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Progressive periorbital swelling, discomfort in 3-year-old male
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A 3-year-old male presents with progressive right periorbital swelling and discomfort. The problem began with the onset of an upper respiratory infection about 5 days earlier. Within a couple of days, the swelling about the eye began, along with some subjective fever, and worsened by the day until he was taken to the ER from where he was admitted after a CT scan was done (Figures 1 and 2). The scan showed a subperiosteal abscess measuring 13 mm x 8 mm x 8 mm on the lamina papyracea, separating the right orbit from the ethmoid sinus, with opacification of all the sinuses.
In the hospital, the vital signs were normal with the eye examination being essentially normal with a normal position, extraocular muscle function and pupillary reflex. Only some periorbital soft tissue swelling and erythema was present, similar to the 6-year-old patient (Figure 3) with left-sided orbital cellulitis.
Figure 1. Initial CT scan of swelling.
Figure 2. Subperiosteal abscess measuring 13 mm x 8 mm x 8 mm on the lamina papyracea.
Source: Brien JH
Figure 3. Left-sided orbital cellulitis.
The past medical history is that of a previously healthy toddler, whose immunizations are up-to-date, and with no previous eye problem or injury. Lab results included a C-reactive protein level of 141 and a normal CBC. A nasal culture obtained by the otolaryngology resident is pending.
Empiric treatment with IV clindamycin plus vancomycin plus Rocephin (ceftriaxone, Hoffmann-La Roche) was begun pending culture results. In the meantime, his clinical course showed very slow improvement in the swelling over the next several days, and he remained afebrile. On hospital-day 4, the nasal culture was still negative for pathogens (only normal respiratory flora) and the CRP level was down to 19.
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Given the available information, C would be the best answer in this case, but other answers could be defended. However, my preference was to do both, incise and drain the abscess (B) based on its size and for a more reliable culture sample, as well as discontinuing clindamycin (C). While clindamycin has many uses these days, sole therapy as an empiric anti-staphylococcal agent in an orbital infection is probably not sufficient, as many strains of Staphylococcusaureus(both MRSA and methicillin-susceptible S. aureus) are resistant to clindamycin. Also, if the infection has the potential to extend intracranially, clindamycin does not penetrate well into the central nervous system; however, many may successfully argue that intracranial extension is very rare in medal orbital infections.
What was actually done in this case was that the clindamycin was discontinued, and the patient was treated with vancomycin and ceftriaxone for 10 days. The nasal culture eventually reported a pathogen, isolating a pan-sensitive Streptococcus pneumoniae on hospital-day 6, and he was discharged home on day 10 on high-dose Augmentin (amoxicillin/clavulanate, Dr. Reddy’s Laboratories). One could use penicillin or amoxicillin, but considering that there may have been other common sinus aerobic and anaerobic organisms that may be beta-lactamase producers involved with the infection — as they often are — and considering that the source of the culture was not optimal, a broader spectrum choice such as amoxicillin/clavulanate is reasonable.
The frequent lack of culture-directed therapy nowadays is part of the controversy. While there are numerous studies addressing the various aspects of diagnosis and management of orbital infections with abscess formation, there seems to be no evidence-based consensus on the criteria for surgical drainage of these abscesses, being more or less left to the discretion and judgment of the consulting surgeon. Most would agree that surgical drainage is indicated in cases of dysfunction of the eye, intracranial extension or associated sepsis. However, in borderline cases where the decision may rest on size alone, the criterion appears to be rather arbitrary, which most sources consider that to be an abscess of at least 1 cm in diameter. However, size alone may not be as predictive as we would like.
Figure 4. In a patient with an orbital abscess, presented in an earlier column, the size of the abscess was smaller than the one in the current case, at 1.2 cm.
Figure 5. In a patient with an orbital abscess, presented in an earlier column, the size of the abscess was smaller than the one in the current case, at 1.2 cm.
Figure 6. In a patient with an orbital abscess, presented in an earlier column, the size of the abscess was smaller than the one in the current case, at 1.2 cm.
Figure 7. Despite its smaller size, the abscess resulted in significant dysfunction.
Figure 8. Despite its smaller size, the abscess resulted in significant dysfunction.
In a patient presented in this column in April 2014 with an orbital abscess, the size of the abscess was smaller than the one in the current case, at 1.2 cm (Figures 4, 5 and 6), but resulted in significant dysfunction (Figures 7 and 8). However, that particular patient did not have associated sinus disease and was 14 years of age, which is consistent with another observation that younger patients have fewer complications with orbital infections than adults and adolescents. In that case, the source turned out to be S. aureus bacteremia, but still had a similar orbital abscess that required drainage because of symptoms with a positive culture of the abscess fluid, leading to true culture-directed therapy.
Additionally, it is commonly observed in some case series that those treated with drainage and culture-directed therapy have significantly shorter hospital stays and shorter courses of more narrow-spectrum antimicrobial therapy; 10 days vs. 3 weeks, for example, depending on the organism. However, everything I could find in my literature search, combined with that of our pediatric ENT colleagues, seems to revolve around outcomes only, with a great deal of reliance on the miracle of modern antimicrobial therapy and sometimes peripherally inserted central catheter lines. The advantage of culture-directed therapy and length of treatment time seems to play little to no role in this drainage decision-making process, and often disregards the problems of maintaining a PICC line, a practice from which we are gradually pulling back.
The patient presented here fulfilled the size criterion normally used (at least 1 cm), but because there were no other clinical concerns, decompression was not needed. However, we had to rely on a suboptimal culture that was slow to produce a result, with a longer period of very broad-spectrum therapy. Of course, in the end, this was better than no culture at all. However, with currently available sinoscopic techniques and interventional radiology capabilities, I would hope we could do better at determining the true etiology.
To be fair, our fellowship-trained sinus surgeon, who does most of the complicated pediatric cases, tells me that there is good correlation of culture results from behind the middle meatus in the nasal cavity with the organisms within the sinus, and there is evidence to that statement. However, there are two problems with this: the study is on adults with chronic sinusitis, and there were no orbital abscesses included. Therefore, we are extrapolating based on what seems to be reasonable, which does not constitute evidence. An additional problem is that the physician or surgeon obtaining the culture may not exercise the attention-to-detail as our sinus surgeon, and these are usually done after hours.
At the risk of sounding like my time has come and gone (and perhaps it has), a couple of decades ago we could count on having an organism, and since it is no secret that these patients get better sooner with drainage, the medical treatment and follow-up was fairly quick and predictable. However, I now find these cases very frustrating, because of the need for treating “in the dark,” which almost always requires broader spectrum coverage for longer periods of time, with the associated increase in drug toxicities and side effects, and a greater need for blood monitoring and possibly more unnecessary imaging, not to mention the pressure on organisms to develop resistance.
I would like to make just one more point: For reasons unknown to me, most of us are seeing more patients who fail to follow up as directed when discharged from the hospital. The patient presented showed up for one ENT clinic follow-up appointment 2 days after discharge, and has not been seen since. He failed to show for the ID clinic follow-up appointment made prior to discharge. I take that to be a sign of clinical resolution of the problem, but nonetheless risky with a sight-threatening infection close to the brain that could reoccur. This is one more reason to at least try to know the actual cause(s) and decrease the chance of relapse as much as possible. I think we can all agree that we should do what we can to protect the child from the unnecessary trauma of surgery, and certainly abscesses can be medically treated successfully, as in the patient presented; but it can also be like crossing the highway blindfolded: with a lack of attention to detail and poor follow-up, your luck could run out.
Lastly, please keep in mind that this is a column, not a peer-reviewed research paper, simply reflecting the opinion of one aging and somewhat irritable pediatrician. And my opinion is no better than anyone else’s. Please keep in touch.
- Reference:
- Ozcan M, et al. Rhinology. 2002;40:24-27.
- For more information:
- James H. Brien, DO, is with the department of infectious diseases at McLane Children’s Hospital, Baylor Scott & White Health, Texas A&M College of Medicine in Temple, Texas. He also is a member of the Infectious Diseases in Children Editorial Board. Brien can be reached at jhbrien@aol.com.
Disclosure: Brien reports no relevant financial disclosures.