Presentation on theme: "Interesting Case Rounds 06.09.2007 Nadim J Lalani PGY 4."— Presentation transcript:
Interesting Case Rounds Nadim J Lalani PGY 4
"Pinkeye" (seventh South Park episode aired October 29, 1997). Mir space station crashes into (and kills) Kenny at a bus stop October 30. Kenny is taken to morgue accidentally embalmed with fluid containing Worcestershire sauce turns Kenny into a zombie. Kenny breaks out of the morgue bites two coroners. The morgue workers on exam: –temp 55°F, pulseless, eyes are puffy and sticky. Doctor makes Dx : pinkeye. Morgue workers turn into zombies spawn a zombie epidemic Culminates in characters dancing to thriller at the end
Case 23 m.o boy presented to PLC c/o L eye swelling, erythema & pain. Doctor?
Hpi: Hx of rhinorrhea, fever and conjunctival injection and R eye swelling 6 days ago. Was rubbing eye. Saw FP 4 days ago who prescribed a topical ABx. R eye got better, but then L eye became swollen, red and tender
ROS: Fever 39.4 Mid-week. Hx finger poke to eye 1/12 ago. Nil else PmHx: normal/healthy pregnancy. Normal vag delivery. No hospitalisations. Immunisations: UTD
What will you look for? Red Flags?
Physical Exam Vitals/general appearance: 37.2, HR 110, RR 24, 98% Flushed cheeks, but looks well H&N: L eyelid swollen and somewhat tender No skin break/No proptosis/No chemosis/ No conjunctivitis Normal red reflexes/PEARL/ N eye movt
Physical Exam H&N contd: Normal TMs/ Oropharynx clear/ No Lymph Ns Rest of exam: N
Ddx? Infection –Periorbital / orbital –Conjunctivitis –herpes or varicella –Hordeolum –Chalazion –Dacrocystitis Inflammation (blepharitis) Allergies Insect Bites Trauma Other: Tumors, Posterior scleritis, Periocular dermoid cyst,Wegener's granulomatosis of the orbit, Orbital pseudotumor.Posterior scleritis Periocular dermoid cystWegener's granulomatosis of the orbitOrbital pseudotumor
Anatomy: orbital septum Extends from the periosteum. Fibrous sheath highly impermeable to infection.
Sinuses: Orbit shares a common wall with three sinuses: frontal sinus ethmoid sinus maxillary sinus. Sinuses line 2/3 of the orbit. Infections from contiguous spread. ethmoid sinus is the usual culprit. Why? –Has paper-thin wall [the lamina papyracea].
Classification Classically: Five categories I Preseptal cellulitis II Orbital cellulitis III Subperiosteal abscess IV Orbital Abscess V Cavernous Sinus thrombosis Whats wrong with this? Chandler JR et.al. The Pathogenesis of orbital complications in acute sinusitis. Laryngoscope 1970; 80:
Preorbital (preseptal) cellulitis: More common than orbital cellulitis. begins anteriorly get spread to eye lids. Etiology: Conjunctivitis Chalazion, hordeolum Allergic reaction Local infection/trauma eg insect bites, puncture wounds (cat bites e.g.) Dacryocystitis conditions such as erysipelas or impetigo. Rarely bacteremia
Lawless M and F Martin. ORBITAL CELLULITIS AND PRESEPTAL CELLULITIS IN CHILDHOOD. Australian and New Zealand Journal of Ophthalmology 1986; 14: Chart Review of 108 cases in Sydney (preseptal orbital abscess) Cited predisposing factors as: URTI (coryza, pharingitis, injected TMs, nasal congestion) Trauma (lacs, blunt injuries, animal bites/scratches) Pimples, styes, chalazia Dacrocystitis other infections (herpes simplex/ varicella)
Preorbital (preseptal) cellulitis: Clinically: no significant fever no leukocytosis symptoms are localized to the lids and conjunctiva. no pain on eye movement and vision is not impaired. there is no evidence of sinusitis on plain film or CT.
Pre orbital cellulitis 2 0 to chalazion
Preorbital cellulits secondary to dacrocystitis
Preorbital (preseptal) cellulitis: Treatment: Oral antibiotics that cover skin flora. amoxicillin-clavulanate first-generation cephalosporin days (Uptodate) Treatment failure in 24-48h warrants further w/u. Etiology, Diagnosis, and Treatment of Orbital Infections Gary Schwartz, MD Curr Infect Dis Rep Jun;4(3):
Orbital Cellulitis: Less common than preorbital Pre antibiotic era mortality 20-50% Mean age: kids years adults 30 Purported seasonality (winter months)
Orbital Cellulitis: Etiology: % related to sinusitis (mostly Ethmoid) Following URTIs Dental infections / surgery erysipelas, impetigo, dacrocystitis Trauma More rarely bacteremia from endocarditis e.g
Clinical features: Classically: High fever Orbital pain Limited extraoccular motion Decreased vision Proptosis Increased WBC/ESR. Positive Blood Culture Nelson Essentials of Pediatrics 4 th Edition. Behrman RE and Kliegman RM. Eds Wb Saunders and Co. Pennsylvania USA
Retrospective review of 49 patients with dx orbital cellulitis. Average age 30. Symptom course 28 pts (57%) less than 7 days, 1-4 weeks in 17 (34%) ALL had eyelid swelling ALL had Chemosis 45 (91%) had reduced occular movement 46 (94%) had displaced eye (proptosis vs downward vs lateral displacement) Bergin DJ and Wright JE. Orbital Cellulitis. British Journal of Ophthalmology. 1986;
Clinical features contd: Only 16 (32%) had a fever. 23 (47%) had reduced visual acuity. 9 (27%) had an increased WBC 16 (32%) had ESR > 15 mm/h 30 (61%) had AbN sinus x-ray Bergin DJ and Wright JE. Orbital Cellulitis. British Journal of Ophthalmology. 1986;
Eustis ES. et al. Staging of orbital Cellulitis in Children: Computerised Tomography Characteristics and treatment Guidelines. Journal of Pediatric Ophthalmology and Strabismus. Sept/Oct 1986, Vol 23 No 5: Retrospective review of 257 cases of periorbital and orbital (22) cellulitis at Sick Kids In Toronto Orbital clinically: 10 in Stage II (no decreased VA but 5 proptosis and 4 abn eye Movt, 3 had normal eye exam) 10 in Stage III ( 2 had decreased VA, 6 proptosis, 8 also had Abn eye movt) 1 in Stage IV (had abn VA, proptosis and Abn eye movt) 1 in Stage V Sinusitis in 100% Blood cultures only positive in 1 pt
Towbin, R et.al. Postseptal Cellulitis: CT in Diagnosis and Management. Radiology. 1986; 158: Retrospective review of 12 cases in Cincinnati 9 (75%) had proptosis on admition. The other 3 developed it later. 11 (91%) had Abn eye movement 6 (50%) had painful eye movt 4 (33%) had diplopia 2 (16%) had decreased VA 2 (16%) had Chemosis
Hirsch M and T Lifshitz. Computerised tomography in the diagnosis and treatment of orbital cellulitis. Pediatric Radiology. 1988; 18: Retrospective Review 9 cases Mean age 9 8 had proptosis 8 had partial/total opthalmoplegia or gaze defect 2 had decreased VA 2 positive cultures (staph)
Summary: Early stages pt may only present with swelling and induration confined lids It is difficult to differentiate early orbital from periorbital cellulitis. Absence of predisposing factor should raise your suspicion.
Summary contd: RED FLAGS: –Proptosis / displaced eye –extraoccular muscle restriction –pain on eye movement, –chemosis –changes in visual acuity are –[NB: likely later signs]. Tip: look for a line of demarcation
If clinical exam not always reliable, What About imaging? Plain Radiographs look for sinusitis: Various Studies radiography sensitivities % range (Spec also % range) Bergin DJ and Wright JE. Orbital Cellulitis. British Journal of Ophthalmology. 1986; Sinus x-rays are an integral part of the evaluation of orbital disease
Xray Summary Can help in Dx, but not sensitive enough
What about U/S? Retrospective review 17 patients (aged 1 to 10 years; mean age 4.5 years U/S performed either immediately or within 12 hr after admission. Orbital cellulitis excluded in 9 pts 8 patients orbital cellulitis diagnosed, –six had subperiosteal abscess –two had inflammation without abscess. Conclude: We recommend orbital sonography in every child with periorbital swelling and erythema. U/S Limitations cant image sinuses or calvarium Mair MH; Geley T; Judmaier W; Gassner I Using orbital sonography to diagnose and monitor treatment of acute swelling of the eyelids in pediatric patients. Am J Roentgenol Dec;179(6):
Who gets a CT? CT: Towbin, R et.al. Postseptal Cellulitis: CT in Diagnosis and Management. Radiology. 1986; 158: Came up with a protocol: Kids with CNS manifestations / Surgery Imminent / Dx difficulty get scanned Everyone else gets trial Abx for hours. If the Abx fail to improve symptoms then the get scanned.
CT: Hirsch M and T Lifshitz. Computerised tomography in the diagnosis and treatment of orbital cellulitis. Pediatric Radiology. 1988; 18: Scan everybody so that one can stage the cellulitis I -II can be treated conservatively III and up go to the OR
CT: Noel LP et.al. Clinical Management of Orbital Cellulitis in Children. Canadian Journal of Ophthalmology. 1990; 25 (1): Most can be managed with Abx for 48h Requires constant monitoring of patient Failure of therapy buys a scan
CT: Most can be managed with aggressive Abx Failure of therapy buys a scan (no comment on how long to trial abx) Indications for surgery are failure to improve on Abx, presence of foreign body, subperiosteal (stage III), Orbital abscess (stage IV) Bergin DJ and Wright JE. Orbital Cellulitis. British Journal of Ophthalmology. 1986;
CT: CT for Visual Acuity decrease, proptosis, limitation of eye movt or uncertain of diagnosis Failure of therapy buys a scan (no comment on how long to trial abx) Indications for surgery are stage III (and presumably stage IV and V). However mild stage III can be managed conservatively Eustis ES. et al. Staging of orbital Cellulitis in Children: Computerised Tomography Characteristics and treatment Guidelines. Journal of Pediatric Ophthalmology and Strabismus. Sept/Oct 1986, Vol 23 No 5:
CT Summary: Indications for CT scanning: Inability to accurately assess vision Gross proptosis, ophthalmoplegia, bilateral edema, or deteriorating visual acuity No improvement despite 24 hours of intravenous antibiotics Signs or symptoms of central nervous system involvement Going to OR
Antibiotics: Suspected orbital cellulitis admit the patient and begin aggressive Rx. Empiric therapy should be directed against: Gram Positives: Streptococcus species: Streptococcus pneumoniae, Streptococcus viridans Staphylococcus aureus and epidermis Gram Negs: Moraxella catarrhalis (Haemophilus influenzae decreasing cause due to immunisations) In adults: Also anaerobes Bacteroides species Veillonella parvula Peptostreptococcus species Fusobacterium species 3 rd Gen Cephalosporin IV or Amoxilin/sulbactam Course should be IV until resolution but 14 d total Sandford 2005
References: Varonen H, Makela M, Savolainen S, Laara E, Hilden J, Comparison of ultrasound, radiography, and clinical examination in the diagnosis of acute maxillary sinusitis: a systematic review. Journal of Clinical Epidemiology, 2000, 53(9), Ros SP. Herman BE. Azar-Kia B. Acute sinusitis in children: is the Water's view sufficient? Pediatric Radiology. 25(4):306- 7, Jain A and PA Rubin. Orbital Cellulitis in Children. Int Ophthalmol Clin Fall;41(4):71-86.
David G Hunter,Michele Trucksis. Preseptal (periorbital) and orbital cellulitis Uptodateonline. Givner, Laurence B. M.D. Periorbital versus orbital cellulitis. Canadian Journal of Ophthalmology Feb;25(1):11-6.