A 7-year-old boy is brought to the emergency department by his parents due to left eye swelling and redness. The patient has had left eye pain for 2 days and the pain worsened today. He has no symptoms in his right eye. He has allergic rhinitis, for which he takes intranasal steroids. The patient developed sinusitis approximately 3 weeks ago and was treated with amoxicillin-clavulanate. He has no other medical conditions and has had no surgeries. The patient's mother was diagnosed with left leg deep vein thrombosis after a recent transatlantic flight. Temperature is 39.2 C (102.5 F), blood pressure is 102/70 mm Hg, pulse is 94/min, and respirations are 18/min. The left eyelid is erythematous, tender, and swollen. The conjunctiva is hyperemic. Movement of the left eye causes pain. Visual acuity and pupillary reaction are normal bilaterally. Purulent mucus is draining from the nose, and nasal turbinates are swollen and erythematous. Examination of the right eye is unremarkable, and facial sensation is intact. Laboratory results are as follows: Which of the following is the best next step in management of this patient?

Question

A 7-year-old boy is brought to the emergency department by his parents due to left eye swelling and redness.  The patient has had left eye pain for 2 days and the pain worsened today.  He has no symptoms in his right eye.  He has allergic rhinitis, for which he takes intranasal steroids.  The patient developed sinusitis approximately 3 weeks ago and was treated with amoxicillin-clavulanate.  He has no other medical conditions and has had no surgeries.  The patient's mother was diagnosed with left leg deep vein thrombosis after a recent transatlantic flight.  Temperature is 39.2 C (102.5 F), blood pressure is 102/70 mm Hg, pulse is 94/min, and respirations are 18/min.  The left eyelid is erythematous, tender, and swollen.  The conjunctiva is hyperemic.  Movement of the left eye causes pain.  Visual acuity and pupillary reaction are normal bilaterally.  Purulent mucus is draining from the nose, and nasal turbinates are swollen and erythematous.  Examination of the right eye is unremarkable, and facial sensation is intact. Laboratory results are as follows:  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c012_073b_8f63_c1a2719041c9_MD0005_00 The diagnosis of orbital abscess should be confirmed promptly with a CT scan of the orbits and sinuses with intravenous contrast. CT scan provides 2 primary advantages when orbital cellulitis is suspected. First, CT scan can differentiate preseptal inflammation from orbital findings, which can be difficult clinically if the eyelid is markedly swollen. Second, CT scan can identify collection(s) of purulent material, as in the image above. Focal collections of pus are consistent with orbital abscess, a serious complication of orbital cellulitis that requires surgical drainage. MRI with contrast can provide similar information if it is readily available. swollen (Choice B) Fungal pathogens such as Rhizopus can cause orbital cellulitis in patients with impaired host defenses (eg, poorly controlled diabetes mellitus, malignancy). However, fungal causes are extremely uncommon in otherwise healthy children, and even immunocompromised patients rarely have fungemia. (Choice C) Cavernous sinus thrombosis may present with oculoplegia and eye redness. However, because cranial nerves III, IV, V, and VI pass through the cavernous sinus, which has anastomoses that cross the midline, symptoms are usually bilateral and include numbness in the V1/V2 distribution in addition to ocular findings. Magnetic resonance venography is the imaging modality of choice to identify sinus venous thrombosis. This patient has unilateral symptoms and intact facial sensation, making cavernous sinus thrombosis unlikely. (Choice D) Needle aspiration of the sinuses is rarely indicated in the management of orbital cellulitis and should not be attempted without confirmation of a drainable fluid collection by CT scan. (Choice E) X-rays lack sensitivity, specificity, and resolution compared with CT scans for detecting sinusitis and orbital cellulitis. Educational objective: Patients with suspected orbital cellulitis should undergo prompt imaging of the orbits and sinuses with either CT scan or MRI with contrast to evaluate for potential complications (eg, abscess) and need for possible surgical drainage. References: Management of pediatric orbital cellulitis and abscess. (http://www.ncbi.nlm.nih.gov/pubmed/22001661)

A 7-Year-Old Boy Is Brought to the Emergency Department by His