A 5-year-old boy is brought to the emergency department with eye pain. This morning, the boy began to have right eye pain that did not improve with ibuprofen and warm compresses. Over the last few hours, he has had blurred vision. The patient has a history of frequent otitis media, multiple dental caries, recurrent sinusitis, and atopic dermatitis. He is allergic to mosquito bites, which result in urticaria. Temperature is 39.4 C (102.9 F), blood pressure is 100/70 mm Hg, pulse is 120/min, and respirations are 20/min. The patient is cooperative but appears tired and uncomfortable. Visual acuity is 20/70 in the right eye and 20/10 in the left. Examination shows conjunctival injection, proptosis, and periorbital edema and erythema on the right. Neurologic examination reveals limited adduction of the right eye and pain with extraocular movements. Funduscopic examination is normal. The left eye is normal. There is moderate tenderness to palpation over the right cheek. Examination of the oral cavity shows a large, malodorous dental caries in the left lower second molar. The remainder of the examination is unremarkable. Which of the following predisposing factors is most likely responsible for this patient's condition?

Question

A 5-year-old boy is brought to the emergency department with eye pain.  This morning, the boy began to have right eye pain that did not improve with ibuprofen and warm compresses.  Over the last few hours, he has had blurred vision.  The patient has a history of frequent otitis media, multiple dental caries, recurrent sinusitis, and atopic dermatitis.  He is allergic to mosquito bites, which result in urticaria.  Temperature is 39.4 C (102.9 F), blood pressure is 100/70 mm Hg, pulse is 120/min, and respirations are 20/min.  The patient is cooperative but appears tired and uncomfortable.  Visual acuity is 20/70 in the right eye and 20/10 in the left.  Examination shows conjunctival injection, proptosis, and periorbital edema and erythema on the right.  Neurologic examination reveals limited adduction of the right eye and pain with extraocular movements.  Funduscopic examination is normal.  The left eye is normal.  There is moderate tenderness to palpation over the right cheek.  Examination of the oral cavity shows a large, malodorous dental caries in the left lower second molar.  The remainder of the examination is unremarkable.  Which of the following predisposing factors is most likely responsible for this patient's condition?

Quizplus · Accepted Answer

11ec25c8_d703_0946_bc81_d3714b0a9852_MD0003_00 This child has pain with eye movements, proptosis, ophthalmoplegia, and visual changes, findings consistent with orbital cellulitis. The most common risk factor for orbital cellulitis is sinusitis, particularly of the ethmoid or maxillary sinuses. Patients may have purulent rhinorrhea, fever, and facial pain, such as the right cheek tenderness in this child. The proximity of the sinuses to the orbital space allows the contiguous spread of bacteria (eg, Streptococcus species, Staphylococcus aureus) during episodes of severe sinusitis. The subsequent intraorbital infection causes inflammation of the extraocular muscles (ophthalmoplegia, painful eye movements) and orbital fat (proptosis). Patients with suspected orbital cellulitis should undergo CT scan of the orbits and sinuses to identify drainable fluid collections within the orbit (ie, orbital abscess). Intravenous antibiotic therapy is the mainstay of treatment, and purulent material in the sinuses or orbit should be drained if present. (Choices A and D) Breaks in the skin due to inflammation (eg, atopic dermatitis) or trauma (eg, insect bite) can lead to cutaneous infections, such as preseptal cellulitis. Unlike orbital cellulitis, preseptal cellulitis is an infection anterior to the orbital septum and does not present with proptosis, visual changes, or ophthalmoplegia. orbital septum (Choice C) Dental caries or abscesses, particularly in maxillary teeth (which are close to the sinuses and orbits), can predispose to orbital cellulitis. This child's abscess is in a mandibular tooth on the contralateral side of the orbital infection. In addition, sinusitis is a much more common predisposing factor for orbital cellulitis. (Choice E) Severe or untreated otitis media can progress to an invasive bacterial infection, such as mastoiditis or meningitis. The orbits are not contiguous with the middle ear, making orbital cellulitis an unlikely sequela. Moreover, this patient does not have active otitis media. Educational objective: Symptoms of orbital cellulitis include proptosis, ophthalmoplegia, and visual changes. Bacterial sinusitis is the most common predisposing factor for orbital cellulitis. References: Management of pediatric orbital cellulitis and abscess. (http://www.ncbi.nlm.nih.gov/pubmed/22001661) Periorbital and orbital cellulitis. (http://www.ncbi.nlm.nih.gov/pubmed/20516236)

A 5-Year-Old Boy Is Brought to the Emergency Department with Eye