Dora, is curious two-year-old female who presents with swelling over her left eye. Mom notes that she began rubbing her eye two days ago. Over the past 24 hours it has gotten "really puffy" and tender to touch. She seems otherwise her normal self, active and exploring the neighborhood to her heart's content. Mom also describes excessive tearing saying that "tears are constantly running down her face."
Temp: 99.9
Physical Exam: Healthy appearing 2 year old in no distress. Periorbital edema is noted and child withdraws with gentle palpation of the area. Cervical, submandibular, and preauricular lymph nodes all feel firm. She can barely open her eye. Pupils appear equal, round, and reactive. You do not appreciate proptosis and she seems to be able to track movement. Vision exam is otherwise limited.
What are you most worried about?
Would you image?
Would you start antibiotics?
If so, what?
What is the medical term for "excessive tearing"?
What former lead actor from the TV Show "Fantasy Island" made a guest voice cameo as "El Encantador" in a 2002 episode of "Dora The Explorer"?
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Weekend Update:
The single greatest challenge with this case is determining whether or not you think this is periorbital (preseptal) cellulitis or orbital cellulitis. The first is essentially a superficial infection that can be managed outpatient with oral antibiotics. The other is a deep tissue space infection located in an anatomical region fraught with complications and it requires CT scan, admission, IV antibiotics, and opthalmology consultation.
The RED FLAGS for orbital cellulitis (the bad guy): decreased eye movement, proptosis, decreased vision, and papilledema are unfortunately, all difficult to assess in this patient. However, I hinted at a couple of negative findings: vision tracking (which would suggest that extra-ocular function was maintained) and the absence of proptosis. But, admittedly this was a limited exam.
Differentiating between these two entities is difficult because both can be associated with fever (our pt had low grade temp elevation but no "fever"), pain, swollen eyelid, and red eye.
If you are worried about orbital cellulitis, CT is the test of choice. However, to make it even more challenging and confounding, CT scan can appear normal in the first 24-48 hours of orbital cellulitis infection.
According to "Pediatric Textbook of Emergency Medicine"; Haemophilus Influenza used to be a relatively common concern with potentially very serious complications related to hematogenous spread (think bad headache, fever, neck stiffness...meningitis). This fueled more aggressive usage of IV antibiotics for the treatment of peri-orbital cellulitis. That was the 80's, Ricardo Montalban was in his prime playing Mr Rourke on "Fantasy Island" (long before he was willing to accept 2-bit voice over gigs from Nickelodeon). Times have changed, or have they? Warren?
I think, in this case, I would defer the CT scan and treat with oral clindamycin, outpatient. It's a tough, uncertain call. Exam was limited and those who elect to CT and start IV antibiotics probably will sleep better, at least for the next 20-40 years until the incidence of head and neck cancers rise in patients having previously undergone pediatric head CT.
There may not be a right answer for this one. But feel free to continue the conversation.
“The scientist is not a person who gives the right answers, he's one who asks the right questions.”
― Claude Lévi-Strauss
High five!
Keep up the good work.
Ricardo Montalban, brother of Tom Waits.
ReplyDeleteCellulitis. No. Yes. Clinda. Epiphora or hyperlacrimation. Which are so awkward so as to promote a lachrymose feeling.
w
Concern is for orbital cellulitis. Clearly she has a periorbital cellulitis and should be started on IV clinda due to the increased risk of MRSA. She should have an orbital CT to assess for orbital cellulitis. Though it is stated that usually there is pain with EOM with orbital cellulitis this is not sensitive for children. I am happy to say I know nothing about Dora the Explorer and I dream to keep it that way as long as possible.
ReplyDeleteKapsner has a Dora the Explorer fanny pack.
ReplyDelete1. IV Clinda
2. CT (I think- can't remember if this is gospel)
3. Admission (I think- would call MCMC ED and speak with one of their docs for advice)
Great job Tom- keep up the good work!