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Maheshwari M, Ho ML, Bosemani T, Dahmoush H, Fredrick D, Guimaraes CV, Gulko E, Jaimes C, Joseph MM, Kaplan SL, Miyamoto RC, Nadel HR, Partap S, Pfeifer CM, Pruthi S. ACR Appropriateness Criteria® Orbital Imaging and Vision Loss-Child. J Am Coll Radiol 2024; 21:S219-S236. [PMID: 38823946 DOI: 10.1016/j.jacr.2024.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 06/03/2024]
Abstract
Orbital disorders in children consist of varied pathologies affecting the orbits, orbital contents, visual pathway, and innervation of the extraocular or intraocular muscles. The underlying etiology of these disorders may be traumatic or nontraumatic. Presumed location of the lesion along with the additional findings, such as eye pain, swelling, exophthalmos/enophthalmos, erythema, conjunctival vascular dilatation, intraocular pressure, etc, help in determining if imaging is needed, modality of choice, and extent of coverage (orbits and/or head). Occasionally, clinical signs and symptoms may be nonspecific, and, in these cases, diagnostic imaging studies play a key role in depicting the nature and extent of the injury or disease. In this document, various clinical scenarios are discussed by which a child may present with an orbital or vision abnormality. Imaging studies that might be most appropriate (based on the best available evidence or expert consensus) in these clinical scenarios are also discussed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Mai-Lan Ho
- Panel Vice Chair, Nationwide Children's Hospital, Columbus, Ohio
| | | | - Hisham Dahmoush
- Lucile Packard Children's Hospital at Stanford, Stanford, California
| | - Douglas Fredrick
- Oregon Health & Science University-Casey Eye Institute, Portland, Oregon; American Academy of Pediatrics
| | | | - Edwin Gulko
- Westchester Medical Center, Valhalla, New York
| | - Camilo Jaimes
- Massachusetts General Hospital, Boston, Massachusetts
| | - Madeline M Joseph
- University of Florida College of Medicine Jacksonville, Jacksonville, Florida; American College of Emergency Physicians
| | - Summer L Kaplan
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Committee on Emergency Radiology-GSER
| | - R Christopher Miyamoto
- Peyton Manning Children's Hospital at Ascension St. Vincent, Indianapolis, Indiana; American Academy of Otolaryngology-Head and Neck Surgery
| | - Helen R Nadel
- Lucile Packard Children's Hospital at Stanford, Stanford, California; Commission on Nuclear Medicine and Molecular Imaging
| | - Sonia Partap
- Stanford University, Stanford, California; American Academy of Pediatrics
| | | | - Sumit Pruthi
- Specialty Chair, Vanderbilt Children's Hospital, Nashville, Tennessee
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2
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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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Gibbons AB, Niknahad A, Bacorn C, Halawa O, Li E. Subperiosteal and Orbital Abscesses: A Comparison of Clinical Features, Management, and Outcomes. Ophthalmic Plast Reconstr Surg 2024; 40:161-166. [PMID: 37581883 DOI: 10.1097/iop.0000000000002495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Abstract
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.
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Affiliation(s)
- Alison B Gibbons
- The Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Ava Niknahad
- The Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
| | - Colin Bacorn
- The Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
- Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - Omar Halawa
- The Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
- Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, U.S.A
| | - Emily Li
- The Johns Hopkins University School of Medicine, Baltimore, Maryland, U.S.A
- Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, U.S.A
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Yosefof E, Reuven Y, Badir S, Rapana OG, Schindel H, Avisar I, Dotan G, Gilony D, Soudry E. Predictors for surgical intervention in orbital complications of pediatric rhinosinusitis. Eur J Ophthalmol 2023; 33:1867-1873. [PMID: 36793220 DOI: 10.1177/11206721231156987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
OBJECTIVES Orbital complications are the most common complication of acute rhinosinusitis, especially among pediatric patients. While most cases are treated with antibiotics alone, severe presentation may demand surgical intervention. Our goal was to determine which factors predict the need for surgery and to investigate the role of computerized tomography in the decision process. METHODS A retrospective review of all children hospitalized between 2001-2018 with orbital complications of acute rhinosinusitis in a university-affiliated children's hospital. RESULTS A total of 156 children were included. Mean age was 7.9 years (1-18 years). Twenty-three children (14.7%) were surgically treated, and the rest were conservatively treated. High fever, ophthalmoplegia and diplopia in association with minimal or no response to conservative treatment were predictive for surgical intervention, as well as higher inflammatory indices. Eighty-nine children (57%) underwent imaging during hospitalization. Presence of a subperiosteal abscess, as well as its size and its location were not found to be predictors for surgery. CONCLUSION Clinical and laboratory findings in association with minimal or no response to conservative treatment predict the need for surgical intervention in cases of orbital complications of acute rhinosinusitis. As Computerized Tomography scans can have long-term implications in the pediatric population, caution and patience should be practiced when deciding on the timing of imaging in this population. Thus, close clinical and laboratory monitoring should lead the decision-making process in these cases and imaging should be reserved for when the decision for surgery has been made.
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Affiliation(s)
- Eyal Yosefof
- Department of Otorhinolaryngology and Head and Neck Surgery, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yonatan Reuven
- Department of Otorhinolaryngology and Head and Neck Surgery, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Samih Badir
- Department of Otorhinolaryngology and Head and Neck Surgery, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Olga Gordon Rapana
- Department of Otorhinolaryngology and Head and Neck Surgery, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hilla Schindel
- Department of Otorhinolaryngology and Head and Neck Surgery, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Inbal Avisar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Ophthalmology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - Gad Dotan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Ophthalmology Unit, Schneider Children's Medical Center, Petach Tikva, Israel
| | - Dror Gilony
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Otorhinolaryngology Unit, Schneider Children's Medical Center, Petach Tikva, Israel
| | - Ethan Soudry
- Department of Otorhinolaryngology and Head and Neck Surgery, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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5
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Schein Y, Lin LY, Revere K, Russo ME, Yu Y, Ying GS, Binenbaum G. Microbial patterns and culture utility in orbital cellulitis. J AAPOS 2023; 27:200.e1-200.e6. [PMID: 37487954 DOI: 10.1016/j.jaapos.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/26/2023] [Accepted: 05/27/2023] [Indexed: 07/26/2023]
Abstract
PURPOSE To determine the prevalence and types of pathogens found in children with orbital cellulitis and to evaluate the utility of nonoperative cultures. METHODS This was a retrospective cohort study of children with imaging-confirmed orbital cellulitis over a period of 8 years. Outcomes included prevalence and types of organisms, polymicrobial infection, mixed aerobic-anaerobic infection, effect of age, and culture utility. RESULTS Of 220 children with orbital cellulitis, 112 (51%) had cultures taken; 69 (31%) had surgical intervention. Culture sources for the 112 children with cultures included blood (57 patients [51%]), sinus (53 [47%]), orbit (42 [38%]), brain (6 [5%]), and skin/conjunctiva/lacrimal sac (6 [5%]). Streptococcus anginosus group strains grew in cultures from 19 children (17%); methicillin-sensitive Staphylococcus aureus (MSSA), in 15 (13%); Streptococcus pyogenes, in 12 (11%); methicillin-resistant Staphylococcus aureus (MRSA), in 6 (5%); anaerobic/facultative gram negative rods, in 8 (7%); anaerobic Gram-positive cocci, other Viridans group streptococci, and Streptococci pneumoniae, in 3 (3%) each; and normal respiratory/skin flora, in 23 (21%). Polymicrobial infection (P = 0.08) and anaerobic organisms (P = 0.58) did not differ by age (range, 0.1-16.8 years). In all 220 (100%) children, nonoperative cultures were either not obtained (108 [49%]), not helpful in avoiding surgery (69 [31%]), showed no growth (39 [18%]), or grew an organism that did not change management from empiric therapy (4 [2%]). CONCLUSIONS While many organisms may be cultured from children with orbital cellulitis, Streptococcus and MSSA were the most common in our study cohort. MRSA is uncommon, so initial empiric coverage is not necessary. Rates of polymicrobial and anaerobic infection were similar across ages. Our results indicate that nonoperative cultures are not indicated in the initial medical management of orbital cellulitis; in our cohort, they neither resulted in treatment changes nor helped avoid surgery.
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Affiliation(s)
- Yvette Schein
- Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Lisa Y Lin
- Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Karen Revere
- Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Scheie Eye Institute, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael E Russo
- Division of Infectious Disease, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yinxi Yu
- Scheie Eye Institute, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gui-Shuang Ying
- Scheie Eye Institute, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gil Binenbaum
- Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Scheie Eye Institute, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
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6
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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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Lu JE, Yoon MK. The Role of Steroids for Pediatric Orbital Cellulitis - Review of the Controversy. Semin Ophthalmol 2023:1-4. [PMID: 36683269 DOI: 10.1080/08820538.2023.2168487] [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] [Indexed: 01/24/2023]
Abstract
Orbital cellulitis in the pediatric population is treated primarily with antibiotic therapy. This leaves the inflammatory component unchecked. Corticosteroid therapy has been used to accelerate recovery and decrease the long-term morbidity in other infectious conditions. Its use has also been proposed for pediatric orbital cellulitis. The aim of this manuscript is to conduct a literature review to summarize existing evidence and understand ongoing controversies. Overall, prior investigations on corticosteroid therapy for pediatric orbital cellulitis are limited by their study design and sample sizes. One of the most discussed potential benefits is that adjuvant steroid therapy for pediatric orbital cellulitis is associated with shorter hospitalization without major infectious complications. However, decreased hospitalization length is an imperfect metric, especially without standardized criteria for hospital discharge. Future studies are warranted to better guide the use of adjuvant steroid therapy and to optimize its potential in the management of pediatric orbital cellulitis.
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Affiliation(s)
- Jonathan E Lu
- Department of Ophthalmology, Division of Oculoplastic Surgery Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Michael K Yoon
- Department of Ophthalmology, Division of Oculoplastic Surgery Massachusetts Eye and Ear Infirmary, Boston, MA, USA
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8
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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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10
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Distinguishing orbital cellulitis from preseptal cellulitis in children. Int Ophthalmol 2022; 43:733-740. [PMID: 36050606 DOI: 10.1007/s10792-022-02472-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 08/20/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE We aimed to evaluate clinical and laboratory characteristics of children with preseptal cellulitis (PC) and orbital cellulitis (OC) and also to determine whether clinical and/or laboratory parameters could be used to distinguish OC from PC. METHODS The medical records of pediatric patients (aged between 1 month and 18 years) with PC and OC who had been hospitalized at our center from January 2008 to December 2020 were retrospectively reviewed. Multivariable regression analysis was performed to identify possible parameters useful in differentiating between PC and OC. RESULTS A total of 375 patients [202 (53.9%) boys], of whom 35 (9.3%) had OC, were evaluated. Median age was 44 (range, 1-192) months. Compared to those with PC, patients with OC were older (p = 0.001), had fever, upper respiratory tract infection (URTI) symptoms, and sinusitis more frequently, and demonstrated prolonged symptom and hospitalization times (p ˂ 0.001 for all). Significant differences between groups were observed for numerous laboratory parameters; however, multivariable regression analysis revealed that only C-reactive protein (CRP) and platelet count could be used to predict OC among the laboratory findings. Taken together, factors independently associated with OC diagnosis were proptosis, ophthalmoplegia, age (>35 months), CRP level (˃116.5 mg/L), and platelet count (˃420.5 × 103/mm3). CONCLUSION In addition to showing previously known properties of OC versus PC, our study demonstrated that combined demographic, clinical and laboratory factors such as being aged above 35 months, having a CRP level of ˃116.5 mg/L, and platelet count of ˃ 420.5 × 103/mm3 could be used to distinguish OC from PC.
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11
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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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12
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Sorotzky M, Shahar-Nissan K, Shack AR, Berant R, Weiser G, Berliner E, Heiman E. Management of intraorbital infections in the pediatric emergency department. Eur J Pediatr 2022; 181:2741-2746. [PMID: 35476291 DOI: 10.1007/s00431-022-04468-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 03/04/2022] [Accepted: 04/05/2022] [Indexed: 11/28/2022]
Abstract
UNLABELLED Intraorbital infections may lead to severe complications, necessitating rapid diagnosis and intervention. The decision process regarding the need for emergent imaging and possible surgical intervention is unclear in the literature. This retrospective cohort study included two major pediatric emergency departments in Israel between 2010 and 2020. Patients arriving at the emergency department with an admission diagnosis of intraorbital infection and at least one high-risk symptom for orbital involvement were included in the study. The main outcome measures were the computerized tomography (CT) timing and results, whether the case was managed surgically or conservatively and whether the patient returned to the same hospital with significant complications. Ninety-five patients were included; 70 underwent a CT scan in the first 24 h, and of those 21 were managed surgically; 16 were treated based on clinical findings alone, with no imaging performed. When comparing groups based on management, we found no significant differences based on presenting symptoms, duration of complaints, or severity of CT findings. However, having three or more high-risk presenting symptoms was associated with a greater likelihood of surgical intervention (multivariate logistic regression p = 0.069, odds ratio 1.73, 95% confidence interval 0.96-3.11; one-way ANOVA and Fisher's exact test p < 0.05). CONCLUSION The decision to treat intraorbital infections at our institutions appears to be based on clinical impression of disease severity rather than radiologic findings. This suggests a need for further interdisciplinary studies to clarify optimal management. WHAT IS KNOWN • Orbital c ellulitis is associated with significant potential complications, necessitating rapid diagnosis and treatment. • Present literature provides insufficiently clear guidance on emergency department management. WHAT IS NEW • Consideration of all relevant factors (clinical features, laboratory findings, timing of imaging, and conservative vs. surgical management) in a single retrospective cohort. • Our findings suggest that decision-making in practice may be guided by clinical impression rather than imaging.
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Affiliation(s)
- Michael Sorotzky
- Department of Pediatrics, Wilf Children's Hospital, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Keren Shahar-Nissan
- Pediatric Emergency Department, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Avram R Shack
- Department of Pediatrics, Wilf Children's Hospital, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Ron Berant
- Pediatric Emergency Department, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Giora Weiser
- Pediatric Emergency Department, Wilf Children's Hospital, Shaare Zedek Medical Center, 12 Shmuel Bait Street, 9103102, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Elihay Berliner
- Pediatric Emergency Department, Wilf Children's Hospital, Shaare Zedek Medical Center, 12 Shmuel Bait Street, 9103102, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Eyal Heiman
- Pediatric Emergency Department, Wilf Children's Hospital, Shaare Zedek Medical Center, 12 Shmuel Bait Street, 9103102, Jerusalem, Israel. .,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
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13
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Dohlman JC, Rizzo JF. Diagnostics for Infectious Orbital and Ocular Adnexal Disease. Int Ophthalmol Clin 2022; 62:87-100. [PMID: 35325912 DOI: 10.1097/iio.0000000000000417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Preseptal and Orbital Cellulitis: Analysis of Clinical, Laboratory and Imaging Findings of 123 Pediatric Cases From Turkey. Pediatr Infect Dis J 2022; 41:97-101. [PMID: 34711787 DOI: 10.1097/inf.0000000000003382] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND We aimed to compare the clinical and laboratory characteristics and imaging methods of patients diagnosed with preseptal cellulitis and orbital cellulitis in the pediatric age group. METHODS The study was designed retrospectively, and the medical records of all patients who were hospitalized with the diagnosis of preseptal cellulitis and orbital cellulitis were reviewed. The findings of preseptal cellulitis and orbital cellulitis groups were compared. The risk factors for the development of orbital involvement were analyzed. RESULTS A total of 123 patients were included, 90.2% with preseptal cellulitis and 9.8% with cellulitis. The male gender ratio was 60.2%, and the mean age was 72 ± 43 months. While all patients had eyelid swelling and redness, 20.3% had fever. Ocular involvement was 51.2% in the right eye and 4.9% in both eyes. The most common predisposing factor was rhinosinusitis (56.1%). Radiologic imaging (computed tomography/magnetic resonance imaging) was performed in 83.7% of the patients. Subperiostal abscess was detected in 7 cases (5.6%) in which three of the cases were managed surgically and four were treated with medically. The levels of C-reactive protein were significantly higher in patients with orbital involvement (P = 0.033), but there was no difference between the presence of fever, leukocyte and platelet values. CONCLUSIONS Rhinosinusitis was the most common predisposing factor in the development of preseptal cellulitis and orbital cellulitis. Orbital involvement was present in 9.8% of the patients. It was determined that high C-reactive protein value could be used to predict orbital involvement.
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15
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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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16
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Lahmini W, Oumou M, Bourrous M. Management of periorbital cellulitis at the Pediatric Emergency Department: A ten years study. J Fr Ophtalmol 2021; 45:166-172. [PMID: 34973820 DOI: 10.1016/j.jfo.2021.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/22/2021] [Accepted: 09/28/2021] [Indexed: 11/17/2022]
Abstract
Periorbital cellulitis is a diagnostic and therapeutic emergency, jeopardizing the prognosis for vision and survival. PURPOSE The goal of this study was to analyze the epidemiological and therapeutic features and outcomes of periorbital cellulitis cases treated in the pediatric emergency department. PATIENTS AND METHODS A retrospective study including all the children aged between 1 month and 15 years treated for periorbital cellulitis in the Pediatric Emergency Department of the Mohamed VI University Teaching Hospital in Marrakech over a period of 10 years (January 1, 2010-December 31, 2019). RESULTS In all, 168 cases of periorbital cellulitis were recorded, with an increasing of the number of cases, from 2 in 2010 to 39 in 2019. The most affected age bracket was the group under 5 years of age (62.5%). The most frequent mode of entry was sinusitis (22%). Preseptal cellulitis was most common (76.7%). The main clinical signs found in orbital cellulitis were proptosis (64%) and chemosis (35.8%), versus conjunctival hyperemia (78%) in preseptal cellulitis. Ophthalmoplegia was present in two cases of orbital cellulitis. The right side was most affected (44%). An orbital CT scan was performed in all cases in our study, showing preseptal cellulitis in 129 patients (76.7%), orbital cellulitis in 14 cases (8.3%), subperiosteal abscess in 20 cases (12%) and orbital abscess in 5 cases (3%). Prior treatment with non-steroidal anti-inflammatory medication was noted in 6%. The most commonly used antibiotic was amoxicillin-clavulanic acid. Steroid treatment was prescribed in 6% of cases. Surgical treatment was indicated in 12 patients (7.1%). The mean hospital length of stay was 3 days for the preseptal cases and 8 days for the orbital cases. All patients had good outcomes with medical and/or surgical treatment. With follow-up of over one year, no complications were noted. CONCLUSION The majority of our cases had positive outcomes, highlighting the advantage of early diagnosis, adapted antibiotic treatment and multidisciplinary care, rendering surgery rarely necessary.
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Affiliation(s)
- W Lahmini
- Department of Paediatric Emergency, Mohamed VI University Hospital, Cadi Ayyad University, Marrakech, Morocco.
| | - M Oumou
- Department of Paediatric Emergency, Mohamed VI University Hospital, Cadi Ayyad University, Marrakech, Morocco.
| | - M Bourrous
- Department of Paediatric Emergency, Mohamed VI University Hospital, Cadi Ayyad University, Marrakech, Morocco.
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17
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Chen L, Guo US, Grutman G, McFarlane SI, Mehta P. Superior Ophthalmic Vein Thrombosis Induced by Orbital Cellulitis: An Ophthalmic Emergency. Cureus 2021; 13:e19038. [PMID: 34853755 PMCID: PMC8608043 DOI: 10.7759/cureus.19038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 10/24/2021] [Indexed: 11/05/2022] Open
Abstract
Superior ophthalmic vein thrombosis (SOVT) is a rare ophthalmologic emergency. The most common etiologies include infection, trauma, inflammation, and malignancy, as well as thyroid-related orbitopathy. Early identification and timely intervention can lead to a significant decrease in complications that include cavernous sinus thrombosis (CST), vision loss, and death. This rare disease entity almost always makes its initial presentation to internal medicine or emergency medicine (EM) physicians. In this report, we present a case of SOVT that presented overnight to the emergency department for worsening right facial swelling and orbital pain. We discuss our experience with the evaluation and management of SOVT and provide a review of the currently available literature to emphasize the importance of obtaining a full history and physical examination, seeking early imaging studies, and ophthalmology consultation for patients with suspected SOVT.
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Affiliation(s)
- Lu Chen
- Department of Cardiology, State University of New York Downstate Medical Center, Brooklyn, USA
| | - Uta S Guo
- Department of Family Medicine and Community Health, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Gennadiy Grutman
- Internal Medicine, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, USA
| | - Samy I McFarlane
- Department of Medicine and Endocrinology, State University of New York Downstate Medical Center, Brooklyn, USA
| | - Parag Mehta
- Internal Medicine, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, USA
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18
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Ohana-Sarna-Cahan L, Hurvitz N, Gross I, Cohen A, Hashavya S. Factors Associated With Increased Risk of Pediatric Orbital Cellulitis-Who Should Be Scanned? Pediatr Emerg Care 2021; 37:e1473-e1477. [PMID: 32205800 DOI: 10.1097/pec.0000000000002083] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Evaluation of a child with POC/OC is complicated due difficulties in physical examination and risks of imaging by computed tomography. METHOD Retrospective review of children 0-16 years admitted to the pediatric emergency department for POC/OC from 2009 to 2019. RESULTS Ten years study period, 243 children younger than 16 years presented to the pediatric emergency department with a diagnosis of POC/OC. OC was documented in 51 (20.6%) patients. The mean age was 7.8 years (±4.3 years). Fever (80.4%), upper respiratory tract infection (43%), swelling of both eyelids (96%), proptosis (33.3%), and tenderness on percussion (24.5%) were more common in comparison to POC (P = 0.0001, 0.03, 0.0001, 0.0001, 0.0001 respectively). All children with suspected diagnosis of OC underwent computed tomography scan. POC accounted for 196 patients. Mean age was 4.6 (±4.3) years. Twenty percent of the cases were recorded as local trauma or insect bite in the infected eye.Mean leukocyte count in the OC group had higher mean of 15.2 (109/L) versus 13.4(109/L) (P = 0.05), absolute neutrophil count was significantly higher in the OC 11.3(109/L) versus 7.2(109/L) (P = 0.0001) whereas the lymphocyte count was higher in the POC 4.5(109/L) versus 2.4(109/L) (P = 0.0001), NLR of 0.318 correlates with orbital cellulitis with sensitivity of 75.5% and specificity of 77.4%.Patients with OC had mean C-reactive protein levels of 11.7 (mg/dL) versus 4.9(mg/dL) (P = 0.0001), erythrocyte sedimentation rate was elevated in the OC 53.6 (cm/h) versus 36.4 (cm/h) (P = 0.02).Based on the aforementioned study a risk calculator for OC was formulated with 6 major variables. CONCLUSIONS Differentiation between POC/OC is cardinal. This study highlights the importance of ancillary laboratory tests especially C-reactive protein in the assessment of infections of the eye.
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Affiliation(s)
| | | | - Itai Gross
- Department of Pediatric Emergency Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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19
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Burek AG, Melamed S, Liljestrom T, Qi J, Kelly TG, Suelzer E, Mitchell M, Harris GJ, Havens PL. Evaluation and Medical Management of the Pediatric Patient With Orbital Cellulitis/Abscess: A Systematic Review. J Hosp Med 2021; 16:680-687. [PMID: 34730499 DOI: 10.12788/jhm.3707] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 09/02/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Pediatric orbital cellulitis/abscess (OCA) can lead to vision loss, intracranial extension of infection, or cavernous thrombosis if not treated promptly. No widely recognized guidelines exist for the medical management of OCA. The objective of this review was to summarize existing evidence regarding the role of inflammatory markers in distinguishing disease severity and need for surgery; the role of imaging in OCA evaluation; and the microbiology of OCA over the past 2 decades. METHODS This review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches were performed in MEDLINE (Ovid), Web of Science Core Collection, Scopus, CINAHL (EBSCO), and Cochrane Central Register of Controlled Trials (CENTRAL), most recently on February 9, 2021. RESULTS A total of 63 studies were included. Most were descriptive and assessed to have poor quality with high risk of bias. The existing publications evaluating inflammatory markers in the diagnosis of OCA have inconsistent results. Computed tomography imaging remains the modality of choice for evaluating orbital infection. The most common organisms recovered from intraoperative cultures are Streptococcus species (Streptococcus anginosus group, group A Streptococcus, and pneumococcus) and Staphylococcus aureus. Methicillin-resistant S aureus in culture-positive cases had a median prevalence of 3% (interquartile range, 0%-13%). CONCLUSION This systematic review summarizes existing literature concerning inflammatory markers, imaging, and microbiology for OCA evaluation and management. High-quality evidence is still needed to define the optimal medical management of OCA.
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Affiliation(s)
- Alina G Burek
- Children's Wisconsin, Milwaukee, Wisconsin
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Svetlana Melamed
- Children's Wisconsin, Milwaukee, Wisconsin
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Tracey Liljestrom
- Children's Wisconsin, Milwaukee, Wisconsin
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jing Qi
- Children's Wisconsin, Milwaukee, Wisconsin
- Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Teresa G Kelly
- Children's Wisconsin, Milwaukee, Wisconsin
- Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Michelle Mitchell
- Children's Wisconsin, Milwaukee, Wisconsin
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Gerald J Harris
- Children's Wisconsin, Milwaukee, Wisconsin
- Department of Ophthalmology and Visual Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Peter L Havens
- Children's Wisconsin, Milwaukee, Wisconsin
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
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20
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Abstract
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.
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21
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Raponi I, Giovannetti F, Buracchi M, Priore P, Battisti A, Scagnet M, Genitori L, Valentini V. Management of orbital and brain complications of sinusitis: A practical algorithm. J Craniomaxillofac Surg 2021; 49:1124-1129. [PMID: 34607756 DOI: 10.1016/j.jcms.2021.09.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 06/24/2021] [Accepted: 09/08/2021] [Indexed: 10/20/2022] Open
Abstract
The aim of this work was to present a practical management algorithm for orbital and brain complications of sinusitis. According to the inclusion criteria, a sample of 68 patients was collected between 2008 and 2018 (39 males and 29 females). Among them, 44 were adults, with a mean age of 50.46 years, and 24 were pediatric patients, with a mean age of 10.33 years. Oral or intravenous antibiotic therapy was administered to all patients. Pharmacological resolution was observed in 14 cases. Early surgical treatment within 48 hours was necessary in 10 cases. Surgery consisted of abscess drainage, associated or not with functional endoscopic sinus surgery. Delayed surgery within 15-30 days was performed in 44 patients. The core procedure was functional endoscopic sinus surgery. Subsidiary procedures were abscess drainage, tooth extraction or cranial base repair. The combination of two or more of these procedures was case selected. Median follow-up was of 46.36 months. Sinusitis complications necessitate rapid diagnosis and prompt treatment. Antibiotic therapy alone is enough for mistreated rhinosinusitis with no anatomical predisposing factor. Surgery is mandatory for altered nasal and paranasal sinus anatomy or odontogenic infections.
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Affiliation(s)
- Ingrid Raponi
- Department of Maxillofacial Surgery, Sapienza University of Rome, Rome, Lazio, Italy.
| | - Filippo Giovannetti
- Department of Maxillofacial Surgery, Sapienza University of Rome, Rome, Lazio, Italy; Department of Neurosurgery, Meyer Children's Hospital, Florence, Toscana, Italy
| | - Matteo Buracchi
- Department of Maxillofacial Surgery, Sapienza University of Rome, Rome, Lazio, Italy
| | - Paolo Priore
- Department of Maxillofacial Surgery, Sapienza University of Rome, Rome, Lazio, Italy.
| | - Andrea Battisti
- Department of Maxillofacial Surgery, Sapienza University of Rome, Rome, Lazio, Italy
| | - Mirko Scagnet
- Department of Neurosurgery, Meyer Children's Hospital, Florence, Toscana, Italy
| | - Lorenzo Genitori
- Department of Neurosurgery, Meyer Children's Hospital, Florence, Toscana, Italy
| | - Valentino Valentini
- Department of Maxillofacial Surgery, Sapienza University of Rome, Rome, Lazio, Italy
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22
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Shifman NT, Krause I, Dotan G, Gilony D, Bilavsky E. Orbital Cellulitis in a Pediatric Population - Experience From a Tertiary Center. Indian Pediatr 2021. [DOI: 10.1007/s13312-022-2417-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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23
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Sharma A, Ingole S, Deshpande M, Ranadive P, Sharma S, Chavan A. An insight on management of odontogenic orbital infections: report of two cases. JOURNAL OF ORAL MEDICINE AND ORAL SURGERY 2021. [DOI: 10.1051/mbcb/2021025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Odontogenic infections are common and very often spread to potential spaces of head and neck. The spread of such infection to adjacent maxillary sinuses or distant sites such as the orbits are a rare occurrence and may develop periorbital and orbital cellulitis. Unfortunately once orbital cellulitis and subsequently orbital abscess develops it can give rise to serious complications such as complete blindness or even more serious and life-threatening situations as cavernous sinus thrombosis, intracranial abscess or even death. Two cases are presented to demonstrate the differences between the two conditions and the necessary management in either case. This article provides an insight into the clinical behaviour of orbital infections of odontogenic origin with contemporary diagnostic and treatment modalities that will help in reducing morbidity and mortality associated with these conditions.
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24
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Fu R, Leader JK, Pradeep T, Shi J, Meng X, Zhang Y, Pu J. Automated delineation of orbital abscess depicted on CT scan using deep learning. Med Phys 2021; 48:3721-3729. [PMID: 33906264 PMCID: PMC8600964 DOI: 10.1002/mp.14907] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 04/06/2021] [Accepted: 04/19/2021] [Indexed: 11/07/2022] Open
Abstract
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.
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Affiliation(s)
- Roxana Fu
- Department of Ophthalmology University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Joseph K. Leader
- Departments of Radiology and Bioengineering, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Tejus Pradeep
- Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Junli Shi
- Departments of Radiology and Bioengineering, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Xin Meng
- Departments of Radiology and Bioengineering, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Yanchun Zhang
- Departments of Radiology and Bioengineering, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Jiantao Pu
- Departments of Radiology and Bioengineering, University of Pittsburgh, Pittsburgh, PA 15213, USA
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25
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Rossetto JD, Forno EA, Morales MC, Moreira JC, Ferrari PV, Herrerias BT, Hirai FE, Gracitelli CPB. Upper Eyelid Necrosis Secondary to Hordeolum: A Case Report. Case Rep Ophthalmol 2021; 12:270-276. [PMID: 34054469 PMCID: PMC8138243 DOI: 10.1159/000513958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 12/20/2020] [Indexed: 12/02/2022] Open
Abstract
We reported a case of upper eyelid necrosis initially misdiagnosed as a preseptal cellulitis following a hordeolum externum resulting in great damage to the upper eyelid (anterior lamella). The infection was successfully treated with surgical cleansing, drainage, and endovenous antibiotics. Early treatment may avoid severe complications such as eyelid deformity, systemic involvement, and blindness.
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Affiliation(s)
- Júlia D Rossetto
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil.,Department of Pediatric Ophthalmology, Institute of Childcare and Pediatrics Martagão Gesteira-Federal University of Rio de Janeiro (IPPMG-UFRJ), Rio de Janeiro, Brazil
| | | | - Melina Correia Morales
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil.,Centro de Estudos Alcides Hirai, Ver Mais Oftalmologia, São Paulo, Brazil.,Vera Cruz Oftalmologia, Campinas, Brazil.,Fundação Roberto Rocha Brito, Hospital Vera Cruz, Campinas, Brazil
| | - Julio Cesar Moreira
- Vera Cruz Oftalmologia, Campinas, Brazil.,Fundação Roberto Rocha Brito, Hospital Vera Cruz, Campinas, Brazil
| | - Pedro V Ferrari
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil.,Centro de Estudos Alcides Hirai, Ver Mais Oftalmologia, São Paulo, Brazil.,Vera Cruz Oftalmologia, Campinas, Brazil.,Fundação Roberto Rocha Brito, Hospital Vera Cruz, Campinas, Brazil
| | - Bruno T Herrerias
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil.,Centro de Estudos Alcides Hirai, Ver Mais Oftalmologia, São Paulo, Brazil.,Vera Cruz Oftalmologia, Campinas, Brazil.,Fundação Roberto Rocha Brito, Hospital Vera Cruz, Campinas, Brazil
| | - Flavio E Hirai
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil.,Centro de Estudos Alcides Hirai, Ver Mais Oftalmologia, São Paulo, Brazil.,Vera Cruz Oftalmologia, Campinas, Brazil.,Fundação Roberto Rocha Brito, Hospital Vera Cruz, Campinas, Brazil
| | - Carolina P B Gracitelli
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil.,Centro de Estudos Alcides Hirai, Ver Mais Oftalmologia, São Paulo, Brazil.,Vera Cruz Oftalmologia, Campinas, Brazil.,Fundação Roberto Rocha Brito, Hospital Vera Cruz, Campinas, Brazil
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26
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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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27
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Kornelsen E, Mahant S, Parkin P, Ren LY, Reginald YA, Shah SS, Gill PJ. Corticosteroids for periorbital and orbital cellulitis. Cochrane Database Syst Rev 2021; 4:CD013535. [PMID: 33908631 PMCID: PMC8092453 DOI: 10.1002/14651858.cd013535.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
| | - Sanjay Mahant
- Pediatric Outcomes Research Team, Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Patricia Parkin
- Pediatric Outcomes Research Team, Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Lily Yuxi Ren
- Lane Medical Library, Stanford University School of Medicine, Palo Alto, California, USA
| | - Yohann A Reginald
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Peter J Gill
- Pediatric Outcomes Research Team, Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
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Pradeep T, Kalra G, Leader JK, McCoy J, Dixit R, Dohar J, Tobey A, Sahel JA, Pu J, Fu R. Lesion-Mapping Software for the Measurement of Subperiosteal Abscess Volume for Pediatric Orbital Cellulitis: A Retrospective Chart Review. Ophthalmol Ther 2021; 10:261-271. [PMID: 33537950 PMCID: PMC8079525 DOI: 10.1007/s40123-021-00333-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 01/15/2021] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Tejus Pradeep
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Gagan Kalra
- Government Medical College and Hospital, Chandigarh, India
| | - Joseph K Leader
- Department of Radiology, University of Pittsburgh, Pittsburgh, PA, 15213, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Jennifer McCoy
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Ronak Dixit
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Joseph Dohar
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Allison Tobey
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - José-Alain Sahel
- Department of Ophthalmology, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Jiantao Pu
- Department of Radiology, University of Pittsburgh, Pittsburgh, PA, 15213, USA.
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, 15213, USA.
| | - Roxana Fu
- Department of Ophthalmology, University of Pittsburgh, Pittsburgh, PA, 15213, USA.
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29
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Basily A, Mansukhani S, Anzeljc A, Gutierrez P. Orbital Cellulitis-When Computed Tomography Imaging Is Falsely Reassuring. Pediatr Emerg Care 2021; 37:e48-e50. [PMID: 29768298 DOI: 10.1097/pec.0000000000001521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT An 8-year-old male presented to the pediatric emergency department with subjective fever, blurry vision, and left eye pain. On physical examination, there was mild left lower lid erythema and a subtle left eye elevation deficit. Computed tomography demonstrated preseptal soft tissue swelling without orbital involvement; however, there was varying amounts of paranasal sinus opacification. Despite the negative scan, a diagnosis of orbital cellulitis associated with sinusitis was made and treatment with intravenous antibiotics was initiated. A magnetic resonance imaging performed subsequently revealed orbital fat stranding and inferior rectus enlargement and enhancement near the orbital apex, indicating the presence of orbital cellulitis. This case demonstrates the utility of magnetic resonance imaging when initial computed tomography imaging is negative in patients with concern for orbital cellulitis.
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Affiliation(s)
- Arsany Basily
- From the Department of Pediatrics, Morehouse School of Medicine
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30
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Solimeno L, Torretta S, Marchisio P, Iofrida E, Bosis S, Tagliabue C, Di Pietro GM, Pignataro L, Guastella C. Abscess of the clivus in an adolescent with complicated acute rhinosinusitis: a case report. Ital J Pediatr 2020; 46:97. [PMID: 32665003 PMCID: PMC7362412 DOI: 10.1186/s13052-020-00863-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 07/06/2020] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Complications of acute sinusitis affecting multiple sites are very uncommon, and generally develop for a delayed diagnosis of the primary infection, with possible severe and life-threatening evolution. Patients can have variable presentations according to the site and extent of the infection. Multiple forms generally include the coexistence of orbital manifestations and intracranial infections. We here present a case with unusual multiple sites locations (i.e.: intraorbital intraconic abscess, sigmoid sinus thrombosis, preclival abscess, multiple splanchnocranium osteomyelitic processes).
Case presentation
A 13-year-old male presented at our hospital with right progressive orbital oedema with eyesight worsening and signs of meningitis. Computed tomography and magnetic resonance (MRI) demonstrated right intraorbital intraconic abscess, left sphenoidal sinusitis, transverse and sigmoid sinus thrombosis. Ophthalmologic evaluation documented a right optic nerve sufferance. Endoscopic and superior right trans-palpebral surgical decompression was performed, and the abscess was drained. Microbiological analysis revealed the presence of multi-sensitive Streptococcus Intermedius. Subsequent prolonged antibiotic and anti-thrombotic treatments were started. In the following two-weeks the sinusal and ophthalmologic clinical conditions improved, whereas the patients complained of mild to moderate cervical pain and suffered from intermittent pyrexia. Control MRI documented clival abscess extending up to preclival soft tissues posterior to the nasopharynx, associated with mandible osteomyelitis, occipital condyles and anterior part of the temporal bone hyper intensity. Endoscopic trans-nasal surgical approach to the clival compartment with neurosurgery navigation-guided achieved preclival abscess drainage. Complete clinical and radiological recovery was achieved after 45 days of medical treatment.
Conclusions
Multiple sites complicated rhinosinusitis is uncommon, and its management is challenging. A proper history and thorough clinical examination along with a radiological evaluation are key factors in the final diagnosis of patients with complicated multiple sites acute rhinosinusitis. A quick multidisciplinary approach is always necessary to avoid unwanted life-threatening complications.
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31
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Jain SF, Ishihara R, Wheelock L, Love T, Wang J, Deegan T, Majerus CR, Oarhe C, Allbery S. Feasibility of rapid magnetic resonance imaging (rMRI) for the emergency evaluation of suspected pediatric orbital cellulitis. J AAPOS 2020; 24:289.e1-289.e4. [PMID: 33049373 DOI: 10.1016/j.jaapos.2020.05.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 05/21/2020] [Accepted: 05/25/2020] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Samiksha Fouzdar Jain
- College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska; Department of Pediatric Ophthalmology & Adult strabismus, Children's Hospital and Medical Center, Omaha, Nebraska.
| | - Rhys Ishihara
- Department of Pediatric Ophthalmology & Adult strabismus, Children's Hospital and Medical Center, Omaha, Nebraska
| | - Lisa Wheelock
- Department of Radiology, Children's Hospital & Medical Center, Omaha, Nebraska
| | - Terri Love
- Department of Radiology, Children's Hospital & Medical Center, Omaha, Nebraska
| | - Jennifer Wang
- Department of Pediatrics, Division of Emergency Medicine, Children's Hospital and Medical Center, Omaha, Nebraska
| | - Thomas Deegan
- Department of Pediatrics, Division of Emergency Medicine, Children's Hospital and Medical Center, Omaha, Nebraska
| | - Chelsea Rae Majerus
- Department of Pediatrics, Division of Emergency Medicine, Children's Hospital and Medical Center, Omaha, Nebraska
| | - Christian Oarhe
- Department of Pediatrics, Division of Emergency Medicine, Children's Hospital and Medical Center, Omaha, Nebraska
| | - Sandra Allbery
- Department of Radiology, Children's Hospital & Medical Center, Omaha, Nebraska
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An Orbital Abscess Secondary to Intraoral Impalement. J Craniofac Surg 2020; 31:1111-1113. [PMID: 32282484 DOI: 10.1097/scs.0000000000006452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
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.
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Gill PJ, Parkin P, Reginald YA, Shah SS, Kornelsen E, Mahant S. Corticosteroids for periorbital and orbital cellulitis. Hippokratia 2020. [DOI: 10.1002/14651858.cd013535] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Peter J Gill
- The Hospital for Sick Children; Pediatric Outcomes Research Team, Division of Pediatric Medicine, Department of Pediatrics; University of Toronto 555 University Ave Toronto ON Canada M5G 1X8
| | - Patricia Parkin
- The Hospital for Sick Children; Pediatric Outcomes Research Team, Division of Pediatric Medicine, Department of Pediatrics; University of Toronto 555 University Ave Toronto ON Canada M5G 1X8
| | - Yohann A Reginald
- The Hospital for Sick Children, University of Toronto; Department of Ophthalmology and Vision Sciences; Peter Gilgan Centre for Research and Learning, 686 Bay Street Toronto Ontario Canada M5G 0A4
| | - Samir S Shah
- Cincinnati Children's Hospital Medical Center; Division of Hospital Medicine; 3333 Burnet Avenue Cincinnati Ohio USA 45229
| | | | - Sanjay Mahant
- The Hospital for Sick Children; Pediatric Outcomes Research Team, Division of Pediatric Medicine, Department of Pediatrics; University of Toronto 555 University Ave Toronto ON Canada M5G 1X8
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Gill PJ, Parkin PC, Begum N, Drouin O, Foulds J, Pound C, Quet J, Vomiero G, Wahi G, Sakran M, Kozlowski N, Bayliss A, Kanani R, Sehgal A, Pullenayegum EM, Reginald A, Wolter N, Mahant S. Care and outcomes of Canadian children hospitalised with periorbital and orbital cellulitis: protocol for a multicentre, retrospective cohort study. BMJ Open 2019; 9:e035206. [PMID: 31871262 PMCID: PMC6937073 DOI: 10.1136/bmjopen-2019-035206] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Peter J Gill
- Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Paediatric Medicine and the Paediatric Outcomes Research Team (PORT), Toronto, Ontario, Canada
- Hospital for Sick Children, 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
| | - Patricia C Parkin
- Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Paediatric Medicine and the Paediatric Outcomes Research Team (PORT), Toronto, Ontario, Canada
- Hospital for Sick Children, 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
| | - Nurshad Begum
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Olivier Drouin
- Department of Pediatrics, University of Montreal, Montreal, Québec, Canada
| | - Jessica Foulds
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Catherine Pound
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Julie Quet
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Gemma Vomiero
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Gita Wahi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Mahmoud Sakran
- Department of Paediatrics, Queen's University, Oshawa, Ontario, Canada
| | - Natascha Kozlowski
- Research, Lakeridge Health Ajax Pickering Hospital, Ajax, Ontario, Canada
| | - Ann Bayliss
- Trillium Health Partners, University of Toronto, Mississauga, Ontario, Canada
| | - Ronik Kanani
- Department of Pediatrics, North York General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Anupam Sehgal
- Department of Paediatrics, Queen's University, Kingston, Ontario, Canada
| | - Eleanor M Pullenayegum
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Arun Reginald
- Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Ophthalmology and Visual Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Nikolaus Wolter
- Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Otolaryngology, University of Toronto, Toronto, Ontario, Canada
| | - Sanjay Mahant
- Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Paediatric Medicine and the Paediatric Outcomes Research Team (PORT), Toronto, Ontario, Canada
- Hospital for Sick Children, 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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Sekhar V, Ao J, Iqbal I, Ooi EH, Munn Z. Effectiveness of endoscopic versus external surgical approaches in the treatment of orbital complications of rhinosinusitis: a systematic review protocol. JBI DATABASE OF SYSTEMATIC REVIEWS AND IMPLEMENTATION REPORTS 2019; 17:2378-2389. [PMID: 31313706 DOI: 10.11124/jbisrir-2017-003972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
OBJECTIVE This review aims to investigate and compare the effectiveness of endoscopic drainage techniques against external drainage techniques for the treatment of orbital and subperiosteal abscesses as a complication of rhinosinusitis. INTRODUCTION Transnasal endoscopic drainage and external drainage techniques have been used in the management of subperiosteal orbital abscesses secondary to rhinosinusitis. Each of these approaches has its own advantages and disadvantages, with extensive literature describing each technique separately. However, there is a lack of guidance in the studies on assessing and comparing the safety, effectiveness and suitability of these techniques. This review aims to compare the effectiveness of these techniques based on measuring outcomes in the literature such as: length of postoperative hospital stay, rate of revision surgery and complication rates. INCLUSION CRITERIA Eligible studies will include people of all ages diagnosed with subperiosteal abscess, orbital abscess or cavernous sinus thrombosis (Chandler stages III-V) secondary to rhinosinusitis disease, who have also undergone drainage via either an endoscopic approach, external approach or combined surgical approach. METHODS A comprehensive search of both published and unpublished literature will be performed to uncover studies meeting the inclusion criteria. Reference lists of studies included in final analyses will also be manually searched and subject matter experts contacted to investigate other sources of literature. Two reviewers will screen studies and a third reviewer will resolve disagreements. Studies will, where possible, be pooled in statistical meta-analysis with heterogeneity of data being assessed using the standard Chi-squared and I tests.
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Affiliation(s)
- Vimal Sekhar
- Joanna Briggs Institute, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
- Department of Otolaryngology Head and Neck Surgery, Flinders Medical Centre, Adelaide, Australia
| | - Jack Ao
- South Australian Institute of Ophthalmology, Discipline of Ophthalmology and Visual Sciences, The University of Adelaide, Adelaide, Australia
| | - Isma Iqbal
- Department of Otolaryngology Head and Neck Surgery, Flinders Medical Centre, Adelaide, Australia
| | - Eng Hooi Ooi
- Department of Otolaryngology Head and Neck Surgery, Flinders Medical Centre, Adelaide, Australia
| | - Zachary Munn
- Joanna Briggs Institute, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
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Jung JS, Lim NK, Kang DH. Delayed intraorbital infection after craniofacial bone surgery. Arch Craniofac Surg 2019; 20:324-328. [PMID: 31658798 PMCID: PMC6822069 DOI: 10.7181/acfs.2019.00360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 09/09/2019] [Indexed: 11/15/2022] Open
Abstract
Intraorbital infection shows a low incidence, but it might cause blindness or even death. This case is unusual in that its origin from a craniofacial bone fracture prior to infection of the maxillary sinus. A 33-year-old female patient was referred for right cheek swelling. When she visited the emergency room, we removed right cheek hematoma and bacterial examination was done. In the past, she had craniofacial bone surgical history due to a traffic accident 6 years ago. Next day, the swelling had remained with proptosis and pus was recognized in the conjunctiva. We planned an emergency operation and removed the pus which was already spread inside the orbit. And the evaluation for sinusitis was consulted to the otorhinolaryngology department simultaneously. There were Prevotella oralis and methicillin-resistant Staphylococcus epidermidis bacterial infection in the intraorbital and sinus respectively. Afterwards, the vigorous dressing was done for over a month with intravenous antibiotics. Though the intraorbital infection was resolved, blindness and extraocular movement limitation were inevitable. In conclusion, close follow up of the maxillary sinus in facial bone fracture patients is important and aggressive treatment is needed when an infection is diagnosed.
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Affiliation(s)
- Joo Sung Jung
- Department of Plastic and Reconstructive Surgery, Dankook University Hospital, Cheonan, Korea
| | - Nam Kyu Lim
- Department of Plastic and Reconstructive Surgery, Dankook University Hospital, Cheonan, Korea
| | - Dong Hee Kang
- Department of Plastic and Reconstructive Surgery, Dankook University Hospital, Cheonan, Korea
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Stead TG, Retana A, Houck J, Sleigh BC, Ganti L. Preseptal and Postseptal Orbital Cellulitis of Odontogenic Origin. Cureus 2019; 11:e5087. [PMID: 31516796 PMCID: PMC6721925 DOI: 10.7759/cureus.5087] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
The authors present a case of combined preseptal and postseptal cellulitis of odontogenic origin. The infection started as a dental abscess associated with a first maxillary molar. The infection spread into the paranasal sinus, developed into a pansinusitis, and then spread into the preseptal and postseptal tissues. In addition to extraction of the infected tooth, the patient underwent bilateral nasal endoscopy, maxillary antrostomy, total ethmoidectomy, sphenoidotomy, and frontal sinusotomy with balloon dilation. Sinus cultures were positive for 2+ microaerophilic streptococci.
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Affiliation(s)
- Tej G Stead
- Emergency Medicine, Brown University, Providence, USA
| | - Armando Retana
- Oral and Maxillofacial Surgery, Capital Center for Oral and Maxillofacial Surgery and for Cosmetic Surgery, Washington, USA
| | - Jessica Houck
- Emergency Medicine, University of Central Florida College of Medicine / Hospital Corporation of America Graduate Medical Education (HCA GME) Consortium, Kissimmee, USA
| | - Bryan C Sleigh
- Emergency Medicine, Mercer University School of Medicine, Macon, USA
| | - Latha Ganti
- Emergency Medicine, Envision Physician Services, Orlando, USA
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Santos JC, Pinto S, Ferreira S, Maia C, Alves S, da Silva V. Pediatric preseptal and orbital cellulitis: A 10-year experience. Int J Pediatr Otorhinolaryngol 2019; 120:82-88. [PMID: 30772617 DOI: 10.1016/j.ijporl.2019.02.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/01/2019] [Accepted: 02/01/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Characterize clinical features, epidemiology and treatment of hospitalized pediatric cases of preseptal and orbital cellulitis. METHODS Retrospective study of children/adolescents admitted to a central hospital with preseptal and orbital cellulitis between 2007 and 2017. RESULTS A total of 122 cases were included, 80.3% with preseptal cellulitis and 19.7% with orbital cellulitis. Patients had a median age of 5 years. Sinusitis was the most common predisposing factor (40.2%), followed by dental abscess (20.4%) in preseptal cellulitis and by external ocular infections (12.5%) in orbital cellulitis. Sinusitis (p < 0.001) was associated with orbital cellulitis, whereas patients with dental abscess (p = 0.007) and trauma (p = 0.040) were most likely to have preseptal cellulitis. Fever, photophobia, ocular pain, painful eye movements, proptosis, rhinorrhea and vison impairment were related with orbital cellulitis. Leukocytosis was present in 34.4% of patients, and associated with orbital cellulitis (p = 0.001). Nearly half of patients (49.2%) had a CT-scan performed. Systemic corticosteroids were used in 19.7%. Complications occurred in 13 patients. Imaging revaluation through CT was performed in 6.6%, with no patients showing deterioration; 1.6% of patients required surgery. CONCLUSIONS Identification of orbital involvement signs suggested orbital cellulitis. We emphasize the impact of dental abscess as a predisposing factor for preseptal cellulitis. Repeated imaging had no impact on treatment or outcome. A high percentage of patients was treated with steroids despite their controversial use.
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Affiliation(s)
| | - Sara Pinto
- Pediatrics Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Portugal
| | - Sofia Ferreira
- Pediatrics Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Portugal
| | - Catarina Maia
- Pediatrics Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Portugal
| | - Sandra Alves
- Otorhinolaryngology Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Portugal
| | - Vinhas da Silva
- Pediatrics Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Portugal
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Common Community-acquired Bacterial Skin and Soft-tissue Infections in Children: an Intersociety Consensus on Impetigo, Abscess, and Cellulitis Treatment. Clin Ther 2019; 41:532-551.e17. [PMID: 30777258 DOI: 10.1016/j.clinthera.2019.01.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 12/20/2018] [Accepted: 01/16/2019] [Indexed: 11/22/2022]
Abstract
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.
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Torretta S, Guastella C, Marchisio P, Marom T, Bosis S, Ibba T, Drago L, Pignataro L. Sinonasal-Related Orbital Infections in Children: A Clinical and Therapeutic Overview. J Clin Med 2019; 8:jcm8010101. [PMID: 30654566 PMCID: PMC6351922 DOI: 10.3390/jcm8010101] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/09/2019] [Accepted: 01/14/2019] [Indexed: 12/21/2022] Open
Abstract
Sinonasal-related orbital infections (SROIs) are typically pediatric diseases that occur in 3⁻4% of children with acute rhinosinusitis. They are characterised by various clinical manifestations, such as peri-orbital and orbital cellulitis or orbital and sub-periosteal abscesses that may develop anteriorly or posteriorly to the orbital septum. Posterior septal complications are particularly dangerous, as they may lead to visual loss and life-threatening events, such as an intracranial abscess and cavernous sinus thrombosis. Given the possible risk of permanent visual loss due to optic neuritis or orbital nerve ischemia, SROIs are considered ophthalmic emergencies that need to be promptly recognised and treated in an urgent-care setting. The key to obtaining better clinical outcomes in children with SROIs is a multi-disciplinary assessment by pediatricians, otolaryngologists, ophthalmologists, radiologists, and in selected cases, neurosurgeons, neurologists, and infectious disease specialists. The aim of this paper is to provide an overview of the pathogenesis, clinical manifestations, diagnosis, and treatment of pediatric SROIs, and to make some practical recommendations for attending clinicians.
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Affiliation(s)
- Sara Torretta
- Otolaryngological Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy.
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy.
| | - Claudio Guastella
- Otolaryngological Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy.
| | - Paola Marchisio
- Otolaryngological Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy.
- Department of Physiopathology and Transplantation, University of Milan, 20122 Milan, Italy.
| | - Tal Marom
- Department of Otolaryngology-Head and Neck Surgery, Samson Assuta Ashdod University Hospital, Faculty of Health Sciences, Ben Gurion University, 7747629 Ashdod, Israel.
| | - Samantha Bosis
- Otolaryngological Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy.
| | - Tullio Ibba
- Otolaryngological Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy.
| | - Lorenzo Drago
- Department of Clinical Microbiology, University of Milan, 20122 Milan, Italy.
| | - Lorenzo Pignataro
- Otolaryngological Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy.
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy.
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Shen A, Katowitz WR, Revere KE. A 12-Month-Old Boy With Bilateral Facial Swelling and Proptosis. JAMA Ophthalmol 2018; 136:823-824. [PMID: 29677235 DOI: 10.1001/jamaophthalmol.2017.5804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Alice Shen
- currently a medical student at Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - William R Katowitz
- Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Karen E Revere
- Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Management of pediatric orbital cellulitis: A systematic review. Int J Pediatr Otorhinolaryngol 2018; 110:123-129. [PMID: 29859573 DOI: 10.1016/j.ijporl.2018.05.006] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/29/2018] [Accepted: 05/03/2018] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Orbital complications account for 74-85% of all complications from acute sinusitis, more often affect the pediatric population, and can result in devastating consequences. Therefore these patients require prompt diagnosis and proper management. We review and summarize the current literature to determine the appropriate management of each stage of pediatric orbital cellulitis and offer a new comprehensive literature-based algorithm. METHODS Data sources were PubMed/MEDLINE, and Google Scholar. Studies relevant to the management of each subcategory of the Chandler criteria in the pediatric population, limited to the period 1997 through Jan 2018, were compiled and interpreted. Seventy-one studies were reviewed in total. RESULTS Pre-septal and post-septal cellulitis can generally be managed non-surgically, while orbital abscess and cavernous sinus thrombosis are managed surgically. For subperiosteal abscess, non-surgical medical management has been successful in certain patients. Results of the literature review were summarized, and subsequently developed into a comprehensive algorithm for management, including criteria for age, location, and volume of abscess on imaging. CONCLUSIONS Orbital cellulitis, particularly subperiosteal abscesses, in children is not an absolute indication for immediate surgical intervention. Conservative measures can be safe and effective if appropriately used, depending on patient characteristics, clinical course, and imaging.
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Orbital cellulitis. Surv Ophthalmol 2018; 63:534-553. [DOI: 10.1016/j.survophthal.2017.12.001] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 11/22/2017] [Accepted: 12/07/2017] [Indexed: 12/12/2022]
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Atfeh MS, Singh K, Khalil HS. Orbital infections: a complete cycle 7-year audit and a management guideline. Eur Arch Otorhinolaryngol 2018; 275:2079-2088. [PMID: 29869159 DOI: 10.1007/s00405-018-5025-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 05/28/2018] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Mihiar Sami Atfeh
- ENT Department, University Hospitals Plymouth NHS Trust, Peninsula Schools of Medicine and Dentistry, Plymouth University, Plymouth, UK
| | - Kathryn Singh
- Department of Critical Care, King's College Hospital, Denmark Hill, London, SE5 9RS, UK.
| | - Hisham Saleh Khalil
- ENT Department, University Hospitals Plymouth NHS Trust, Peninsula Schools of Medicine and Dentistry, Plymouth University, Plymouth, UK
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Hamed-Azzam S, AlHashash I, Briscoe D, Rose GE, Verity DH. Common Orbital Infections ~ State of the Art ~ Part I. J Ophthalmic Vis Res 2018; 13:175-182. [PMID: 29719647 PMCID: PMC5905312 DOI: 10.4103/jovr.jovr_199_17] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 10/02/2017] [Indexed: 11/26/2022] Open
Abstract
Infections of the orbit and periorbita are relatively frequent, and can cause significant local and systemic morbidity. Loss of vision occurs in more than 10% of patients, and systemic sequelae can include meningitis, intracranial abscess, and death. Numerous organisms infect the orbit, but the most common are bacteria. There are many methods through which orbital infections occur, with infection from the neighboring ethmoid sinuses the most likely cause for all age groups. Prompt management is essential in suspected orbital cellulitis, and involves urgent intravenous antibiotics, rehydration, and treatment of any co-existent underlying systemic disease, e.g., diabetes, renal failure. This review summarizes the common infectious processes of the orbit in both pediatric and adult groups. We review pathophysiology, symptoms, signs, and treatment for infectious orbital processes.
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Affiliation(s)
- Shirin Hamed-Azzam
- Orbital Service, Moorfields Eye Hospital, London EC1V 2PD, UK
- St John Ophthalmic Association, London EC1M 6BB, UK
| | | | | | - Geoffrey E Rose
- Orbital Service, Moorfields Eye Hospital, London EC1V 2PD, UK
| | - David H. Verity
- Orbital Service, Moorfields Eye Hospital, London EC1V 2PD, UK
- St John Ophthalmic Association, London EC1M 6BB, UK
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Jabarin B, Eviatar E, Israel O, Marom T, Gavriel H. Indicators for imaging in periorbital cellulitis secondary to rhinosinusitis. Eur Arch Otorhinolaryngol 2018; 275:943-948. [PMID: 29450710 DOI: 10.1007/s00405-018-4897-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 02/01/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE Our objective was to identify the clinical indicators for subperiosteal orbital abscess (SPOA) among patients who present with periorbital cellulitis secondary to rhinosinusitis, and to evaluate the need for performing a computerized tomography (CT) scan. METHODS A retrospective cohort study of all patients admitted to our tertiary care emergency department between 2006 and 2014 was conducted. Included were healthy patients with acute periorbital cellulitis secondary to rhinosinusitis. Variables analyzed included age, gender, duration of symptoms, previous antibiotic therapy, highest recorded temperature, physical examination findings, ophthalmologist's examination results, laboratory results, and interpretation of imaging studies, when performed. RESULTS Of the 123 identified patients, 78 (63%) were males, with a mean age of 4 years (range 1-70). 68 patients were categorized as Chandler's 1 disease, 2 as Chandler's 2, and 53 as Chandler's 3. 68 patients underwent a CT scan, of those 53 had SPOA. Proptosis and ophthalmoplegia were strongly associated with the presence of an abscess (P < 0.001). However, 14 patients with no ophthalmoplegia or proptosis who underwent a CT scan were older (mean age, 10 years; P < 0.028), and had higher neutrophil count of 78 versus 59% (P = 0.01). This group of patients had a clinically rapidly progressive disease, receiving wider broad-spectrum antibiotics or had their antibiotic treatment replaced to broader spectrum antibiotics through their course of treatment (48.2% compared to only 6.1%). CONCLUSIONS We confirmed that patients with proptosis and/or limitation of extraocular movements are at high risk for developing SPOA, yet many do not have these predictors. Other features can identify patients who do not have proptosis and/or limitation of extraocular movements but do have significant risk of SPOA, and in these cases performing an imaging study is strongly suggested.
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Affiliation(s)
- Basel Jabarin
- Department of Otolaryngology-Head and Neck Surgery, Assaf Harofeh Medical Center, Tel Aviv University Sackler School of Medicine, 70300, Zerifin, Israel
| | - Ephraim Eviatar
- Department of Otolaryngology-Head and Neck Surgery, Assaf Harofeh Medical Center, Tel Aviv University Sackler School of Medicine, 70300, Zerifin, Israel
| | - Ofer Israel
- Department of Otolaryngology-Head and Neck Surgery, Assaf Harofeh Medical Center, Tel Aviv University Sackler School of Medicine, 70300, Zerifin, Israel
| | - Tal Marom
- Department of Otolaryngology-Head and Neck Surgery, Assaf Harofeh Medical Center, Tel Aviv University Sackler School of Medicine, 70300, Zerifin, Israel
| | - Haim Gavriel
- Department of Otolaryngology-Head and Neck Surgery, Assaf Harofeh Medical Center, Tel Aviv University Sackler School of Medicine, 70300, Zerifin, Israel.
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Markham JL, Hall M, Bettenhausen JL, Myers AL, Puls HT, McCulloh RJ. Variation in Care and Clinical Outcomes in Children Hospitalized With Orbital Cellulitis. Hosp Pediatr 2017; 8:28-35. [PMID: 29208694 DOI: 10.1542/hpeds.2017-0040] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To describe variation in the care of children hospitalized with orbital cellulitis and to determine associations with length of stay (LOS), emergency department (ED) revisits, and hospital readmissions. METHODS By using the Pediatric Health Information System, we performed a multicenter, retrospective study of children aged 2 months to 18 years with a primary International Classification of Diseases, Ninth Revision, Clinical Modification discharge diagnosis code for orbital cellulitis from 2007 to 2014. We assessed hospital-level variation in the use of diagnostic tests, corticosteroids, and antibiotics individually and in aggregate for association with outcomes (LOS, ED revisits, readmissions) after risk-adjusting for important clinical and demographic factors. RESULTS A total of 1828 children met inclusion criteria. Complete blood cell counts (median [interquartile range]: 81.8% [66.7-89.6]), C-reactive protein levels (57.1% [22.2-84.0]), blood cultures (57.9% [48.9-63.6]), and computed tomography imaging (74.7% [66.7-81.0]) were the most frequently performed diagnostic tests, with significant variation observed across hospitals (all P < .001). Corticosteroids were used in 29.2% of children (interquartile range: 18.4-37.5). There was significant variation in antibiotic exposure across hospitals (P < .001). Increased total diagnostic test usage was associated with increased LOS (P = .044), but not with 30-day ED revisits (P = .176) or readmissions (P = .403). CONCLUSIONS Children hospitalized with orbital cellulitis experience wide variation in clinical management. Increased hospital-level usage is associated with increased LOS. Our findings highlight a critical need to identify treatment strategies that optimize resource use and outcomes for children hospitalized with orbital cellulitis.
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Affiliation(s)
| | - Matthew Hall
- Divisions of Pediatric Hospital Medicine and.,Children's Hospital Association, Lenexa, Kansas
| | | | - Angela L Myers
- Divisions of Pediatric Hospital Medicine and.,Infectious Diseases, Children's Mercy Kansas City, Kansas City, Missouri; and
| | | | - Russell J McCulloh
- Divisions of Pediatric Hospital Medicine and.,Infectious Diseases, Children's Mercy Kansas City, Kansas City, Missouri; and
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Flam JO, Platt MP, Sobel R, Devaiah AK, Brook CD. Association of oral flora with orbital complications of acute sinusitis. Am J Rhinol Allergy 2017; 30:257-60. [PMID: 27456595 DOI: 10.2500/ajra.2016.30.4328] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Acute and chronic sinusitis in children and adults can spread to the orbit. Oral flora has been seen in orbital infections, but the extent of synergy between pathogens in such infections remains unknown. METHODS A retrospective case series of patients with complicated sinusitis that involved the orbit from acute sinusitis who were admitted to a tertiary care hospital from January 2000 to December 2014 and who had surgical cultures obtained. Patients were identified by the International Classification of Diseases, Ninth Revision code for periorbital cellulitis, subperiosteal abscess, or orbital abscess. RESULTS Sixteen patients underwent surgical drainage via external drainage or endoscopic sinus surgery of an orbital infection associated with sinusitis and had cultures obtained. Nine patients (56%) grew organisms that exist in oral flora, whereas seven patients (44%) grew common respiratory pathogens. The most common organisms recovered were viridans group streptococcus (VGS) (50%), Staphylococcus aureus (31%), Eikenella corrodens (25%), and Prevotella species (19%). Oral flora anaerobes were cultured alongside a VGS species in seven of eight patients (88%) as opposed to the respiratory pathogens, which were less frequently associated with concomitant VGS infection (29%) (p = 0.04). CONCLUSION There are two main sources for infectious orbital complications from acute sinusitis: respiratory pathogens and oral flora. The high prevalence of concurrent anaerobic oral flora and VGS infection supports a suspected synergy between VGS and other oral organisms.
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Affiliation(s)
- Juliette O Flam
- Department of Otolaryngology, Boston University School of Medicine, Boston, Massachusetts, USA
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Crosbie RA, Nairn J, Kubba H. Management of paediatric periorbital cellulitis: Our experience of 243 children managed according to a standardised protocol 2012-2015. Int J Pediatr Otorhinolaryngol 2016; 87:134-8. [PMID: 27368460 DOI: 10.1016/j.ijporl.2016.06.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 05/31/2016] [Accepted: 06/04/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Paediatric periorbital cellulitis is a common condition. Accurate assessment can be challenging and appropriate use of CT imaging is essential. We audited admissions to our unit over a four year period, with reference to CT scanning and adherence to our protocol. METHODS Retrospective audit of paediatric patients admitted with periorbital cellulitis, 2012-2015. RESULTS Total of 243 patients included, mean age 4.7 years with slight male predominance, the median length of admission was 2 days. 48/243 (20%) underwent CT during admission, 25 (52%) of these underwent surgical drainage. As per protocol, CT brain performed with all orbital scans; no positive intracranial findings on any initial scan. Three children developed intracranial complications subsequently; all treated with antibiotics. Our re-admission rate within 30 days was 2.5%. CONCLUSIONS Our audit demonstrates benefit of standardising practice and the low CT rate, with high percentage taken to theatre and no missed abscesses, supports the protocol. There may be an argument to avoid CT brain routinely in all initial imaging sequences in those children without neurological signs or symptoms.
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Affiliation(s)
- Robin A Crosbie
- Department of Otolaryngology, Royal Hospital for Children, Glasgow, Scotland.
| | | | - Haytham Kubba
- Department of Otolaryngology, Royal Hospital for Children, Glasgow, Scotland
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Orbital infections: five-year case series, literature review and guideline development. The Journal of Laryngology & Otology 2015; 129:670-6. [DOI: 10.1017/s0022215115001371] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractBackground:Periorbital infections represent a spectrum of sepsis that carries potentially significant morbidity and mortality. Early recognition, systematic assessment and aggressive treatment of the condition are essential.Methods:A retrospective five-year case note review on the management of periorbital infections was performed at a tertiary centre. A literature review on the management of periorbital infections was also undertaken. A multidisciplinary guideline on the management of periorbital infections was developed based on the findings of the case and literature reviews.Results:The results of the retrospective case series correlate well with those of recent reports.Conclusion:The new multidisciplinary guideline has been finalised and approved for practice and future auditing.
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