Orbital complications of sinusitis: avoid delays in diagnosis

Artificial Intelligence Automation of Proptosis Measurement: An Indicator for Pediatric Orbital Abscess Surgery

INTRODUCTION

To evaluate the ability of artificial intelligence (AI) software to quantify proptosis for identifying patients who need surgical drainage.

METHODS

We pursued a retrospective study including 56 subjects with a clinical diagnosis of subperiosteal orbital abscess (SPOA) secondary to sinusitis at a tertiary pediatric hospital from 2002 to 2016. AI computer software was developed to perform 3D visualization and quantitative assessment of proptosis from computed tomography (CT) images acquired at the time of hospital admission. The AI software automatically computed linear and volume metrics of proptosis to provide more practice-consistent and informative measures. Two experienced physicians independently measured proptosis using the interzygomatic line method on axial CT images. The AI software and physician proptosis assessments were evaluated for association with eventual treatment procedures as standalone markers and in combination with the standard predictors.

RESULTS

To treat the SPOA, 31 of 56 (55%) children underwent surgical intervention, including 18 early surgeries (performed within 24 h of admission), and 25 (45%) were managed medically. The physician measurements of proptosis were strongly correlated (Spearman r = 0.89, 95% CI 0.82-0.93) with 95% limits of agreement of ± 1.8 mm. The AI linear measurement was on average 1.2 mm larger (p = 0.007) and only moderately correlated with the average physicians' measurements (r = 0.53, 95% CI 0.31-0.69). Increased proptosis of both AI volumetric and linear measurements were moderately predictive of surgery (AUCs of 0.79, 95% CI 0.68-0.91, and 0.78, 95% CI 0.65-0.90, respectively) with the average physician measurement being poorly to fairly predictive (AUC of 0.70, 95% CI 0.56-0.84). The AI proptosis measures were also significantly greater in the early as compared to the late surgery groups (p = 0.02, and p = 0.04, respectively). The surgical and medical groups showed a substantial difference in the abscess volume (p < 0.001).

CONCLUSION

AI proptosis measures significantly differed from physician assessments and showed a good overall ability to predict the eventual treatment. The volumetric AI proptosis measurement significantly improved the ability to predict the likelihood of surgery compared to abscess volume alone. Further studies are needed to better characterize and incorporate the AI proptosis measurements for assisting in clinical decision-making.

Clinical Characteristics and Risk Factors for Evisceration in Trauma-Dominant Orbital Cellulitis: A 10-Year Review

Purpose

To analyze the clinical characteristics of trauma-dominant orbital cellulitis (OC) and evaluate the risk factors associated with evisceration.

Methods

This retrospective study included inpatients diagnosed with orbital cellulitis at the Zhongshan Ophthalmic Center between January 2010 and December 2020. The demographic features, etiology, clinical characteristics, microbiological isolates, and risk factors associated with evisceration were analyzed.

Results

Among 148 consecutive subjects (n = 148, 148 eyes), the mean age was 42.07 ± 20.35 years and 70.27% were male. Penetrating globe injuries were the most common (52.03%). No light perception (NLP) was recorded in 50% of patients on admission. Endophthalmitis was observed in 103 cases (69.59%), intraocular foreign bodies (IOFB) were detected in 43 cases (29.05%), and total corneal melting was observed in 31 cases (20.95%). Sixty patients (40.54%) underwent evisceration. Logistic regression analysis showed that total corneal dissolution [odds ratio (OR) = 83.019, P = 0.000], IOFB (OR = 3.402, P = 0.016), and NLP (OR = 0.185, P = 0.001) were risk factors for evisceration. Microorganism detection showed that Pseudomonas aeruginosa and Bacillus cereus were the leading pathogens.

Conclusion

Among hospitalized trauma-dominant OC patients, middle-aged men were the major subjects and penetrating globe injury was the major cause. Significant complications such as complete visual loss and evisceration were unavoidable in many patients with OC in the current study. NLP, IOFB, and total corneal melting were the risk factors for evisceration.

Automated delineation of orbital abscess depicted on CT scan using deep learning

OBJECTIVES

To develop and validate a deep learning algorithm to automatically detect and segment an orbital abscess depicted on computed tomography (CT).

METHODS

We retrospectively collected orbital CT scans acquired on 67 pediatric subjects with a confirmed orbital abscess in the setting of infectious orbital cellulitis. A context-aware convolutional neural network (CA-CNN) was developed and trained to automatically segment orbital abscess. To reduce the requirement for a large dataset, transfer learning was used by leveraging a pre-trained model for CT-based lung segmentation. An ophthalmologist manually delineated orbital abscesses depicted on the CT images. The classical U-Net and the CA-CNN models with and without transfer learning were trained and tested on the collected dataset using the 10-fold cross-validation method. Dice coefficient, Jaccard index, and Hausdorff distance were used as performance metrics to assess the agreement between the computerized and manual segmentations.

RESULTS

The context-aware U-Net with transfer learning achieved an average Dice coefficient and Jaccard index of 0.78 ± 0.12 and 0.65 ± 0.13, which were consistently higher than the classical U-Net or the context-aware U-Net without transfer learning (P < 0.01). The average differences of the abscess between the computerized results and the experts in terms of volume and Hausdorff distance were 0.10 ± 0.11 mL and 1.94 ± 1.21 mm, respectively. The context-aware U-Net detected all orbital abscess without false positives.

CONCLUSIONS

The deep learning solution demonstrated promising performance in detecting and segmenting orbital abscesses on CT images in strong agreement with a human observer.

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.

Lesion-Mapping Software for the Measurement of Subperiosteal Abscess Volume for Pediatric Orbital Cellulitis: A Retrospective Chart Review

Introduction

Our objective was to assess the utility of using lesion-mapping software to calculate precise orbital volumes to predict patients who would benefit from early surgical intervention.

Methods

We retrospectively reviewed patients diagnosed with subperiosteal orbital abscess (SPOA) secondary to sinusitis at a tertiary pediatric hospital from 2005 to 2016. Diagnoses were confirmed by CT scans. Lesion-mapping software was used to measure SPOA volume using initial CT images. Data collected included patient demographics, length of hospital stay, and subsequent medical or surgical treatment.

Results

Thirty-three (52%) patients ultimately underwent surgical intervention, while 30 (48%) were managed medically. Between the surgical and medical groups, there were no differences in gender, age, or comorbidities. The surgical group had larger abscess volumes than the medically managed group (0.94 mL vs. 0.31 mL, p < 0.01). Overall, increased SPOA volume was associated with increased age (Pearson’s coefficient = 0.374, p ≤ 0.01) and increased total days of intravenous (IV) antibiotic administration (Pearson’s coefficient = 0.260, p = 0.039). Patients who underwent surgery on the day of admission had 25% shorter hospital stay than patients who had delayed surgery (p < 0.01). Our calculated sensitivity-optimized SPOA volume cutoff of 0.231 mL yielded sensitivity of 90.9% and specificity of 70.0%.

Conclusions

This is the first study to use lesion-mapping software for precise calculation of SPOA volumes, which can help refine indications for early surgical intervention and help decrease length of hospital stay.

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.

Do Medical Students Receive Adequate Otolaryngology Training? A Canadian Perspective

Objectives:

Otolaryngology—head and neck surgery (OHNS) training has been found to be underrepresented in medical school curricula. The study aimed to assess (i) students’ clinical OHNS exposure, (ii) their confidence managing OHNS conditions, and (iii) the correlation between OHNS exposure and confidence managing OHNS conditions.

Methods:

Fourth-year medical students at two Canadian Universities completed a survey assessing baseline characteristics, OHNS training, and confidence managing OHNS conditions.

Results:

Of 87 returned surveys, 46 students had no clinical OHNS exposure, while 29 felt there was adequate OHNS exposure. The majority of students lacked confidence recognizing conditions requiring emergent referral. Students with greater OHNS training had greater confidence managing OHNS conditions ( r = 0.267, P = .012).

Conclusion:

The majority of medical students have minimal OHNS exposure. Students with greater OHNS exposure have greater confidence managing OHNS conditions. A review of Canadian medical school curricula is warranted to ensure adequate OHNS exposure.

Ophthalmic manifestations of paranasal sinus disease: a clinical grading system

BACKGROUND

Ophthalmic complications are common manifestations of paranasal sinus disease. We propose a clinical grading system to standardize the category, treatment, and outcome of these complications.

METHODS

Forty-two patients with paranasal sinus disease-induced ophthalmic complications were included in the study. The patients were categorized according to their clinical presentation: Grade I, patients with anatomical disturbance; Grade II, patients with ophthalmic functional involvement; Grade III, patients with orbital infection; and Grade IV, patients with visual impairment.

RESULTS

The age of the patients ranged from 8 to 65 years (mean = 30 years). Overall, 36% patients had ophthalmologic manifestations with anatomical disturbance (Grade I), 26% had functional disturbance (Grade II), 26% had orbital infections (Grade III), and 12% had visual loss (Grade IV). The cause of the ophthalmic manifestations was allergic fungal sinusitis in 50%, chronic rhinosinusitis in 36%, acute sinusitis in 10%, and mucocele in 4%. The most common ophthalmic manifestation was proptosis (36%), followed by orbital infection (26%), functional involvement (26%), and visual impairment (12%). The patients underwent functional endoscopic sinus surgery and medical treatment when indicated. The outcome in Grades I, II, and III was favorable; the outcome in Grade IV was not favorable.

CONCLUSION

This simple clinical grading system provides a useful tool for assessing the overall status of ophthalmic complications of Acute and chronic paranasal sinus disease at the initial clinical assessment and for subsequent management of these complications.

Acute Rhinosinusitis—Related Orbital Infection in Pediatric Patients: A Retrospective Analysis

Objectives:

Periorbital infection frequently originates from acute rhinosinusitis in children. We tried to find the characteristics of pediatric patients who are likely to develop subperiosteal orbital abscesses and to need emergency surgery for acute orbital swelling.

Methods:

In an observational retrospective cohort study, we reviewed 64 children less than 18 years of age who visited emergency rooms for periorbital swelling and were hospitalized with a diagnosis of periorbital cellulitis and subperiosteal orbital abscess between 1996 and 2007 at Chang Gung Memorial Hospital. The presence of periorbital abscess was diagnosed radiographically, and all of the patients had concomitant sinusitis that was proved by computed tomographic scan.

Results:

The mean age of the patients was 6.95 years, and 42 (65.63%) were male (male-to-female ratio, 1.91). Thirty patients (46.88%) had surgical drainage, and 34 (53.13%) received antibiotic therapy only. The factors associated on bivariate analysis with abscess formation were age of 6 years or less (p = 0.023), proptosis (p = 0.012), fever (p < 0.001), and a white blood cell count of more than 11,100 cells per microliter (p = 0.004). On multivariate analysis, fever and proptosis were independent factors that predicted abscess formation. In patients who underwent surgical drainage, the most frequently cultured microbes were Staphylococcus aureus, Streptococcus viridans, and coagulase-negative staphylococci, and 29% of our patients had polymicrobial pus cultures.

Conclusions:

The most important factor in predicting the failure of antibiotic treatment of sinusitis-related periorbital infections is abscess formation. Patients with fever and proptosis are prone to develop subperiosteal orbital abscesses.

Periorbital and orbital cellulitis: a 10-year review of hospitalized children

PURPOSE

Periorbital cellulitis is often difficult to distinguish from orbital cellulitis, which is a potentially lethal infection involving the contents of the orbit. A delay in diagnosis and appropriate treatment may result in serious complications. We studied the predisposing factors, microbiologic data, clinical features, complications, and treatment of periorbital and orbital cellulitis in childhood.

METHODS

Eighty-three medical records of patients (mean age 3.7 ± 3.1 years) admitted to the Department of Pediatrics with a diagnosis of periorbital or orbital cellulitis during the 10-year period January 1997 to December 2007 were retrospectively studied.

RESULTS

In this series, periorbital cellulitis occurred more frequently (83%) than orbital cellulitis (17%). Of the children with periorbital cellulitis, 85% were younger than 5 years of age, while 62% of the children with orbital cellulitis were older than 5 years of age. The most common predisposing factors in periorbital cellulitis were upper respiratory infection (68%) and trauma to the eyelids (20%), while sinusitis was more frequently associated with orbital cellulitis (79%). Blood and skin cultures were usually negative. The most common isolated pathogens were Staphylococcus aureus, Streptococcus pneumoniae, and Staphylococcus epidermidis. Forty-five of the 83 children were treated with intravenous ceftriaxone + clindamycin (mean duration 8.6 ± 5.5 days). Intravenous antibiotics alone was an effective management in most of the patients, but a small proportion (6%) required surgical intervention.

CONCLUSIONS

Upper respiratory infection and sinusitis are the most important predisposing factors for periocular infection. Streptococcus species are the predominant causative agents. Both diseases can usually be successfully treated with intravenous antibiotics, but some patients may require surgery to control extensive infection.

Audit of management of periorbital cellulitis and abscess in a district general hospital and a tertiary referral centre, in line with published guidelines

OBJECTIVE

To audit the management of periorbital cellulitis or abscess, in line with guidelines published in 2004, within a district general hospital and a tertiary referral centre.

METHOD

Retrospective audit analysing 58 cases at a district general hospital and 61 cases at a tertiary referral centre, encountered since 2004.

RESULTS

At the tertiary referral centre, 22 patients were diagnosed with pre-septal cellulitis and discharged, as were 20 cases at the district general hospital. At the tertiary referral centre, 95 per cent of patients were correctly seen by an ophthalmologist and 82 per cent by a senior ENT surgeon, compared with 63 and 39 per cent, respectively, at the district general hospital. In both centres, one patient did not receive a computed tomography scan where this was indicated. Despite the need for twice daily monitoring of ophthalmological criteria, both sites lacked 100 per cent compliance. At the tertiary referral centre, 76 per cent of patients were correctly treated with intravenous antibiotics, compared with 68 per cent at the district general hospital.

CONCLUSION

At both sites, adherence to guidelines was suboptimal. Management may be improved through improved education and online information support.

Orbital abscess after facial trauma

This paper reports a rare case of acute severe orbital abscess manifested 2 days after a facial trauma without bone fracture in a 20-year-old Afro-American female. The symptoms worsened within the 24 h prior to hospital admission resulting in visual disturbances such as diplopia and photophobia. The clinical findings at the first consultation included fever, periorbital swelling and redness, ptosis, proptosis and limitation of ocular movements upwards, downwards, to the right and to the left. Computed tomography scan showed proptosis with considerable soft tissue swelling on the left side and no fracture was evidenced in the facial skeleton, including the zygomatic-orbital complex. After hospital admission and antibiotic therapy intravenously the patient was conducted to the operation room and submitted to incision and drainage under general anesthesia. The orbit was approached thorough both eyelids and the maxillary sinus was reached only through the Caldwell-Luc approach. The postoperative period was uneventful and the rapid improvement of symptoms was remarkable. Visual acuity and ocular motility returned to the normal ranges within 2 days after the surgical intervention. After 12 postoperative days, the patient presented with significative improvement in the ptosis and proptosis, and acceptable scars.

Preseptal and orbital cellulitis: a 10-year review of hospitalized patients

BACKGROUND

Preseptal and orbital cellulitis range in severity from minor to potentially severe complications. The purpose of this study is to describe the clinical features of patients with preseptal or orbital cellulitis in one medical center in Taiwan, and to assess the effectiveness of treatments and the complications.

METHODS

Patients admitted between 1996 and 2005 to Taipei Veterans General Hospital under the diagnosis of preseptal or orbital cellulitis were retrospectively reviewed. The demographics, administrative history, past history, clinical presentations, treatments, and complications were analyzed.

RESULTS

In total, 94 patients fulfilling the diagnostic criteria for preseptal or orbital cellulitis were identified (67 had preseptal cellulitis, 27 had orbital cellulitis). While paranasal sinus disease was the most common predisposing cause in orbital cases, skin lesions in children and dacryocystitis in adults were the most common in preseptal cases. Microbiologic investigations showed variable results, but the most common pathogen isolated was Staphylococcus aureus. Cultures from eye swabs and local abscesses gave the highest positive yield. Blood cultures were taken in some patients, but the positive rate was extremely low. Treatments included intravenous antibiotics alone, or intravenous antibiotics combined with surgical drainage. Only one case had permanent ocular motility impairment after removal of the orbital foreign body.

CONCLUSION

Despite the past history of potential morbidity and even mortality from orbital cellulitis, early diagnosis and prompt treatment with proper antibiotics and/or surgical intervention can achieve a good prognosis.

Une expérience sénégalaise des cellulites orbitaires

AIM

To show the etiological, clinical, and epidemiological aspects of orbital cellulitis at the ophthalmological clinic of A. le Dantec hospital.

PATIENTS AND METHOD

This is a retrospective study conducted from January 1994 to October 2003. Sixty-eight patient records were used. We noted patients' civil status, past medical history, clinical and paraclinical examinations, treatment received before and at admission to the clinic, and progression.

RESULTS

The incidence of orbital cellulitis was 8.9 cases per year. The average age of patients was 18 years and the sex ratio 2.78 in favor of males. Patients were hospitalized for a mean of 11 days. The fever was often stopped at admission. All patients had violent retrobulbar pain, associated with inflammatory exophthalmos in 77.8% of cases, and ophthalmoplegia in 67.2%. Two cases of diplopia were noted; 57.5% had sinusitis. Streptococcus was the bacterium found most frequently. In hospital, all patients received three antibiotics (ampicillin, aminoglycoside, metronidazole) and prednisone. In 51.5% of the cases, surgical treatment was necessary. Progression was favorable in 55.88% of the cases. Three patients died and 18 cases of blindness were noted.

CONCLUSION

Orbital cellulitis is a young people's disorder with serious complications. This medical emergency requires a combination of effective antibiotics and a corticosteroid. Treating the source of infections is essential to avoid recurrence. In our practice, these three drugs in association in first intention was beneficial without an antibiogram.

Orbital cellulitis: a rare complication after orbital blowout fracture

PURPOSE

To report the incidence of orbital cellulitis after orbital blowout fracture.

DESIGN

Retrospective, noncomparative, interventional case series.

PARTICIPANTS

All patients with orbital cellulitis and a history of recent orbital fracture.

METHODS

A medical record review of clinical history, imaging studies, and surgical and treatment outcome was performed.

MAIN OUTCOME MEASURES

Resolution of orbital cellulitis and surgical and imaging findings.

RESULTS

Four patients (3 male; mean age, 30 years [range, 4.5-58]) were treated for orbital cellulitis complicating orbital fracture. All patients had evidence of paranasal sinusitis before or after the orbital injury, and 2 also reported forceful nose blowing after sustaining orbital trauma. Although 3 patients received prophylactic oral antibiotics after the fracture, this failed to prevent infection. Sinusitis commenced 1 to 2 weeks before and as late as 5 weeks after orbital injury. All patients were treated with IV antibiotics. Two developed an orbital abscess that required surgical drainage; 1 patient improved after an endonasal maxillary antrostomy. One patient improved on IV antibiotics alone and underwent fracture repair at a later stage. These 4 patients represent 0.8% of all cases of orbital fractures treated in the study period.

CONCLUSIONS

Orbital cellulitis is a rare complication of orbital fracture, and seems to be more common when paranasal sinus infection preexists or occurs within several weeks of the injury. Oral antibiotics given after the orbital injury may not prevent orbital cellulitis or abscess formation. Surgery may be required to drain orbital abscess or in nonresolving cellulitis to drain the paranasal sinuses. Fracture repair, if indicated, should be delayed, particularly if an alloplastic implant is used.

Referral patterns in paediatric orbital cellulitis

OBJECTIVES

Orbital cellulitis in children may result in severe visual morbidity and even mortality if not managed appropriately. The definitive management of orbital cellulitis is in the realms of the otolaryngologist, as the underlying pathology is associated with sinus disease in more than 90% of cases. Our observations suggest that there is a tendency for patients with suspected orbital cellulitis not to be referred promptly for otolaryngological opinion and management, which may result in adverse outcomes. The aim of this study was to determine the initial management by establishing general practitioners' attitudes to the referral and management of suspected orbital cellulitis.

METHODS

Anonymous questionnaires were sent to general practitioners to ascertain details on their initial treatment modalities and preferred specialist referral. General practitioners in Worcestershire and North Staffordshire, two major regions in the West Midlands, UK, were targeted.

RESULTS

The majority of general practitioners initially commenced patients on oral antibiotics, and referred patients primarily to ophthalmologists for further assessment, although significant variations in referral patterns were found.

CONCLUSION

Better education for primary care physicians is needed regarding the initial management and referral of paediatric patients with suspected orbital cellulitis. They should be referred promptly for hospital admission. A good multidisciplinary approach with quick involvement of the three specialities (ear, nose and throat, ophthalmology and paediatrics) would avoid delays in the definitive management and ensure optimal outcomes.

Guidelines for the management of periorbital cellulitis/abscess

Orbital and periorbital swelling secondary to acute sinusitis is relatively common. Distinguishing between preseptal and orbital involvement can be difficult based on clinical observations alone. A delay in diagnosis and appropriate treatment may result in serious complications including blindness. The literature is reviewed and simple guidelines suggested to manage such patients, including their initial assessment, investigations with particular reference to the indications and timing of CT scanning, antimicrobial therapy and the type of surgery. These guidelines have been approved across disciplines in our unit and trialled successfully for 2 years.

Clinical practice guidelines for the management of orbital cellulitis

PURPOSE

A retrospective study was performed to review the management of periorbital and orbital cellulitis at Miami Children's Hospital, between January 1, 1993 and February 15, 1996.

RESULTS

One hundred and one patients were included in this study. The variables analyzed in this study included age, sex, length of hospital stay, imaging studies, laboratory tests, and microbiology specimens collected. Patients were classified according to the modified Chandler classification. Average length of stay for our patient population was 4.5 days. Data regarding the radiologic studies, laboratory tests, and microbiology yield of specimens were analyzed.

CONCLUSIONS

The incidence of orbital infection, manifested by lid swelling alone is much more common (stages I and II) than orbital infection involving postseptal findings (stages III, IV, and V); 84.16% compared with 15.84%, respectively. An updated approach and a general guideline for the management of periorbital and orbital cellulitis according to the clinical staging of the process is presented.

Space-occupying and life-threatening infections of the head, neck, and thorax

Infections of the deep structures of the head and neck are polymicrobial, rapidly progressive, and frequently life-threatening. The bacteriology, clinical presentation, and the need for multidisciplinary management of these infections are stressed. In addition, this article discusses selected head and neck infections of immunocompromised hosts and postexposure prophylaxis for serious infections of the pharynx.