A care pathway for the optimal management of paediatric periorbital cellulitis Poster No.: C-1777 Congress: ECR 2010 Type: Topic: Scientific Exhibit Head and Neck Authors: F. Shameem, V. Malik, A. James, L. Ramamurthy, K. Ikram, N. Kay, I. Mecrow, A. H. Choudhri; Stockport/UK Keywords: DOI: paediatric orbital cellulitis, paediatric periorbital cellulitis, Care pathway 10.1594/ecr2010/C-1777 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 20
Purpose Periorbital cellulitis (POC) is relatively common in the paediatric population, and can usually be effectively treated with antibiotics. However, it can be difficult to distinguish from orbital cellulitis (OC) which is a rare but potentially sight threatening or even fatal condition. In common with many other institutions, our hospital had no unified management protocol for these patients. Referrals can be made to a number of specialities (Otorhinolaryngology, Ophthalmology and Paediatrics) each of which may have a different emphasis on clinical management, further exacerbated by differences of opinion on best treatment even by clinicians within the same department. The accuracy and extent of clinical orbital assessment varies depending on the experience and skill of the examining physician, and with their specialty. Further confusion and subsequent delay in management could also occur as definitive surgical management is carried out by referral to a tertiary centre, Manchester Royal Eye Hospital (MREH). Early identification of patients with orbital involvement is critical, as orbital cellulitis can be a rapidly progressive condition with high rates of morbidity. Computed Tomography (CT) has become the radiographic method of choice for demonstrating the extent of orbital involvement. It is essential for the Radiologist to communicate, in particular, if there is an intra-orbital collection, as these patients commonly require immediate surgical management. The purpose of the Care Pathway is to ensure a clear understanding from all staff so that appropriate management decisions are made in a timely fashion to enable an optimal outcome. Methods and Materials A series of meetings were convened between the departments of Otorhinolaryngology, Ophthalmology, Paediatrics and Radiology. Following discussions drawing on the experience of senior clinicians in each department, along with consideration of guidelines Page 2 of 20
developed in other centres and review of the published literature, a provisional Care Pathway suitable for the circumstances in our organisation was formulated in February 2009 (Fig 1, for a magnified image please click on the image in the side bar and select 'high resolution') Page 3 of 20
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Fig.: Care pathway for the management of paediatric periorbital cellulitis currently in use at Stockport NHS trust. References: A. H. Choudhri; Radiology, Stepping Hill Hospital, Stockport, UNITED KINGDOM This dictated all cases were to be initially assessed by Paediatrics, who would also subsequently co-ordinate management. Patients were divided into those safe to discharge (including simple POC), and those requiring admission, the latter receiving an urgent Ophthalmology assessment. POC can be classified as Group 1 of Chandler's original clinical classification of orbital cellulitis, comprising inflammatory oedema of the eyelid without oedema of the orbital contents. Group II is orbital cellulitis with diffuse oedema of the orbital contents but no abscess. Group III represents subperiosteal abscess, Group IV intra-orbital abscess and Group V cavernous sinus thrombosis. Patients with any of the features listed below(fig 2) were considered likely to have orbital involvement, and a high risk category for which an urgent CT examination of the orbits was justified. Diplopia Ophthalmoplegia Afferent pupillary defect Reduced visual acuity or colour vision Proptosis Systemically unwell CNS involvement CT with a thin slice (isovoxel) protocol is recommended which allows multiplanar interrogation, with intravenous contrast enhancement. For the purposes of reporting orbital CT, POC is confined to the pre-septal structures and OC is defined as involvement of structures deep to the orbital septum (Figs 3, 4 & 5). Diffuse fat infiltration is characterised by increased attenuation of the extra- and/or intraconal fat (Figs 6 & 7). A subperiosteal abscess can be diagnosed by elevation of enhancing periosteum from an orbital wall by a non enhancing collection adjacent to a paranasal sinus (Fig 8). An orbital abscess can be defined if there is an abnormal heterogenous density (with or without rim enhancement) within the orbital fat. An audit of the management of POC was carried out by reviewing the casenotes and radiology of all paediatric patients having a CT scan of the orbits in the 5 year period Page 5 of 20
between 2005 and 2009 and comparing it with optimal management as set down in the Care Pathway. Images for this section: Page 6 of 20
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Fig. 1: Care pathway for the management of paediatric periorbital cellulitis currently in use at Stockport NHS trust. Fig. 2: Table showing features suggestive of orbital involvement. Page 8 of 20
Fig. 3: Coronal section from a CT scan of the orbits. The orbital septum extends from the bony orbital rim to the tarsal plates of the upper and lower eye lids. Page 9 of 20
Fig. 4: Diagramatic representation of the orbit in the sagittal plane. The ornital septum extends from the orbital rim to tarsal plates of both eye lids. Page 10 of 20
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Fig. 5: Magnified axial CT scan of the orbits. The orbital septum is to extend from the bony orbital rim towards the globe. Fig. 6: Axial CT scan of the orbits showing Periorbital & Orbital Cellulitis of the left eye, with ipsilateral sinusitis. Page 12 of 20
Fig. 7: Axial CT scan of the orbits. There is left sided periorbital cellulitis as well as orbital cellulitis extending towards the orbital apex. Mild stranding of the intraconal fat is present(compare to right side). Ipsilateral sinusitis. Page 13 of 20
Fig. 8: Post contrast coronal CT reformat showing a left sided subperiosteal abscess and ipsilateral sinusitis. Page 14 of 20
Results 10 patients were identified in the period audited: 8 males and 2 females Average Age of 7.4 years and range of 6 months to 16 years None had optimal management as defined by the Care Pathway (Fig 1) leading to delays in treatment with potentially serious consequences. In 2 of the 3 cases where there was a delay in CT scanning, lack of ownership of patient management appeared to be the underlying problem, and in the third a lack of understanding of the role of urgent imaging by both clinicans and radiologist. Out of the 10 patients, 4 had orbital involvement and required transfer to MREH, and of these 2 were managed conservatively. The remaining 2 patients underwent drainage of orbital collections as well as sinus drainage. Both these patients had a delay in recognition of their orbital cellulitis and were left with longterm complications. Case 1; 11 year old male presented to Paediatricians in Jan 2006, generally unwell with head aches and initial junior review suspected?cluster headaches. Senior review 24-36h after admission led to CT which showed left sided POC with possible early orbital involvement. Patient not improving, developed diplopia; repeat CT requested 5 days after admission showing orbital abscess, referred urgently to MREH and had drainage same day. Prolonged Post op course; on discharge having regular review due to recurrent unexplained orbital swelling. Recurrent episode of POC at the end of 2008 treated with oral antibiotics. Case 2; 4 year old female presented to A&E in Dec 2008 Initially thought to have meningitis and worked up as such - however continued to deteriorate over next 12h. Eyes deteriorating fast but clinical assessment inconclusive as patient would not allow eye examination. Page 15 of 20
CT scan performed 24h after admission showed bilateral orbital involvement (Figs 2 & 3). Miscommunication between reporting radiologist and clinical team leads to the scan being considered inconclusive, therefore clinical decision taken to continue conservative management. Patient deteriorates further over 12 hours and subsequently transferred to MREH where left subperiosteal abscess is drained and right subperiosteal abscess is treated conservatively. Patient makes slow recovery and at discharge is felt to have permanent reduction in visual acuity to 6/12 corrected bilaterally Visual acuity spontaneously returns to normal 3 months following discharge. Since the introduction of the Care Pathway, 3 further cases have been identified, each of which had optimal management including timely Ophthalmology assessments and prompt CT scanning. Images for this section: Page 16 of 20
Fig. 1: Pie chart showing the issues identified in the pre-guideline group. Fig. 2: Case 2, labelled CT scan showing sinusitis with bilateral sub-periosteal orbital collections. Page 17 of 20
Fig. 3: Case 2: Post contrast axial CT scan Page 18 of 20
Conclusion OC is a rare condition, but often not easily differentiated from POC, potentially with very serious consequences. A multidisciplinary approach with rapid involvement of the appropriate specialties is necessary for best clinical practice, and to ensure the best possible outcome. A Care Pathway can standardise processes and aid in optimal management of the condition, particularly by acting as guidance when the presentation is out of hours when the burden of care may fall on relatively inexperienced staff. References 1. Beech T, et al. Paediatric periorbital cellulitis and its management. Rhinology. 2007; 45: 47-49. 2. Pereira FJ, et al. Computed tomographic patterns of orbital cellulitis due to sinusitis. Arq Bras Oftalmol. 2006; 69(4): 513-8. 3. Ting Liu, et al. Preseptal and orbital cellulitis: A 10-year review of hospitalized patients. J Chin Med Assoc. 2006; 69(9): 415-422. 4. Kyprianou I, et al. Referral patterns in paediatric orbital cellulitis. European Journal of Emergency Medicine. 2005; 12(1): 6-9. 5. Hopper KD, et al. CT and MR imaging of the pediatric orbit. Radiographics. 1992; 12: 485-503. 6. Barts and The London NHS Trust guidelines. http:// www.bartsandthelondon.nhs.uk/docs/peri-orbital_cellulitis_pathway.pdf 7. Nottingham University Hospitals NHS Trust guidelines. http://www.nottinghamchildhealth.org.uk/clinicalguidelines/ Infections/8.1%20Periorbital%20cellulitis%20&%20abscess.doc Page 19 of 20
Personal Information Dr. Fawad Shameem, Radiology Registrar Dr. A James, Radiology Registrar Mr. K. Ikram, Consultant Ophthalmologist Mr. V. Malik, ENT Registrar, Miss. L. Ramamurthy & Mr. N. Kay, Consultant ENT Surgeons Dr. I. Mecrow, Consultant Paediatrician Dr. Abdul H. Choudhri, Consultant Radiologist are all based at Stockport NHS Trust Poplar Grove Hazel Grove Stockport SK2 7JE United Kingdom All correspondance should be addressed to Dr. Abdul H. Choudhri. (abdul.choudhri@stockport.nhs.uk) Page 20 of 20