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

doi:10.1016/j.ijporl.2016.06.025

International Journal of Pediatric Otorhinolaryngology

Volume 87, August 2016, Pages 134-138

https://doi.org/10.1016/j.ijporl.2016.06.025 Get rights and content

Abstract

Introduction

Paediatric periorbital cellulitis is a common condition. Accurate assessment can be challenging and appropriate use of CT imaging is essential. We audited admissions to our unit over a four year period, with reference to CT scanning and adherence to our protocol.

Methods

Retrospective audit of paediatric patients admitted with periorbital cellulitis, 2012–2015.

Results

Total of 243 patients included, mean age 4.7 years with slight male predominance, the median length of admission was 2 days. 48/243 (20%) underwent CT during admission, 25 (52%) of these underwent surgical drainage. As per protocol, CT brain performed with all orbital scans; no positive intracranial findings on any initial scan. Three children developed intracranial complications subsequently; all treated with antibiotics. Our re-admission rate within 30 days was 2.5%.

Conclusions

Our audit demonstrates benefit of standardising practice and the low CT rate, with high percentage taken to theatre and no missed abscesses, supports the protocol. There may be an argument to avoid CT brain routinely in all initial imaging sequences in those children without neurological signs or symptoms.

Introduction

Periorbital cellulitis is a relatively common clinical condition encountered in the paediatric population. The potential devastating complications with regards to vision and/or intracranial extension are thankfully rare, particularly with timely antibiotic treatment. The incidence in the literature shows some variability, depending on geographic location, but admission rates have been reported 0.3–2.0 per month [1]. Characterising the infection into pre-septal or post-septal is essential in managing these children. Chandler et al. devised a scoring system which continues to form the main disease classification in current practice Worldwide [2]. The management of periorbital cellulitis involves a multidisciplinary approach, commonly ENT surgeons and Ophthalmologists, with some input from Paediatricians. There remains ambiguity in other studies, but in our tertiary referral hospital, ENT take charge of these children's care with daily input from our Ophthalmology colleagues.

Accurate assessment of the paediatric population when acutely unwell is a challenge for any healthcare professional, but orbital examination complicated by soft tissue oedema can cause the most equable clinician to become disheartened. Thus, the use of imaging as an adjunct to clinical examination is important. The most difficult decision is often whether to image these children, and this has led to the development of various guidelines [1], [3], [4], [5], [6].

It is widely accepted that radiation exposure from CT imaging of the head and neck region, especially in the paediatric population, can lead to increased risks of malignancy; leukaemia and primary brain tumours [7], [8]. There is also limited evidence suggesting a link between exposure to ionised radiation in children with neurodevelopmental disorders or delays [9], although these findings have not been supported by a recent study from Sweden [10]. Despite lack of consensus, there is ongoing concern for the developing brain exposed to ionised radiation and recent novel studies on infant mice, may have again found an association with low to moderate doses of ionised radiation and neurofunctional disorders and/or reduced cognitive capacity [11]. Obviously, further studies exploring the effect of neuroimaging on the developing brain in humans are required. It is therefore clearly important to strike the correct balance between clinical need and risk in the use of CT scans in the paediatric population.

In our hospital, we have developed a protocol for the management of periorbital cellulitis, which has evolved into the current form (Fig. 1) through multiple prospective audits and multidisciplinary revisions over the last 15 years. Initially the protocol was developed as a result of data showing that children were admitted under 6 different specialties with widely differing management protocols and occasionally poor outcomes. The main features of the protocol are to concentrate the management and decision making in the hands of one specialty team, to standardise antibiotic choice and decisions about scanning and to ensure early involvement of senior, experienced clinicians. Subsequent audits have refined the antibiotic protocol according to local microbiological sensitivities, and have confirmed widespread adherence to the protocol across the hospital. The aim of this study was to audit the admissions to a tertiary referral paediatric hospital with periorbital cellulitis over the past four years with particular reference to the appropriateness of CT scanning.

Section snippets

Methods

We retrospectively reviewed all children requiring admission to the ENT Department within Glasgow (Yorkhill Hospital until July 2015, thereafter Royal Hospital for Children) between January 2012 and January 2016. The stored electronic ward summary sheets were utilised to ensure capture of all admissions during the observation period. All electronic records were reviewed; patients' demographics, radiology, management plans and outcomes were analysed. Data were recorded and analysed using Excel

Results

A total of 243 patients were included. The mean age was 4.7 years (SD 3.9), there were 126 males and 117 females (1.1:1). The median number of patients treated per year was 59 (range, 46 to 79), shown in Fig. 2, which equates to 5 children per month. The median length of admission was 2 days (range, 0 to 32). All patients followed the protocol, in terms of decisions on medical management and investigations. All patients were given intravenous Cefotaxime (50 mg/kg every 8–12 h, max 12 mg daily)

Discussion

The data collected validates the overall design and implementation of our treatment protocol, which appears to have been successful in standardising the management of periorbital cellulitis within a busy paediatric centre. Our unit seems to have a higher than normal number of children admitted with periorbital cellulitis compared to the reported rates in the literature; 5 children per month compared to up to 2 in previous studies [1].

Of the 243 children who presented during the study period,

Conclusion

The design and structure of the protocol has allowed the care of periorbital cellulitis to be standardised throughout a large children's hospital. Our patients and their families appear to receiving appropriate investigations, being managed safely and spared anxiety of over-treatment. The protocol may be of benefit to other regional paediatric centres to assist in the coordination and delivery of care for this difficult to manage condition.

Acknowledgements

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

References (15)

M.S. Pearce et al.
Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study
Lancet
(2012)
P. Eriksson et al.
Neonatal exposure to whole body ionizing radation induces adult neurobehavioural defects: critical period, dose-response effects and strain and sex comparison
Behav. Brain. Res.
(2016)
M.S. Atfeh et al.
Orbital infections: five-year case series, literature review and guideline development
J. Laryngol. Otol.
(2015)
J.R. Chandler et al.
The pathogenesis of orbital complications in acute sinusitis
Laryngoscope
(1970)
L. Howe et al.
Guidelines for the management of periorbital cellulitis/abscess
Clin. Otolaryngol.
(2004)
J. Bedwell et al.
Management of pediatric orbital cellulitis and abscess
Curr. Op. Otolaryngol. Head. Neck. Surg.
(2011)
S.E. Sobol et al.
Orbital complications of sinusitis in children
J. Otolaryngol.
(2002)

There are more references available in the full text version of this article.

Cited by (35)

Orbital complications of sinusitis in children - Retrospective analysis of an 8.5 year experience
2024, International Journal of Pediatric Otorhinolaryngology
Orbital complications account for approximately 74–85 % of all complications of acute sinusitis, affect the pediatric population more frequently, and can have devastating consequences.
In the years following the COVID-19 pandemic (2022, 2023), a high number of children presented to our clinic with orbital complications.
1)Has there been an increase in orbital complications in the post-covid era? 2)To what extent has the use of MRI reduced radiation in pediatric patients?
In our retrospective data analysis, all pediatric patients (age 0–16 years) treated at a university ENT clinic during the period 01/2014-06/2023 who presented with an orbital complication of rhinosinusitis were included. The analysis was descriptive.
Forty-four children with orbital complications of rhinosinusitis were treated during the study period, 14 females and 30 males. Most patients (n = 23, 52 %) presented during the years of the waning Covid-19 pandemic (01/2022 to 06/2023). MRI was the initial imaging modality (n = 22,50 %); CT was performed in 17 of 44 cases (39 %) when surgery was indicated. The most common germ detected was of the Streptococcus species, and the predominant antibiotic administered was amipicillin/sulbactam.
The standard operating procedure (SOP) established at our hospital in 2014 was followed in 42/44 cases. Except for 2 cases, CT was performed exclusively when surgery was indicated. Imaging-related radiation could be avoided in 27 patients (61 %). There was a 30 % increase in orbital complications related to sinus infections postpandemically.
Factors Associated with Surgery and Imaging Characteristics in Severe Orbital Infections
2022, Journal of Pediatrics
To evaluate risk factors associated with surgical intervention and subperiosteal/orbital abscess in hospitalized children with severe orbital infections.
We conducted a multicenter cohort study of children 2 months to 18 years hospitalized with periorbital or orbital cellulitis from 2009 to 2018 at 10 hospitals in Canada. Clinical details were extracted, and patients were categorized as undergoing surgical or medical-only management. Primary outcome was surgical intervention and the main secondary outcome was clinically important imaging. Logistic regression was used to identify predictors.
Of 1579 patients entered, median age was 5.4 years, 409 (25.9%) had an orbital/subperiosteal abscess, and 189 (12.0%) underwent surgery. In the adjusted analysis, the risk of surgical intervention was associated with older age (age 9 to <14: aOR 3.9, 95% CI 2.3-6.6; and age 14 to ≤18 years: aOR 7.0, 95% CI 3.4-14.1), elevated C-reactive protein >120 mg/L (aOR 2.8, 95% CI 1.3-5.9), elevated white blood cell count of 12-20 000/μL (aOR 1.7, 95% CI 1.1-2.6), proptosis (aOR 2.6, 95% CI 1.7-4.0), and subperiosteal/orbital abscess (aOR 5.3, 95% CI 3.6-7.9). There was no association with antibiotic use before hospital admission, sex, presence of a chronic disease, temperature greater than 38.0°C, and eye swollen shut. Complications were identified in 4.7% of patients, including vision loss (0.6%), intracranial extension (1.6%), and meningitis (0.8%).
In children hospitalized with severe orbital infections, older age, elevated C-reactive protein, elevated white blood cell count, proptosis, and subperiosteal/orbital abscess were predictors of surgical intervention.
Role of systemic corticosteroids in orbital cellulitis: a meta-analysis and literature review
2022, Brazilian Journal of Otorhinolaryngology
The standard management of orbital cellulitis is to administer a combination of intravenous broad-spectrum antibiotics along with treatment of associated sinusitis.
The purpose of this study was to evaluate whether the addition of corticosteroids could lead to earlier resolution of inflammation and improve disease outcome.
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.
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.
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.
Management of periorbital cellulitis at the Pediatric Emergency Department: A ten years study
2022, Journal Francais d'Ophtalmologie
Periorbital cellulitis is a diagnostic and therapeutic emergency, jeopardizing the prognosis for vision and survival.
The goal of this study was to analyze the epidemiological and therapeutic features and outcomes of periorbital cellulitis cases treated in the pediatric emergency department.
A retrospective study including all the children aged between 1 month and 15 years treated for periorbital cellulitis in the Pediatric Emergency Department of the Mohamed VI University Teaching Hospital in Marrakech over a period of 10 years (January 1, 2010–December 31, 2019).
In all, 168 cases of periorbital cellulitis were recorded, with an increasing of the number of cases, from 2 in 2010 to 39 in 2019. The most affected age bracket was the group under 5 years of age (62.5%). The most frequent mode of entry was sinusitis (22%). Preseptal cellulitis was most common (76.7%). The main clinical signs found in orbital cellulitis were proptosis (64%) and chemosis (35.8%), versus conjunctival hyperemia (78%) in preseptal cellulitis. Ophthalmoplegia was present in two cases of orbital cellulitis. The right side was most affected (44%). An orbital CT scan was performed in all cases in our study, showing preseptal cellulitis in 129 patients (76.7%), orbital cellulitis in 14 cases (8.3%), subperiosteal abscess in 20 cases (12%) and orbital abscess in 5 cases (3%). Prior treatment with non-steroidal anti-inflammatory medication was noted in 6%. The most commonly used antibiotic was amoxicillin-clavulanic acid. Steroid treatment was prescribed in 6% of cases. Surgical treatment was indicated in 12 patients (7.1%). The mean hospital length of stay was 3 days for the preseptal cases and 8 days for the orbital cases. All patients had good outcomes with medical and/or surgical treatment. With follow-up of over one year, no complications were noted.
The majority of our cases had positive outcomes, highlighting the advantage of early diagnosis, adapted antibiotic treatment and multidisciplinary care, rendering surgery rarely necessary.
La cellulite périorbitaire constitue une urgence diagnostique et thérapeutique, mettant en jeu le pronostic fonctionnel et vital.
Étudier les aspects épidémiologiques, thérapeutiques et évolutifs des cas de cellulites périorbitaires traitées aux Urgences Pédiatriques.
Étude rétrospective incluant tous les enfants âgés de 1 mois à 15 ans traités pour cellulite périorbitaire aux Urgences Pédiatriques du CHU Mohamed VI de Marrakech, durant une période de 10 ans (1^er janvier 2010–31 décembre 2019).
Au total, 168 cas de cellulites périorbitaires ont été colligés avec une augmentation du nombre de cas de 2 en 2010 à 39 en 2019. La tranche d’âge la plus touchée était celle des moins de 5 ans (62,5 %). La porte d’entrée la plus retrouvée était sinusienne (22 %). La cellulite préseptale était la plus fréquente (76,7 %). Les principaux signes cliniques retrouvés dans la cellulite rétroseptale étaient l’exophtalmie (64 %) et le chémosis (35,8 %) versus la rougeur oculaire (78 %) dans la cellulite préseptale. Une ophtalmoplégie était présente dans deux cas de cellulite rétroseptale. Le côté droit était le plus atteint (44 %). Un scanner orbitaire a été réalisé dans tous les cas de notre étude, montrant une cellulite préseptale chez 129 patients (76,7 %), une cellulite rétroseptale dans 14 cas (8,3 %), un abcès sous-périosté dans 20 cas (12 %) et un abcès orbitaire dans 5 cas (3 %). La prise préalable d’anti-inflammatoires non stéroïdiens a été notée dans 6 %. L’antibiotique le plus utilisé était l’amoxicilline-acide clavulanique. Un traitement corticoïde a été prescrit dans 6 %. Un traitement chirurgical a été indiqué chez 12 patients (7,1 %). La durée moyenne d’hospitalisation était de 3 jours pour la forme préseptale et de 8 jours pour la forme rétroseptale. Tous nos patients ont eu une bonne évolution sous un traitement médical et/ou chirurgical. Avec un recul de plus d’un an, aucune complication n’a été notée.
La majorité de nos malades ont eu une évolution favorable mettant en évidence l’intérêt d’un diagnostic précoce, une antibiothérapie adaptée, et une prise en charge multidisciplinaire, rendant le recours à la chirurgie rarement nécessaire.
Management of post-septal complications of acute rhinosinusitis in children: A 14-year experience in a tertiary hospital
2021, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
In fact, MRSA is currently a prevalent causative organism in paediatric orbital complications of acute rhinosinusitis and should therefore be considered when prescribing the initial empirical treatment. Furthermore, 65.45% of patients did not undergo sampling for bacteriologic/mycologic cultures and even among those who did a significant proportion did not provide any identifiable results (42.11%), a common drawback in many other papers [26,49,50]. Thus, prompt initiation of an effective empirical antibiotic therapy is of paramount importance.
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.
This study aims to report the clinical presentation and management of post-septal orbital complications of acute rhinosinusitis in the paediatric population.
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).
Fifty-five children (mean age of 6.91 $\pm$ 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 $\pm$ 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).
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.
Something in your eye: Periorbital cellulitis
2021, Pediatric Imaging for the Emergency Provider
Periorbital cellulitis is often seen in pediatric patients and commonly involves infection with Staphylococcus (both methicillin-sensitive and methicillin-resistant varieties) and Streptococcus species. While the diagnosis is clinical, the examination of a pediatric patient can be difficult for many reasons, including anxiety, fear, pain, and the inability to properly examine the eye due to clinical condition. In many instances, imaging is employed to assist the clinician in determining if there is periorbital infection, if there is orbital involvement, or if there is an abscess. Intravenous contrast–enhanced orbital computed tomography is the most commonly employed imaging modality in the evaluation of these patients. Indications for obtaining this imaging test include the inability to thoroughly examine the eye, signs of systemic illness, concerns for complications (neurologic symptoms or increasing pain), or worsening clinical examination. Plain radiography does not play a role in evaluating a patient with suspected periorbital infection. Magnetic resonance imaging is used as a follow-up imaging study to computed tomography and is employed when greater anatomic detail is desired or there are suspected intracranial complications.

View all citing articles on Scopus

View full text

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

Abstract

Introduction

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Conclusion

Acknowledgements

Lancet

Behav. Brain. Res.

Orbital infections: five-year case series, literature review and guideline development

J. Laryngol. Otol.

The pathogenesis of orbital complications in acute sinusitis

Laryngoscope

Guidelines for the management of periorbital cellulitis/abscess

Clin. Otolaryngol.

Management of pediatric orbital cellulitis and abscess

Curr. Op. Otolaryngol. Head. Neck. Surg.

Orbital complications of sinusitis in children

J. Otolaryngol.