ACEP ID:

Pediatric Emergency Medicine

Pediatric EM Section - Case Study #2

By Bryan Wilson, MS3; Larry B. Mellick, MS, MD, FAAP, FACEP

12 Month Old Periorbital Erythema 

 

Case:

 
A 12 month old male presented to the emergency department with painful periorbital erythema and edema. On physical exam an internal hordeolum was noted.
A limited intracranial computerized tomography (CT) found preseptal cellulitis with two focal fluid collections suspicious for abscesses located anterior and anterolateral to the right globe.  Mucosal thickening of the bilateral maxillary sinuses was also noted. There was no evidence of subperiosteal abscesses or involvement of the globes and the mastoid air cells were clear.
The patient was admitted and treated with clindamycin, ceftriaxone, and polysporin ophthalmic ointment. He also underwent abscess incision and drainage twice with a needle placed on the palpebral side. The documented cause of the infection was Staphylococcus aureus.
CT Scan Periorbital Erythema and Edema
 

Discussion:

 
The vast majority of hordeola are self-limited infections which will resolve by pointing and draining within 1 to 2 weeks. As this patient demonstrates, however, some cases will progress to a more serious infection. This raises the following discussion questions:
 
  1. What is a hordeola and what are its potential complications? 
  2. What is the role of imaging in the evaluation of acute periorbital infections?
  3. What is the proper technique for surgically draining a hordeolum?
  4. When are antibiotics indicated?
 
Hordeola are acute, focal infections of the sebaceous or sweat glands of the eyelid generally caused by Staphylococcus aureus (including the rare case of MRSA).1,2 They are categorized as either external, representing an infection of a gland of Zeiss or Moll, or internal, representing an infection of a meibomian gland.  External hordeola generally point to the lid margin. Internal hordeola may also point to the lid margin, but frequently point to the conjunctival surface of the eyelid. This delicate pustule on the internal surface of the eyelid is diagnostic for internal hordeolum.3 They typically present with unilateral erythema, swelling, and tenderness of the eyelid.
 
A small number of internal hordeola do not spontaneously resolve and may progress to a number of complications including a chalazion, preseptal cellulitis, orbital infection, and systemic infection. In addition, several cases of toxic shock syndrome and periorbital necrotizing fasciitis have been documented in the literature.4-7 It should be noted that many, if not most, complications are iatrogenic and include cosmetic defects, lid deformities, and fistulas associated with the surgical treatment of the hordeolum.8,9 Suggestions for safely draining a hordeolum are given bellow.
 
Because of the mild and self-limiting course of an uncomplicated hordeolum, a disproportionate number of patients presenting in the ED have already progressed to more disseminated periorbital infection.  In this setting, the concern is identifying the presence of or risk for developing more serious orbital infections such as a subperiosteal abscesses and orbital cellulitis. Care should be taken to rule out sinusitis, odontic infections, hematogenous seeding, and sterile inflammation as the source of the periorbital inflammation.10-13 

 
A thorough evaluation should be performed with particular attention paid to the presence of:  
  • Deteriorating visual acuity or color vision
  • Ophthalmoplegia
  • Proptosis
  • Fundal swelling
  • Moderate-to-severe periorbital edema
  • Absolute neutrophil count (ANC) > 10,000 cells per L 
  • Systemic symptoms
 

The presence of any of these findings suggests a high-risk for orbital or disseminated disease and is an indication for emergent contrast-enhanced CT scan.14,15 Additionally, a CT scan may be indicated in cases where an adequate exam cannot be performed such as an uncooperative child or extensive periorbital edema. Orbital ultrasound is being investigated as a non-irradiating option for the evaluation of periorbital edema with erythema.16 

In the case of rapidly deteriorating vision, diagnostic evaluation should not delay prompt surgical decompression of the orbit.14 Ophthalmologic consultation is recommended in cases where the eye cannot be evaluated, orbital spread is suspected, and for all pediatric patients.
Conservative therapy in the form of lid hygiene and warm soaks for 10-15 minutes 4 times a day is generally considered sufficient for the treatment of a simple hordeolum, though evidence of their efficacy is lacking.17 Surgical drainage of pointed lesions, as described below, can speed the healing process and is indicated for hordeola large in size or refractory to medical therapy.

Drainage of a Hordeolum 9 
  • Local anesthesia should not be injected directly into the hordeolum.  The anesthesia injections are recommended along the lid margins above the upper or below the lower tarsus.
  • A chalazion clamp can be used and the drainage is performed with stab incisions at the site of pointing.  An 18 gauge needle or a #11 blade is used.  Avoid external incisions that can lead to scarring.
  • Internal incisions are made vertically (for functional reasons) and external incisions (when the lesion is pointing outward) are made horizontally for best cosmetic results.
  • No incisions should be made along eyelash margins in order to protect eyelash growth.
  • Fistulae through the lid can develop if one drains a lesion that points both internally and externally.  Drain internally as far away as possible from the external site of pointing.
  • It is possible to cause an excessive loss of tarsal tissue and a future lid deformity by attempting to remove everything that seems to be purulent material.
  • Always leave the incision open.
 
Antibiotics are indicated only when inflammation has spread beyond the immediate area of the hordeolum. Topical antibiotics may be used for recurrent lesions and for those that are actively draining, but they do not improve the healing of surgically drained lesions.18 A trial of oral antibiotics can be pursued for older children and adults with a mild preseptal cellulitis. Broad spectrum antibiotics with coverage for Staphylococcus and Streptococcus should be used for a minimum of 7-10 days with a response expected within 24-48 hours.13 
Admission for monitoring and IV antibiotics is indicated when there is a more severe preseptal cellulitis, younger children, or dissemination of the infection beyond the preseptal area.  A clinical severity score has been proposed for guiding the treatment of preseptal cellulitis in patients 1 to 16 years of age.19 
Follow up is critical to ensure the infection is responding to treatment. Without follow-up, an infection unresponsive to the prescribed treatment may progress to an orbital, intracranial, or systemic infection. 

Learning Points: 

 
  1. Most hordeola will spontaneously resolve within 2 weeks and can be treated conservatively.
  2. Most complications are iatrogenic so great care should be exercised when draining hordeola.
  3. Internal hordeola can lead to disseminated preseptal, orbital, and systemic infections.
  4. Infections beyond the preseptal area represent a significant risk to vision and life and must be ruled out.
  5. Timely follow-up is critical for verifying response to treatment and promptly identifying complications.  
 

References:  

 
  1. Lederman C, Miller M. Hordeola and chalazia. Pediatr Rev. Aug 1999;20(8):283-284.
  2. Rutar T, Chambers HF, Crawford JB, et al. Ophthalmic manifestations of infections caused by the USA300 clone of community-associated methicillin-resistant Staphylococcus aureus. Ophthalmology. Aug 2006;113(8):1455-1462.
  3. Wald ER. Periorbital and orbital infections. Infect Dis Clin North Am. Jun 2007;21(2):393-408, vi.
  4. Brower MF, Levine RA, Boyer KM. Preseptal cellulitis complicated by toxic shock syndrome. Case report. Arch Ophthalmol. Dec 1987;105(12):1631-1632.
  5. Ingraham HJ, Ryan ME, Burns JT, et al. Streptococcal preseptal cellulitis complicated by the toxic Streptococcus syndrome. Ophthalmology. Aug 1995;102(8):1223-1226.
  6. Lazzeri D, Lazzeri S, Figus M, et al. Periorbital necrotising fasciitis. Br J Ophthalmol. Dec 2010;94(12):1577-1585.
  7. Raja V, Job R, Hubbard A, Moriarty B. Periorbital necrotising fasciitis: delay in diagnosis results in loss of lower eyelid. Int Ophthalmol. Feb 2008;28(1):67-69.
  8. Kim JH, Yang SM, Kim HM, Oh J. Inadvertent ocular perforation during lid anesthesia for hordeolum removal. Korean J Ophthalmol. Sep 2006;20(3):199-200.
  9. Bessette MJ. Hordeolum and Stye in Emergency Medicine. Mescape Reference 2010; http://emedicine.medscape.com/article/798940-overview. Accessed September 1, 2011.
  10. Kim I-K, Kim J-R, Jang K-S, Moon Y-S, Park S-W. Orbital abscess from an odontogenic infection. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2007;103(1):e1-e6.
  11. Lamoreau KP, Fanciullo LM. Pott's puffy tumour mimicking preseptal cellulitis. Clin Exp Optom. Jul 2008;91(4):400-402.
  12. Youssef OH, Stefanyszyn MA, Bilyk JR. Odontogenic orbital cellulitis. Ophthal Plast Reconstr Surg. Jan-Feb 2008;24(1):29-35.
  13. Hauser A, Fogarasi S. Periorbital and orbital cellulitis. Pediatr Rev. Jun 2010;31(6):242-249.
  14. Howe L, Jones NS. Guidelines for the management of periorbital cellulitis/abscess. Clin Otolaryngol Allied Sci. Dec 2004;29(6):725-728.
  15. Rudloe TF, Harper MB, Prabhu SP, Rahbar R, VanderVeen D, Kimia AA. Acute Periorbital Infections: Who Needs Emergent Imaging? Pediatrics. April 1, 2010 2010;125(4):e719-e726.
  16. Mair MH, Geley T, Judmaier W, Gassner I. Using orbital sonography to diagnose and monitor treatment of acute swelling of the eyelids in pediatric patients. AJR Am J Roentgenol. Dec 2002;179(6):1529-1534.
  17. Lindsley K, Nichols JJ, Dickersin K. Interventions for acute internal hordeolum. Cochrane Database Syst Rev. 2010(9):CD007742.
  18. Hirunwiwatkul P, Wachirasereechai K. Effectiveness of combined antibiotic ophthalmic solution in the treatment of hordeolum after incision and curettage: a randomized, placebo-controlled trial: a pilot study. J Med Assoc Thai. May 2005;88(5):647-650.
  19. Vu BL, Dick PT, Levin AV, Pirie J. Development of a clinical severity score for preseptal cellulitis in children. Pediatr Emerg Care. Oct 2003;19(5):302-307.
 
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