Interesting Case Rounds

06.09.2007
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
mov’t
 Physical Exam
• H&N cont’d:
Normal TM’s/ Oropharynx clear/ No
Lymph N’s
• 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.
 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
What’s wrong with this?
Chandler JR et.al. The Pathogenesis of orbital complications in
acute sinusitis. Laryngoscope 1970; 80: 1414-1428
 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: 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)
 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.
Chalazia
Pre orbital cellulitis 20
to chalazion
Allergic
reaction
Herpes blepharitis
Preorbital cellulits
secondary to
dacrocystitis
 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.
 Orbital Cellulitis:
• Less common than preorbital
• Pre antibiotic era mortality 20-50%
• Mean age:
kids 3 - 14 years
adults 30
• Purported seasonality (winter months)
 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
 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
 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)
 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
 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

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
 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)
 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 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”

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”
 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  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.
 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.
 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
 CT:
Noel LP et.al. Clinical Management of Orbital Cellulitis in
Children. Canadian Journal of Ophthalmology. 1990; 25 (1): 11-
16

Most can be managed with Abx for 48h

 Requires constant monitoring of patient
 Failure of therapy buys a scan
 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)
 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
 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

 3rd 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), 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.
• David G Hunter,Michele Trucksis. Preseptal (periorbital) and orbital cellulitis
Uptodateonline.

Givner, Laurence B. M.D. Periorbital versus orbital cellulitis.

Canadian Journal of Ophthalmology. 1990 Feb;25(1):11-6.