Interesting Case Rounds

1. Interesting Case Rounds 06.09.2007 Nadim J Lalani PGY 4

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3. "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

4. Case • 23 m.o boy presented to PLC • c/o L eye swelling, erythema & pain. • Doctor?

5. 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

6. 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

7. What will you look for? • Red Flags?

8. 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 mov’t

9. Physical Exam • H&N cont’d: Normal TM’s/ Oropharynx clear/ No Lymph N’s • Rest of exam: N

10. 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.

11. Anatomy: orbital septum Extends from the periosteum. Fibrous sheath highly impermeable to infection.

12. Sinuses: • Orbit shares a common wall with three sinuses: frontal sinus ethmoidsinus maxillarysinus. • 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].

14. Classification • Classically: Five categories I Preseptal cellulitis II Orbital cellulitis III Subperiosteal abscess IV Orbital Abscess V Cavernous Sinus thrombosis What’s wrong with this? Chandler JR et.al. The Pathogenesis of orbital complications in acute sinusitis. Laryngoscope 1970; 80: 1414-1428

15. 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

16. Lawless M and F Martin. ORBITAL CELLULITIS AND PRESEPTAL CELLULITIS IN CHILDHOOD. Australian and New Zealand Journal of Ophthalmology 1986; 14: 211-219 • Chart Review of 108 cases in Sydney (preseptal  orbital abscess) • Cited predisposing factors as: • URTI (coryza, pharingitis, injected TM’s, nasal congestion) • Trauma (lacs, blunt injuries, animal bites/scratches) • Pimples, styes, chalazia • Dacrocystitis • other infections (herpes simplex/ varicella)

17. 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.

18. Chalazia

19. Pre orbital cellulitis 20 to chalazion

20. Allergic reaction

21. Herpes blepharitis

22. Preorbital cellulits secondary to dacrocystitis

23. Preorbital (preseptal) cellulitis: • Treatment: • Oral antibiotics that cover skin flora. • amoxicillin-clavulanate • first-generation cephalosporin. • 7-10 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. 2002 Jun;4(3):201-205.

24. Orbital Cellulitis: • Less common than preorbital • Pre antibiotic era mortality 20-50% • Mean age: kids 3 - 14 years adults 30 • Purported seasonality (winter months)

25. Orbital Cellulitis: • Etiology: • 60-90 % related to sinusitis (mostly Ethmoid) • Following URTI’s • Dental infections / surgery • erysipelas, impetigo, dacrocystitis • Trauma • More rarely bacteremia from endocarditis e.g

26. Clinical features: • Classically: • High fever • Orbital pain • Limited extraoccular motion • Decreased vision • Proptosis • Increased WBC/ESR. Positive Blood Culture Nelson Essentials of Pediatrics 4th Edition. Behrman RE and Kliegman RM. Eds. 2002. Wb Saunders and Co. Pennsylvania USA

27. Bergin DJ and Wright JE. Orbital Cellulitis. British Journal of Ophthalmology. 1986; 70 174-178. • 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)

28. Clinical features cont’d: Bergin DJ and Wright JE. Orbital Cellulitis. British Journal of Ophthalmology. 1986; 70 174-178. • 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

29. 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: 246-251 • 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 Mov’t, 3 had normal eye exam) • 10 in Stage III ( 2 had decreased VA, 6 proptosis, 8 also had Abn eye mov’t) • 1 in Stage IV (had abn VA, proptosis and Abn eye mov’t) • 1 in Stage V • Sinusitis in 100% • Blood cultures only positive in 1 pt

30. Towbin, R et.al. Postseptal Cellulitis: CT in Diagnosis and Management.Radiology. 1986; 158: 735-737 • 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 mov’t • 4 (33%) had diplopia • 2 (16%) had decreased VA • 2 (16%) had Chemosis

31. Hirsch M and T Lifshitz. Computerised tomography in the diagnosis and treatment of orbital cellulitis. Pediatric Radiology. 1988; 18: 302-305 • 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)

32. 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.

33. Summary cont’d: • 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”

37. If clinical exam not always reliable, What About imaging? • Plain Radiographs look for sinusitis: • Various Studies • radiography sensitivities 60 - 90% range (Spec also 60 -90% range) Bergin DJ and Wright JE. Orbital Cellulitis. British Journal of Ophthalmology. 1986; 70 174-178. “Sinus x-rays are an integral part of the evaluation of orbital disease”

39. Xray Summary • Can help in Dx, but not sensitive enough

40. 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  can’t 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. 2002 Dec;179(6):1529-34.

41. CT: • Who gets a CT? Towbin, R et.al. Postseptal Cellulitis: CT in Diagnosis and Management.Radiology. 1986; 158: 735-737 • Came up with a protocol: • Kids with CNS manifestations / “Surgery Imminent” / Dx difficulty get scanned • Everyone else gets trial Abx for 36-48 hours. • If the Abx fail to improve symptoms then the get scanned.

42. CT: Hirsch M and T Lifshitz. Computerised tomography in the diagnosis and treatment of orbital cellulitis. Pediatric Radiology. 1988; 18: 302-305 • Scan everybody so that one can stage the cellulitis • I -II can be treated conservatively • III and up go to the OR

43. CT: Noel LP et.al. Clinical Management of Orbital Cellulitis in Children. CanadianJournalofOphthalmology. 1990; 25 (1): 11-16 • Most can be managed with Abx for 48h • Requires constant monitoring of patient • Failure of therapy buys a scan

44. CT: Bergin DJ and Wright JE. Orbital Cellulitis. British Journal of Ophthalmology. 1986; 70 174-178. • 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)

45. CT: 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: 246-251 • CT for Visual Acuity decrease, proptosis, limitation of eye mov’t 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

46. 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

49. Antibiotics: • Suspected orbital cellulitis  admit the patient and begin aggressive Rx. • Empiric therapy should be directed against: Gram Positives: Streptococcus species: Streptococcus pneumoniae, Streptococcus viridansStaphylococcus aureus and epidermis Gram Negs: Moraxella catarrhalis (Haemophilus influenzae decreasing cause due to immunisations) • In adults: Also anaerobes  Bacteroides species  Veillonella parvulaPeptostreptococcus species  Fusobacterium species   • 3rd Gen Cephalosporin IV or Amoxilin/sulbactam • Course should be IV until resolution but 14 d total Sandford 2005

50. 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), 940-948 Ros SP. Herman BE. Azar-Kia B. Acute sinusitis in children: is the Water's view sufficient? Pediatric Radiology. 25(4):306-7, 1995. Jain A and PA Rubin. Orbital Cellulitis in Children. Int Ophthalmol Clin. 2001 Fall;41(4):71-86.