809 An Unusual Presentation of Left Sided Orbital Pathology- Intraconal Abscess

Introduction

Orbital cellulitis is a severe, life-threatening infection of the orbit and its contents posterior to the septum.

Case Report

A 41-year-old admitted to hospital under ENT with complete proptosis on left eye and raising intra ocular pressure (IOP) - 26mmHg. He initially presented to Ophthalmology with worsening left eyelid swelling, pain, reduced visual acuity (VA) from 6/18 to 6/12 for the past 4 weeks. This was associated with restricted EOM, proptosis of left eye but intact colour vision and left sided headaches refractory to topical management. His ENT exam including a flexible nasoendoscopy was normal.

The CT Sinuses showed poorly enhancing retro orbital poorly enhancing mass. The differential diagnosis is wide and further assessment with MRI and tissue biopsy highly advised. He subsequently underwent MRI Head and Orbit with contrast: Appearances are suggestive of left periorbital cellulitis with an intraconal abscess.

He was started on intravenous (IV) antibiotics. His IOP had now increase to 35mmHg for which he underwent emergency lateral canthotomy and cantholysis (LCC) in clinic. This successfully reduced the IOP to 21mmHg and he subsequently had formal drainage of the abscess.

He made significant recovery and was discharged home a week after the operation. He went on to have repeat MRI- which showed almost complete resolution of the disease process. He was reviewed 4weeks postoperatively, his VA returned to 6/7.5 unaided 4 weeks but continued to have proptosis in that eye for which he is being followed up.

1384 Managing Peri-Orbital and Orbital Cellulitis: A New Multi-Specialty Care Pathway

Aim

1) To review current practice in the diagnosis and management of peri-orbital and orbital cellulitis in children at a London University Teaching Hospital. 2) To design and implement a streamlined, multi-specialty care pathway to improve the quality of care.

Background

Clinical differentiation between peri-orbital cellulitis and orbital cellulitis is often difficult, especially in young children. Early recognition and aggressive, multi-specialty treatment are required in order to prevent any vision and life-threatening sequelae.

Method

A retrospective case note analysis was performed for all paediatric patients with suspected peri-orbital or orbital cellulitis over a nineteen-month period. Extensive literature review was undertaken to ascertain current best practice in diagnosis and management. A streamlined, multi-specialty care pathway was developed, ratified by specialist departments, and introduced to optimise safety and quality of care.

Results

The results correlate with trends found in recent literature. 94.3% of patients had a blood culture taken with only 9.1% being positive. There were inadequate eye (37.1%) and endonasal (17.1%) cultures. Wide variation was noted in the criteria for imaging and in the antibiotic regimen used. 25.7% of patients received any nasal treatment. Suboptimal specialist review was identified in both orbital (60%) and peri-orbital (50.0%) cellulitis.

Conclusions

The new care pathway clearly informs investigation and empiric treatment based on initial risk stratification. The paediatric team is now the main, named care provider responsible for coordinating specialist input.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

The Kenya orthopaedic project: surgical outcomes of a travelling multidisciplinary team

We report the results of six trauma and orthopaedic projects to Kenya in the last three years. The aims are to deliver both a trauma service and teaching within two hospitals; one a district hospital near Mount Kenya in Nanyuki, the other the largest public hospital in Kenya in Mombasa. The Kenya Orthopaedic Project team consists of a wide range of multidisciplinary professionals that allows the experience to be shared across those specialties. A follow-up clinic is held three months after each mission to review the patients. To our knowledge there are no reported outcomes in the literature for similar projects. A total of 211 operations have been performed and 400 patients seen during the projects. Most cases were fractures of the lower limb; we have been able to follow up 163 patients (77%) who underwent surgical treatment. We reflect on the results so far and discuss potential improvements for future missions.

Post-traumatic left ventricular false aneurysm

Most false aneurysms of the heart represent contained ventricular free wall ruptures after myocardial infarction. Post-traumatic aneurysms also may follow penetrating or non-penetrating trauma to the chest. Regardless of the origin of the false aneurysm there is a propensity for aneurysm rupture. We report a patient who developed a false aneurysm of her left ventricle that developed post-motor vehicle accident. Her orthopedic problems were the clinical problems identified and after a hospital admission of 10 days she was discharged home. Four weeks later she died suddenly from anterior left ventricle false aneurysm rupture and tamponaide. Patients with significant chest wall trauma should be assessed for cardiac pathology prior to discharge. Presentation may be delayed and be overshadowed by more evident pathology. Trauma-related aneurysms may cause sudden death, and this may occur some later time after the trauma. Attributing the cause of death to the trauma, which may be remote, is important for the forensic investigator to remember.

Olfactory neuroblastoma metastatic to the breast

Olfactory neuroblastoma (Esthesioneuroblastoma) is a rare malignant tumour arising from olfactory epithelium. It has a predilection for cervical lymph node metastasis and also has potential for distant metastasis to unusual sites like scalp, face, aorta, spleen, liver, adrenal gland and ovary. We report here a rare case of olfactory neuroblastoma in an adolescent girl with metastatic deposits in the breast. A poor prognosis due to rapidly progressive disseminated disease was observed. The relevant literature regarding metastatic olfactory neuroblastoma and metastasis in the breast from non-mammary malignant neoplasms is reviewed.

Olfactory epileptic auras

BACKGROUND

Olfactory epileptic auras are rare, constituting about 0.9% of all auras, and are typically described as unpleasant. They have usually been associated with tumors, but in some recent studies they have not.

METHODS

We identified 13 patients (7 male, 6 female) with olfactory epileptic auras from 1423 patients with partial epilepsy evaluated for intractable seizures between 1991 and 1996. All had routine EEGs and MRI. Twelve underwent prolonged video-EEG monitoring.

RESULTS

Olfactory sensations were of various types but unpleasant in only seven. Auras evolved to complex partial seizures (automotor, hypermotor, or dialeptic seizures) in 12 patients, with further evolution to generalized tonic-clonic seizures in three and aphasic seizures in one patient. The EEG focus was localized to the mesial temporal region in all. Ten patients had a mesial temporal tumor; in one patient, it extended to the superior temporal gyrus, and in another, the frontal lobe. The tumor involved only the amygdala in two patients and both amygdala and hippocampus in six; none had hippocampal involvement alone. Surgery was performed in nine patients. All except one with partial tumor resection had a seizure-free outcome. This patient also became seizure-free after repeat surgery to remove residual tumor tissue in the amygdala.

CONCLUSIONS

Olfactory auras are not necessarily unpleasant. The amygdala is the most likely symptomatogenic zone of olfactory auras. Tumors are the commonest etiology; mesial temporal sclerosis is a relatively rare cause.

Letter: Maltese cross of surgery

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