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. CT scan reveals inflammation of extraocular muscles, fat stranding, and mild anterior displacement of the globe. No fluid collections are identified. 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. CT scan reveals inflammation of extraocular muscles, fat stranding, and mild anterior displacement of the globe.  No fluid collections are identified.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c012_7c6d_8f63_07a702f33949_MD0005_00 Treatment of uncomplicated orbital cellulitis includes hospital admission and administration of intravenous antibiotics. Empiric therapy should include coverage against organisms commonly implicated in sinusitis, including viridans group streptococci, Streptococcus pneumoniae, nontypeable Haemophilus influenzae, and Staphylococcus aureus. Therefore, empiric therapy generally includes a third-generation cephalosporin (eg, ceftriaxone) or ampicillin-sulbactam. For patients with a history of methicillin-resistant S aureus or whose clinical presentation is severe, vancomycin should be added. Prompt treatment is important to prevent the development of orbital abscess or intracranial extension of infection (eg, meningitis, cerebral abscess). Patients who develop orbital abscess (eg, fluid collection on CT scan) should undergo surgical drainage and have cultures obtained to help guide antibiotic therapy. This patient's CT scan does not show drainable pus; therefore, surgical debridement is not indicated (Choice E). (Choice B) Immunocompromised hosts are at high risk for serious fungal infection. Empiric antifungal therapy is not warranted in this immunocompetent patient at low risk for fungal infection. (Choice C) Intravenous heparin is included along with intravenous antibiotics in the treatment of cavernous sinus thrombosis. Because this patient has unilateral findings and normal facial sensation, cavernous sinus thrombosis is not present. (Choice D) Oral broad-spectrum antibiotic therapy is the preferred treatment for preseptal cellulitis. It is also an option for orbital cellulitis that is clearly responding to intravenous therapy. However, orbital cellulitis can lead to serious complications if not adequately treated; therefore, the initial therapy is always parenteral. Educational objective: Orbital cellulitis is treated with intravenous antibiotics. Surgical debridement is indicated when there is evidence of a drainable fluid collection such as an abscess. References: Periorbital and orbital cellulitis. (http://www.ncbi.nlm.nih.gov/pubmed/20516236)

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