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A 77-year-old Lithuanian man presented to our institution with recurrent episodes of periorbital cellulitis, submandibular swelling and sialadenitis. Investigations revealed a positive QuantiFERON, raised inflammatory markers and normal autoimmune screen. Cross-sectional imaging showed no signs of occult malignancy, and work-up for mycobacterial infection including imaging and bronchoalveolar lavage did not show active tuberculosis. During hospitalisation, the patient developed fevers of unknown origin, which were investigated with a positron emission tomography (PET) scan and a bone marrow aspiration, without evidence of occult infection or malignancy. Serum IgG4 level was three times the upper limit of normal. The patient responded well to oral steroids but relapsed after completing a slow taper. Serum IgG4 level was three times the upper limit of normal. He had an American College of Rheumatology/European League Against Rheumatism score of 20, in conjunction with involvement of orbital and salivary tissue. Therefore, IgG4-related disease was considered the most likely diagnosis, despite prominent fevers, which are among the exclusion criteria for this diagnosis. After a multidisciplinary review including rheumatology and ophthalmology, the patient was commenced on maintenance methotrexate with remission of symptoms.

Bilateral recurrent periorbital cellulitis is a very rare condition, with only five cases having been reported. Two cases are presented of recurrent bilateral asynchronous eyelid oedema in two paediatric patients. It was associated with respiratory infections, with no systemic disease. The patients had recurrent episodes (three times) since nine months old. They received oral and intravenous antibiotics, with a good response. There were no complications and no surgery was needed.

A case of ocular marginal zone non-Hodgkin B-cell lymphoma of mucosa-associated lymphoid tissue of the conjunctiva masquerading as chalazion is reported in a 57-year-old Chinese man, known to have diabetes mellitus. He presented with painless swelling of the lower lid and redness in the right eye for 3 months duration. A diagnosis of chalazion was made, and incision and curettage were performed by a general ophthalmologist. The swelling worsened and spread to the whole lower lid. Magnetic resonance imaging showed a lesion involving the right periorbital region limited to the anterior orbital septum that was hypointense on T1 and hyperintense on T2. A diagnosis of periorbital cellulitis with possibility of lymphoma was suggested. When he came to our eye clinic for expert opinion, his visual acuity, anterior segment and fundus were normal except early cataract changes in both eyes. There was a hard, non-tender, immobile mass within the lower eyelid associated with conjunctival injection and chemosis. Histopathology of the conjunctival biopsy showed features of low-grade non-Hodgkin B-cell lymphoma and the immunohistochemistry report was suggestive of marginal zone lymphoma. He was treated with chemotherapy (cyclophosphamide, vincristine, prednisolone) and radiotherapy, following which the swelling resolved. When patients do not respond to treatment as expected after incision and curettage of chalazion, a high index of possibility of malignancy should be kept in mind whenever a recurrence of hard swelling is observed at the same site in the eyelid. All suspicious lesions should be biopsied to find out the correct diagnosis.

Angiosarcoma is a rare form of malignant endothelial cell tumour characterised by rapidly infiltrating anaplastic cells of vascular or lymphatic origin. We report an uncommon case of cutaneous angiosarcoma (cAS) manifesting as rapidly progressive unilateral periorbital oedema. Due to the acute onset of disease, the patient was initially treated with antibiotics for presumed periorbital cellulitis. The lack of response to conservative management raised the suspicion of a more serious condition, which eventually revealed the diagnosis of angiosarcoma through skin biopsy. As suggested by several previous case reports, the subtle manifestation of cAS made it a great mimicker of benign skin conditions. This case report serves as a reminder to the aggressive nature of angiosarcoma which can lead to marked facial swelling within several weeks. As the tumour was not resectable by the time of diagnosis, the patient was offered palliative radiotherapy.

Nasal extranodal natural killer/T-cell lymphoma (ENKL) is a rare clinical entity. It may, however, masquerade as a commonly encountered disease, such as sinusitis. A high index of clinical suspicion of nasal ENKL should be raised when there is inadequate clinical response despite appropriate therapeutic intervention of sinusitis. Biopsy would be warranted and crucial in those instances to make an accurate and timely diagnosis.

Influenza may pave the way for some specific bacterial infections. In this case study we present a rare complication of influenza A infection – periorbital cellulitis followed by streptococcal toxic shock syndrome and scarlet fever. A 4-year-old otherwise healthy girl presented with her mother to a general practitioner with fatigue, irritability and fever not responding to antipyretics. Due to the positive rapid influenza diagnostic test, treatment with oseltamivir was implemented. The Quick Strep Test was negative. During the following days, the patient’s condition worsened, leading to an admission to a paediatric otolaryngology unit. Doctors observed an asymmetrical swelling of the lids with exophthalmos of the right eye, pharyngitis, petechiae in skin folds, a strawberry tongue and skin exfoliation on the lips. The patient was treated with intravenous broadspectrum antibiotics (cefotaxime, vancomycin) and underwent drainage of sinuses, without any significant improvement. On the following day, the girl showed signs of systemic infection, confusion and further swelling of both eyes, and therefore was moved to an intensive care unit. Computed tomography of the head showed signs of periorbital cellulitis with destruction of the surrounding bones. After obtaining a positive blood culture for group A streptococcus, penicillin and clindamycin were immediately administered. The patient’s condition improved within 24 hours. The described case emphasises the importance of yearly influenza vaccination, especially in the groups with risk factors like very young age. Early diagnosis of the streptococcal infection as a complication of influenza and a targeted treatment may prevent the potentially fatal outcome in the form of streptococcal toxic shock syndrome.

Aim To identify the predictors of poor outcome and need for surgical management in paediatric patients with periorbital cellulitis. To assess the adherence to local guidelines in the management of periorbital cellulitis. Methods Retrospective descriptive analysis of clinical, laboratory and radiological characteristics of 175 paediatric periorbital cellulitis presentations at a UK teaching hospital over a 10‐year period. Regression investigated correlations for continuous and categorical variables. Results A total of 175 paediatric presentations were diagnosed as periorbital infections over the 10‐year period. Of these, 139 had pre‐septal cellulitis, 27 had a subperiosteal abscess, 6 had an orbital cellulitis, 1 had an orbital abscess, 1 a cavernous sinus thrombosis and 1 an extradural abscess. Median age at presentation was 5 years (range: 1 month–17 years). In total, 169 (97%) cases received systemic antimicrobial treatment. Cross‐sectional imaging occurred in 30% of cases and 18% required surgical intervention. Increasing C‐reactive protein was associated with greater risk of post‐septal disease and requiring surgery. The best predictors of post‐septal disease in the multivariate analysis (R2 = 0.49, P = ≤0.001) were ophthalmoplegia (P = 0.009), proptosis (P = 0.016) and pain on eye movement (P = 0.046). Proptosis was the single most significant predictor of surgical management (R2 = 0.53, P =

The role of adjuvant systemic corticosteroids in the management of periorbital cellulitis and subperiosteal/orbital abscesses secondary to sinonasal infections is not well understood. Our objective was to systematically review the current evidence on the efficacy and side effects of systemic steroids when used in the management of periorbital cellulitis. A systematic review of literature was conducted in accordance with PRISMA guidance. A systematic search of MEDLINE, Embase and Cochrane databases, MetaRegister and ISI conference proceedings was conducted. The outcomes of interest were duration of inpatient stay, requirement for surgical intervention, adverse effects and recurrent/residual symptoms. Four studies were identified involving 118 patients. Of these, 78 underwent treatment with systemic corticosteroids and 40 were controls. Meta-analysis demonstrated that the mean duration of inpatient stay was significantly shorter in the steroid group (WMD − 2.90 days; 95% CI − 3.07, − 2.73; p

Objective: This study aimed to determine the most frequent clinical aspects in patients with odontogenic orbital inflammation, the computed tomography (CT) aspect, and the most appropriate treatment. Material and Methods: This is a retrospective case-series study conducted on 3 patients with ages between 16 and 55 years old, in the Ophthalmology and Oro-Maxillo-Facial Clinics of "Sf. Spiridon" Emergency Hospital, Iași, Romania. The following investigations were performed in all selected cases: visual acuity (VA), ocular motility examination, anterior segment examination at slit-lamp, fundus examination, intraoral clinical examination, sinus and orbital involvement on CT scan, pathogens involved. Results: All three patients presented swelling of the genic and periorbital regions, conjunctival chemosis, hyperemia of the conjunctiva, proptosis, pain, decreased vision and extraocular movement restriction. The CT examination identified orbital and periorbital cellulitis and ethmoidal expanded maxillary sinusitis or pansinusitis. Dental extraction, transalveolar drainage and orbital decompression were performed in all three cases. The evolution was favorable with remission of proptosis, edema of the genic and periorbital regions and conjunctival chemosis. Visual acuity remained poor in one case due to total optic nerve atrophy. Conclusions: Our study had a small number of patients, but the data was pertinent to ophthalmologists and maxillofacial surgeons who need to be aware of typical clinical features and the most common etiologies. Late treatment of dental infections can lead to severe ocular manifestations such as orbital cellulitis. Odontogenic orbital inflammation management involves a long-term and multidisciplinary approach. Abbreviations: CT = computed tomography, VA = visual acuity, CBCT = cone beam computed tomography, TED = thyroid eye disease, MRI = magnetic resonance imaging, OOC = odontogenic orbital cellulitis, RAPD = relative afferent pupillary defect.

Background Periorbital cellulitis is a potential sight-threatening complication of sinusitis. The majority of patients improve with medical management. Previous studies have suggested significant variations in practice and lack of evidence regarding the optimal management of this condition. Methods A prospective study was conducted over a 12-month period at 8 centers in the United Kingdom assessing the management of patients requiring inpatient treatment for periorbital cellulitis secondary to sinonasal infections. Results A total of 143 patients were recruited, of whom 40 were excluded. Of the remaining 103 patients, 5 (4.9%) were diagnosed with neurosurgical complications. This resulted in 98 patients admitted with periorbital cellulitis secondary to an upper respiratory tract infection/sinusitis. A total of 72 were children, of whom 12 (16.7%) required surgical intervention; and of 26 adults, 5 (19.2%) required surgery: the most common antimicrobial regimes administered were intravenous ceftriaxone (with or without metronidazole), and co-amoxiclav. The use of both ceftriaxone and metronidazole from admission was associated with the shortest duration of inpatient stay (3.8 days) in comparison to ceftriaxone alone (5.8 days) or co-amoxiclav (4.5 days) and a reduction in number of patients requiring surgical intervention. There was also an association between the early use of intranasal decongestants and steroids and reduction in requirement for surgical intervention. Conclusion For a condition where swab and blood cultures are often negative, this study supports the use of ceftriaxone in combination with metronidazole. The administration of intranasal decongestants and corticosteroids correlated with a smaller percentage of those progressing to surgery in those with and without periorbital abscesses.

Sickle cell disease is a hemoglobinopathy that results in paroxysmal vascular occlusion and tissue infarction that can manifest in a plurality of tissues. Vasoocclusive crises in sickle cell disease commonly involve bone marrow of the long bones and vertebrae. Involvement of bones with less marrow space, including the bones of the orbit, is reported rarely in the literature and can closely mimic orbital cellulitis, both clinically and radiologically. The present case is a 3 years old boy, a known case of sickle cell disease, who presented with what was thought to be orbital cellulitis and was treated accordingly. Subtle radiologic features of sickle cell orbitopathy were initially overlooked, resulting in an incorrect diagnosis and a treatment delay for the patient. Correctly treated most cases resolve with no adverse effects. This case highlights the importance of maintaining a high index of suspicion in patients with known sickle cell disease, even when the presentation is not classic.

Anushree Kucheria,1 Johan Bastianpillai,2 Shaharyar Khan,3 Vikas Acharya4 1Royal Berkshire Hospital, Royal Berkshire NHS Foundation Trust, Berkshire, UK; 2Northwick Park Hospital, London North west University Healthcare NHS Trust, London, UK; 3London North west University Healthcare NHS Trust, London, UK; 4Department of ENT Surgery, Northwick Park Hospital, London North west University Healthcare NHS Trust, London, UKCorrespondence: Anushree Kucheria Email anushreekuch@gmail.comIntroduction: General practitioners (GPs) encounter many adult and paediatric patients presenting with ear, nose and throat (ENT) complaints. There is a paucity of learning opportunities to develop knowledge and skills in ENT at undergraduate and postgraduate level. GP trainees starting an ENT rotation have very little prior experience, and therefore we recognise a need for an introduction through a focused induction programme. The aim of this study was to understand whether a GP trainee focussed induction programme can improve the confidence of these doctors in managing emergency hospital presentations in ENT.Methods: An ENT-focussed induction program was created: a didactic teaching program, shadowing period and supervised on-calls. Five GP trainees completed the induction programme. Questionnaires assessed the GP trainees’ confidence in managing common emergency presentations and performing common procedures before and after the induction program. For comparison, questionnaires were given to seven GP trainees who did not complete induction program before starting the rotation and 2 weeks subsequently.Results: With no induction in place, the mean increase in confidence was by 0.81. In comparison, the GP trainees who did complete the induction program had a mean increase in confidence by 1.2. The induction program had a dramatic increase in confidence in ENT-specific skills which would not have been experienced in other specialties such as flexible nasal endoscopy, post-tonsillectomy bleeding, neck sepsis, stridor and periorbital cellulitis.Limitations: A small cohort of participants in one hospital were included, thus affecting the reliability of the results.Conclusion: There was a greater level in confidence in managing ENT presentations of those who completed the induction program, and we recommend a similar structured programme for GP trainees who rotate in ENT. This may have wider implications in fostering interest in postgraduate degrees in ENT and improving the quality of primary care management of ENT complaints.Keywords: otolaryngology, ENT, general practitioner trainees, induction programs, confidence

We present a severe case of orbital necrotizing fasciitis that was treated utilizing negative pressure wound therapy (NPWT). The conditions caused by the disease and the utility of the treatment were discussed. Additionally, the functionality and the process of the treatment were thoroughly analyzed. Potential complications from utilizing NPWT were also identified. When the patient was tested, it was found that he had intra op cultures with group B Streptococcus pyogenes (Strep pyogenes). CT scans were also conducted to analyze his right lateral periorbital tissue. Subsequently, the patient was admitted to the ICU, where a wound vacuum-assisted closure (VAC) was placed on his right eye. Once the NPWT was complete, the patient was prescribed antibiotics and was able to improve the health within his right eye.

Periorbital cellulitis (POC) is an acute bacterial infection of the eyelids. In the past, before the introduction of Haemophilus influenzae type B vaccination, POC was usually caused by this bacterium. Vaccination was introduced in 1985 and extended in 1990. Since then, most cases are caused by Staphylococcus aureus or Group A β-hemolytic Streptococcus. We present a case of POC caused by H. influenzae in a 95-year-old woman: to our knowledge, this is the oldest patient with POC reported in the literature.

Purpose: To present a 1-year-old boy with cyclic neutropenia who presented with multiple episodes of periorbital cellulitis (POC). Methods: The child presented with three episodes of POC. In the second episode, the cellulitis was associated with nasolacrimal duct obstruction, and in the third episode, a pansinusitis was noted. He underwent a thorough systemic evaluation. Results: Patient's evaluation revealed the diagnosis of cyclic neutropenia. Conclusion: This report emphasizes the possibility of an underlying immunodeficiency with recurrent POC, even in an apparently healthy child.

Background Frontotemporal dermal sinus tracts with associated dermoid cysts are very rare, with only 1 found in the largest series to date and 10 total documented case reports. Case Description We present the first case to our knowledge of a dermal sinus tract associated with 2 intradiploic dermoid cysts in the rare location of the pterion and sphenosquamosal suture. The patient was a 15-month-old girl presenting with periorbital cellulitis who was found to have 2 connected intradiploic cysts on radiographic imaging. The mass was excised, and pathology was consistent with a ruptured dermoid cyst. Conclusions We review of the literature and argue for early identification and prophylactic surgical resection to avoid complications associated with infection and to mitigate risk of subtotal resection.

The role of corticosteroids in the management of cervicofacial infections continues to cause controversy. Systemic anti-inflammatory and immunomodulatory effects that reduce swelling and improve symptoms in the head and neck may make these agents an effective addition to the antibiotics used and to surgical management, although this same effect may dull the physiological response to infection, and allow infections to progress. We have systematically reviewed the evidence for the use of corticosteroids in common cervicofacial infections following the PRISMA guidelines. MeSH terms included "head", "neck", "infection", and "glucocorticoid". In total, 31 papers were identified. Eight reported the use of corticosteroids for peritonsillar abscess (PTA), 10 for pharyngitis, four for deep neck space infection (DNSI), four for periorbital cellulitis, and five for supraglottitis. Whilst there is an established evidence base for their use in the treatment of PTA and pharyngitis, other indications need further study, and we highlight the potential pitfalls. The evidence suggests that the use of adjunctive, short-term, high-dose corticosteroids in cervicofacial infections may be safe and effective.

Objective To evaluate whether outpatient treatment of periorbital cellulitis with daily administration of intravenous antibiotics and physician evaluation is an effective and safe alternative to admission. Design A retrospective chart review study of paediatric patients treated on an outpatient basis for periorbital cellulitis at a tertiary children's hospital between 2013 and 2015 was performed. Children were assessed day by a paediatrician to monitor for resolution of symptoms or complications. Setting The Montreal Children's hospital, a tertiary care centre. Participants Children diagnosed with an uncomplicated periorbital cellulitis secondary to an acute sinusitis or upper respiratory tract infection. Main outcome measures The number of days of intravenous antibiotics, complications or need for subsequent admission. Complications were defined as formation of an abscess or phlegmon confirmed on computerised tomography scan, worsening or recurrent persistent cellulitis, failure to improve on intravenous antibiotics, and intracranial complications. Results Sixty-six children with a diagnosis of uncomplicated periorbital cellulitis secondary to sinusitis who received intravenous antibiotics via medical day hospital and who fit the inclusion criteria were identified. The mean duration of intravenous antibiotic therapy was 4.1 days. All children received ceftriaxone, with one patient also receiving cefuroxime. Two of 66 patients developed complications; one patient required admission for failure to improve/subperiosteal phlegmon and later underwent functional endoscopic sinus surgery, and one patient developed an eyelid abscess that did not require admission. No patients developed severe neurological or visual deficits. Conclusions Outpatient intravenous therapy with daily reassessment by a physician may be a safe alternative to admission in select cases of periorbital cellulitis without systemic signs of illness.

INTRODUCTION Preseptal (periorbital) and orbital cellulitis are potentially catastrophic infections near the eye. Preseptal cellulitis is far more common, and although classically reported to be associated with dacrocystitis, sinusitis/upper respiratory infection, trauma/surgery, or infection from contiguous areas, it can also be associated with insect bites. The objective of this study was to determine the prevalence of insect bite-associated preseptal cellulitis and to compare clinical findings and outcomes of these patients with those having other causes for the condition. METHODS Retrospective chart review of children with a final discharge diagnosis of periorbital cellulitis from January 2009 to December 2014 at a tertiary care children' hospital. RESULTS 213 children were diagnosed with preseptal cellulitis during the 5-year study period, of whom 60 (28%) were associated with insect bites. Patients in the noninsect bite group more commonly had fever at presentation (P < 0.001), with increased white blood cell and C reactive protein values (both P < 0.001). No patient with insect bite-associated preseptal cellulitis presented with fever, and none underwent radiographic testing or computerized tomography; their mean age was also lower (P < 0.001) and length of stay was significantly shorter. CONCLUSIONS This study suggests that children with preseptal cellulitis associated with insect bites could be candidates for oral antibiotic therapy with outpatient follow-up by.

OBJECTIVES: Periorbital and orbital cellulitis are common but serious infections in children. Management of these infections varies because of an absence of clinical guidelines, but it is unclear if management within institutions has changed over time. We compared the management and outcomes of children hospitalized with periorbital and orbital cellulitis in 2 eras. METHODS: Data were extracted from records of children hospitalized at a tertiary care children’s hospital with periorbital or orbital cellulitis from 2000 to 2005 and 2012 to 2016. Patient demographics, cross-sectional imaging, antibiotic and corticosteroid use, length of stay, and surgical rates were collected. Data from the eras were compared by using descriptive statistics, t tests, Mann–Whitney U tests, Fisher’s exact tests, and χ2 tests. RESULTS: There were 318 children included, 143 from 2000 to 2005 and 175 from 2012 to 2016. Compared with the first era, in the second era there were increased rates of MRI (5% vs 11%, P = .04), although rates of computed tomography scan use remained unchanged (60% vs 65%); increased number (1 vs 3, P < .01) and spectrum of antibiotics; increased use of intranasal corticosteroids (3% vs 49%, P < .01); and subspecialty consultation (89% vs 99%, P = .01). There were no differences in length of stay, readmission, or surgical rates between eras. CONCLUSIONS: There has been considerable change in the management of hospitalized children with severe orbital infections at our institution, including the rates of MRI, number and spectrum of antibiotics used, use of adjunctive agents, and increased subspecialty involvement with no observed impact on clinical outcomes. Future research is needed to rationalize antimicrobial therapy and reduce low-value health care.

Background Periorbital and orbital cellulitis are infections of the tissue anterior and posterior to the orbital septum, respectively, and can be difficult to differentiate clinically. Periorbital cellulitis can also progress to become orbital cellulitis. Orbital cellulitis has a relatively high incidence in children and adults, and potentially serious consequences including vision loss, meningitis, and death. Complications occur in part due to inflammatory swelling from the infection creating a compartment syndrome within the bony orbit, leading to elevated ocular pressure and compression of vasculature and the optic nerve. Corticosteroids are used in other infections to reduce this inflammation and edema, but they can lead to immune suppression and worsening infection. Objectives To assess the effectiveness and safety of adjunctive corticosteroids for periorbital and orbital cellulitis, and to assess their effectiveness and safety in children and in adults separately. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2020, Issue 3); Ovid MEDLINE; Embase.com; PubMed; Latin American and Caribbean Health Sciences Literature Database (LILACS); ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 2 March 2020. Selection criteria We included studies of participants diagnosed with periorbital or orbital cellulitis. We excluded studies that focused exclusively on participants who were undergoing elective endoscopic surgery, including management of infections postsurgery as well as studies conducted solely on trauma patients. Randomized and quasi-randomized controlled trials were eligible for inclusion. Any study that administered corticosteroids was eligible regardless of type of steroid, route of administration, length of therapy, or timing of treatment. Comparators could include placebo, another corticosteroid, no treatment control, or another intervention. Data collection and analysis We used standard methodological procedures recommended by Cochrane. Main results The search yielded 7998 records, of which 13 were selected for full-text screening. We identified one trial for inclusion. No other eligible ongoing or completed trials were identified. The included study compared the use of corticosteroids in addition to antibiotics to the use of antibiotics alone for the treatment of orbital cellulitis. The study included a total of 21 participants aged 10 years and older, of which 14 participants were randomized to corticosteroids and antibiotics and 7 participants to antibiotics alone. Participants randomized to corticosteroids and antibiotics received adjunctive corticosteroids after initial antibiotic response (mean 5.13 days), at an initial dose of 1.5 mg/kg for three days followed by 1 mg/kg for another three days before being tapered over a one- to two-week period. We assessed the included study as having an unclear risk of bias for allocation concealment, masking (blinding), selective outcome reporting, and other sources of bias. Risk of bias from sequence generation and incomplete outcome data were low. The certainty of evidence for all outcomes was very low, downgraded for risk of bias (-1) and imprecision (-2). Length of hospital stay was compared between the group receiving antibiotics alone compared to the group receiving antibiotics and corticosteroids (mean difference (MD) 4.30, 95% confidence interval (CI) -0.48 to 9.08; 21 participants). There was no observed difference in duration of antibiotics between treatment groups (MD 3.00, 95% CI -0.48 to 6.48; 21 participants). Likewise, preservation of visual acuity at 12 weeks of follow-up between group was also assessed (RR 1.00, 95% CI 0.82 to 1.22; 21 participants). Pain scores were compared between groups on day 3 (MD -0.20, 95% CI -1.02 to 0.62; 22 eyes) along with the need for surgical intervention (RR 1.00, 95% CI 0.11 to 9.23; 21 participants). Exposure keratopathy was reported in five participants who received corticosteroids and antibiotics and three participants who received antibiotic alone (RR 1.20, 95% CI 0.40 to 3.63; 21 participants). No major complications of orbital cellulitis were seen in either the intervention or the control group. No side effects of corticosteroids were reported, although it is unclear which side effects were assessed. Authors' conclusions There is insufficient evidence to draw conclusions about the use of corticosteroids in the treatment of periorbital and orbital cellulitis. Since there is significant variation in how corticosteroids are used in clinical practice, additional high-quality evidence from randomized controlled trials is needed to inform decision making. Future studies should explore the effects of corticosteroids in children and adults separately, and evaluate different dosing and timing of corticosteroid therapy.

Nasal-type extranodal natural killer/T-cell lymphoma (ENKTCL) is a rare disease with a poor prognosis. It has features similar to other granulomatous and infectious diseases of the nose and paranasal sinuses, which can make diagnosis challenging and delayed. We present a case of 38-year-old man who was admitted to the hospital on three occasions over a 3-month period for right periorbital erythema, nasal congestion and discharge. Following two separate surgical debridement and biopsies, ENKTCL was diagnosed and the patient was commenced on chemoradiotherapy. The case highlights the atypical nature of his presentation and the high degree of suspicion for a pathological process that must be maintained to formulate the diagnosis.

Background/aimsTo understand whether the epidemiology, aetiologies, common pathogens and the antibiotic efficacy against the identified bacteria of periorbital cellulitis in adults have changed recently (2010–2019) compared with the past decade (2000–2009).MethodsAdult patients (n=224) diagnosed with preseptal cellulitis and orbital cellulitis admitted to Kaohsiung Veterans General Hospital during 2000–2019 were retrospectively reviewed. Demographic and clinical characteristics, isolated pathogens and antibiotic susceptibility tests against the commonly cultured bacteria were analysed.ResultsPreseptal cellulitis showed a tendency of female predominance. Patients in their 60s showed an incidence peak; more cases were observed during winter. The most common predisposing factor was dacryocystitis (15.5%–30.5%), followed by hordeolum (15.5%–24.8%). Aetiology of sinusitis (p=0.001) decreased and that of conjunctivitis (p=0.007) increased significantly with time. Culture results of nasopharyngeal swabs and local abscess showed higher positivity rate than conjunctival swab. The most common isolates were methicillin-susceptibleStaphylococcus aureus, methicillin-resistantS. aureus, coagulase-negative staphylococci andPseudomonas aeruginosa. Antibiotics including fluoroquinolones and vancomycin were effective; in contrast, ampicillin/sulbactam and oxacillin showed decreasing efficacy against gram-positive bacteria. For antibiotic treatment againstP. aeruginosa, fluoroquinolones, ceftazidime, piperacillin and imipenem were ideal choices.ConclusionIn isolated pathogens, the increasing trend of methicillin-resistantS. aureusdetection was compatible with reducing oxacillin efficacy against periorbital infection. In our study, the report of antibiotic efficacy against the most common identified bacteria offered empirical choices for hospitalised patients with periorbital infection before obtaining culture results.

Odontogenic infections are common and very often spread to potential spaces of head and neck. The spread of such infection to adjacent maxillary sinuses or distant sites such as the orbits are a rare occurrence and may develop periorbital and orbital cellulitis. Unfortunately once orbital cellulitis and subsequently orbital abscess develops it can give rise to serious complications such as complete blindness or even more serious and life-threatening situations as cavernous sinus thrombosis, intracranial abscess or even death. Two cases are presented to demonstrate the differences between the two conditions and the necessary management in either case. This article provides an insight into the clinical behaviour of orbital infections of odontogenic origin with contemporary diagnostic and treatment modalities that will help in reducing morbidity and mortality associated with these conditions.

Head and neck pathology in the paediatric population is distinct from the adult population, requiring a different gamut of investigations, including those pertaining to radiology and a tailored differential given the patient’s age. Assessment should consider potential congenital aetiologies as well as acquired causes for the child’s symptoms, particularly related to neck infections. Neck masses are also common in children, are often benign, and can be categorised according to the location to help narrow the differential diagnosis. Paediatric airway disorders are another frequent ENT presentation where clinical assessment often plays a greater role in diagnosis than radiological investigations.

Introduction Orbital infection is an ophthalmological emergency as it can lead to blindness and intracranial spread. Imaging is needed to determine the extent of the infection, to localize an abscess, and for surgical planning. The role of magnetic resonance imaging (MRI) is well established in the evaluation of orbital pathologies, including orbital cellulitis and abscess, mainly due to its ability to evaluate early intracranial involvement. The objective of the study was to highlight the spectrum of MR imaging findings and the pattern of spread in fifteen patients with orbital cellulitis. Methods A prospective study was conducted in a tertiary care hospital. Fifteen patients of all age groups, of either sex, presenting with clinical findings suggestive of orbital cellulitis, referred for MRI of orbits, were included in the study. Written informed consent was obtained prior to the study. Patients' demographic data such as age and gender, associated co-morbidities, complications, and the pattern of spread of disease on MRI were recorded and evaluated. Descriptive statistics were used. Results Orbital/periorbital abscess was found to be the most common complication of orbital cellulitis (eight cases, 53.3%), followed by optic neuritis/perineuritis (four cases, 26.67%), intracranial involvement (four cases, 26.67%), dacryoadenitis (three cases, 20%) and cavernous sinus thrombophlebitis (three cases, 20%). Seven cases (46.67%) had right orbital involvement. Sinusitis was found to be the most common predisposing factor. Amongst the cases associated with sinusitis, the commonest inflamed paranasal sinus was found to be the ethmoid sinus (twelve cases). Amongst the fifteen cases of orbital/periorbital cellulitis, there were only two cases of isolated preseptal cellulitis (13.33%), five cases of postseptal cellulitis (33.33%) and eight cases of both preseptal and postseptal orbital cellulitis (53.33%). Conclusion MRI is the imaging modality of choice in the evaluation of orbital cellulitis because of its superior soft tissue and contrast resolution. It is vital to evaluate the extent of the orbital infection, underlying paranasal sinus involvement, as well as detect complications of orbital cellulitis, especially intracranial spread.

This case report describes a child who developed Pott's puffy tumor and was treated at the Children's Mercy Hospital in Kansas City. In addition to a discussion of a case, a review of the literature was completed on this topic describing the typical embryology and development of the frontal sinus, and the epidemiology, diagnosis, and treatment of Pott's puffy tumor. The patient was a 23-month-old boy who developed Pott's puffy tumor after recovery from influenza. The patient presented to the hospital with progressing edema of the unilateral eye that spread bilaterally within a few days. A CT scan demonstrated pansinusitis, developed frontal sinuses, right periorbital cellulitis, and medial forehead subperiosteal abscess. Functional endoscopic sinus surgery and transcutaneous abscess drainage were urgently performed and the patient made a full recovery following a course of ertapenem and levofloxacin. The presence of a developed frontal sinus in a 23-month-old is an unexpected radiologic finding. This case represents the youngest patient reported in the literature to develop this rare complication of frontal sinusitis.

Posterior scleritis is a rare sight-threatening condition that typically presents with an acutely painful eye, often with associated reduced visual acuity. Diagnosis can be challenging and requires specialist ophthalmological assessment. Consequences of delayed treatment include permanent loss of vision. We present a case of posterior scleritis initially managed as periorbital cellulitis. We highlight the importance of broad differential diagnoses when assessing painful periorbital swelling, and present a review of current management strategies for posterior scleritis.

Pfeiffer syndrome is one of six craniosynostosis syndromes and presents with craniosynostosis (the premature fusion of one or more calvarial sutures) and skeletal abnormalities. The aetiology of Pfeiffer syndrome is thought to be caused by mutations in the fibroblast growth factor genes FGFR1 and FGFR2. The anatomical complexity of craniosynostosis syndromes means that the long-term management of patients requires a multidisciplinary team approach. Patients with craniosynostosis syndromes are predisposed to sinus infections, including sinusitis, due to structural abnormalities and iatrogenic alterations in sinus anatomy following reconstruction. In this case report, we report a 14-year-old boy with Pfeiffer syndrome who presented with periorbital cellulitis secondary to recurrent ethmoid sinusitis. To the best of our knowledge, this is the first case of ethmoid sinusitis in a patient with Pfeiffer syndrome reported in the literature.

Botox injection is increasingly performed for prevention and elimination of wrinkles. However, it is not without complications. Severe periorbital cellulitis, also known as preseptal cellulitis is among the uncommon complications of Botox injection. Herein, we report a case of preseptal cellulitis after Botox injection, which we believe is the first reported case in the literature.

Langerhans cell histiocytosis (LCH) is a rare multi-system disease. It presents infrequently as a childhood orbital tumor, and can mimic more common inflammatory orbital disease processes. We report the clinical, histopathological, and electron microscopic findings of orbital LCH in an 18-month-old child, along with a review of the recent literature regarding molecular pathogenetic analysis of LCH. The child presented with a two-week history of progressive left periorbital edema and redness. He was initially diagnosed and treated empirically for bacterial periorbital cellulitis, but subsequently underwent ophthalmological consultation after he failed to improve. Histopathological examination of an orbital biopsy specimen revealed numerous Langerhans-type cells, which stain positive for CD1A and CD207 (langerin). Electron microscopic examination demonstrated characteristic Birbeck granules within the Langerhans-type cells. Three year follow-up did not demonstrate recurrence or disease progression. Keywords: Langerhans cell histiocytosis, Langerin, Periorbital cellulitis, Birbeck granules, LCH-III protocol

Introduction Sickle cell disease (SCD) affects millions worldwide. It has a spectrum of clinical manifestations. However, SCD is more prone to have invasive infection compared with normal individual, and one of the main pathogen of concern is salmonella, where the individual with SCD is more susceptible to salmonella infection. Furthermore, several distinct clinical syndromes can develop in children infected with salmonella, depending on both host factors and the specific serotype involved Objectives We aim to describe the infection patterns and whole range of potential complications in children with SCD exposed to invasive salmonella infection. Method This is a retrospective observational cohort study which was conducted at King Fahad Medical City (KFMC), Riyadh, Saudi Arabia between 2012 and 2018. All sickle cell patients who are exposed to invasive salmonella infections and treated in our hospital over the last 6 years were included in our study. Results Six patients were enrolled in the study, five males and one female with ratio of (M: F) 5:1, age range from 20 months–14 years, and the diagnosis at admission were as follows: (three as vasooclusive crisis, three as infection) with different kind of infections (three sepsis, three septic arthritis, four osteomyelitis, one meningitis, one myositis, one periorbital cellulitis, one diskitis), where three (50%) suffered multiple sites of infections and the other three (50%) with one site of infection, two (50%) of osteomyelitis patients suffered multifocal infection. Species identification is as follows: (three group D, one group C, and two were not specified), only two occasions where resistant to ciprofloxacin while all others were pan sensitive. Fever was prolonged (take more than seven days to subside even with appropriate therapy and intervention) in five out of six. Conclusions Multiple site of infection, sever osteomylitis, and delay in fever response consolidated the fact of high virulence of salmonella in SCD patients. We did not encounter significant resistant rate to both quinolone and cephalosporin.

Periorbital cellulitis is much more common in younger children than in adolescents or adults, and most cases of uncomplicated periorbital cellulitis can be treated with antibiotics alone. Here, we report a case of a 53-year-old man with periorbital purulent discharge. Computed tomography imaging revealed pansinusitis. Pus culture isolated a pathogen of Streptococcus constellatus, but it was refractory to 2 weeks of antibiotic therapy with amoxicillin–clavulanate. The patient underwent debridement and functional endoscopic sinus surgery, followed by 10 days of hyperbaric oxygen treatment. The above antibiotic was changed to full-dose intravenous clindamycin. Two weeks after the surgery, the patient was discharged from the hospital. At 1-month follow-up, no purulent discharge was noted; however, mild left-eyelid contracture was observed. This study suggested that if conservative therapy for periorbital purulent discharge in an adult is not effective, progressive treatment, including surgery, should be considered.

Fibrous dysplasia (FD) is a mosaic skeletal disorder in which the craniofacial bones are commonly affected. Normal structures are replaced by expansile, highly vascular, fibro-osseous tissue. The typical clinical course is a gradual, asymptomatic expansion of the osseous structures. However, in the periorbital region, even minor structural changes may cause functional impairment, such as diplopia and hyposmia. Furthermore, rapidly evolving secondary lesions, such as fluid-filled cysts, can sometimes develop. In the midface and periorbital regions, such acute change may be associated with severe pain, vision loss, and, signs of inflammation. Here we describe three patients with craniofacial FD who presented with recurrent episodes of periorbital inflammation mimicking orbital cellulitis. All presented with pain, edema, erythema, and warmth, with varying degrees of functional impairment. On imaging, all had cystic changes in the FD lesion, including two with aneurysmal bone cysts (ABCs). Two were initially diagnosed with periorbital cellulitis and treated with antibiotics; in two, the radiographic findings were misdiagnosed as osteomyelitis. Recurrent episodes were recognized as not infectious and effectively managed with corticosteroids. Given the vascular nature of FD and the association of ABCs, it is likely the findings in these patients represent inflammation associated with vascular leak in the relatively confined space of the tissues overlying the periorbital bones. Recognition of this entity can lead to more rapid and appropriate treatment.

Summary:. Defects of the frontal bone require thoughtful consideration of reconstructive material to satisfy the aesthetic and functional demands of the region, as well as the anatomic adjacency to the frontal sinus. Some cases may be further complicated by a suboptimal operative field due to prior radiation, reconstructive procedures, or infection. Vascularized bone offers an ideal option to successfully reconstruct bony defects in harsh wound beds. Here, we report the case of a 47-year-old man with adenoid cystic carcinoma who underwent secondary reconstruction of the frontal bone with a split-iliac crest bone flap based on the deep circumflex iliac artery. The patient’s course following an initial ablative procedure was complicated by recurrent periorbital cellulitis, radiation, and eventual recurrence of the malignancy. Reconstructive requirements included restoration of the superior orbital rim, cranialization of the frontal sinus, and reconstruction of a sizeable frontal bone defect. In this setting, the iliac crest served as an excellent reconstructive option owing to its natural curvature and large surface area. The split-iliac crest deep circumflex iliac artery bone flap offers a robust and valuable reconstructive option for calvarial defects in hostile surgical fields.

A 14 months baby presented with left sided periorbital cellulitis. A detailed history revealed he had 2 previous episodes over a 9 months period. All episodes resolved with conventional broad-spectrum antibiotic therapy. Imaging studies revealed a left orbital lamina papyracea dehiscence as a possible predisposing factor for recurrent periorbital cellulitis.

Coccidioidomycosis is usually acquired by inhalation of spores of Coccidioides immitis and C. posadasii. The disease ranges from a self-limited acute pneumonia (Valley Fever) to a disseminated disease. We present a 44-year-old healthy male who had patchy hair loss of several months duration resembling discoid lupus. He developed a firm non-scaly red plaque on the right forehead. Initial biopsy showed spongiotic dermatitis, and he was treated with systemic steroids. He then developed forehead and periorbital cellulitis and was treated with systemic antibiotics. A second biopsy showed fungal hyphae, and he was treated with itraconazole 200mg bid for 4months beyond clinical resolution. A year later, he presented with intermittent swelling of the right forehead lesion and worsening of the scalp lesions. A forehead biopsy showed interface dermatitis and negative PAS stain for fungi. Scalp biopsy was highly suggestive of discoid lupus and he was started on plaquenil. Many months later, a third biopsy showed fungal infection, and the culture grew C. immitis. He was treated with itraconazole. Retrospectively, the patient gave a history of Valley fever 6 years back when he was in Arizona, USA.

The authors present a rare case of nontraumatic medial orbital wall fracture in an 11-year-old girl. Fractures of the orbital wall secondary to nose blowing have not been previously described in the pediatric population. The patient reported a history of chronic forceful nose blowing, followed by periorbital swelling after an episode of vigorous nose blowing. Erroneous diagnoses of sinusitis and periorbital cellulitis lead to unnecessary antibiotic treatment. The authors hypothesize that repeated and aggressive nose blowing is analogous to stress fractures, leading to weakening and eventual fracture of the medial orbital wall.

IntroductionSkin and soft tissue infections of the eye can be classified based on anatomic location as either anterior to the orbital septum (ie, periorbital cellulitis) or posterior to the orbital septum (ie, orbital cellulitis). These two conditions are often considered together in hospitalised children as clinical differentiation is difficult, especially in young children. Prior studies have identified variation in management of hospitalised children with orbital cellulitis; however, they have been limited either as single centre studies or by the use of administrative data which lacks clinical details important for interpreting variation in care. We aim to describe the care and outcomes of Canadian children hospitalised with periorbital and orbital cellulitis.Method and analysisThis is a multisite retrospective cohort study including previously healthy children aged 2 months to 18 years admitted to hospital with periorbital or orbital cellulitis from 2009 to 2018. Clinical data from medical records from multiple Canadian hospitals will be collected, including community and academic centres. Demographic characteristics and study outcomes will be summarised using descriptive statistics, including diagnostic testing, antibiotic therapy, adjunctive therapy, surgical intervention and clinical outcomes. Variation will be described and evaluated using χ² test or Kruskal-Wallis test. Generalised linear mixed models will be used to identify predictors of surgical intervention and longer length of stay.Ethics and disseminationApproval of the study by the Research Ethics Board at each participating site has been obtained prior to data extraction. Study results will be disseminated by presentations at national and international meetings and by publications in high impact open access journals. By identifying important differences in management and outcomes by each hospital, the results will identify areas where care can be improved, practice standardised, unnecessary diagnostic imaging reduced, pharmacotherapy rationalised and where trials are needed.

Orbital infection is the most frequent complication of ethmoiditis. Recurrent periorbital cellulitis is a very rare complication of rhinosinusitis with only three reports in the literature describing this pathological process. This complication can be favored by an anatomical abnormality of the uncinate process or mucocele obstructing the normal drainage pathway, in addition to ethmoidal sinusitis. Computed tomography and magnetic resonance guide the diagnosis. The treatment is based on antibiotics, corticosteroids and local decongestants. Surgical treatment is indicated in the absence of response to treatment established after 48 hours or decrease in visual acuity or recurrent orbital complications without underlying tumor pathology. In this report, we present a case of orbital complication of rhinosinusitis in a 4 year-old-child with six episodes of unilateral periorbital cellulitis and one episode of subperiosteal orbital abscess since the age of 3 months. There was a complete resolution with no recurrence after the surgical intervention.

International audience; Background: Tick-borne rickettsioses are infectious diseases caused by obligate intracellular Gram-negative bacteria belonging to the spotted fever groupof Rickettsia. Methods: We describe an unusual case of SENLAT (Scalp eschar and neck lymphadenopathy after tick bite), caused byRickettsia slovaca, associated with a cellulitis of the face in a 70-year-old woman, and diagnosed using qPCR on a scalp eschar swab. We review the literature regarding cases of SENLAT-associated-cellulitis and case of SENLAT diagnosed by qPCR on scalp eschar swabs. Results: We found only one previous report of SENLAT associated with a cellulitis of the face. It was a nine-year-old French girl diagnosed by seroconversion for Rickettsia sp. Our review of the literature showed that qPCR on eschar swab samples is a less invasive method than performing cutaneous biopsy of the eschar and has good sensitivity and specificity (90% and 100%, respectively). Conclusions: We report the second case of cellulitis of the face associated with the SENLAT syndrome. Detection of Rickettsia by qPCR on swab sample of the scalp eschar is a simple, noninvasive technique allowing rapid diagnosis and treatment when SENLAT is suspected.

The authors present a case of combined preseptal and postseptal cellulitis of odontogenic origin. The infection started as a dental abscess associated with a first maxillary molar. The infection spread into the paranasal sinus, developed into a pansinusitis, and then spread into the preseptal and postseptal tissues. In addition to extraction of the infected tooth, the patient underwent bilateral nasal endoscopy, maxillary antrostomy, total ethmoidectomy, sphenoidotomy, and frontal sinusotomy with balloon dilation. Sinus cultures were positive for 2+ microaerophilic streptococci.

Case Report CH presented to Cavan General Hospital with a one day history of erythema and swelling over the right eye. This was associated with fever, lethargy and pain. CH was unable to open his right eye fully. There was normal visual acuity and eye movements. Diplopia was not a feature. The initial differential was periorbital cellulitis. CT brain was performed and showed no evidence of intracranial pathology and no suspicious bone lesions. Pansinusitis was shown. He had a WBC of 22.9 (neutrophils of 20.6) and a CRP of 110. CH was started on antibiotics as per local guidelines (ceftriaxone and clindamycin). On day 4 of admission CH developed diplopia on lateral gaze. A repeat CT showed increased inflammatory changes of the right maxillary and frontal sinuses, infraorbital soft tissue density under the superior orbital wall and proptosis suggestive of orbital cellulitis. It also showed subcutaneous soft tissue swelling suggestive of underlying abscess formation. MRSA was also grown on a nasal swab with Vancomycin started to cover. An MRI brain was performed which showed soft tissue oedema around the right orbit, osteomyelitis of the right frontal bone, as well as small subperiosteal collections extending into the right medial orbit and an intracranial subperiosteal collection. These findings confirmed a diagnosis of Pott’s Puffy tumour. Treatment involved adding metronidazole and rifampicin. FESS (functional endoscopic sinus surgery) with drainage of the orbital abscess was performed in Temple Street Children’s Hospital. IV antibiotics were eventually stopped one month from presentation and CH was discharged home on PO antibiotics for a further 3 weeks having made an excellent recovery. Discussion Pott’s Puffy tumour was first described by Dr Perival Pott in 1760. It is characterised by osteomyelitis of the frontal bone with associated subperiosteal abscess. This presents as a fluctuant, tender swelling over the forehead. It is a life threatening complication of infectious sinusitis. Complications include intracranial extension with epidural abscess, subdural empyema, meningitis and cerebral abscess. Treatment is through surgical drainage and prolonged IV antibiotics.

Aim To study epidemiology and management of Periorbital and orbital cellulitis in children admitted in University Hospital Waterford, Ireland. Methods The medical records of children ≤16 years old and hospitalised from 01/01/2007 to 31/12/2017, at the University of Hospital Waterford with discharge code ICD-10-AM indicating diagnosis of acute inflammation of orbit were reviewed. Results Total 33 cases were included in this study. Conclusion Literature says periorbital and orbital cellulitis typically affects a child under 5, but our main population was between 5–16 years with mean age 0f 7.8 years. Periorbital cellulitis occurs as a complication of sinusitis. All 9 children with orbital cellulitis had radiological evidence of sinusitis and 7 (29%) out of 24 children with periorbital cellulitis had radiological evidence of sinusitis. So, >70% children with periorbital cellulitis had source of infection other than sinusitis. Total of 9 children had Subperiosteal abscess which required drainage. Discussion Epidemiology of Periorbital infections in Paediatric Population in that particular area was slightly different compared to the literature. Fortunately all children had good outcome after the appropriate treatment.