Orbital cellulitis in children-medical treatment versus surgical management

Pediatric preseptal and orbital cellulitis - a 6 year experience from a London tertiary centre

PURPOSE

This study reports the experience of pediatric preseptal and orbital cellulitis at a London tertiary centre during a 6-year period and highlights the role of orbital surgeons in the management of subperiosteal abscess (SPA).

METHODS

A retrospective review was conducted of all pediatric patients hospitalised for preseptal and orbital cellulitis.

RESULTS

A total of 201 children including 152 cases of preseptal cellulitis and 49 cases of orbital cellulitis were admitted at a London tertiary centre over the study period. Patients with orbital cellulitis and especially those managed surgically had higher rates of fever, higher presenting white cell count and C-reactive protein level compared to cases of preseptal cellulitis. 77.6% of patients with orbital cellulitis had SPA. 81.6% of SPA had a medial component, while 28.9% had superior component. 61.2% of orbital cellulitis cases were managed surgically. Surgical intervention was carried out by otorhinolaryngologists (ENT) in 76.7% of cases, jointly between ENT and orbital surgeons in 16.7% of cases and by orbital surgeons alone in 6.7% of cases. Of the 11 SPA involving the orbital roof, all were surgically managed and orbital surgeons were involved in 54.5% of cases. When SPA involved the medial wall, orbital surgeons were only involved in 6.5% of cases.

CONCLUSIONS

We recommend all patients with superior SPA be treated at a centre with both ENT and orbital surgeons as these may not be amenable to drainage by ENT alone.

Overwhelming orbital cellulitis in a neonate

This article discusses a rare ophthalmic manifestation of neonatal bacterial infection and its management, including surgical drainage. The case discussed is that of a neonate who presented with rapidly progressing ophthalmic symptoms suggestive of orbital cellulitis. The neonate also had extensive intracranial involvement and had spread to contiguous structures causing a temporal lobe abscess. As there was no local injury, a haematogenous spread was strongly considered. With blood culture and pus culture yielding the growth of Staphylococcus aureus, systemic antibiotics and surgical interventions were required to successfully manage the neonate. Through this case report, we emphasise that orbital infections are grave in neonates and may culminate into devastating intracranial complications; hence, it necessitates appropriate medical and surgical interventions right from hospital admission.

Surgical Approaches in Odontogenic Orbital Cellulitis (OOC): Our Experience and Review of Literature

Aims Odontogenic orbital cellulitis represents a complication of root infections of upper pre-molars and molars. The severity depends on the orbital structure involved. The treatment is based on antibiotic therapy associated or not to surgery. Through the presentation of three cases and a review of literature, we purpose as aim of our study to underline the necessity of a timely diagnosis and to provide the correct surgical approach in each different types and stages of orbital infections. Methods We present three patients that were affected by dental infection evolved in orbital cellulitis. In two cases the disease was solved with the extraction of infected tooth and a surgical endoscopic drainage of the abscess through antrostomy of maxillary sinus. In the third patient the disease had already induced a bulbar perforation and endophthalmitis, so an orbit evisceration was necessary. Results Review of literature showed that the standard treatment of orbital cellulitis is the transnasal approach associated or not by a transoral and/or transcutaneous procedure depending on the stage of the disease and on the causes. In our 3 cases these indications were followed without relapses of the disease. Conclusion An early diagnosis is mandatory in odontogenic orbital cellulitis specially to avoid serious complications. Surgical treatment can be simple and effective mostly in early-stage infection: it is based on extraction of infected tooth and on the drainage of abscess. Surgical approach consists in transnasal procedure flanked or not by transoral and transcutaneous procedures based on the stage of the infection considering involved structures.

Antibiotic Choices for Pediatric Periorbital Cellulitis—A 20-Year Retrospective Study from Taiwan

The delayed treatment of pediatric periorbital cellulitis may have severe consequences. In addition, the antibiotic efficacy against causative bacteria may change over time, and it is important to understand the appropriate antibiotic options for effective treatment in pediatric patients. We compared the changes in cultured bacteria and drug susceptibility tests between two decades, 2010–2019 and 2000–2009, to establish antibiotics for empirical use. The patient characteristics, etiologies, culture sites, and isolated bacteria, and the antibiotic susceptibility tests of the admitted pediatric patients (n = 207) diagnosed with preseptal and orbital cellulitis during 2000 to 2019, were recorded. Insect/animal bites (p = 0.084) showed an increasing trend, and sinusitis (p = 0.016) showed a significant decrease in the past decades. The most common bacteria were Staphylococcus aureus, and methicillin-resistant S. aureus (MRSA) infections increased in recent decades (p = 0.01). Moreover, we found that vancomycin was ideal for MRSA infections. The decreasing efficacy of oxacillin correlates with the increasing proportion of MRSA in pediatric periorbital cellulitis. Our study thus offers antibiotic choices against the most common isolates that can be administered before culture results are available.

Management of post-septal complications of acute rhinosinusitis in children: A 14-year experience in a tertiary hospital

INTRODUCTION

Acute rhinosinusitis accounts for most of the cases of orbital infections and is the most common cause of periorbital oedema in children. Up to 10% of patients with orbital complications of acute rhinosinusitis may experience vision loss and other complications such as meningitis, intracranial abscess or even death. Therefore, these patients require prompt diagnosis and proper treatment.

OBJECTIVES

This study aims to report the clinical presentation and management of post-septal orbital complications of acute rhinosinusitis in the paediatric population.

MATERIALS AND METHODS

A retrospective medical chart review of all children aged under 18 years old who were diagnosed with post-septal orbital complications of acute rhinosinusitis at a tertiary academic hospital, between 01/2007 and 12/2020. Patients were grouped according to the Chandler Classification (groups 2-5).

RESULTS

Fifty-five children (mean age of 6.91 ± 4.61 years) fulfilled the entry criteria for post-septal orbital complications of acute rhinosinusitis, based on clinical evaluation by an otorhinolaryngologist and CT-scan findings. Forty (72.72%) patients were also evaluated by an ophthalmologist. Most patients were male (76.36%). Twenty-four patients had post-septal cellulitis (43.63%), 21 patients had a subperiosteal abscess (38.18%) and 10 patients had an orbital abscess (18.18%). Eyelid swelling was the most frequent sign, followed by fever. Microbiology varied considerably and gram-positive agents were clearly predominant. Eighteen (32.73%) patients had been treated with oral antibiotics prior to hospital admission, exhibiting a significantly higher risk of recurrence of orbital infection (p = 0.020). Ethmoid and maxillary sinuses were the most involved paranasal sinuses (90.91%). Thirty-three patients (60%) were successfully treated medically, and 22 patients (40%) required surgical drainage. Seven patients (12.73%) developed further complications and six recovered without sequelae. The mean length of hospital stay was 8.0 ± 5.0 days and recurrence of orbital infection occurred in six patients (10.91%). The absolute neutrophil blood count was significantly different amongst Chandler groups (p = 0.021), with higher counts in patients with subperiosteal abscess. The duration of hospitalization was significantly higher in patients submitted to surgery (p < 0.001).

CONCLUSION

Post-septal orbital complications of acute rhinosinusitis are infrequent but dangerous events in the paediatric population. Close collaboration with Ophtalmology is paramount, as the child's vision is at risk. Eyelid swelling and proptosis are early signs. CT-scan imaging plays an invaluable role in the diagnosis and decision-making. Predictive indicators for surgery were not found. However, emergency endoscopic nasal surgery with abscess drainage should be considered whenever vision is at risk, if there is no improvement after aggressive medical treatment, and in cases of intracranial complications.

Surgical multidisciplinary approach of orbital complications of sinonasal inflammatory disorders

Orbital infection complicating sinonasal inflammatory disorders may lead to serious sequelae, including blindness and death, if untreated. Communication between the otorhinolaryngologist, neuroradiologist, ophtalmologist, neurosurgeon and maxillo-facial surgeon is critical and time-sensitive for a successful treatment. The large majority of pre-septal cellulitis cases resolves after broad-spectrum antibiotic therapy. Also orbital cellulitis has been found responsive to pharmacological approach in most cases. The management of the subperiosteal abscess (SPA) is more controversial. An aggressive surgical approach is always recommended also in case of cavernous sinus thrombosis. In cases of surgical indication, debate is still open on the timing and the approach (endoscopic or external). The surgeon should be prepared to convert an endoscopic approach to an external one if needed and this should be included in the informed consent. Decompression of one or more orbital walls may be necessary if orbital pressure remains elevated. Immediate surgery is indicated in children with large SPA or orbital abscesses (OA), or in immune-compromised patients. Moreover, any worsening in the ophthalmological function must be carefully considered as a landmark in candidacy to surgery.

Corticosteroids for periorbital and orbital cellulitis

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.

Role of systemic corticosteroids in orbital cellulitis: a meta-analysis and literature review

Introduction

The standard management of orbital cellulitis is to administer a combination of intravenous broad-spectrum antibiotics along with treatment of associated sinusitis.

Objective

The purpose of this study was to evaluate whether the addition of corticosteroids could lead to earlier resolution of inflammation and improve disease outcome.

Methods

We independently searched five databases (PubMed, SCOPUS, Embase, the Web of Science, and the Cochrane database) for studies published as recent as December 2019. Of the included studies, we reviewed orbital cellulitis and disease morbidity through lengths of hospitalization, incidence of surgical drainage, periorbital edema, vision, levels or C-reactive protein, and serum WBC levels in order to focus on comparing steroid with antibiotics treated group and only antibiotics treated group.

Results

Lengths of hospitalization after admission as diagnosed as orbital cellulitis (SMD = −4.02 [−7.93; −0.12], p-value = 0.04, I² = 96.9%) decrease in steroid with antibiotics treated group compared to antibiotics only treated group. Incidence of surgical drainage (OR = 0.78 [0.27; 2.23], p-value = 0.64, I² = 0.0%) was lower in the steroid with antibiotics treated group compared to the antibiotics only treated group.

Conclusion

Use of systemic steroids as an adjunct to systemic antibiotic therapy for orbital cellulitis may decrease orbital inflammation with a low risk of exacerbating infection. Based on our analysis, we concluded that early use of steroids for a short period can help shorten hospitalization days and prevent inflammation progression.

A child with refractory orbital cellulitis after water pipe smoking

Orbital cellulitis in children rarely occurs secondary to smoking water pipe. A 3-year-old girl who presented with fever, eyelid swelling, pain, and proptosis of the left eye for 4 days after water pipe consumption. The patient was given the usual course of antibiotics for a few days along with subperiosteal abscess drainage however no improvement was noticed for a week. Cultures were positive for methicillin-resistant Staphylococcus aureus and pseudomonas aeruginosa. Intravenous dexamethasone was co-administered in three courses for 3 weeks, during which residual symptoms was slowly resolving. In conclusion, attempt of dexamethasone in children can shorten hospital stay and augment full recovery.

Non-medial infectious orbital cellulitis: etiology, causative organisms, radiologic findings, management and complications

BACKGROUND

Orbital cellulitis is an ophthalmic emergency, which is associated with vision-threatening adverse effects. The purpose of this study is investigating etiology, radiologic findings, management and complications of patients with non-medial orbital cellulitis.

METHOD

A retrospective medical record and radiologic file review of patients with infectious orbital cellulitis was performed to detect all patients with non-medial orbital cellulitis who referred to Khalili hospital from 2016 to 2019. Age, sex, origin of infection, size of collection or abscess, medical or surgical management, microbiology, first and final best-corrected visual acuity, duration of admission, and complications was recorded. Patients divided into two groups; medical management and surgical management groups and all of data compared between in this groups.

RESULTS

Of ninety-six patients with infectious orbital cellulitis, 23 cases (14 male, 9 female) were included. Five patients (21.7%) were managed medically and 18 patients (78.3%) were managed surgically. Patients' age range was 5-70 years old. Most common location for non-medial cellulitis was superior space (66.7% in surgical and 40% in medical group; p = 0.511). In 13 cases of surgical group (72.3%) were detected microorganisms. The mean ± SD of collection volume in medical group were 476.5 ± 290.93 mm³ and 2572.94 ± 1075.75 mm³ in surgical group (p < 0.001). Ten patients in surgical group had compressive optic neuropathy. The mean ± SD of collection volume was 3204.97 ± 879.88 mm³ in patient with compressive optic neuropathy and 1280.43 ± 880.68 mm³ in patient without compressive optic neuropathy (P < 0.001). One case complicated by subdural empyema and another case progressed to necrotizing fasciitis.

CONCLUSION

Non-medial orbital cellulitis is an uncommon but sight-threatening and life-threatening condition. Timely diagnosis and accurate management reduce morbidity and mortality. Combined surgery for patients with superior or supra-temporal and large non-medial abscess is recommended.

Pediatric Subperiosteal Abscess Secondary to Acute Sinusitis: A Systematic Review and Meta-analysis

OBJECTIVES/HYPOTHESIS

The surgical versus medical management of subperiosteal abscess can be controversial. The purpose of this study was to summarize current literature and provide pooled analyses to help direct management decisions.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Patients <18 years old with subperiosteal abscess secondary to acute sinusitis were reviewed, and a meta-analysis was conducted. Studies including five or more patients written in English were the primary search focus.

RESULTS

Thirty-eight studies met inclusion criteria for the systematic review, and seven studies contained sufficient data for the meta-analysis. A total of 1,167 patients between the ages of 10 days and 18 years were included. Eleven sign/symptom categories were identified, with restricted ocular motility (n = 289, 45.9%), proptosis (n = 277, 44%), and fever (n = 223, 35.4%) being most frequent. Staphylococcus aureus was the most common pathogen isolated from cultures. Patients with abscess volume greater than the threshold specified in each individual study were over three times more likely to require surgical intervention compared to those with smaller abscess volume (pooled risk ratio [RR] = 3.61, 95% confidence interval [CI]: 2.40-5.44). Proptosis and gaze restriction also significantly predicted surgical intervention (pooled RR = 1.65: 95% CI: 1.29-2.12 for proptosis/pooled RR = 1.90; 95% CI: 1.20-3.00 for gaze restriction).

CONCLUSIONS

Approximately half of patients with a subperiosteal abscess undergo surgical drainage. Abscess volume appears to be the most significant predictive risk factor. Detailed data from future studies regarding radiologic and ophthalmologic parameters are needed to provide more definitive values predictive of which patients are likely to fail medical therapy.

LEVEL OF EVIDENCE

2a Laryngoscope, 2020.

Applying Pharmacodynamics and Antimicrobial Stewardship to Pediatric Preseptal and Orbital Cellulitis

Orbital and preseptal cellulitis are most commonly caused by organisms that originate in the upper respiratory tract or from the skin. There is significant variation in antibiotics used, but ampicillin-sulbactam, ceftriaxone, metronidazole, clindamycin, amoxicillin, amoxicillin-clavulanate, cefuroxime, and vancomycin are often used in the treatment of these infections. The choice of antibiotic, however, is only one consideration. It is also important that antibiotics are dosed to optimize their pharmacodynamic target attainment. Like other serious infections, therapy can be transitioned from initial intravenous therapy to an oral regimen when there are clear signs of clinical and laboratory improvement. The total duration of therapy for these infections have also been decreasing in recent years with durations of approximately 2 weeks becoming more common, even for orbital or subperiosteal infections. Antimicrobial stewardship programs can work closely with providers who manage these infections to create pathways, choose optimal antibiotics and dosage, transition from intravenous to oral therapy, and provide shortest effective durations.

Microbiology of Pediatric Orbital Cellulitis and Trends in Methicillin-Resistant Staphylococcus aureus Cases

We reviewed medical records of children with orbital cellulitis with positive cultures at a tertiary institution from 2005 to 2018 to identify microbiology trends and features associated with methicillin-resistant Staphylococcus aureus (MRSA) cases. Cultures obtained from the orbits (n = 33), sinuses (n = 31), and dural cavities (n = 4) had yields of 66.7%, 61.3%, and 75%, respectively, compared with 17.6% of blood cultures (n = 69). Fifty-five patients had positive culture results. Staphylococcus aureus was the most common pathogen isolated (n = 19), followed by Streptococcus species, most commonly Streptococcus anginosus (n = 8). The most frequently prescribed antibiotic combination regimen was ampicillin-sulbactam followed by amoxicillin-clavulanate. There were 8 cases of MRSA. MRSA was associated with an age of presentation <1 year old (P = .034). Other clinical features were similar between MRSA and non-MRSA cases. In infants and neonates, or those with epidemiologic risk factors, MRSA should also be considered.

Trend of surgery for orbital cellulitis: An analysis of state inpatient databases

OBJECTIVES/HYPOTHESIS

To evaluate the trend and factors associated with surgical management of orbital cellulitis.

STUDY DESIGN

Retrospective database study.

METHODS

Study using the State Inpatient Databases (SIDs) from 2008 to 2015. Patients with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code for orbital cellulitis were identified in the SIDs for the following states: Arkansas, Florida, Iowa, Maryland, Nebraska, New York, and Wisconsin. Surgery was defined as an ICD-9-CM procedure code for orbitotomy and/or functional endoscopic sinus surgery. The trend of surgery over time was evaluated using the Cochran-Armitage test. Multivariable logistic regression models were used to identify patient- and hospital-level factors associated with surgery.

RESULTS

From 2008 to 2013, the number of hospitalizations for orbital cellulitis ranged from 1,349 to 1,574, but declined to 865 in 2014. From 2008 to 2015, the number of surgeries ranged from 103 to 154. For children (n = 3,041), age, ophthalmologic comorbidity, and conjunctival edema were significantly associated with surgery, whereas for adults (n = 7,961), male gender, private insurance, optic neuritis, and cranial nerves III/VI/VI palsy were associated with surgery.

CONCLUSIONS

Although the number of inpatient hospitalizations for orbital cellulitis has markedly declined, the number of surgeries for orbital cellulitis has remained fairly stable, leading to an observed higher proportion of hospitalized patients undergoing surgery. Future directions include extending the time frame to the present day to assess current rates of hospitalization and surgery. Knowledge of surgical trends and patient- and hospital-level characteristics associated with surgery may help improve management guidelines for and understanding of this vision-threatening disease.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:567-574, 2020.

Pediatric preseptal and orbital cellulitis: A 10-year experience

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.

Surgical Treatment of Rhinosinusitis-Related Orbital Complications: Factors Affecting Irreversible Blindness

If left untreated, rhinosinusitis can rarely cause a devastating complication irreversible blindness (IB). Despite new technologies in endoscopic sinus surgery and use of new broad-spectrum antibiotics, IB outcome is still a problem for surgically treated orbital complication of paranasal sinus infection (OCPSI) patients, and factors leading to IB outcome are not actually known. The aim of this study was to assess the factors leading to the IB outcome for surgically treated OCPSI patients. Results of 25 surgically treated OCPSI patients in our clinic were combined with surgically treated OCPSI patients reported through the PubMed database search from the year 2007. Patients were divided into 2 groups: IB group and recovery group. Patients having at least 1 immune status-related additional risk factor (ARF) were more common in the IB group, having an at least 1 ARF had 1.683 risk value of IB outcome (RR: 1.683, P = 0.006). IB patients had statistically significant higher mean (21.87 ± 40.35, P = 0.005) time interval (days) (TI) between onset of ophthalmological symptoms and surgical intervention compared to recovery group patients (2.92 ± 2.53). ROC curve analysis for an estimation of IB outcome according to the TI value demonstrated that a cut-off value of ≥2.5 days had the ideal sensitivity (87.5%) and specificity (71.9%) that resulted in IB outcome. (80.5% power, P = 0.008) IB and recovery group patients did not differ according to orbital complication type according to Chandler's classification (P = 0.492) and white blood cell count status (P = 0.584). In conclusion, OCPSI patients with ARFs and delayed admission after onset of orbital symptoms have a higher risk of IB outcome. These patients deserve prompt evaluation and early surgical intervention to prevent blindness. With future studies, new surgical criteria, including the ARF status and onset of ophthalmological symptoms (≥2.5 days) may be added to classical surgical criteria to prevent IB for OCPSI cases.

Management of pediatric orbital cellulitis: A systematic review

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.

Management of Extraocular Infections

Extraocular infection is a frequently encountered problem in children including neonates and infants. Prompt recognition of the extraocular disease and management at first contact reduces the ocular morbidity and visual impairment. Delay in administering appropriate therapy and referral to an eye care personnel may result in blindness; sometimes bilateral, due to severe ophthalmia neonatorum. This review is mainly aimed at offering basic, brief information about common extraocular infections prevalent among infants and children living in developing countries as a ready reference to practising pediatricians and neonatologists. Through this review, the pediatricians, as the first contact may feel confident and comfortable in managing ocular infection in pediatric population particularly living in remote rural and tribal region. Literature search was made by retrieving related publications through peer reviewed journals, PUBMED and Cochrane meta-analysis.

Evaluation of patients with orbital infections

Aim

Orbital tissue infections are common infections of childhood that can lead to severe complications. Herein, we aimed to evaluate the etiologic factors, diagnosis, follow-up, and treatment procedures in pediatric patients with orbital infections.

Material and Methods

This study was performed retrospectively between January 2014 and December 2015 in Cerrahpasa Medical Faculty Pediatric Infectious Disease Unit. Patients were studied for age, ophthalmologic examination features, laboratory and radiology results, treatment modalities, and the response to these treatments.

Results

Thirty-six patients (21 males, 15 females) with an average age of 71.43±42.24 months (5-168 months) participated in the study in the two-year period. Thirty-two patients (88.9%) had preseptal cellulitis, and four (11.9%) had orbital cellulitis. All patients had eyelid hyperemia, edema, and ocular pain, with chemosis in seven and proptosis in four cases. Twenty-five patients were admitted with fever. All cases were unilateral and 44.4% occurred secondary to paranasal sinusitis. All cases were treated with intravenous cefazolin-amikacin. The mean of duration of hospitalization was 12.02±8.75 days (range, 3-28 days) and the duration of parental antibiotics was 12.83±8.18 days (range, 7-21 days). All patients recovered without any vision loss, only one patient experienced subdural empyema complicating preseptal cellulitis.

Conclusions

Most orbital tissue infections occur secondary to paranasal sinusitis in childhood. Orbital tissue infections can be complicated by brain abscess, cavernous sinus thrombophlebitis, and vision loss. Early diagnosis and proper antibiotic treatment are essential to prevent these life-threatening complications.

Adverse Events in Endoscopic Sinus Surgery for Infectious Orbital Complications of Sinusitis: 30-Day NSQIP Pediatric Outcomes

Objective Identify predictors of adverse events for children who underwent endoscopic sinus surgery for treatment of orbital complications associated with sinusitis. Study Design Cross-sectional analysis of a US national database. Setting American College of Surgeons National Surgical Quality Improvement Program (NSQIP), pediatric version (2012-2015). Subjects and Methods Patients were identified with a combination of codes from the International Classification of Diseases, Ninth Revision and 2014 Current Procedural Terminology. Our primary outcome measure was adverse events, which were compared with clinical risk factors to examine for any associations. Results A total of 57 patients were included for analysis. No significant relationship was identified between 30-day postoperative adverse events and age, sex, race, body mass index, prematurity, history of asthma, steroid use (within 30 days), and preoperative white blood cell count. There was a statistically significant increase in adverse events for those patients who underwent delayed surgery ( P < .0001). No serious adverse events related to death, sepsis, nerve injury (eg, visual loss), or other organ space infections (eg, intracranial infection) were identified. After controlling for age group and race, delayed operative intervention was a significant clinical predictor of adverse events (odds ratio = 25.65; 95% CI, 3.86-170.45; P = .0008). We observed unplanned reoperation and readmission rates of 5.3% and 7%, respectively. Conclusions Endoscopic surgical drainage for infectious orbital complications of sinusitis in children appears to be safe. Serious or significant adverse events were uncommon. Areas for improvement include limiting and reducing unplanned reoperations and readmissions.

Periorbital cellulitis in children: Analysis of outcome of intravenous antibiotic therapy

Periorbital cellulitis is a relatively common ocular disease in the pediatric population. Early diagnosis of this disease with a prompt intervention is critical to avoid vision and life-threatening complications. In the last years, medical therapy has been expanding for the treatment of orbital cellulitis, instead of the standard surgical approach. The purpose of this study was to describe the outcome of treatment with intravenous antibiotic of periorbital cellulitis in children. A retrospective review of all children admitted with periorbital cellulitis in our hospital between January 2002 and July 2013 was conducted. Cases were divided in two subgroups, pre-septal and post-septal infection. The demographics, clinical findings, treatment and outcomes were analyzed. In total 110 children were included, 93 with pre-septal and 17 with post-septal cellulitis. The mean age was 3.5 years in children with pre-septal cellulitis and 5.5 years in those with post-septal cellulitis (p = 0.149). For both subgroups the most common predisposing factor was sinusitis. Intravenous antibiotic therapy was successful in all except one patient with an orbital abscess who required surgical intervention. In our study complete recovery was achieve in all (except for one) children with periorbital cellulitis treated with intravenous antibiotics only.

Orbital Cellulitis and Subperiosteal Abscess: A 5-year Outcomes Analysis

PURPOSE

Orbital cellulitis and subperiosteal abscess (SPA) are historically associated with poor outcomes. We seek to characterize current associations with abscess formation, surgical failure and vision loss.

METHODS

All cases of orbital cellulitis presenting to an affiliated hospital between April 2008 and 2013 were critically reviewed.

RESULTS

Thirty patients met inclusion criteria. Average age was 28.7 ± 24.4. The male to female ratio was 2:1. Abscesses were identified in 56.7% of patients. Adults were less likely than children to present with abscesses (28.6% vs. 81.3%, p = 0.008). Of the other factors analyzed, only antibiotic use before admission (70.5% vs. 23.1%, p = 0.03) and maximum restriction (-2.5 ± 1.2 vs. -0.9 ± 0.7, p = 0.008) were associated with SPA. Temperature at presentation (37.9 ± 0.9 vs. 37.1 ± 0.4, p = 0.04), relative proptosis (5.8 ± 3.3 mm vs. 2.1 ± 1.1, p = 0.002) and abscess volume (4.3 ± 1.3 mm(3) vs. 0.7 ± 0.5 mm(3), p = 0.0004) were associated with progression to surgery. Reoperation was required in 26.7% of patients. Of these, two-thirds had combined superior/medial abscesses that re-accumulated after isolated endonasal surgery. Two of the 3 patients with profound vision loss had a dental etiology.

CONCLUSIONS

Only young age, prior antibiotics and degree of restriction predicted the presence of an abscess. Re-accumulation was more common than anticipated, and drainage of superior/medial abscesses by endoscopic surgery alone had the strongest association with surgical failure. Patients with odontogenic abscesses must be treated with particular caution.

Subperiosteal orbital abscess: volumetric criteria for surgical drainage

OBJECTIVE

To investigate predictive factors of surgical management of subperiosteal orbital abscess in children.

METHODS

A retrospective monocentric study was conducted between 2000 and 2011 with children hospitalized for acute pediatric orbital cellulitis (APOC). Clinical, biological and radiological data as well as medical and surgical management were collected and analyzed. All patients received intravenous antibiotics and underwent a CT-scan. Orbit and subperiosteal intraorbital abscess dimensions were measured on axial and coronal planes and the abscess volume was calculated using a spheroid model.

RESULTS

Eighty-three children with APOC (mean age: 4.5 years) were included, 53 were boys (63.9%). Thirty-two children (38.6%) presented with a subperiosteal orbital abscess. Mean abscess volume was 570mm(3) and mean exophthalmos was 4.7mm. Twenty patients were treated surgically, 11 of which by an endoscopic approach. A positive correlation was observed between the volume of the abscess or exophthalmos and surgical drainage: 57.9% of patients underwent surgery when exophthalmos was >4mm, 29.4% between 2 and 4mm, and none when <2mm. All patients with an abscess volume >500mm(3) or >5% of orbital volume were operated on whereas only 30% or 39% of patients, respectively, in case of smaller volumes (P<0.05).

CONCLUSION

Surgery for subperiosteal orbital abscess is usually performed in case of visual complications or unfavorable medical outcome. The importance of the exophthalmos and the volume of the abscess measured on the CT-scan are predictive factors of surgery in children with subperiosteal orbital abscess without visual complications.

Predicting the need for surgical intervention in pediatric orbital cellulitis

PURPOSE

To investigate the predictive value of the complete ophthalmic examination at first presentation in foreseeing the need for surgery in patients with pediatric orbital cellulitis.

DESIGN

Retrospective observational case series.

METHODS

We reviewed 136 cases of radiographically confirmed orbital cellulitis between 2004 and 2012 at Children's Hospital Colorado. The presenting ophthalmic examinations, imaging results, medical and surgical interventions, and clinical complications were recorded. The main outcome measures were ophthalmic examinations on presentation, medical or surgical interventions, and complications.

RESULTS

The median age was 6.5 years. Of the patients, 56 (41%) underwent surgical intervention, and 80 patients (59%) were managed medically. Patients requiring surgery had higher rates of extraocular motility (EOM) restriction (78.6% vs 38.8% P<0.01), proptosis (64.3% vs 21.2%, P<0.01), elevated intraocular pressure (IOP) (35.7% vs 12.5%, P<0.01), and age over 9 years (58.9% vs 20.0%, P<0.01). Using any combination of the above risk factors at presentation, the probability of surgical intervention increases from 7% (95% confidence interval [CI] 1%-13%) with zero risk factors to 95% (95% CI 89%-100%) with 4 risk factors.

CONCLUSIONS

In pediatric orbital cellulitis, the likelihood of surgical intervention can be estimated accurately based on the ophthalmic examination on initial presentation to the hospital. Risk factors for surgery include age older than 9 years, proptosis, EOM restriction, and elevated IOP. These factors may be used to identify patients at high risk for failure of medical management early in the clinical course.

Orbital cellulitis and intraconal abscess formation after strabismus surgery in an adult patient

We report a 60-year-old woman who presented with orbital cellulitis, restricted ocular motility, proptosis, and visual acuity of counting fingers in her left eye 3 days after strabismus surgery. Although she initially responded well to antibiotic and anti-inflammatory therapy, visual acuity in the left eye again decreased on postoperative day 5. Radiographic imaging revealed an intraconal orbital abscess, and she underwent left lateral orbitotomy with abscess drainage, with continued antibiotics and a tapering dose of steroids. To our knowledge, this is the first case of orbital cellulitis and intraconal abscess after strabismus surgery in an adult.

Role of oral corticosteroids in orbital cellulitis

PURPOSE

To evaluate the role of oral corticosteroids as an anti-inflammatory adjunct in the treatment of orbital cellulitis.

DESIGN

Prospective, comparative, single-masked, interventional clinical study.

METHODS

setting: Tertiary eye care center (All India Institute of Medical Sciences). study population: Patients with acute onset (within 14 days) of orbital cellulitis with or without abscess. intervention: Patients were randomized into 2 groups in the ratio of 1:2. Both groups received initial intravenous antibiotics. In Group 2, oral steroids were added after an initial response to intravenous antibiotics. main outcome measures: Resolution of signs and symptoms, duration of intravenous antibiotics, length of hospital stay, and sequelae of disease (ptosis, proptosis, and movement restriction) were evaluated and compared between the 2 groups.

RESULTS

A total of 21 patients (age range, 11-59 years) with orbital cellulitis were studied. There were 7 patients in Group 1, who received standard intravenous antibiotics, and 14 in Group 2, who received adjuvant steroids. Patients in Group 2 showed an earlier resolution of inflammation in terms of periorbital edema (P = .002 at day 7), conjunctival chemosis (P < .001 at day 10), and pain (P = .012 at day 7). They also attained vision of 0.02 on logMAR earlier than Group 1 patients. Decrease in proptosis and improvement in extraocular movements were also significantly better with the use of steroids (P = .027 at day 10, P = .003 at day 14, respectively). While a significant number of patients in Group 1 had mild residual ptosis, proptosis, and movement restriction at 12 weeks, none of the patients treated with steroids had any residual changes (P = .023, P = .001, and P = .001, respectively). The durations of intravenous antibiotics and hospital stay were significantly less in Group 2.

CONCLUSION

Use of oral steroids as an adjunct to intravenous antibiotic therapy for orbital cellulitis may hasten resolution of inflammation with a low risk of exacerbating infection.

[Endoscopic treatment of orbital cellulitis in pediatric patients: transethmoidal approach]

Orbital cellulitis is a septic process of the soft tissues behind the orbital septum and is the most frequent cause of the monolateral exophthalmos in pediatrics. Approximately 90% of the orbital cellulitis in pediatrics are associated to acute ethmoiditis. From the 01.01.2001 to 31.12.2010 we treated 36 patients, less than 18 years-old affected by Chandler stage II, III, or IV orbital cellulitis. The inflammation was resolved medically in 6 patients. In the 30 cases that showed no improvement in 48-72 h, an endoscopic drainage of the pus was performed by the transethmoidal route. In children, an adenoidectomy should be included, in order to eliminate eventual infections of this lymphatic organ. Endoscopic treatment has resulted in rapid resolution of disease without any complications. In addition, postoperative discomfort is minimal, with a rapid return to daily activities.

Presentation and management of pediatric orbital cellulitis

BACKGROUND

Orbital cellulitis is a serious, vision-threatening infection.

OBJECTIVE

To review the epidemiology and clinical data of pediatric orbital cellulitis in Manitoba.

METHODS

A 12-year retrospective review was conducted of all children (younger than 18 years of age) with orbital cellulitis admitted to Manitoba's only tertiary pediatric centre. Admission rates for orbital cellulitis were compared over three distinct time periods, based on licensure and funding levels of the heptavalent pneumococcal conjugate vaccine (PCV7) in Manitoba.

RESULTS

Thirty-eight patients with orbital cellulitis were identified. Of these, 11% were of Aboriginal ethnicity in contrast with 30% to 40% of children who were admitted for other respiratory illnesses. Subperiosteal abscesses occurred in 31.5%. Only eight patients (21%) required surgery. Follow-up imaging after presentation usually did not indicate a need for subsequent surgical drainage. The mean number of orbital cellulitis cases per 1000 admissions for the following periods - before PCV7 licensure, after licensure and before full provincial funding, and after licensure and full funding - were 0.39, 0.53 and 0.90, respectively. No significant difference was noted among any of the periods as PCV7 coverage increased.

CONCLUSIONS

The rate of subperiosteal abscesses was lower than other reports. This may be due to the median age at presentation. In contrast to admissions for most other respiratory infections at the Winnipeg Children's Hospital (Winnipeg, Manitoba), Aboriginal ethnicity was uncommon. Surprisingly, rates of admissions for orbital cellulitis appeared to show an increasing trend with increasing access to PCV7 in Manitoba, although overall the number of cases was very small. Studies into the changing microbiology of orbital cellulitis and sinusitis are warranted.