| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Original Report |
1 Department of Radiology, LKH Feldkirch, Carinagasse 47, 6800 Feldkirch,
Austria.
2 Department of Pediatrics, Section of Pediatric Radiology, University of
Innsbruck, Medical School, Anichstras. 35, A-6020 Innsbruck, Austria.
3 Department of Magnetic Resonance, University of Innsbruck, Medical School,
A-6020 Innsbruck, Austria.
Received October 22, 2001;
accepted after revision June 10, 2002.
Address correspondence to I. Gaßner.
Abstract
 Top Abstract IntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
CONCLUSION. We recommend orbital sonography in every child with periorbital swelling and erythema. In contrast to superficial infection in which edematous swelling of the eyelid can be documented without lesions of the orbital content, either a hyper- or a hypo-echoic mass displacing the medial rectus muscle laterally is highly suggestive of orbital infection. Introducing sonography into early diagnostic interventions in pediatric patients avoids delaying appropriate treatment and allows disease monitoring on a daily basis.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
Distinguishing preseptal and postseptal inflammation on clinical grounds can, at times, be difficult. According to our experience and to reports in the literature, findings at clinical examination can miss the diagnosis of orbital infection [3].
Contrast-enhanced CT is commonly used in the diagnosis of orbital infection but exposes the patient to radiation and carries a reported risk of inaccuracy [4]. MR imaging is superior to CT in the resolution of soft-tissue disease; however, MR imaging is not widespread and may require sedation in pediatric patients [5]. We used sonography to examine 17 pediatric patients who presented with swelling and erythema of the eyelids. Eight patients were diagnosed with preseptal cellulitis, seven with bacterial infection, one with fungal postseptal infection, and one with an allergic reaction.
We show that sonography is a useful tool in diagnosing orbital infection and in monitoring its treatment.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
The patients ranged in age from 1 to 10 years, with a mean age of 4 years 6 months. Thirteen patients showed unilateral and four patients bilateral swelling and erythema of the periorbital region.
Laboratory studies, including inflammatory parameters such as blood sedimentation rate, WBC, and C-reactive protein, were performed in 15 patients.
All patients were examined using an Ultramark 8 HDI or HDI 5000 scanner (Advanced Technology Laboratories, Bothell, WA) equipped with a 5-8—MHz curved array transducer (C8-5) and a 5-12—MHz linear array transducer (L12-5). The patients were examined in the supine position. The transducer was placed on the closed upper eyelid using nonirritating gel. Any pressure on the eyeball and orbital tissues was avoided. For evaluation of the medial orbital wall, we preferred axial and coronal sections. The coronal sections were obtained by moving the transducer as far as possible toward the lateral canthus of the eye until the medial orbital wall just behind the eyeball could be assessed. Sedation of the children during the examination was not necessary.
Orbital sonography was performed either immediately or at least within 12 hr after admission of the patients to the hospital. Patients presenting with postseptal inflammation on the initial sonographic examination were subsequently referred to our department to monitor the treatment on a daily basis after the beginning of IV antibiotic therapy.
Additional CT was performed in three patients. One was also examined with MR imaging; another patient was examined with MR imaging only.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
Preseptal cellulitis related to a recent common cold was diagnosed in seven patients (five girls and two boys; age range, 2-10 years). Six of them presented with unilateral and one with bilateral swelling of the eyelids.
One girl developed severe unilateral swelling of the eyelids after an insect bite. Laboratory studies in seven patients revealed slightly to significantly elevated inflammatory parameters.
In all these patients, orbital sonography of the affected eyelid showed hypoechoic swelling of the soft tissues without thickening of the conjunctiva (Fig. 1). An inflammatory process posterior to the orbital septum could not be shown. One patient received local treatment only. The remaining seven were treated with oral or IV antibiotics. All made uneventful recoveries.
|
Seven patients (one girl and six boys; age range, 3-7 years) were found to have an orbital infection associated with bacterial sinusitis. Six presented with unilateral and one with bilateral swelling of the eyelids. In three patients, massive edema of the eyelids did not allow a thorough clinical examination. Only two of the seven patients were clinically diagnosed with postseptal involvement. Laboratory findings showed significantly elevated inflammatory parameters. In five patients, orbital sonography showed a nearly anechoic mass, fusiform on axial sections and oval on coronal sections, bulging from the echogenic medial orbital wall with lateral displacement of the medial rectus muscle (Figs. 2A,2B,2C and 3A,3B,3C). These findings were considered to be a subperiosteal abscess. In one patient, the mass had a dumbell-like appearance on axial sections associated with coalescence of two distinct subperiosteal abscesses (Fig. 4A,4B). In another patient, broadening of the distance between the bony orbit and a laterally displaced medial rectus muscle by hyperechoic tissue was encountered on sonography. Complete resolution after antibiotic treatment indicated bacterial induced subperiosteal inflammation. The explanation for the different sonographic appearance in this patient compared with other patients with subperiosteal abscess would be the timing of orbital sonography before liquefaction.
|
|
|
|
|
|
|
|
Sound transmission through the ethmoid cellulae in these patients indicated replacement of air by secretions associated with sinusitis (Figs. 2A,2B,2C and 3A,3B,3C).
Orbital sonography was initially repeated daily to confirm adequate response to antibiotic therapy in patients with subperiosteal abscess. After 48 hr, subperiosteal abscess appeared unchanged, despite dramatic clinical improvement, followed by a decrease of the abscess within 72 hr (Fig. 2C). These patients were successfully treated with vigorous antibiotics and made uneventful recoveries.
A 4-year-old boy had invasive rhinocerebral mucormycosis, complicating a relapsing acute lymphoblastic leukemia. Infection accessed the orbital contents after destruction of the bony orbital walls. Orbital sonography showed a hyperechoic mass along the medial wall of the orbit, displacing the medial rectus muscle, consistent with inflammatory infiltration due to the invasive fungal infection (Fig. 5A). CT and MR images confirmed these findings and permitted further evaluation of the destruction of the base of the skull and intracranial and cerebral extension of the infection (Fig. 5B).
|
|
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
However, the amount of information obtained from the physical examination depends on the patient's age and cooperation. Massive edema of the eyelids may even completely prevent physical examination of the orbital content [4]. Furthermore, orbital inflammation presenting with swelling and erythema of the eyelid as the only signs has been reported in the literature [3].
Our experiences and reports in the literature about misinterpretation of clinical signs led to the impression that a reliable and easy-to-perform diagnostic procedure used at an early stage in the diagnostic workup of patients would be of great value.
Unenhanced radiography of the paranasal sinuses is not helpful in evaluating the orbital contents, unless opacification of the ethmoidal sinuses raises suspicion of sinusitis-induced orbital complications [2].
CT is currently considered the imaging technique of choice because it is supposed to provide accurate staging of orbital inflammatory conditions [7]. However, serous exudate, granulation tissue, and even inflammatory edema might simulate a subperiosteal abscess on CT, suggesting an advanced stage of orbital involvement [4].
MR imaging provides reliable differentiation between the appearances of orbital inflammation [5] (Figs. 3C and 5B) but is rarely immediately available and generally requires the administration of an anesthetic in pediatric patients.
The use of orbital sonography in the treatment of ethmoiditis-induced orbital infection has recently been reported. In both studies, an excellent correlation between CT and sonography was found [8, 9].
We used orbital sonography in 17 patients to exclude and classify orbital inflammatory conditions. Sonography was performed either immediately or at least within 12 hr after admission of the patient to the hospital. Orbital infection was reliably excluded in nine patients. In eight patients, an orbital inflammatory process was diagnosed. In six of them the sonographic appearance of an anechoic mass bulging from the medial orbital wall displacing the medial rectus muscle laterally suggested a subperiosteal abscess (Figs. Figs. 2A,2B,2C,3A,3B,3C,4A,4B). The remaining two patients showed a hyperechoic mass indicating subperiosteal inflammatory infiltration without abscess formation (Fig. 5A,5B).
Only in cases in which clinical signs and laboratory findings indicated a bacterial infection was IV or oral antibiotic treatment administered immediately after admission. Compared with previous treatment of patients, appropriate treatment was applied earlier with nonspecific clinical and laboratory findings because of the fast and easy diagnostic approach of sonography.
Subperiosteal inflammatory infiltration and subperiosteal abscess are, according to recent reports, treated equally unless clinical deterioration requires surgical intervention [10, 11].
Because fever and inflammatory swelling may subside under antibiotic treatment despite persistent smoldering of the subperiosteal infection, monitoring based on clinical examinations alone seems to be of little value [12]. To assess the value of sonography in monitoring the treatment, we subsequently referred patients who initially showed subperiosteal inflammation on orbital sonography to the department on a daily basis. Surprisingly, despite dramatic improvement of periorbital swelling and clinical symptoms after onset of therapy, the sonographic appearance of the subperiosteal abscess remained unchanged for up to 48-72 hr. This initially unchanged sonographic appearance was followed by the continuous decrease of the subperiosteal abscess in subsequent investigations (Fig. 2C).
We therefore regard clinical improvement despite unchanged sonographic features of the subperiosteal abscess within the first 72 hr as a result of effective antibiotic treatment. Because intensive antibiotic treatment should not be stopped until complete resolution of the subperiosteal abscess, monitoring with orbital sonography provides important information that influences the duration of IV antibiotic treatment.
Although sonography can reliably depict an abscess because of its nearly anechoic appearance, differentiation between a slightly hypoechoic inflammatory edema and a slightly hyperechoic inflammatory infiltration of the subperiosteal space causes difficulties. These conditions are, however, part of a continuous spectrum of subperiosteal inflammation and are treated equally.
A further limitation of orbital sonography is the exact assessment of the orbital apex and the paranasal sinuses. However, echogenic exudate occupying the ethmoid cellulae may, at times, be documented (Figs. 2A,2B,2C, 3A,3B,3C, and 5A,5B).
Intracranial extension of orbital infection, which is associated with a mortality rate up to 80%, is certainly not assessed sufficiently with sonography. Patients exhibiting signs of clinical deterioration, neurologic symptoms, lack of improvement under antibiotic treatment, or increasing subperiosteal abscess on sonographic monitoring should be referred for additional CT and MR imaging [5].
Because orbital inflammation reflects a serious condition associated with a mortality rate of 1-2% and a 3-11% incidence of permanent ocular sequels, any delay in appropriate treatment can be fatal [2].
We believe that sonography is the method of choice to investigate orbital infection because it allows reliable differentiation between pre- and postseptal infection, is portable and immediately available, and does not require an anesthetic in pediatric patients. The diagnostic workup is fast, and, especially in patients with nonspecific clinical and laboratory findings, the interval between admission to the hospital and the start of appropriate therapy is short. Because of the use of nonionizing sound propagation, close monitoring of therapy progress is possible. We therefore recommend orbital sonography in every child with periorbital swelling and erythema.
Further studies, however, must investigate the accuracy of sonography in staging postseptal inflammation compared with CT and MR imaging.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
