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DCMC Emergency Department Radiology Case of the Month “DOCENDO DECIMUS” VOL 3 No 8 AUGUST 2016 DCMC Emergency Department Radiology Case of the Month These cases have been removed of identifying information. These cases are intended for peer review and educational purposes only. Welcome to the DCMC Emergency Department Radiology Case of the Month! In conjunction with our pediatric radiology specialists from ARA, we hope you enjoy these monthly radiological highlights from the case files of the Emergency Department at DCMC. These cases are meant to highlight important chief complaints, cases, and radiology findings that we all encounter every day. Conference Schedule: August 2016 3rd 9:15 Radiology Rounds: c-spine…Drs McClug & Vezzetti If you enjoy these reviews, we invite you to 10:15 Biostats 2………………………..……….Dr Wilkinson check out Pediatric Emergency Medicine 5th PEM Fellow Interview Day! Fellowship Radiology rounds, which are offered 9th Finding a job/Contracts……………………Drs Allen & Yee quarterly and are held with the outstanding 10th 8:00 Complex Airway Management………….Dr Vezzetti support of the pediatric radiology specialists at 9:00 Simulation: Respiratory….……Simulation Faculty Austin Radiologic Association. 17th 10:15 Ultrasound in the ED……….…Drs Levine & Gorn 12:00 ED Staff Meeting If you have and questions or feedback regarding 19th PEM Fellow Interview Day! the Case of the Month format, feel free to 23rd Research Round Table……………….….……Dr Johnson email Robert Vezzetti, MD at 24th 9:15 Global and Indigent Care……………….Dr Bonnell [email protected]. 10:15 Coagulopathies…………………..Drs Gorn & Irwin 11:15 Hemoglobinopathies….Drs Schwartz & Schwarz This Month: Facial swelling in a child without trauma! 31st 9:15 M&M…………………….…………Drs Wyrick & Irwin 10:15 Board review: GI…………………..……Dr Gardiner You don’t want to miss this diagnosis in your patients, as 12:15 Research Update………………………Dr Wilkinson the sequelae of doing so can be disastrous. A special Page "1 thanks to Drs Guyon Hill (PEM Fellow) and Sujit Iyer (PEM Simulations are held at the CEC at UMC Breckenridge. Attending) and Brittany Christianson (ED NP) who Lectures are held at DCMC Command Rooms 3&4. provided this case. Locations subject to change. All are welcome! The Romans gave August its name in 8BC, after the first Roman Emperor Augustus who ruled from 27BC until his death in AD14. VOL 3 No 8 AUGUST 2016 Case: It’s a nice, quite, summer evening in the Pediatric Emergency Department; some fractures, bug bites, allergies, the occasional trauma, but not much else. There has been, you’ve noticed, a bit of an uptick in cellulitis and abscesses, but not nearly the amount that a typical summer brings. Oddly enough, just as you are thinking this, you pick up a chart that has a chief complaint of facial erythema and edema. Hmm… You speak to the parents and learn that your patient is an 11 year old male with 4 days of progressively worsening facial erythema and edema. The child has been in good health, with the exception of a history of asthma and sinus infections in the past. He and his parents state that the involved area is somewhat itchy but he denies insect bites/stings or any other trauma. There is no history of fever, cough, congestion, vomiting, or headache, but the child has had a “runny nose” for the past few weeks which seems to be improving with his allergy medications. He was seen yesterday at Urgent Care and was diagnosed with a facial cellulitis. He was started on Keflex four times a day. The parents report that the child’s symptoms appear worse and they are concerned that the antibiotics are not helping. He denies vision changes, eye discharge, the feeling that there is a foreign object in the eye, or painful eye movements. This is good, because when you examine the child you note some impressive erythema and edema of the left side of the face (as seen on the right; this is a depiction from the chart illustration). He is afebrile but mildly tachycardia (heart rate 110) and complains of tenderness when you palpate the erythematous area. There is warmth as well but no fluctuance or streaking. There is no photophobia or proptosis and his extra-oscular muscles are grossly intact; he does complain of some pain with upward gaze but the pain he localizes to his forehead. He is able to partially open his eye, but this is difficult secondary to the edema. His neurologic examination seems grossly normal and he is otherwise in no distress. This child clearly has cellulitis, but the soft tissue swelling he is demonstrating is significant. Could he have an abscess as well? Does he have orbital involvement? How can you tell one way or the other? Will imaging help and if so, what study should you get? Imaging facial infections is important to rule out complications, such as a facial abscess or to evaluate for orbital involvement, such as occurs with orbital cellulitis. In cases where cellulitis is minimal, imaging is not warranted. However, if there is any question of facial abscess or orbital involvement, then imaging is indicated. Options include : 1. CT - with IV contrast material. CT is very quick and certainly can be effective in evaluating a patient for an abscess or orbital involvement. However, it is difficult to distinguish on CT scanning between preseptal edema and periorbital cellulitis. As always, radiation exposure is a concern. 2. MRI - generally MRI is not indicated and often will not significantly impact management. This modality can be useful if there is a concern for brain involvement (ie empyema). No ionizing radiation, but this imaging technique requires the patient to remain still for a useful study. Page "2 On Aug. 21, 1911, the Mona Lisa was stolen from the Louvre Gallery and not recovered for two years. After one of his assistants working on his X-ray project showed signs of illness, Thomas Edison said, “Don’t talk to me about X-rays. I am afraid of them.” VOL 3 No 8 AUGUST 2016 Given the extent of the edema, warmth, and tenderness, the concern for an abscess is paramount. The imaging options include ultrasound, CT, and MRI. While ultrasound is quick, involves no ionizing radiation, and readily available, the extent of the child’s symptoms are concerning for an orbital process as well, so this imaging modality will not be particularly helpful. MRI would be great at detecting fine detail and if there is any optic nerve or muscle involvement. But this imaging test is time consuming and may require sedation. In this patient, CT with IV contrast is the most appropriate imaging modality. While this requires IV placement and involves, of course, ionizing radiation, it is also very quick (a few seconds with today’s scanners) and can rule out an abscess, boy involvement, and orbital involvement. CT it is… Selected CT images are seen here above and to the right. The first finding is the presence of soft tissue edema (yellow arrow). There is also left frontal ethmoid and maxillary sinusitis (red arrow). More concerning, though, is the erosion of the frontal sinusitis to the left frontal soft tissues, causing what appears to be a subperiosteal abscess (blue arrow), which runs inferiorly resulting in a post septal superior orbital abscess (purple arrow). finally, there is a questionable frontal empyema (green arrow). Wow. Now what? further imaging? Admission? Antibiotics? 1873 - The Clay Street Hill Railroad began Page "3 operating the first cable car in San Francisco's famous cable car system. August 1610 - Henry Hudson sailed into what is now known as Hudson Bay (he thought he had made it through VOL 3 No 8 the Northwest Passage, and reached the Pacific Ocean). AUGUST 2016 The CT images are concerning for a serious infection, including an orbital abscess and possible frontal empyema. Pediatric Occuloplastics and Pediatric ENT were initially consulted. Both agreed that an MRI may be helpful in this case, especially since there is a concern for a frontal empyema. Selected images from that study are seen here. Note the left maxillary/ ethmoid sinusitis (yellow arrow). There is subperiosteal abscess (red arrow) with septal extension, but no obvious abscess. There is no epidural abscess noted. Now what? T2 image T1 image T2 image The MRI shows that there is indeed cellulitis and a subperiosteal abscess. Although this abscess extends to and involves the septum, there does not appear to be an orbital abscess. Additional good news is the apparent lack of frontal epyema. The superisoteal abscess does extend to the orbit and involves the septum. This is consistent with orbital cellulitis. What happened next? Read on and find out… What is the orbital septum? This is a thin fibrous sheet that comes from the orbital rim periosteum and meets the tendon of the Page "4 levator palpebral superioris and the tarsal plate. Penicillin discoverer Alexander Fleming (1881-1955) was born August 6th in Lochfield, Scotland. By accident, he found that mold from soil killed deadly bacteria without injuring VOL 3 No 8 human tissue. He received the Nobel Prize in 1954.AUGUST 2016 Periorbital cellulitis is often the result of contiguous spread of an infection typically involving the face or teeth. These infections are limited to the soft tissues that are anterior to the orbital septum. Orbital cellulitis is typically the result of a paranasal sinus infection. This infection extends posterior to the orbital septum. It is important to distinguish between these two clinical entities, as orbital cellulitis, being a more serious infection, is managed with hospitalization and parenteral antibiotics. Sometimes, it can be difficult to clinically distinguish between orbital and periorbital cellulitis. Orbital cellulitis classically presents with proptosis, decreased visual acuity, fever, and an overall more toxic appearing child.
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