Acute Periorbital Infections: Who Needs Emergent Imaging?

Abstract

WHAT'S KNOWN ON THIS SUBJECT:Orbital infections may be difficult to distinguish from periorbital cellulitis on the basis of clinical examination. CT can be used to delineate orbital anatomy and determine if an abscess is present. WHAT THIS STUDY ADDS:We present here an algorithm to stratify patients who are at risk for subperiosteal or orbital abscess and need emergent imaging, and to identify a population of patients at low risk. abstract OBJECTIVES: Computed tomography (CT) is used often in the evaluation of orbital infections to identify children who are most likely to benefit from surgical intervention. Our objective was to identify predictors for intraorbital or intracranial abscess among children who present with signs or symptoms of periorbital infection. These predictors could be used to better target patients for emergent CT. METHODS:This was a retrospective cohort study of all patients admitted to an urban pediatric tertiary care emergency department between 1995 and 2008. We included otherwise healthy patients with suspected acute clinical periorbital or orbital cellulitis without a history of craniofacial surgery, trauma, or external source of infection. Immunocompromised patients and patients with noninfectious causes of periorbital swelling were excluded. Variables analyzed included age, duration of symptoms, highest recorded temperature, previous antibiotic therapy, physical examination findings, laboratory results, and interpretation of imaging. CT scans of the orbit were reread by a neuroradiologist. RESULTS: Nine hundred eighteen patients were included; 298 underwent a CT scan, and of those, 111 were shown to have an abscess. Although proptosis, pain with external ocular movement, and ophthalmoplegia were associated with presence of an abscess, 56 (50.5%) patients with abscess did not experience these symptoms. Other variables associated with the presence of an abscess in multivariate analysis were a peripheral blood neutrophil count greater than 10 000/ L, absence of infectious conjunctivitis, periorbital edema, age greater than 3 years, and previous antibiotic therapy (P Ͻ .05 for all). Our recursive partitioning model identified all high-risk (44%) patients as well as a low-risk (0.4%-2%) group (Rsq ϭ 0.27). CONCLUSIONS: We confirmed that patients with proptosis and/or pain or limitation of extraocular movements are at high risk for intraorbital abscess, yet many do not have these predictors.

Management of paediatric periorbital cellulitis: Our experience of 243 children managed according to a standardised protocol 2012–2015

“…Both of these papers had much smaller cohorts, 54 and 34 patients respectively, but their mean admission period was approximately 4 days in both groups. A much larger study from an Emergency department in Boston, studied 918 patients (both paediatric and adult) who attended with periorbital cellulitis over a 13 year period [13]. Of the 469 patients admitted to hospital, the median length of stay was 2.1 days, comparable to our paediatric cohort.…”

“…As mentioned earlier, children can be notoriously difficult to assess therefore we would not anticipate much higher conversion rates. Indeed, the smaller cohorts from the UK had comparable rates [1,12], but some North American studies appear to have less favorable rates; 30% and 24% respectively [13,14]. Of course, characterising children using the Chandler system is only possible following imaging; when children present initially they have an acutely swollen eye and accurate assessment can be challenging.…”

Clinical features and outcome of preseptal and orbital cellulitis in hospitalized children: Four years experience

“…But in young children it may require sedation. Guidelines from United Kingdom describe indications for radiologic imaging with CT as follows: inability to evaluate vision; ophthalmoplegia, proptosis, bilateral edema or worsening visual acuity; no improvement after 24 hours of administration of intravenous antibiotics; fever not resolved within 36 hours; or evidence of central nervous system involvement 13 .…”

Folliculitis Extending into Preseptal Cellulitis and Abscess in Children

“…They also found that abscess formation often occur after 2-40 days delay in seeking medication (mean 9.4 days) [19]. Meanwhile, Rudloe et al reported that patients presenting with ophthalmoplegia, proptosis, moderate-to-severe periorbital edema, and a peripheral blood neutrophil count > 10,000/ μL are considered high risk for developing abscess, and will mostly benefit from emergent MRI [11].…”

“…Abscess formation can be a complication of preseptal or orbital cellulitis [9]. It is an ocular emergency, as it is sight-threatening and lifethreatening as a result of serious intracranial complications [9][10][11][12]. Children are at greater risk of these complications [13].…”