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Krueger C, Nguyen ELV, Mahant S, Borkhoff CM, Cichon J, Drouin O, Pound C, Quet J, Wahi G, Bayliss A, Vomiero G, Foulds J, Kanani R, Sakran M, Sehgal A, Pullenayegum E, Widjaja E, Reginald A, Wolter N, Parkin P, Gill PJ. Association of empiric antibiotic selection and clinical outcomes in hospitalised children with severe orbital infections: a retrospective cohort study. Arch Dis Child 2024:archdischild-2023-326175. [PMID: 38589203 DOI: 10.1136/archdischild-2023-326175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 03/27/2024] [Indexed: 04/10/2024]
Abstract
OBJECTIVE To determine the association of initial empiric antibiotic regimens with clinical outcomes in hospitalised children with severe orbital infections. DESIGN Multi-centre observational cohort study using data from 2009 to 2018 clinical records. SETTING Canadian children's hospitals (7) and community hospitals (3). PATIENTS Children between 2 months and 18 years hospitalised for >24 hours with severe orbital infections. INTERVENTIONS Empiric intravenous antibiotic regimen in the first 24 hours of hospitalisation. MAIN OUTCOME MEASURES Length of hospital stay and surgical intervention using multivariable median regression and multivariate logistic regression, with adjustment for covariates. RESULTS Of 1421 patients, 60.0% were male and the median age was 5.5 years (IQR 2.4-9.9). Median length of stay was 86.4 hours (IQR 56.9-137.5) and 180 (12.7%) received surgical intervention. Patients receiving broad-spectrum empiric antibiotics had an increased median length of stay, ranging from an additional 13.8 hours (third generation cephalosporin and anaerobic coverage) to 19.5 hours (third generation cephalosporin, staphylococcal and anaerobic coverage). No antibiotic regimen was associated with a change in the odds of surgical intervention. These findings remained unchanged in sensitivity analyses restricted to more severely ill patients. There was a twofold increase in the percentage of patients receiving the broadest empiric antibiotic regimens containing both staphylococcal and anaerobic coverage from 17.8% in 2009 to 40.3% in 2018. CONCLUSIONS Empiric use of broad-spectrum antibiotics with staphylococci and anaerobic coverage was associated with longer length of stay and similar rates of surgery in children with orbital infections. There is an urgent need for comparative effectiveness studies of various antibiotic regimes.
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Affiliation(s)
| | | | - Sanjay Mahant
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Cornelia M Borkhoff
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jessica Cichon
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Olivier Drouin
- Division of General Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
- Department of Social and Preventive Medicine, School of Public Health, Université de Montréal, Montreal, Quebec, Canada
- Division of General Pediatrics, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Catherine Pound
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Julie Quet
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Gita Wahi
- Department of Pediatrics, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Ann Bayliss
- Department of Pediatrics, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Gemma Vomiero
- Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Jessica Foulds
- Stollery Children's Hospital, Edmonton, Alberta, Canada
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Ronik Kanani
- North York General Hospital, Toronto, Ontario, Canada
| | | | - Anupam Sehgal
- Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Eleanor Pullenayegum
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Elysa Widjaja
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Arun Reginald
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Ophthalmology and Visual Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Nikolaus Wolter
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Otolaryngology - Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Patricia Parkin
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Peter J Gill
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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2
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Lohnherr V, Baumann I. Orbital complications of sinusitis in children - Retrospective analysis of an 8.5 year experience. Int J Pediatr Otorhinolaryngol 2024; 177:111865. [PMID: 38262225 DOI: 10.1016/j.ijporl.2024.111865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 01/02/2024] [Accepted: 01/10/2024] [Indexed: 01/25/2024]
Abstract
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.
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Bliss A, Craft A, Haber J, Inger H, Mousset M, Chiang T, Elmaraghy C. Visual outcomes following orbital decompression for orbital infections. Int J Pediatr Otorhinolaryngol 2024; 176:111824. [PMID: 38134589 DOI: 10.1016/j.ijporl.2023.111824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 11/30/2023] [Accepted: 12/10/2023] [Indexed: 12/24/2023]
Abstract
OBJECTIVE To analyze the visual outcomes and sequelae of endonasal intervention for orbital infections. INTRODUCTION Orbital infections pose a serious threat to vision in the pediatric population and can result in complications such as blindness, diplopia, intracranial involvement, and death. [1] Orbital decompression by endonasal intervention is a common treatment to address a variety of orbital infections including orbital cellulitis, orbital abscesses, and subperiosteal abscesses. [2] The outcomes of visual sequelae such as loss or limitation of visual acuity, extraocular movements, and increased intraocular pressure following orbital decompression via endonasal intervention have not been sufficiently investigated in the current literature. METHODS This retrospective cohort study was performed at our tertiary care pediatric hospital using data from 69 patients aged 0-18 years who were admitted between 2008 and 2018. Data was extracted from the electronic medical record system. RESULTS Following endoscopic sinus surgery, symptoms of orbital infection improved throughout the cohort. Improvement in visual acuity is demonstrated by a statistically significant decrease in the average logMAR value in both the right and left eye (P = 0.002 and P = 0.028 respectively). There was also a significant improvement to normal values postoperatively for patients who initially presented with abnormal tonometry, extraocular movement, and the appearance of eyelids and eyelashes. CONCLUSION There is no decline or loss of vision with otolaryngology surgical intervention for orbital cellulitis in our cohort. This retrospective chart review demonstrates the efficacy of surgical intervention on overall visual outcomes following endonasal intervention for orbital infections such as orbital cellulitis, orbital abscesses, and subperiosteal abscesses.
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Affiliation(s)
- Alessandra Bliss
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Aaron Craft
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Jordan Haber
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Hilliary Inger
- Dept of Pediatric Ophthalmology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Marike Mousset
- Dept of Pediatric Otolaryngology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Tendy Chiang
- Dept of Pediatric Otolaryngology, Nationwide Children's Hospital, Columbus, OH, USA; Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, OH, USA
| | - Charles Elmaraghy
- Dept of Pediatric Otolaryngology, Nationwide Children's Hospital, Columbus, OH, USA.
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4
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McKerlie MF, Wolter NE, Mahant S, Cichon J, Widjaja E, Drouin O, Pound C, Quet J, Wahi G, Bayliss A, Vomiero G, Foulds JL, Kanani R, Sakran M, Sehgal A, Borkhoff CM, Pullenayegum E, Reginald A, Parkin PC, Gill PJ. Abscess volume as a predictor of surgical intervention in children hospitalized with orbital cellulitis: A multicentre cohort study. Int J Pediatr Otorhinolaryngol 2023; 171:111629. [PMID: 37437497 DOI: 10.1016/j.ijporl.2023.111629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 06/04/2023] [Accepted: 06/07/2023] [Indexed: 07/14/2023]
Abstract
IMPORTANCE Orbital cellulitis with subperiosteal or orbital abscess can result in serious morbidity and mortality in children. Objective volume criterion measurement on cross-sectional imaging is a useful clinical tool to identify patients with abscess who may require surgical drainage. OBJECTIVE To determine the predictive value of abscess volume and the optimal volume cut-point for surgical intervention. DESIGN We conducted an observational cohort study using medical records from children hospitalized between 2009 and 2018. SETTING Multicentre study using data from 6 children's hospitals. PARTICIPANTS Children were included if they were between 2 months and 18 years of age and hospitalized for an orbital infection with an abscess confirmed on cross-sectional imaging. EXPOSURE Subperiosteal or orbital abscess volume. MAIN OUTCOME AND MEASURES The primary outcome was surgical intervention, defined as subperiosteal and/or orbital abscess drainage. Multivariable logistic regression was performed to assess the association of abscess volume with surgery. To determine the optimal abscess volume cut-point, receiver operating characteristic (ROC) analysis was performed using the Youden Index to optimize sensitivity and specificity. RESULTS Of the 150 participants (mean [SD] age, 8.5 [4.5] years), 68 (45.3%) underwent surgical intervention. On multivariable analysis, larger abscess volume and non-medial abscess location were associated with surgical intervention (abscess volume: adjusted odds ratio [aOR], 1.46; 95% CI, 1.11-1.93; abscess location: aOR, 3.46; 95% CI, 1.4-8.58). ROC analysis demonstrated an optimal abscess volume cut-point of 1.18 mL [AUC: 0.75 (95% CI 0.67-0.83) sensitivity: 66%; specificity: 79%]. CONCLUSIONS AND RELEVANCE: In this multicentre cohort study of 150 children with subperiosteal or orbital abscess, larger abscess volume and non-medial abscess location were significant predictors of surgical intervention. Children with abscesses >1.18 mL should be considered for surgery.
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Affiliation(s)
- Morgyn F McKerlie
- Queens School of Medicine, Faculty of Health Sciences, Queen's University, Kingston, ON, Canada
| | - Nikolaus E Wolter
- The Hospital for Sick Children, Toronto, ON, Canada; Department of Otolaryngology, Head & Neck Surgery, University of Toronto, Toronto, ON, Canada
| | - Sanjay Mahant
- The Hospital for Sick Children, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Jessica Cichon
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada
| | - Elysa Widjaja
- The Hospital for Sick Children, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Olivier Drouin
- Department of Pediatrics, Université de Montreal, Montreal, QC, Canada; Division of General Pediatrics, Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada; Department of Social and Preventive Medicine, School of Public Health, Université de Montréal, Montreal, QC, Canada
| | - Catherine Pound
- Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario (CHEO), Ottawa, ON, Canada
| | - Julie Quet
- Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario (CHEO), Ottawa, ON, Canada
| | - Gita Wahi
- Department of Pediatrics, McMaster University, McMaster Children's Hospital, Hamilton, ON, Canada
| | - Ann Bayliss
- Trillium Health Partners, Department of Paediatrics, University of Toronto, Mississauga, ON, Canada
| | - Gemma Vomiero
- Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, AB, Canada
| | - Jessica L Foulds
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Ronik Kanani
- North York General Hospital, University of Toronto, Toronto, ON, Canada
| | - Mahmoud Sakran
- Department of Paediatrics, Queens University, Lakeridge Health, Oshawa, ON, Canada; Research, Lakeridge Health, Oshawa, ON, Canada
| | - Anupam Sehgal
- Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Cornelia M Borkhoff
- The Hospital for Sick Children, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Eleanor Pullenayegum
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Arun Reginald
- The Hospital for Sick Children, Toronto, ON, Canada; Department of Ophthalmology and Visual Sciences, University of Toronto, Toronto, ON, Canada
| | - Patricia C Parkin
- The Hospital for Sick Children, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Peter J Gill
- The Hospital for Sick Children, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
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5
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Nguyen ELV, Hersi L, Mahant S, Cichon J, Drouin O, Pound C, Quet J, Wahi G, Bayliss A, Vomiero G, Foulds JL, Kanani R, Sakran M, Sehgal A, Borkhoff CM, Pullenayegum E, Widjaja E, Reginald A, Wolter NE, Oni S, Anwar R, Louriachi H, Ge Y, Kirolos N, Patel A, Jasani H, Kornelsen E, Chugh A, Gouda S, Akbaroghli S, McKerlie M, Parkin PC, Gill PJ. Variation in the Management of Hospitalized Children With Orbital Cellulitis Over 10 Years. Hosp Pediatr 2023; 13:375-391. [PMID: 37122049 DOI: 10.1542/hpeds.2022-007006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
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.
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Affiliation(s)
| | - Leo Hersi
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sanjay Mahant
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Departments of Pediatrics
- Institute of Health Policy, Management and Evaluation
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Jessica Cichon
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Olivier Drouin
- Departments of Pediatrics and
- Social and Preventive Medicine, School of Public Health, Université de Montréal, Montreal, Quebec, Canada
- Division of General Pediatrics, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Catherine Pound
- Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Julie Quet
- Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Gita Wahi
- Department of Pediatrics, McMaster University, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Ann Bayliss
- Trillium Health Partners, Department of Paediatrics, University of Toronto, Mississauga, Ontario, Canada
| | - Gemma Vomiero
- Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Jessica L Foulds
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | | | - Mahmoud Sakran
- Department of Paediatrics, Queens University
- Research, Lakeridge Health, Oshawa, Ontario, Canada
| | - Anupam Sehgal
- Kingston Health Sciences Centre, Queens University, Kingston, Ontario, Canada
| | - Cornelia M Borkhoff
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Departments of Pediatrics
- Institute of Health Policy, Management and Evaluation
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Eleanor Pullenayegum
- Departments of Pediatrics
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Elysa Widjaja
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Departments of Pediatrics
| | - Arun Reginald
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Ophthalmology and Visual Sciences
| | - Nikolaus E Wolter
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Otolaryngology, Head & Neck Surgery
| | - Semipe Oni
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rashid Anwar
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Yipeng Ge
- Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Nardin Kirolos
- Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Ashaka Patel
- Department of Pediatrics, McMaster University, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Hardika Jasani
- Trillium Health Partners, Department of Paediatrics, University of Toronto, Mississauga, Ontario, Canada
| | - Emily Kornelsen
- Trillium Health Partners, Department of Paediatrics, University of Toronto, Mississauga, Ontario, Canada
| | - Ashton Chugh
- Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Sandra Gouda
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | | | - Morgyn McKerlie
- Kingston Health Sciences Centre, Queens University, Kingston, Ontario, Canada
| | - Patricia C Parkin
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Departments of Pediatrics
- Institute of Health Policy, Management and Evaluation
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Peter J Gill
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Departments of Pediatrics
- Institute of Health Policy, Management and Evaluation
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
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Nazari MA, Rosenblum JS, Zhuang Z, Malik A, Lonser RR, Pacak K, Aronoff S. A 13-Year-Old Male With Left Eye Swelling. Pediatrics 2022; 150:189930. [PMID: 36353857 DOI: 10.1542/peds.2021-056037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2022] [Indexed: 11/11/2022] Open
Abstract
A 13-year-old male presented with a 10-day history of left eye swelling and pain. These symptoms prompted presentation to the emergency department. He had no significant past medical history and no preceding fevers or chills. He was found on examination of the eyes and the orbit to have left supraorbital erythema, edema, and pain with upward and medial gaze. Examination of the globe, fundus, and visual fields were normal. His white blood cell count was 6.2 (x1000/mm3) with an erythrocyte sedimentation rate of 4 (mm/hr). Diagnostic endoscopic biopsy was performed. Here we present this case alongside clinical reasoning and diagnostic evaluation with relevant input from respective experts. This case discussion reviews the final diagnosis, as well as the corresponding evaluation and management. Diagnostic algorithms based on literature review and clinical experience are also included.
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Affiliation(s)
- Matthew A Nazari
- Department of Internal Medicine and Pediatrics, Georgetown University Hospital, Washington, District of Columbia.,Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | | | - Zhengping Zhuang
- Neuro-Oncology Branch, National Cancer Institute.,Surgical Neurology Branch, National Institute of Neurologic Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Archana Malik
- Department of Pediatric Diagnostic Radiology, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
| | - Russell R Lonser
- Department of Neurologic Surgery, Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Karel Pacak
- Section on Medical Neuroendocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Stephen Aronoff
- Department of Pediatrics, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania.,Section of Pediatric Infectious Diseases, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
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Clinical Markers of Need for Surgery in Orbital Complication of Acute Rhinosinusitis in Children: Overview and Systematic Review. J Pers Med 2022; 12:jpm12091527. [PMID: 36143312 PMCID: PMC9504785 DOI: 10.3390/jpm12091527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/09/2022] [Accepted: 09/13/2022] [Indexed: 11/22/2022] Open
Abstract
Background: Although they can occur at all ages, orbital (OC) and periorbital cellulitis (POC) prevail in the pediatric population. Acute rhinosinusitis (ARS) is the most frequent predisposing factor of OC. Recent literature has suggested a medical management approach for OC and POC, with surgery reserved only for more severe cases. However, there is still a lack of consensus on the clinical markers of a need for surgery. The aim of this systematic review was to identify clinical markers of a need for surgery in children with OC. Our systematic review, in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) process, yielded 1289 articles finally screened. This resulted in 31 full texts that were included in a qualitative analysis. The results of this review suggest that in children aged over 9 years, large subperiosteal orbital abscesses (SPOAs), impaired vision, ophthalmoplegia, proptosis, elevated C-reactive protein (CRP) and absolute neutrophil counts (ANC), hemodynamic compromise, no clinical improvement after 48/72 h of antibiotic therapy, and a Chandler III score or higher are clinical markers of the need for surgery. However, most of the studies are observational and retrospective, and further studies are needed to identify reliable and repeatable clinical markers of the need for surgery.
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8
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Gill PJ, Drouin O, Pound C, Quet J, Wahi G, Bayliss A, Vomiero G, Foulds J, Kanani R, Sakran M, Sehgal A, Pullenayegum E, Widjaja E, Reginald A, Wolter NE, Oni S, Anwar R, Cichon J, Louriachi H, Ge Y, Kirolos N, Patel A, Jasani H, Kornelsen E, Chugh A, Gouda S, Akbaroghli S, McKerlie M, Parkin PC, Mahant S. Factors Associated with Surgery and Imaging Characteristics in Severe Orbital Infections. J Pediatr 2022; 248:66-73.e7. [PMID: 35568061 DOI: 10.1016/j.jpeds.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 05/02/2022] [Accepted: 05/06/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To evaluate risk factors associated with surgical intervention and subperiosteal/orbital abscess in hospitalized children with severe orbital infections. STUDY DESIGN We conducted a multicenter cohort study of children 2 months to 18 years hospitalized with periorbital or orbital cellulitis from 2009 to 2018 at 10 hospitals in Canada. Clinical details were extracted, and patients were categorized as undergoing surgical or medical-only management. Primary outcome was surgical intervention and the main secondary outcome was clinically important imaging. Logistic regression was used to identify predictors. RESULTS Of 1579 patients entered, median age was 5.4 years, 409 (25.9%) had an orbital/subperiosteal abscess, and 189 (12.0%) underwent surgery. In the adjusted analysis, the risk of surgical intervention was associated with older age (age 9 to <14: aOR 3.9, 95% CI 2.3-6.6; and age 14 to ≤18 years: aOR 7.0, 95% CI 3.4-14.1), elevated C-reactive protein >120 mg/L (aOR 2.8, 95% CI 1.3-5.9), elevated white blood cell count of 12-20 000/μL (aOR 1.7, 95% CI 1.1-2.6), proptosis (aOR 2.6, 95% CI 1.7-4.0), and subperiosteal/orbital abscess (aOR 5.3, 95% CI 3.6-7.9). There was no association with antibiotic use before hospital admission, sex, presence of a chronic disease, temperature greater than 38.0°C, and eye swollen shut. Complications were identified in 4.7% of patients, including vision loss (0.6%), intracranial extension (1.6%), and meningitis (0.8%). CONCLUSIONS In children hospitalized with severe orbital infections, older age, elevated C-reactive protein, elevated white blood cell count, proptosis, and subperiosteal/orbital abscess were predictors of surgical intervention.
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Affiliation(s)
- Peter J Gill
- The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada.
| | - Olivier Drouin
- Department of Pediatrics, Université de Montreal, Montreal, Quebec, Canada; Division of General Pediatrics, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada; Department of Social and Preventive Medicine, School of Public Health, Université de Montréal, Montreal, Quebec, Canada
| | - Catherine Pound
- Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada
| | - Julie Quet
- Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada
| | - Gita Wahi
- Department of Pediatrics, McMaster University, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Ann Bayliss
- Trillium Health Partners, Department of Paediatrics, University of Toronto, Mississauga, Ontario, Canada
| | - Gemma Vomiero
- Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Jessica Foulds
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Ronik Kanani
- North York General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mahmoud Sakran
- Department of Paediatrics, Queens University, Lakeridge Health, Oshawa, Ontario, Canada; Research, Lakeridge Health, Oshawa, Ontario, Canada
| | - Anupam Sehgal
- Kingston Health Sciences Centre, Queens University, Kingston, Ontario, Canada
| | - Eleanor Pullenayegum
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Elysa Widjaja
- The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Arun Reginald
- The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Ophthalmology and Visual Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Nikolaus E Wolter
- The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Otolaryngology, Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Semipe Oni
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rashid Anwar
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jessica Cichon
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hossam Louriachi
- Department of Pediatrics, Université de Montreal, Montreal, Quebec, Canada
| | - Yipeng Ge
- Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada
| | - Nardin Kirolos
- Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada
| | - Ashaka Patel
- Department of Pediatrics, McMaster University, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Hardika Jasani
- Trillium Health Partners, Department of Paediatrics, University of Toronto, Mississauga, Ontario, Canada
| | - Emily Kornelsen
- Trillium Health Partners, Department of Paediatrics, University of Toronto, Mississauga, Ontario, Canada
| | - Ashton Chugh
- Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Sandra Gouda
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Susan Akbaroghli
- North York General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Morgyn McKerlie
- Kingston Health Sciences Centre, Queens University, Kingston, Ontario, Canada
| | - Patricia C Parkin
- The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Sanjay Mahant
- The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
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9
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Gill PJ, Mahant S, Hall M, Parkin PC, Shah SS, Wolter NE, Mestre M, Markham JL. Association Between Corticosteroids and Outcomes in Children Hospitalized With Orbital Cellulitis. Hosp Pediatr 2022; 12:70-89. [PMID: 34877598 DOI: 10.1542/hpeds.2021-005910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Peter J Gill
- Division of Paediatric Medicine, Department of Paediatrics, Faculty of Medicine.,Institute of Health Policy, Management and Evaluation.,Hospital for Sick Children, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Sanjay Mahant
- Division of Paediatric Medicine, Department of Paediatrics, Faculty of Medicine.,Institute of Health Policy, Management and Evaluation.,Hospital for Sick Children, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Patricia C Parkin
- Division of Paediatric Medicine, Department of Paediatrics, Faculty of Medicine.,Hospital for Sick Children, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Nikolaus E Wolter
- Department of Otolaryngology, Head & Neck Surgery, The University of Toronto, Toronto, Ontario, Canada.,Hospital for Sick Children, Toronto, Ontario, Canada
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10
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Krueger C, Mahant S, Begum N, Widjaja E, Science M, Parkin PC, Gill PJ. Changes in the Management of Severe Orbital Infections Over Seventeen Years. Hosp Pediatr 2021; 11:613-621. [PMID: 34031136 DOI: 10.1542/hpeds.2020-001818] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Carsten Krueger
- Pediatric Outcomes Research Team, Divisions of Pediatric Medicine and
| | - Sanjay Mahant
- Pediatric Outcomes Research Team, Divisions of Pediatric Medicine and.,Departments of Pediatrics and.,Child Health Evaluative Sciences and.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; and
| | - Nurshad Begum
- Pediatric Outcomes Research Team, Divisions of Pediatric Medicine and
| | - Elysa Widjaja
- Neurosciences & Mental Health, SickKids Research Institute, Toronto, Canada.,Medical Imaging, Faculty of Medicine, and
| | - Michelle Science
- Infectious Diseases, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Patricia C Parkin
- Pediatric Outcomes Research Team, Divisions of Pediatric Medicine and.,Departments of Pediatrics and.,Child Health Evaluative Sciences and.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; and
| | - Peter J Gill
- Pediatric Outcomes Research Team, Divisions of Pediatric Medicine and .,Departments of Pediatrics and.,Child Health Evaluative Sciences and.,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; and
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