Pediatric emergency medicine trisk 1011

FIGURE 123.5 CT scan of a child with right-sided orbital cellulitis demonstrating retro-orbital
inflammation and a subperiosteal abscess.

Diagnostic Testing. Imaging is not routinely indicated in periorbital cellulitis. In
patients with concern for orbital cellulitis, CT or MRI scanning is used to confirm
the diagnosis and detect its complications including subperiosteal abscess, orbital
abscess, cavernous sinus thrombosis, and/or brain abscess. An MRI spares the
patient radiation exposure and can readily identify orbital disease that can mimic
orbital cellulitis such as tumor, hemorrhage, or inflammatory pseudotumor. CT
imaging however is cheaper, more readily available, less likely to require
sedation, and affords excellent views of the bony orbital wall ( Fig. 123.5 ).
Contrast-enhanced imaging should generally be expedited in all cases with highrisk features including limitation or pain with eye movements, vision loss,
proptosis, signs of CNS involvement, inability to perform a reliable examination,
and cases of presumed periorbital cellulitis which do not improve on IV
antibiotics within 48 hours.
Management and Disposition. In otherwise well children who are beyond infancy
and have mild periorbital cellulitis and no systemic signs or symptoms, oral
antibiotics are appropriate. The prognosis for complete recovery without
complications is excellent. The patient should be reevaluated within 24 to 48
hours to ensure improvement. If no improvement occurs, the patient should then
be admitted for IV antibiotics.


All cases of suspected orbital cellulitis should be promptly hospitalized and
treated with IV antibiotics. Recent studies confirm that in the absence of acute
visual compromise or other signs of disease progression, even children with small
or moderate-sized abscesses deserve a trial of medical therapy before surgical
intervention. Empiric broad-spectrum antibiotic treatment should be directed
toward known common pathogens, including skin flora when local trauma is the
likely etiology, and upper respiratory flora in cases of presumed underlying sinus
disease. Appropriate empiric regimens should include coverage for S. aureus

(including MRSA if unwell or risk factors are present), streptococci, and gramnegative bacilli. Anaerobic coverage should be added for cases associated with
sinusitis, an odontogenic source, or proven or suspected intracranial extension.
The yield of blood cultures post Hib vaccine is very low, however blood cultures
should be considered before initiating IV antibiotic therapy. Percutaneous
aspiration from the area of cellulitis is not recommended. Other systemic cultures
(e.g., cerebrospinal fluid) may be indicated if signs of systemic toxicity or
findings of CNS disease are present. The patient should be reevaluated daily
looking for signs of improvement. Ophthalmic consultation and evaluation is
recommended for all pediatric patients with orbital cellulitis.
Otorhinolaryngology consultation should also be considered in those with
associated sinusitis. Neurosurgical consultation is needed for those with
intracranial extension.

Conjunctivitis
CLINICAL PEARLS AND PITFALLS
Not all cases of “red eye” are due to conjunctivitis.
Gonorrhea should be suspected in a neonate with purulent
conjunctivitis.
Antimicrobial therapy is not indicated for cases of viral conjunctivitis.
Contact lens wearers with conjunctivitis are at risk for keratitis and
should remove their contact lens and be evaluated by an
ophthalmologist.
Steroid drops should not be prescribed by the ED clinician.
Current Evidence
The conjunctiva is the mucous membrane that lines the inner surface of the
eyelids and reflects back to cover the surface of the globe up until the cornea.


Conjunctivitis refers to “inflammation of the conjunctiva” and it is the most
common acute eye disorder seen by pediatric ED clinicians. Acute conjunctivitis

is generally classified as either infectious or noninfectious. Infectious
conjunctivitis may be bacterial or viral. Bacterial conjunctivitis in children is
commonly caused by Streptococcus pneumoniae, H. influenzae, S. aureus, and
Moraxella catarrhalis. N. gonorrhea can be a causative agent in sexually active
adolescents. Viral conjunctivitis is typically caused by adenovirus, although
enteroviruses and herpes simplex virus (HSV) are also possible pathogens.
Noninfectious conjunctivitis includes both allergic conjunctivitis from airborne
allergens (which may manifest as acute hypersensitivity reactions or more gradual
seasonal reactions) and nonallergic conjunctivitis resulting from a mechanical or
chemical insult.
Goals of Treatment
Acute conjunctivitis is typically a benign self-limited disease but can cause
significant patient discomfort. Goals of treatment include symptomatic relief and
shortening of the clinical course when possible. Eye lubricants (artificial tears)
and/or cool compresses may provide symptomatic relief in all cases. Topical
antibiotics may be used for bacterial conjunctivitis to hasten healing time and
eradicate the pathogen. Cases with atypical courses and those that do not respond
to treatment as expected should be referred to an ophthalmologist for further
evaluation.
Clinical Considerations
Clinical Recognition. The hallmark of conjunctivitis is dilation of conjunctival
blood vessels resulting in erythema and edema. Common symptoms include eye
redness, irritation, tearing, discharge, and morning crusting. The patient’s age is
often useful in determining a specific diagnosis. Almost all newborn nurseries
now use erythromycin ointment or dilute betadine solutions for prophylaxis
against gonorrhea. However, no prophylaxis is completely effective. An infection
with gonorrhea typically presents 2 to 5 days after birth with sudden onset,
severe, grossly purulent conjunctivitis, with profuse exudate and swelling of the
eyelids ( Fig. 123.6 ). Left untreated it can rapidly progress to corneal ulceration
and perforation. Neonatal chlamydia trachomatis conjunctivitis, also known as

inclusion conjunctivitis of the newborn (ICN), typically presents 5 to 14 days
after delivery and can range from mild swelling with a watery to mucopurulent
discharge, to marked swelling of the eyelids with red, thickened, and friable
conjunctivae. Untreated infection can cause corneal and conjunctival scarring.


These two forms of conjunctivitis, as well as other forms of bacterial
conjunctivitis (S. aureus, Escherichia coli , Pseudomonas aeruginosa ), can be
difficult to distinguish clinically and may coexist.

FIGURE 123.6 Neonatal gonorrheal conjunctivitis. Note the dramatic lid swelling and severe
purulent discharge.

In children beyond the neonatal period, a wide range of organisms, both viral
and bacterial, as well as chlamydia, can cause conjunctivitis. Clinically, these
entities may be indistinguishable. Table 123.1 is designed to give some additional
help in differentiating causes of conjunctivitis. In general, purulence is more
characteristic of bacterial infections, whereas clear serous discharge is more
characteristic of viral infection. Bacterial and viral conjunctivitis can be
associated with otitis media and pharyngitis, respectively. Although both viral and
bacterial conjunctivitis may be unilateral or bilateral, a history of multiple
infected contacts, or consecutive involvement of one eye and then the other,
argues in favor of a viral etiology. Likewise, dramatic lid swelling associated with
preauricular adenopathy, mucoid or serous discharge, and perhaps an
uncomfortable, sandy, foreign-body sensation is strongly suggestive of epidemic
keratoconjunctivitis secondary to adenovirus. This fulminant viral infection is
usually easy to recognize ( Fig. 123.7 ). Both HSV and varicella zoster virus can
cause infections limited to the skin surrounding the eye ( Fig. 123.8 ) or may also
involve the cornea and/or conjunctiva. Patients with ocular HSV infection usually