to compile the available data regarding the kinds, prevalence, and treatment of ocular problems related to juvenile rhinosinusitis. Methods: A comprehensive analysis of electronic databases, such as PubMed, Embase, and Cochrane Library, was carried out to pinpoint pertinent research articles written in English and published between the beginning and August of 2023. Included were studies that discuss ocular problems in young children suffering from rhinosinusitis. Study characteristics, ocular complication kinds, occurrence rates, and management approaches were the main topics of data extraction. Results: A significant number of pertinent research on ocular problems related to juvenile rhinosinusitis was found through the literature search. Preliminary searches indicated that orbital cellulitis, subperiosteal abscess, cavernous sinus thrombosis, and optic neuritis are probably the most often reported ocular problems. It is expected that these problems will occur at a wide range of incidence rates, from somewhat unusual to more prevalent. Depending on the severity of the consequences, management techniques are expected to require a combination of surgical and medicinal procedures. Healthcare professionals will benefit from the findings since they will improve knowledge of the clinical presentation, diagnosis, and treatment of these potentially blinding consequences. The evaluation also assists in identifying knowledge gaps and guides future directions for this field of study, both of which are critical to enhancing patient outcomes. Conclusions: The wide range of topics included in this study will help to better understand the burden of ocular consequences related to juvenile rhinosinusitis and will make it easier to build preventative and treatment plans that work better.

Improving Antibiotic Use in Pediatric Preseptal Cellulitis Using a Clinical Practice Guideline

OBJECTIVES

The purpose of this study was to evaluate the impact of a clinical practice guideline (CPG) on antibiotic use and resource utilization for pediatric preseptal cellulitis.

METHODS

This retrospective quasiexperimental study included patients between the age of 2 months and 17 years admitted for preseptal cellulitis between January 2013 and December 2023. The preseptal cellulitis CPG was implemented in December 2020 using a multifaceted strategy that included buy-in from key stakeholders, education of frontline providers, the official CPG launch, and stakeholder check-ins. The primary outcome was the use of broad-spectrum antibiotics, including dual/triple therapy and methicillin-resistant Staphylococcus aureus (MRSA) active antibiotics. The secondary outcome was resource utilization including blood testing and imaging. Outcomes were compared pre- and post-CPG implementation using the Fisher exact test and logistic regressions.

RESULTS

Of 236 patients meeting inclusion criteria, 175 and 61 patients composed the pre- and post-CPG cohorts, respectively. Median age (interquartile range) was 4.0 (1.8-8.3) years and 46% of the population were female. Post-CPG implementation changes in empirical antibiotic use included decreases in broad-spectrum use from 100% to 66% (P < .001), dual/triple therapy from 47% to 16% (P < .001), and MRSA active agents from 86% to 26% (P < .001). There was a decrease in complete blood count and blood culture orders from 75% to 57% (P = .014) and 32% to 18% (P = .047), respectively.

CONCLUSIONS

Use of broad-spectrum antibiotics, including dual/triple therapy and MRSA active antibiotics for the treatment of pediatric preseptal cellulitis, decreased after CPG implementation.

Assessing the Usefulness of Ultrasonography for the Diagnosis and Evaluation of Intra-Orbital Lesions in Pediatric Patients: A Retrospective Analysis

OBJECTIVES

To assess the usefulness of ultrasonography in the diagnosis and evaluation of extraocular intra-orbital lesions in pediatric patients.

METHODS

Twenty-three pediatric patients with intra-orbital lesions who underwent both ultrasound and computed tomography/magnetic resonance imaging (CT/MRI) were included. The following parameters were evaluated using ultrasound: 1) lesion detection rate (presence or absence of lesions), 2) lesion characteristics, 3) lesion location (extraconal or intraconal), and 4) the lesion longest linear dimensions, and these were compared using Fisher's exact test and Mann-Whitney U test.

RESULTS

Two lesions could not be detected using ultrasound; in the other 21 cases, the lesion characteristics diagnosed by ultrasound were correct. Diagnostic accuracy of detection and characteristics assessment using ultrasound were 91.3% and 91.3%, respectively. The lesion location was not significantly different between the two groups (intraconal/extraconal in those detected using ultrasound versus those in the absence on ultrasound = 7/14 versus 0/2, P > .999); however, in two cases that were not detected on ultrasound, the lesions were located at extraconal. Lesions that were small in longest linear dimensions on CT/MRI were not detected using ultrasound (the longest linear dimensions in lesions detected using ultrasound versus that in the absence of ultrasound: 29.5 ± 8.2 [range, 13-46] versus 10 and 11 mm, P = .043).

CONCLUSIONS

Ultrasonography proved to be useful for visualizing and evaluating intra-orbital lesions except for lesions that were relatively small in size. Therefore, although ultrasound could not detect lesions located behind bone and bone invasion, it could be used for diagnosing and selecting treatment strategies for intra-orbital lesions.

Subperiosteal and Orbital Abscesses: A Comparison of Clinical Features, Management, and Outcomes

PURPOSE

To compare the clinical features, management, and outcomes between orbital cellulitis patients with subperiosteal abscess (SPA) and those with orbital abscess (OA).

METHODS

A retrospective study was conducted at a tertiary care center through medical record search to identify patients with orbital cellulitis from January 1, 2000 to December 31, 2022. Charts were screened for those with radiographic evidence of SPA or OA. Demographic data and presenting clinical features were compared between the 2 cohorts. Primary outcomes compared included rates of surgical intervention, reoperation, and readmission; and length of hospital stay and final vision.

RESULTS

A total of 189 patients, 162 with SPA and 27 with OA, met the criteria. The OA group (mean 46.5 ± 18.6 years) was older than the SPA group (mean 19.1 ± 21.4 years). Comorbid sinusitis was significantly more common in the SPA cohort (95.7% SPA; 70.4% OA; p < 0.001), while OA was more likely to occur with orbital trauma (29.6% vs. 8.0%; p = 0.003), implanted hardware (11.1% vs. 0.6%; p = 0.005), and comorbid diabetes (22.2% vs. 4.3%; p = 0.001). OA patients more often presented with a relative afferent pupillary defect (21.7% vs. 3.9%; p = 0.005), vision worse than 20 of 50 (42.3% vs. 16.2%; p = 0.005), and methicillin-resistant Staphylococcus aureus infection (20.8% vs. 5.8%; p = 0.036). OA was associated with a higher reoperation rate (47.8% vs. 21.3%; p = 0.019), readmission rate (18.5% vs. 5.6%, p = 0.047), and limited extraocular motility at follow-up (4.3% vs. 25%; p = 0.013); while mean length of hospital stay and final visual acuity were similar.

CONCLUSION

OA may affect an older population with a divergent risk factor profile compared with SPA. OA may cause more severe functional impairment on presentation, warranting more aggressive management to achieve visual outcomes similar to SPA.

Wilderness Medical Society Clinical Practice Guidelines for Treatment of Eye Injuries and Illnesses in the Wilderness: 2024 Update

A panel convened to develop an evidence-based set of guidelines for the recognition and treatment of eye injuries and illnesses that may occur in the wilderness. These guidelines are meant to serve as a tool to help wilderness providers accurately identify and subsequently treat or evacuate for a variety of ophthalmologic complaints. Recommendations are graded based on the quality of their supporting evidence and the balance between risks and benefits according to criteria developed by the American College of Chest Physicians.

Orbital complications of sinusitis in children - Retrospective analysis of an 8.5 year experience

OBJECTIVE

Orbital complications account for approximately 74-85 % of all complications of acute sinusitis, affect the pediatric population more frequently, and can have devastating consequences. In the years following the COVID-19 pandemic (2022, 2023), a high number of children presented to our clinic with orbital complications. 1)Has there been an increase in orbital complications in the post-covid era? 2)To what extent has the use of MRI reduced radiation in pediatric patients?

DESIGN

In our retrospective data analysis, all pediatric patients (age 0-16 years) treated at a university ENT clinic during the period 01/2014-06/2023 who presented with an orbital complication of rhinosinusitis were included. The analysis was descriptive.

RESULTS

Forty-four children with orbital complications of rhinosinusitis were treated during the study period, 14 females and 30 males. Most patients (n = 23, 52 %) presented during the years of the waning Covid-19 pandemic (01/2022 to 06/2023). MRI was the initial imaging modality (n = 22,50 %); CT was performed in 17 of 44 cases (39 %) when surgery was indicated. The most common germ detected was of the Streptococcus species, and the predominant antibiotic administered was amipicillin/sulbactam.

CONCLUSION

The standard operating procedure (SOP) established at our hospital in 2014 was followed in 42/44 cases. Except for 2 cases, CT was performed exclusively when surgery was indicated. Imaging-related radiation could be avoided in 27 patients (61 %). There was a 30 % increase in orbital complications related to sinus infections postpandemically.

Bacterial orbital cellulitis - A review

Infections of orbit and periorbita are frequent, leading to significant morbidity. Orbital cellulitis is more common in children and young adults. At any age, infection from the neighboring ethmoid sinuses is a likely cause and is thought to result from anatomical characteristics like thin medial wall, lack of lymphatics, orbital foramina, and septic thrombophlebitis of the valveless veins between the two. Other causes are trauma, orbital foreign bodies, preexisting dental infections, dental procedures, maxillofacial surgeries, Open Reduction and Internal Fixation (ORIF), and retinal buckling procedures. The septum is a natural barrier to the passage of microorganisms. Orbital infections are caused by Gram-positive, Gram-negative organisms and anaerobes in adults and in children, usually by Staphylococcus aureus or Streptococcus species. Individuals older than 15 years of age are more likely to harbor polymicrobial infections. Signs include diffuse lid edema with or without erythema, chemosis, proptosis, and ophthalmoplegia. It is an ocular emergency requiring admission, intravenous antibiotics, and sometimes surgical intervention. Computed tomography (CT) and magnetic resonance imaging (MRI) are the main modalities to identify the extent, route of spread from adjacent structures, and poor response to intravenous antibiotics and to confirm the presence of complications. If orbital cellulitis is secondary to sinus infection, drainage of pus and establishment of ventilation to the sinus are imperative. Loss of vision can occur due to orbital abscess, cavernous sinus thrombosis, optic neuritis, central retinal artery occlusion, and exposure keratopathy, and possible systemic sequelae include meningitis, intracranial abscess, osteomyelitis, and death. The article was written by authors after a thorough literature search in the PubMed-indexed journals.

Variation in the Management of Hospitalized Children With Orbital Cellulitis Over 10 Years

OBJECTIVES

No previous study has examined the management of hospitalized children with orbital cellulitis at both children's and community hospitals across multiple sites in Canada. We describe variation and trends over time in diagnostic testing and imaging, adjunctive agents, empiric antibiotics, and surgical intervention in children hospitalized with orbital cellulitis.

PATIENTS AND METHODS

Multicenter cohort study of 1579 children aged 2 months to 18 years with orbital cellulitis infections admitted to 10 hospitals from 2009 to 2018. We assessed hospital-level variation in the use of diagnostic tests, imaging, antibiotics, adjunctive agents, surgical intervention, and clinical outcomes using X2, Mann-Whitney U, and Kruskal-Wallis tests. The association between clinical management and length of stay was evaluated with median regression analysis with hospital as a fixed effect.

RESULTS

There were significant differences between children's hospitals in usage of C-reactive protein tests (P < .001), computed tomography scans (P = .004), MRI scans (P = .003), intranasal decongestants (P < .001), intranasal corticosteroids (P < .001), intranasal saline spray (P < .001), and systemic corticosteroids (P < .001). Children's hospital patients had significantly longer length of hospital stay compared with community hospitals (P = .001). After adjustment, diagnostic testing, imaging, and subspecialty consults were associated with longer median length of hospital stay at children's hospitals. From 2009 to 2018, C-reactive protein test usage increased from 28.8% to 73.5% (P < .001), whereas erythrocyte sedimentation rate decreased from 31.5% to 14.1% (P < .001).

CONCLUSIONS

There was significant variation in diagnostic test usage and treatments, and increases in test usage and medical intervention rates over time despite minimal changes in surgical interventions and length of stay.

Differences in characteristics, aetiologies, isolated pathogens, and the efficacy of antibiotics in adult patients with preseptal cellulitis and orbital cellulitis between 2000-2009 and 2010-2019

BACKGROUND/AIMS

To understand whether the epidemiology, aetiologies, common pathogens and the antibiotic efficacy against the identified bacteria of periorbital cellulitis in adults have changed recently (2010-2019) compared with the past decade (2000-2009).

METHODS

Adult patients (n=224) diagnosed with preseptal cellulitis and orbital cellulitis admitted to Kaohsiung Veterans General Hospital during 2000-2019 were retrospectively reviewed. Demographic and clinical characteristics, isolated pathogens and antibiotic susceptibility tests against the commonly cultured bacteria were analysed.

RESULTS

Preseptal cellulitis showed a tendency of female predominance. Patients in their 60s showed an incidence peak; more cases were observed during winter. The most common predisposing factor was dacryocystitis (15.5%-30.5%), followed by hordeolum (15.5%-24.8%). Aetiology of sinusitis (p=0.001) decreased and that of conjunctivitis (p=0.007) increased significantly with time. Culture results of nasopharyngeal swabs and local abscess showed higher positivity rate than conjunctival swab. The most common isolates were methicillin-susceptible Staphylococcus aureus, methicillin-resistant S. aureus, coagulase-negative staphylococci and Pseudomonas aeruginosa. Antibiotics including fluoroquinolones and vancomycin were effective; in contrast, ampicillin/sulbactam and oxacillin showed decreasing efficacy against gram-positive bacteria. For antibiotic treatment against P. aeruginosa, fluoroquinolones, ceftazidime, piperacillin and imipenem were ideal choices.

CONCLUSION

In isolated pathogens, the increasing trend of methicillin-resistant S. aureus detection was compatible with reducing oxacillin efficacy against periorbital infection. In our study, the report of antibiotic efficacy against the most common identified bacteria offered empirical choices for hospitalised patients with periorbital infection before obtaining culture results.

Orbital Complications of Chronic Rhinosinusitis: Two Years' Experience in a Tertiary Referral Hospital

PURPOSE

To investigate the different clinical manifestations in Egyptian patients with orbital complications of rhinosinusitis (RS) according to the pathology within the paranasal sinuses.

METHODS

The medical records of patients presented with chronic RS between August 2018 and December 2020 were retrospectively reviewed.

RESULTS

This study included 64 patients: 28 patients with subperiosteal abscess (SPA), 10 with allergic fungal RS, 6 with isolated fungal RS, 6 with invasive fungal RS, and 14 with mucocele. The most common manifestation was proptosis, limitation of ocular motility, periorbital swelling, and pain. A relative afferent pupillary defect was present in all cases of invasive fungal sinusitis. Surgical interventions were performed in 63 out of 64 cases. All the ophthalmological manifestations were reversible except for patients with invasive fungal rhinosinusitis.

CONCLUSION

Orbital complications of RS may require early surgical intervention with multidisciplinary counseling between ophthalmologists, otorhinolaryngologists, radiologists, and neurologists.

Systemic corticosteroids for orbital complications of pediatric rhinosinusitis: A systematic review

OBJECTIVES

Determine if systemic corticosteroids administration is associated with reduced length of stay, surgical intervention, and abscess formation in pediatric patients with orbital complications of rhinosinusitis.

METHODS

Systematic review and meta-analysis were performed utilizing the PubMed and MEDLINE databases to identify articles published between January 1990 and April 2020. Retrospective cohort study of the same patient population over the same time period at our institution.

RESULTS

Eight studies, 477 individuals, met criteria for inclusion in the systematic review. 144 patients (30.2%) received systemic corticosteroids, while 333 patients (69.8%) did not. Meta-analyses of frequency of surgical intervention and subperiosteal abscess showed no difference between those who did and did not receive systemic steroids ([OR = 1.06; 95% CI: 0.46 to 2.48] and [OR = 1.08; 95% CI: 0.43 to 2.76], respectively). 6 articles evaluated hospital length of stay (LOS). 3 of these reported enough data to perform meta-analysis, which showed patients with orbital complications who received systemic corticosteroids had shorter mean hospital LOS when compared with those who did not receive systemic steroids (SMD = -2.92, 95% CI: 5.65 to -0.19).

CONCLUSION

While available literature was limited, systematic review and meta-analysis suggests systemic corticosteroids decrease length of stay for hospitalized pediatric patients with orbital complications of sinusitis. Further research is needed to more clearly define the role of systemic corticosteroids as an adjunctive treatment.

Periorbital and orbital cellulitis in children: a survey of emergency physicians and analysis of clinical practice guidelines across the PERUKI network

BACKGROUND

Due to limited evidence to guide management of periorbital cellulitis (POC), we surveyed current practice and assessed quality and consistency of local clinical practice guidelines (CPGs) to highlight future research priorities.

METHODS

A web-based survey was sent to a designated emergency physician (who clinically assesses children) at Paediatric Emergency Research United Kingdom and Ireland (PERUKI) sites between 23 November 2018 to 22 January 2019. A nominated site lead offered one response as a department-wide perspective on admission, severity assessment, treatment, disposition and specialty consultation request. Sites shared their CPG. These were compared using a standardised data collection tool, and quality assessed using Standardised Reporting Practice Guidelines in Healthcare (RIGHT) criteria. Survey responses were also compared against CPG recommendations.

RESULTS

83% (49/59) institutions invited submitted an individual survey response. 67% of responding sites had a CPG and 63% (31/49) submitted these. CPG quality was poor (mean 6.7/35 RIGHT criteria). 21 different severity markers were identified across CPGs. Most CPGS recommend investigations for severe disease, yet 23% (7/31) advise blood culture universally. 90% of CPGs advise discharge with oral antibiotics for milder cases, yet 86% of respondents reported departmental admission of all patients with POC. Nearly all respondents included proptosis, systemically unwell and visual disturbance as indications for admission but differed regarding importance of other signs.

CONCLUSIONS

We demonstrated variation in practice across the PERUKI network in assessment of severity and management of POC. CPGs vary in recommendations, and clinical practice appears to differ from CPGs. Guidelines were generally of poor quality when compared against RIGHT standards.

Fungi of the human eye: Culture to mycobiome

The focus of the current review is multi-fold and compares the diversity and abundance of fungi on the ocular surface by the conventional culture-based method with the more sensitive, high throughput, culture-independent NGS method. The aim is to highlight the existence of a core ocular mycobiome and explore the transition of the ocular fungal microbiota from the normal eye to the diseased eye. PubMed, Google Scholar and Medline were used to search for publications and reviews related to cultivable fungi and the mycobiome of the normal and diseased eye. The conventional cultivable approach and the NGS approach confirm that the eye has its own mycobiome and several confounding factors (age, gender, ethnicity etc.) influence the mycobiome. Further, dysbiosis in the mycobiome appears to be associated with ocular diseases and thus impacts the health of the human eye. Considering that the mycobiome of the eye is influenced by several confounding factors and also varies with respect to the disease status of the eye there is a need to extensively explore the mycobiome under different physiological conditions, different ethnicities, geographical regions etc. Such studies would unravel the diversity and abundance of the mycobiomes and contribute to our understanding of ocular health. Research focused on ocular mycobiomes may eventually help to build a targeted and individualized treatment.

Orbital Complications of Acute Sinusitis in Pediatric Patients: Management of Chandler III Patients

Background

Surgery is often avoided in the setting of pediatric orbital complications from acute sinusitis unless necessitated by alarming ophthalmological signs. Criteria for surgical intervention are not well-defined.

Objective

We aim to review our experiences, management practices and patient outcomes over a ten-year period for Chandler III patients.

Methods

A retrospective review was performed from January 1, 2007 through December 31, 2016 of patients treated for orbital symptoms secondary to acute sinusitis at a free-standing tertiary-care pediatric hospital.

Results

Of the 186 patients reviewed, 42 Chandler III patients were included. Average age was 82.6 months (SD 50.6) with a slight male predominance (M to F, 1.8 to 1). 27 patients (64.3%) underwent intervention including endoscopic sinus surgery (ESS) with or without orbitotomy. Late surgical intervention (>48hrs from admission) demonstrated significant increase in overall length of stay (LOS) when compared with early surgical intervention and/or medical management (median, 6.9 vs 3.6 vs 3.7 days; p < 0.01). Postoperative LOS was also higher in the late surgery group compared with patients who had surgery within 48 hours of admission, but this did not reach statistical significance [median, 3.8 vs 2.8 days, p= 0.12]. There was no significant difference in overall abscess volume between patients who underwent intervention and those who did not (1019 mm³ vs 805 mm³, p = 0.5), but abscess width ≥ 1.2 cm was associated with higher rates of intervention. An alarming extraocular exam was the most common factor associated with surgical intervention.

Conclusion

Pediatric subperiosteal orbital abscess may prompt surgical intervention by ESS. An alarming ophthalmologic exam should prompt consideration of early intervention, which may lead to decreased overall and post-operative length of hospital stay.

Level of Evidence

4

Meeting Information

American Rhinologic Society, Fall National Meeting. Chicago, IL, USA. September 8–9, 2017.

Association Between Corticosteroids and Outcomes in Children Hospitalized With Orbital Cellulitis

OBJECTIVES

To examine the association between systemic corticosteroid use and outcomes for children hospitalized with orbital cellulitis at US children's hospitals.

METHODS

We conducted a multicenter observational study using administrative data from the Pediatric Health Information System database from 2007 to 2019. Children between the ages of 2 months and 18 years with International Classification of Diseases, Ninth Revision, Clinical Modification or 10th Revision, Clinical Modification discharge diagnostic codes of orbital cellulitis were included. The primary exposure was receipt of systemic corticosteroids on the day of hospital admission. The primary outcome was hospital length of stay, and secondary outcomes included surgical intervention, ICU admissions, revisits, and health care costs. We used generalized logit model with inverse probability weighting logistic regression to adjust for demographic factors and assess for differences in clinical outcomes reported.

RESULTS

Of the 5832 patients hospitalized with orbital cellulitis, 330 (5.7%) were in the corticosteroid group and 5502 (94.3%) were in the noncorticosteroid group. Patients in the corticosteroid group were older, had more severe illness, and received broad spectrum antibiotics. In adjusted analyses, corticosteroid exposure was not associated with differences in length of hospital stay, need for surgical intervention, ICU admissions, emergency department revisits, 30-day hospital readmissions, or hospital costs. Restricting the analysis to only those patients who received broad spectrum antibiotics did not change the findings.

CONCLUSIONS

Early use of systemic corticosteroids in hospitalized children with orbital cellulitis is not associated with improved clinical outcomes. Use of corticosteroids in hospitalized children with orbital cellulitis should be discouraged outside of clinical trials.

Preseptal Versus Orbital Cellulitis in Children: An Observational Study

BACKGROUND

Preseptal and orbital cellulitis are two types of infection surrounding the orbital septum with very different potential outcomes. Our aim was to describe key differential features of both conditions, laying special emphasis on diagnostic and therapeutic tools.

METHODS

A retrospective review of patients admitted to a tertiary hospital over a 15-year period (January 2004-October 2019) was conducted. We included 198 patients with preseptal and 45 with orbital cellulitis. Descriptive statistics were performed to examine the available information.

RESULTS

Statistically significant differences were found between patients with preseptal and orbital cellulitis regarding age (3.9 ± 2.14 vs. 7.5 ± 4.24 years), presence of fever (51.5% vs. 82.2%), and preexisting sinusitis (2% vs. 77.8%) (all P < 0.001). Diplopia, ophthalmoplegia and proptosis were only present in orbital cellulitis (P < 0.001). Median values of C-reactive protein were significantly higher among children with orbital involvement [136.35 mg/L (IQR 74.08-168.98) vs. 17.85 (IQR 6.33-50.10), P < 0.0001]. A CRP>120 mg/L cut-off point for orbital cellulitis was obtained. Early CT scans were performed in 75.6% of suspected orbital cellulitis and helped detecting complications at an early stage. Abscesses were revealed in 70.6% of cases, especially medial subperiosteal abscesses (58.8%). All patients received intravenous antibiotics, whereas corticosteroids were preferred in patients with orbital implication (8.6% vs. 73.3%, P < 0.001). Only 26.7% of patients required additional surgery.

CONCLUSIONS

Clinical presentation and CRP are extremely sensitive for differential diagnosis of preseptal and orbital cellulitis. Prompt initiation of intravenous antibiotics is mandatory and can prevent surgical procedures even in cases with incipient abscesses.

Corticosteroids for Acute Orbital Cellulitis

OBJECTIVES

Standard treatment of children hospitalized for acute orbital cellulitis includes systemic antibiotics. Recent data from single-center studies suggest the addition of systemic corticosteroids may hasten clinical improvement and reduce hospital length of stay (LOS). We investigate the potential relationship between corticosteroid exposure and duration of hospitalization for pediatric orbital cellulitis.

METHODS

Using Pediatric Health Information System registry data from 51 children's facilities, we performed a retrospective cohort study of children hospitalized for orbital cellulitis <18 years of age from 2007 to 2018. The primary study outcome was hospital LOS. Secondary outcomes included frequency of surgical interventions, PICU admission, and 30-day related-cause readmission.

RESULTS

Of the 5645 children included for study, 1347 (24%) were prescribed corticosteroids within 2 days of admission. Corticosteroid prescription was not associated with LOS in analyses adjusted for age; presence of meningitis, abscess, or vision issues; and operative episode and PICU admission within 2 days (e ^β = 1.01, 95% confidence interval [CI]: 0.97-1.06). Corticosteroid exposure was associated with operative episodes after 2 days of hospitalization (odds ratio = 2.05, 95% CI: 1.29-3.27) and 30-day readmission (odds ratio = 2.40, 95% CI: 1.52-3.78) among patients with a primary diagnosis of orbital cellulitis.

CONCLUSIONS

In this database query, we were not able to detect a reduction in LOS associated with corticosteroid exposure during hospitalization for orbital cellulitis. Corticosteroid prescription was associated with PICU admission and operative episodes after 2 days of hospitalization. Before the adoption of routine corticosteroid use, prospective, randomized control trials are needed.

Orbital Infection Due to Medial Wall Fracture: Three Cases of Orbital Complications Caused by Paranasal Sinusitis Secondary to Medial Orbital Wall Fracture

PURPOSE

The aim of this study was to report 3 cases of orbital complications in patients with secondary sinusitis due to medial orbital wall fracture. We believe that sinusitis can be secondary to the fracture of the medial orbital wall when the sinus drainage orifice is blocked due to some fracture pieces or other blocking factors. We precisely show the direct evidence of the blocking factors through radiology.

DESIGN

Retrospective, noncomparative, interventional case series.

PARTICIPANTS

All patients had intraorbital complications and a history of traumatic orbital medial fracture as well as imaging findings of sinusitis.

METHODS

A medical record review of clinical history, imaging studies, and surgical and treatment outcomes were performed.

MAIN OUTCOME MEASURES

Postoperative visual acuity, appearance, eye movement, surgical and imaging findings.

RESULTS

Three patients (2 males and 1 female; average age 38.33 years [range, 11-65]) received endoscopic surgery for orbital complications related to sinusitis. All patients had evidence of paranasal sinusitis after the orbital injury. Two patients were treated with antibiotics before the operation, but there was no significant improvement. All patients underwent transnasal endoscopic sinotomy. Two patients received orbital abscess incision and drainage surgery and 1 patient underwent a cyst excision operation. The visual acuity of the 3 patients was improved after the operation, and the clinical examination was significantly improved.

CONCLUSIONS

The anatomy of the orbit is closely related to the nasal cavity. The fracture of the medial orbital wall often causes abnormal anatomy of the sinus outflow tract. For the 3 of our patients, the blocking factors of sinus orifices were fracture fragment, orbital bone deformation, and the formation of giant nasal intraorbital mucocele. Sinusitis possibly occurs when drainage is not smooth. Infections develop due to the secretions retaining and accumulation of microorganisms. Inflammation from the sinus can be spread into the orbit in various ways. Our 3 patients indicate that a fracture of the inner orbital wall may cause sinusitis. When the patient is injured again or sneezing or in other conditions when the pressure in the nasal cavity increases, inflammation of the sinuses enters the orbit, causing serious intraorbital complications. It is necessary to carefully follow-up on the medical history, combined with imaging examination, to prevent the misdiagnosis of intraorbital hemorrhage or hematoma from affecting the treatment.In recent years, more and more cases of intraorbital complications caused by sinusitis have been reported.1,2 Severe intraorbital inflammation can pose a threat to vision and even life. With the great tool of the endoscope, nasal-orbital problems can be well solved. For our 3 patients, we opened the paranasal sinus and removed the occlusion of the sinus orifice through transnasal endoscopy. All patients achieved good surgical and clinical results.

Imaging of orbital infectious and inflammatory disease in children

Most acute nontraumatic periorbital and intraorbital pathologies in pediatric patients have an underlying infectious or inflammatory etiology, and imaging frequently plays a key role in the workup and management of these children. In this paper we review the clinical presentation and imaging findings in children with some of the most common infectious and inflammatory diseases involving the orbit. Basic relevant anatomy and imaging findings on various imaging modalities are also reviewed.

Changes in the Management of Severe Orbital Infections Over Seventeen Years

OBJECTIVES

Periorbital and orbital cellulitis are common but serious infections in children. Management of these infections varies because of an absence of clinical guidelines, but it is unclear if management within institutions has changed over time. We compared the management and outcomes of children hospitalized with periorbital and orbital cellulitis in 2 eras.

METHODS

Data were extracted from records of children hospitalized at a tertiary care children's hospital with periorbital or orbital cellulitis from 2000 to 2005 and 2012 to 2016. Patient demographics, cross-sectional imaging, antibiotic and corticosteroid use, length of stay, and surgical rates were collected. Data from the eras were compared by using descriptive statistics, t tests, Mann-Whitney U tests, Fisher's exact tests, and χ² tests.

RESULTS

There were 318 children included, 143 from 2000 to 2005 and 175 from 2012 to 2016. Compared with the first era, in the second era there were increased rates of MRI (5% vs 11%, P = .04), although rates of computed tomography scan use remained unchanged (60% vs 65%); increased number (1 vs 3, P < .01) and spectrum of antibiotics; increased use of intranasal corticosteroids (3% vs 49%, P < .01); and subspecialty consultation (89% vs 99%, P = .01). There were no differences in length of stay, readmission, or surgical rates between eras.

CONCLUSIONS

There has been considerable change in the management of hospitalized children with severe orbital infections at our institution, including the rates of MRI, number and spectrum of antibiotics used, use of adjunctive agents, and increased subspecialty involvement with no observed impact on clinical outcomes. Future research is needed to rationalize antimicrobial therapy and reduce low-value health care.

Corticosteroids for periorbital and orbital cellulitis

BACKGROUND

Periorbital and orbital cellulitis are infections of the tissue anterior and posterior to the orbital septum, respectively, and can be difficult to differentiate clinically. Periorbital cellulitis can also progress to become orbital cellulitis. Orbital cellulitis has a relatively high incidence in children and adults, and potentially serious consequences including vision loss, meningitis, and death. Complications occur in part due to inflammatory swelling from the infection creating a compartment syndrome within the bony orbit, leading to elevated ocular pressure and compression of vasculature and the optic nerve. Corticosteroids are used in other infections to reduce this inflammation and edema, but they can lead to immune suppression and worsening infection.

OBJECTIVES

To assess the effectiveness and safety of adjunctive corticosteroids for periorbital and orbital cellulitis, and to assess their effectiveness and safety in children and in adults separately.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2020, Issue 3); Ovid MEDLINE; Embase.com; PubMed; Latin American and Caribbean Health Sciences Literature Database (LILACS); ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 2 March 2020.

SELECTION CRITERIA

We included studies of participants diagnosed with periorbital or orbital cellulitis. We excluded studies that focused exclusively on participants who were undergoing elective endoscopic surgery, including management of infections postsurgery as well as studies conducted solely on trauma patients. Randomized and quasi-randomized controlled trials were eligible for inclusion. Any study that administered corticosteroids was eligible regardless of type of steroid, route of administration, length of therapy, or timing of treatment. Comparators could include placebo, another corticosteroid, no treatment control, or another intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane.

MAIN RESULTS

The search yielded 7998 records, of which 13 were selected for full-text screening. We identified one trial for inclusion. No other eligible ongoing or completed trials were identified. The included study compared the use of corticosteroids in addition to antibiotics to the use of antibiotics alone for the treatment of orbital cellulitis. The study included a total of 21 participants aged 10 years and older, of which 14 participants were randomized to corticosteroids and antibiotics and 7 participants to antibiotics alone. Participants randomized to corticosteroids and antibiotics received adjunctive corticosteroids after initial antibiotic response (mean 5.13 days), at an initial dose of 1.5 mg/kg for three days followed by 1 mg/kg for another three days before being tapered over a one- to two-week period. We assessed the included study as having an unclear risk of bias for allocation concealment, masking (blinding), selective outcome reporting, and other sources of bias. Risk of bias from sequence generation and incomplete outcome data were low. The certainty of evidence for all outcomes was very low, downgraded for risk of bias (-1) and imprecision (-2). Length of hospital stay was compared between the group receiving antibiotics alone compared to the group receiving antibiotics and corticosteroids (mean difference (MD) 4.30, 95% confidence interval (CI) -0.48 to 9.08; 21 participants). There was no observed difference in duration of antibiotics between treatment groups (MD 3.00, 95% CI -0.48 to 6.48; 21 participants). Likewise, preservation of visual acuity at 12 weeks of follow-up between group was also assessed (RR 1.00, 95% CI 0.82 to 1.22; 21 participants). Pain scores were compared between groups on day 3 (MD -0.20, 95% CI -1.02 to 0.62; 22 eyes) along with the need for surgical intervention (RR 1.00, 95% CI 0.11 to 9.23; 21 participants). Exposure keratopathy was reported in five participants who received corticosteroids and antibiotics and three participants who received antibiotic alone (RR 1.20, 95% CI 0.40 to 3.63; 21 participants). No major complications of orbital cellulitis were seen in either the intervention or the control group. No side effects of corticosteroids were reported, although it is unclear which side effects were assessed.

AUTHORS' CONCLUSIONS

There is insufficient evidence to draw conclusions about the use of corticosteroids in the treatment of periorbital and orbital cellulitis. Since there is significant variation in how corticosteroids are used in clinical practice, additional high-quality evidence from randomized controlled trials is needed to inform decision making. Future studies should explore the effects of corticosteroids in children and adults separately, and evaluate different dosing and timing of corticosteroid therapy.

Acute ptosis as a presentation of preseptal cellulitis leading to cerebral abscess in a patient with uncontrolled diabetes

Acute ptosis due to preseptal cellulitis requires urgent medical attention, as the infection can extend posteriorly into the orbit, leading to significant visual and cerebral complications. We report a case of a 58-year-old woman with uncontrolled diabetes mellitus presenting with acute ptosis due to preseptal cellulitis. After initial resolution of fever with intravenous amoxicillin-clavulanate, she experienced a seizure due to cerebral abscess a week later and was treated with intravenous ceftriaxone. Preseptal cellulitis is usually treated on an outpatient basis with oral antibiotics, as it rarely extends posteriorly to cause cerebral complications. We wish to highlight the importance of admitting patients with preseptal cellulitis in patients with uncontrolled diabetes for intravenous antibiotics due to the potential for visual and cerebral complications.

Paediatric periorbital cellulitis: A 10-year retrospective case series review

AIM

To identify the predictors of poor outcome and need for surgical management in paediatric patients with periorbital cellulitis. To assess the adherence to local guidelines in the management of periorbital cellulitis.

METHODS

Retrospective descriptive analysis of clinical, laboratory and radiological characteristics of 175 paediatric periorbital cellulitis presentations at a UK teaching hospital over a 10-year period. Regression investigated correlations for continuous and categorical variables.

RESULTS

A total of 175 paediatric presentations were diagnosed as periorbital infections over the 10-year period. Of these, 139 had pre-septal cellulitis, 27 had a subperiosteal abscess, 6 had an orbital cellulitis, 1 had an orbital abscess, 1 a cavernous sinus thrombosis and 1 an extradural abscess. Median age at presentation was 5 years (range: 1 month-17 years). In total, 169 (97%) cases received systemic antimicrobial treatment. Cross-sectional imaging occurred in 30% of cases and 18% required surgical intervention. Increasing C-reactive protein was associated with greater risk of post-septal disease and requiring surgery. The best predictors of post-septal disease in the multivariate analysis (R² = 0.49, P = ≤0.001) were ophthalmoplegia (P = 0.009), proptosis (P = 0.016) and pain on eye movement (P = 0.046). Proptosis was the single most significant predictor of surgical management (R² = 0.53, P = <0.001).

CONCLUSION

Multidisciplinary involvement and early medical management can improve outcomes for most patients. Those who deteriorate despite medical management should be considered for prompt imaging and surgical management to avoid serious life-threatening or sight-threatening complications.

Feasibility of rapid magnetic resonance imaging (rMRI) for the emergency evaluation of suspected pediatric orbital cellulitis

PURPOSE

To determine the feasibility of noncontrast rapid magnetic resonance imaging (rMRI), compared with traditional contrast-enhanced computed tomography (CT) in assessing pediatric emergency department patients with suspected orbital cellulitis or orbital abscess.

METHODS

All subjects <19 years of age who presented emergently with suspected orbital cellulitis from July 1, 2017, to July 31, 2019, were included. Participants received both the standard contrast orbital CT, if deemed necessary, with the addition of the noncontrast rMRI after informed consent was obtained. No sedation was used for either examination. All clinical decisions were based on CT findings; rMRI was interpreted within 24 hours of the visit. Three pediatric radiologists, with 8-21 years' experience of pediatric neuroradiology, interpreted the rMRI, masked to the CT and clinical results. Results were analyzed for interobserver bias.

RESULTS

A total of 14 patients were enrolled during the study period. Mean age was 5.9 years (range, 0.33-13). Of the 14 patients, 13 (93%) were able to complete the rMRI at 1.5 and 3T; 1 patient (1.67 years of age) was unable to complete the rMRI (no images obtained). Of the 26 unilateral orbital units assessed, 3 were positive for retroseptal orbital cellulitis by CT and were diagnosed correctly by rMRI. Interobserver agreement was 100% in detecting presence or absence of retroseptal cellulitis. CT and rMRI findings were concordant in 100% of cases in differentiating preseptal vs orbital cellulitis. Kappa statistics for three-category ratings by three raters for right eye/orbit was 0.921 and for left eye/orbit was 0.9288, suggesting almost perfect agreement. Concordance correlation coefficients were 0.938 for the right eye and 0.955 for the left eye.

CONCLUSIONS

Noncontrast rMRI orbits showed findings concordant in all cases with contrast-enhanced CT for differentiating preseptal cellulitis from orbital cellulitis.

The Role of Endoscopic Sinus Surgery in Children Undergoing External Drainage of Non-Medial Subperiosteal Orbital Abscess

BACKGROUND

The extent of surgery required in the management of pediatric non-medial subperiosteal orbital abscess (SPOA) due to medically refractory complicated acute sinusitis is unknown.

OBJECTIVES

The primary objective is to compare operative outcomes of children treated with combined endoscopic sinus surgery (ESS) and external orbital drainage (EOD) versus those treated with EOD alone.

METHODS

Retrospective case series from a tertiary children's hospital analyzing outcomes in children requiring surgical management for acute sinusitis complicated by non-medial SPOA between November 2007 and September 2019.

RESULTS

Sixteen children with a mean age of 9.4 years (95% CI: 7.3-11.4) met inclusion. Eleven (68.8%) underwent combined EOD and ESS, while five (31.2%) underwent EOD alone. Groups were similar in age, symptom duration, white blood cell count, C-reactive protein level, intraocular pressure, Lund-Mackay score, and abscess volume. There was no significant difference in median length of stay between patients treated with a combined approach versus those treated by EOD alone. Cultures identified non-beta-hemolytic Streptococcus species in 56.3% of patients, with Streptococcus intermedius representing the most common organism in 37.5%. In one case, ESS identified a pathogen not acquired via concomitant EOD, which did influence management. No child required a subsequent surgical procedure and there were no operative complications.

CONCLUSIONS

The addition of ESS in the management of pediatric non-medial SPOA was not associated with a statistically different duration of hospitalization. Cultures from concomitant ESS rarely aided in diagnosis or antibiotic therapy. Further study should delineate the indications for ESS in these cases.

Hemicentral Retinal Artery Occlusion: A Rare Complication of Orbital Cellulitis

A 14-year-old boy presented with acute vision loss and swelling of the right eye. An anterior segment examination revealed a relative afferent pupillary defect, severe proptosis, and ophthalmoplegia in his right eye. The fundus examination revealed inferior hemicentral retinal artery occlusion. Although the authors proceeded with systemic medical treatment, the findings did not improve. An endoscopic orbital decompression was performed. With both medical and surgical treatment, the orbital cellulitis resolved and the patient's visual acuity improved. [J Pediatr Ophthalmol Strabismus. 2020;57:e51-e55.].

Subperiosteal orbital abscess from odontogenic origin: A case report

•

Subperiosteal orbital abscess is a rare complication of a dental infection.

•

Antibiotics alone are ineffective and do not guarantee arrest of the infection spread.

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The possible route of infection spread should be determined, and is illustrated in this report.

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Postseptal infections require a more aggressive approach compared to preseptal infections.

•

In case of an orbital infection, intraoral examination and dental radiography may not be overlooked.

Introduction

Subperiosteal orbital abcess is a rarely reported complication of odontogenic infections and can be associated visual impairment and neurological symptoms. Because of fast infection spreading, delay in diagnosis and treatment can result in permanent damage.

Presentation of case

A 55-year old presented with a right-sided subperiosteal orbital abscess originating from a decayed first upper molar. The associated loss of vision improved only after a extraoral surgical drainage. Three years later, recurrent headaches, photobia and ptosis still persist.

Discussion

Our case demonstrates a rare but potentially hazardous complication of untreated dental infections. The effect of antibiotics is often overestimated, and lack of treatment may lead to serious sequelae, certainly when the orbital infection is located posterior to the orbital septum. When intraoral drainage is insufficient, the infection should be accessed extraorally.

Conclusion

Orbital infections require a thorough clinical evaluation, including the oral cavity as dental infections may be overlooked. Dental radiograpy plays a major role. Prompt and adequate treatment is crucial in preventing further spreading of odontogenic infections.

An Orbital Abscess Secondary to Intraoral Impalement

Penetrating orbital trauma in the pediatric population is rare. Even more unusual is a secondary orbital infection following penetrating trauma. Here we present a highly unusual case of fulminant facial cellulitis with an orbital abscess in an otherwise healthy 3-year-old boy following a penetrating injury to the orbit from a point of entry on the gingiva-buccal sulcus, sustained during a fall while carrying a wooden lollipop stick. Examination of the retina revealed a focal injury at the inferior pole of the globe. The organisms cultured from pus sampled from the abscess and from the discharging intraoral wound revealed the same oral commensals while the MRI revealed a track in continuity with the orbital collection.

The management of periorbital cellulitis secondary to sinonasal infection: a multicenter prospective study in the United Kingdom

BACKGROUND

Periorbital cellulitis is a potential sight-threatening complication of sinusitis. The majority of patients improve with medical management. Previous studies have suggested significant variations in practice and lack of evidence regarding the optimal management of this condition.

METHODS

A prospective study was conducted over a 12-month period at 8 centers in the United Kingdom assessing the management of patients requiring inpatient treatment for periorbital cellulitis secondary to sinonasal infections.

RESULTS

A total of 143 patients were recruited, of whom 40 were excluded. Of the remaining 103 patients, 5 (4.9%) were diagnosed with neurosurgical complications. This resulted in 98 patients admitted with periorbital cellulitis secondary to an upper respiratory tract infection/sinusitis. A total of 72 were children, of whom 12 (16.7%) required surgical intervention; and of 26 adults, 5 (19.2%) required surgery: the most common antimicrobial regimes administered were intravenous ceftriaxone (with or without metronidazole), and co-amoxiclav. The use of both ceftriaxone and metronidazole from admission was associated with the shortest duration of inpatient stay (3.8 days) in comparison to ceftriaxone alone (5.8 days) or co-amoxiclav (4.5 days) and a reduction in number of patients requiring surgical intervention. There was also an association between the early use of intranasal decongestants and steroids and reduction in requirement for surgical intervention.

CONCLUSION

For a condition where swab and blood cultures are often negative, this study supports the use of ceftriaxone in combination with metronidazole. The administration of intranasal decongestants and corticosteroids correlated with a smaller percentage of those progressing to surgery in those with and without periorbital abscesses.

Care and outcomes of Canadian children hospitalised with periorbital and orbital cellulitis: protocol for a multicentre, retrospective cohort study

INTRODUCTION

Skin and soft tissue infections of the eye can be classified based on anatomic location as either anterior to the orbital septum (ie, periorbital cellulitis) or posterior to the orbital septum (ie, orbital cellulitis). These two conditions are often considered together in hospitalised children as clinical differentiation is difficult, especially in young children. Prior studies have identified variation in management of hospitalised children with orbital cellulitis; however, they have been limited either as single centre studies or by the use of administrative data which lacks clinical details important for interpreting variation in care. We aim to describe the care and outcomes of Canadian children hospitalised with periorbital and orbital cellulitis.

METHOD AND ANALYSIS

This is a multisite retrospective cohort study including previously healthy children aged 2 months to 18 years admitted to hospital with periorbital or orbital cellulitis from 2009 to 2018. Clinical data from medical records from multiple Canadian hospitals will be collected, including community and academic centres. Demographic characteristics and study outcomes will be summarised using descriptive statistics, including diagnostic testing, antibiotic therapy, adjunctive therapy, surgical intervention and clinical outcomes. Variation will be described and evaluated using χ² test or Kruskal-Wallis test. Generalised linear mixed models will be used to identify predictors of surgical intervention and longer length of stay.

ETHICS AND DISSEMINATION

Approval of the study by the Research Ethics Board at each participating site has been obtained prior to data extraction. Study results will be disseminated by presentations at national and international meetings and by publications in high impact open access journals. By identifying important differences in management and outcomes by each hospital, the results will identify areas where care can be improved, practice standardised, unnecessary diagnostic imaging reduced, pharmacotherapy rationalised and where trials are needed.

Recurrent Maxillary Sinusitis and Periorbital Cellulitis Revealing an Unnoticed Medial Wall Orbital Fracture

Unilateral recurrent maxillary sinusitis is a common sinunasal pathology, mostly related to the ostiomeatal complex dysfunction. Although sinusitis can potentially spread to the adjacent structures, orbital cellulitis remains an exceptionally rare sequela.The authors report the unusual case of a patient who presented with recurrent maxillary sinusitis complicated by cyclic episodes of periorbital cellulitis related to ostiomeatal complex obstruction from herniated periorbital fat through an unnoticed medial orbital wall fracture. To the best of our knowledge, no other similar case has previously been reported. The possible explanation for such an unusual association is discussed.

An unusual case of intra orbital foreign body; diagnosis, management, and outcome: a case report

Background

An orbitocranial injury with a penetrating Intraorbital Foreign Body (IOFB) is listed as a rare cause of penetrating trauma. Since this type of trauma is considered a surgical emergency, taking a thorough history along with careful examination to find out the mechanism and cause of the trauma is crucial towards correct diagnosis and management of the disease.

Case presentation

A 35-year-old male patient was presented to the ER with an occupational craniofacial injury because of an IOFB. The patient underwent an extra-dural orbitocranial craniotomy procedure to remove the foreign body. Interestingly, a plastic foreign body (a piece of a plastic pipe) was removed from the orbital cavity, which was suspected to be a fractured orbital bone, at first place.

Conclusion

In this study, we demonstrated that plastics could mimic bone structure in a Computerized Tomography (CT) scan leading to possible initial misdiagnosis. Hence high clinical suspicion is necessary for the correct diagnosis of such cases. However, despite the prompt intervention, our patient ended up with permanent vision loss in his injured eye.

Are We Over-Treating Insect Bite Related Periorbital Cellulitis in Children? The Experience of a Large, Tertiary Care Pediatric Hospital

INTRODUCTION

Preseptal (periorbital) and orbital cellulitis are potentially catastrophic infections near the eye. Preseptal cellulitis is far more common, and although classically reported to be associated with dacrocystitis, sinusitis/upper respiratory infection, trauma/surgery, or infection from contiguous areas, it can also be associated with insect bites. The objective of this study was to determine the prevalence of insect bite-associated preseptal cellulitis and to compare clinical findings and outcomes of these patients with those having other causes for the condition.

METHODS

Retrospective chart review of children with a final discharge diagnosis of periorbital cellulitis from January 2009 to December 2014 at a tertiary care children' hospital.

RESULTS

213 children were diagnosed with preseptal cellulitis during the 5-year study period, of whom 60 (28%) were associated with insect bites. Patients in the noninsect bite group more commonly had fever at presentation (P < 0.001), with increased white blood cell and C reactive protein values (both P < 0.001). No patient with insect bite-associated preseptal cellulitis presented with fever, and none underwent radiographic testing or computerized tomography; their mean age was also lower (P < 0.001) and length of stay was significantly shorter.

CONCLUSIONS

This study suggests that children with preseptal cellulitis associated with insect bites could be candidates for oral antibiotic therapy with outpatient follow-up by.

Fifteen-minute consultation: Preseptal and orbital cellulitis

'It is midnight and you are called to see a thirteen-year-old boy who has been brought to the paediatric emergency department with a 24-hour history of swelling and redness of his left eye. He has had a 'runny nose' for a couple of days. He is systemically well. His upper and lower lids are red and swollen such that his eye is not open fully, though you elicit normal eye movements when you open his eye. Pupils are equal and reactive with no afferent pupillary defect. Visual acuity and colour vision are normal on examination.' In this article, we consider the approach to preseptal and orbital cellulitis in children including the initial assessment and management options.

Common Community-acquired Bacterial Skin and Soft-tissue Infections in Children: an Intersociety Consensus on Impetigo, Abscess, and Cellulitis Treatment

PURPOSE

The main objective of this article was to offer practical suggestions, given the existing evidence, for identifying and managing bacterial impetigo, abscess, and cellulitis in ambulatory and hospital settings.

METHODS

Five Italian pediatric societies appointed a core working group. In selected conditions, specially trained personnel evaluated quality assessment of treatment strategies according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Only randomized controlled trials (RCTs) and observational studies were included for quality assessment according to the GRADE methodology. MEDLINE, Ovid MEDLINE, EMBASE, and Cochrane Library databases were searched with a strategy combining MeSH and free text terms.

FINDINGS

The literature review included 364 articles focusing on impetigo, skin abscess, and cellulitis/orbital cellulitis. The articles included for quality assessment according to the GRADE methodology for impetigo comprised 5 RCTs and 1 observational study; for skin abscess, 10 RCTs and 3 observational studies were included; for cellulitis and erysipelas, 5 RCTs and 5 observational studies were included; and for orbital cellulitis, 8 observational studies were included. Recommendations were formulated according to 4 grades of strength for each specific topic (impetigo, skin abscesses, cellulitis, and orbital cellulitis). Where controversies arose and expert opinion was considered fundamental due to lack of evidence, agreement according to Delphi consensus recommendations was included.

IMPLICATIONS

Based on a literature review and on local epidemiology, this article offers practical suggestions for use in both ambulatory and hospital settings for managing the most common bacterial SSTIs.

Daily outpatient intravenous antibiotic therapy for the management of paediatric periorbital cellulitis, a retrospective case series

OBJECTIVE

To evaluate whether outpatient treatment of periorbital cellulitis with daily administration of intravenous antibiotics and physician evaluation is an effective and safe alternative to admission.

DESIGN

A retrospective chart review study of paediatric patients treated on an outpatient basis for periorbital cellulitis at a tertiary children's hospital between 2013 and 2015 was performed. Children were assessed day by a paediatrician to monitor for resolution of symptoms or complications.

SETTING

The Montreal Children's hospital, a tertiary care centre.

PARTICIPANTS

Children diagnosed with an uncomplicated periorbital cellulitis secondary to an acute sinusitis or upper respiratory tract infection.

MAIN OUTCOME MEASURES

The number of days of intravenous antibiotics, complications or need for subsequent admission. Complications were defined as formation of an abscess or phlegmon confirmed on computerised tomography scan, worsening or recurrent persistent cellulitis, failure to improve on intravenous antibiotics, and intracranial complications.

RESULTS

Sixty-six children with a diagnosis of uncomplicated periorbital cellulitis secondary to sinusitis who received intravenous antibiotics via medical day hospital and who fit the inclusion criteria were identified. The mean duration of intravenous antibiotic therapy was 4.1 days. All children received ceftriaxone, with one patient also receiving cefuroxime. Two of 66 patients developed complications; one patient required admission for failure to improve/subperiosteal phlegmon and later underwent functional endoscopic sinus surgery, and one patient developed an eyelid abscess that did not require admission. No patients developed severe neurological or visual deficits.

CONCLUSIONS

Outpatient intravenous therapy with daily reassessment by a physician may be a safe alternative to admission in select cases of periorbital cellulitis without systemic signs of illness.

Skin Infections

The primary care provider will commonly see skin and soft tissue infections in the outpatient setting. Skin and soft tissue infections range from the uncomplicated impetigo to the potentially lethal necrotizing fasciitis. This article reviews these infections based on their underlying etiology: bacterial, fungal, and viral causes. This article discusses the etiology, presentation, evaluation, and management of impetigo, bullous impetigo, erysipelas, cellulitis, periorbital cellulitis, orbital cellulitis, folliculitis, furuncles, carbuncles, abscess, necrotizing fasciitis, sporotrichosis, tinea corporis, tinea pedis, tinea capitis, Herpes Simplex Virus, zoster, molluscum contagiosum, and warts.

Isolated left upper eyelid ptosis with pansinusitis and contralateral otitis media in a 9-year-old boy

Purpose

Upper eyelid ptosis has different etiologies in children and adults. In children, the common causes include orbital cellulitis, congenital ptosis, Cranial Nerve (CN) III palsy, and Horner's syndrome. The purpose of this report is to discuss an unusual presentation of ptosis.

Observations

We describe a case of a 9-year-old boy with left-sided ptosis with no apparent clinical signs of orbital or preseptal infection. Magnetic resonance imaging (MRI) revealed pansinusitis and contralateral otitis media with direct extension into the superior aspect of the left orbit affecting the levator palpebrae superioris muscle.

Conclusions and importance

This finding on imaging disclosed the etiology of an otherwise unexplained case of upper lid ptosis.

Orbital infections: a complete cycle 7-year audit and a management guideline

OBJECTIVES

Orbital infections are regularly encountered and are managed by various healthcare disciplines. Sepsis of the orbit and adjacent tissues can be associated with considerable acute complication and long-term sequelae. Therefore, prompt recognition and management of this condition are crucial. This article presents the outcomes of a 7-year complete cycle audit project and describes the development of the new local guideline on the management of orbital infections in our tertiary centre.

METHODS

(1) A retrospective 5-year audit cycle on patients with orbital infections. (2) A review of available evidence on the management of orbital infections. (3) A new local multidisciplinary guideline on the management of orbital infections. (4) A retrospective 2-year second audit cycle to assess the clinical outcomes.

RESULTS

Various disciplines intersect in the management of orbital infections. Standardising the management of this condition proved to be achievable through the developed guideline. However, room for improvement in practice exists in areas such as the promptness in referring patients to specialist care, the multidisciplinary assessment of patients on admission, and the improvement of scanning requests of patients.

A case report of orbital Langerhans cell histiocytosis presenting as a orbital cellulitis

CLINICAL CASE

A 10-year-old girl was seen with a 3-week history of right upper lid swelling and with no other symptoms or fever. There was no recent history of sinusitis, trauma, or previous infection involving the periorbital area, or response to oral antibiotic treatment. Orbital computed tomography showed a lesion involving the upper margin of the orbit, and bone destruction at the orbital roof. Biopsy performed revealed the presence of Langerhans cell Histiocytosis. The lesion was surgically debulked and corticosteroids were used intra-operatively. The lesion responded to treatment.

DISCUSSION

The orbital involvement of Langerhans cell histiocytosis, despite its low incidence, should be considered in the examination of acute peri-orbital swelling. It usually presents as an osteolytic lesion, and it is confirmed with a histological examination and immunohistochemical techniques for CD1a and S100. An interdisciplinary approach is recommended to rule out multifocal or multisystemic diseases, as well as to develop an appropriate treatment strategy.

[Management of Rhinosinusitis in Primary Care]

Acute rhinosinusitis is an important health problem. Even though its frequency is not well documented in our country?, the economic burden it bears is not insignificant as it notably alters the quality of life of affected patients. Its diagnosis is generally clinical in nature, with further studies reserved only for the differential diagnoses of complications or tumour-like processes. The most frequent causes are viral infections, although Streptococcus pneumoniae and Haemophilus influenzae are the most commonly isolated bacterial agents. Although complications are uncommon nowadays, they can be serious when they occur, and commonly include orbital infections, closely followed in frequency by intracranial and bone infections. Treatment should consist of symptomatic measures, like saline rinses and antibiotics in cases of bacterial origin.