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眼窩炎症疾患(眼窩蜂巣炎を含む)

著者: 久保田敏信 国立病院機構名古屋医療センター 眼科

監修: 沖波聡 倉敷中央病院眼科

著者校正/監修レビュー済:2021/09/08
患者向け説明資料

概要・推奨   

  1. 眼窩蜂巣炎の重症度の分類はCT検査所見に基づく(推奨度1)
  1. 眼窩炎症疾患が疑われたとき、CT画像検査は強く推奨される(推奨度1)
  1. 乳幼児と複視、視力低下がみられる大人は、入院がおそらく推奨される(推奨度2)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
久保田敏信 : 特に申告事項無し[2021年]
監修:沖波聡 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 眼窩とは眼球周囲の組織で、眼窩炎症疾患は眼窩に炎症が生じる疾患群である。
  1. 眼窩炎症疾患には、眼窩蜂巣炎と特発性眼窩炎症がある。<図表>
  1. 眼窩蜂巣炎は片眼性急性炎症性の疾患で幼児から成人まで罹患する。細菌感染が原因で、抗菌薬によって加療する[1][2]
  1. 特発性眼窩炎症は片眼性急性炎症性の疾患で、あらゆる年代の大人に発生する。原因が不明で、ステロイド薬によって加療する。
  1. 眼窩蜂巣炎と特発性眼窩炎症の症状・徴候はきわめて類似していて、鑑別がしばしば困難である。
  1. 眼窩蜂巣炎と特発性眼窩炎症の鑑別は、主にCT画像検査所見に基づく。
  1. 眼窩蜂巣炎と特発性眼窩炎症は速やかな治療が必要である。
 
眼窩蜂巣炎(a、c)と特発性眼窩炎症(b、d)の眼瞼所見

眼窩蜂巣炎と特発性眼窩炎症は鑑別がしばしば困難である。眼窩蜂巣炎のCT検査所見は<図表>を、特発性眼窩炎症のCT検査所見は<図表>を参照されたい。
a:6歳男児の眼窩蜂巣炎。血清生化学的所見では白血球数6,900/ul(正常値3,500~8,500/ul)、眼脂培養は陰性であった。アンピシリン点滴で治癒した。
b:15歳女児の特発性眼窩炎症。ステロイドパルス療法(ソル・メルコート 1日1000mg  点滴 3日間)で治癒した。
c:53歳女性の眼窩蜂巣炎(Group I:CT検査所見は<図表>のa)。モダシンの点滴静注(1日 2~4g 2週間)で治癒した。
d:58歳男性の特発性眼窩炎症。ステロイドパルス療法(ソル・メルコート 1日1000mg点滴3日間)で治癒した。

 
眼窩蜂巣炎のCT検査所見

5歳未満の小児は、上気道炎からの感染経路も考慮する。5歳以上は経皮、経結膜の感染もあるが、多くは副鼻腔炎からの感染の波及である。
a:53歳女性の眼窩蜂巣炎。びまん性陰影が左眼瞼のみにとどまっている状態(Group I)。眼瞼の所見はID0601〔眼窩蜂巣炎(a、c)と特発性眼窩炎症(b、d)の眼瞼所見〕のcを参照。
b:58歳男性の眼窩蜂巣炎。副鼻腔炎が眼窩内に波及している(Group II)。
c:右上の状態からさらに眼窩内に波及した状態。眼瞼の状態は<図表>(眼窩蜂巣炎の眼瞼、CT画像検査所見)を参照。
d:12歳女児の眼窩蜂巣炎(Group III)。眼瞼の状態とMRI検査所見は<図表>(眼窩蜂巣炎の眼瞼所見、CT 、脂肪抑制T2強調MRI画像所見)を参照。

出典

img1:  著者提供
 
 
 
特発性眼窩炎症のCT検査所見

特発性眼窩炎症は、それぞれの眼付属器に特異的に炎症を引き起こすことが特徴である。特発性眼窩炎症に副鼻腔炎を伴っていないことに注目。しかし、副鼻腔炎はありふれた疾患であり、慢性副鼻腔炎を合併した眼球周囲型の特発性眼窩炎症は、CT検査で類似するかもしれない。
a:涙腺型、b:びまん型、c:視神経周囲型、d:眼球周囲型、e:眼窩先端部型、f:眼窩筋炎型

 
  1. 眼窩蜂巣炎が疑われたとき、血算とCRPや血沈はルーチンとして施行することはおそらく推奨される(推奨度2O)
  1. 眼窩炎症性疾患の血液生化学所見を検討した文献によると、小児の眼窩蜂巣炎はより重篤例で白血球数が上昇する[6]。5歳未満は上気道感染から眼窩へと波及するため、副鼻腔の所見が乏しい。ただし、重症度の判定は理学所見と画像検査所見の組み合わせによる重症度の診断のほうが鋭敏である。さらに、成人の眼窩蜂巣炎は約50%のみで白血球数が上昇する[7]。また、炎症の状態は視診で評価できる。これらにより血算や炎症の数値は、眼窩蜂巣炎を含んだ眼窩炎症性疾患において参考所見にとどまる。
 
  1. 初期検査として、眼窩蜂巣炎の起炎菌を同定する方法として、眼脂や鼻腔粘膜からのぬぐい液の採取は強く推奨される。しかし、それらから同定できる可能性は50%未満である(推奨度2O)
  1. 眼窩蜂巣炎の起炎菌の同定に関するメタ分析によれば血液培養による検出は4%、眼脂培養や鼻腔粘膜からの培養による検出は50%、外科加療による膿からの検出は75%であるというエビデンスがある[8]。眼脂や鼻腔からの採取は比較的容易であることより、初期検査として推奨される。しかし常在菌の混入の可能性や検出率が50%未満であることを考慮したほうがよい。外科加療による起炎菌の同定は、眼窩蜂巣炎がより重篤例、血液培養から検出される症例は非常に重篤例、あるいは他の病巣(例:感染性心内膜炎からの眼窩への波及)が考慮される状態である。
 
  1. 眼窩蜂巣炎の重症度の分類はCT検査所見に基づく(推奨度1O)
  1. 眼窩蜂巣炎の場合、副鼻腔炎、骨膜下膿瘍、眼球の形状の変化がみられる。そして、その重症度分類は画像検査所見に基づく[3]
 
眼窩蜂巣炎の状態の分類

眼窩蜂巣炎の重症度はⅠ~Ⅴに分類される。Ⅰは細菌感染とそれによる炎症が眼瞼のみにとどまっている段階、Ⅱ~Ⅳは眼窩内に進展し、眼症状を引き起こしている段階、Ⅴは眼窩から頭蓋内や髄膜に進展した段階である。

 
  1. 眼窩炎症疾患が疑われたとき、CT画像検査は強く推奨される(推奨度1OM)
  1. 眼窩炎症性疾患のとき、CT画像検査所見は有用な情報を提供する。第1に、眼窩蜂巣炎と特発性眼窩炎症の鑑別がかなり可能である。特発性眼窩炎症の場合、それぞれの眼付属器(例:涙腺、外眼筋)に肥厚やびまん性陰影の所見がみられる[4]。一方、眼窩蜂巣炎の場合、副鼻腔炎、骨膜下膿瘍、眼球の形状の変化がみられる。<図表><図表>
 
  1. 理学所見と眼窩CT検査所見でも、眼窩蜂巣炎か特発性眼窩炎症の診断が困難なとき、そして眼窩蜂巣炎が考慮され、さらに眼窩内に膿の形成が考慮されたとき、脂肪抑制T2強調冠状断MRI検査所見はおそらく推奨される(推奨度2O)
  1. 眼窩炎症性疾患の場合、脂肪抑制T2強調冠状断MRI検査所見では、眼窩蜂巣炎は膿の局在を同定できる。さらに膿の同定は診断、手術の適応、さらに起炎菌の検出率を高める。一方、特発性眼窩炎症はそれぞれの眼付属器に限定した炎症の局在を示す[4]
 
眼窩炎症性疾患の鑑別を必要とする疾患。リンパ管腫による眼瞼腫脹

14歳男児の右眼瞼の病変(a)。突然に右眼瞼が腫脹した。炎症所見はない(b)点と<図表>(眼窩蜂巣炎の眼瞼所見、CT、脂肪抑制T2強調MRI画像所見)との違いに注目。MRI検査所見は特徴的で、冠状断(T1、T2強調画像:c、d)にて内部が不均一である。
a:右眼の眼瞼腫脹がみられる。発赤がない点に注目。
b:CT検査所見で、腫瘤性病変とそれによる眼球圧迫がみられる。
c:水平断(T2強調画像)で、腫瘤性病変は低信号と高信号を伴った不均一な病態である。
d:水平断(T1強調画像)で、腫瘤性病変は低信号と高信号を伴った不均一な病態である。

出典

img1:  著者提供
 
 
 
眼窩蜂巣炎の眼瞼所見、CT 、脂肪抑制T2強調MRI画像所見

12歳女児の眼窩蜂巣炎(グループIII)(a)。CT検査所見では眼窩内のびまん性の陰影病変を示し、眼球が下方に圧排されている(b)。MRI検査所見(c、d)では硝子体と等信号所見(矢印)を示し、膿を形成している。<図表>(眼窩炎症性疾患の鑑別を必要とする疾患。リンパ管腫による眼瞼腫脹)との違いに注目。骨膜下に膿瘍があるため、膿がドーム状である(b、d)。加療は切開排膿を施行し、培養は嫌気性菌を示した。

問診・診察のポイント  
  1. 眼窩炎症疾患の診断は眼球周囲の理学的所見と画像検査所見に基づく。

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文献 

著者: Roberta M S Costa, Oana M Dumitrascu, Lynn K Gordon
雑誌名: Curr Allergy Asthma Rep. 2009 Jul;9(4):316-23.
Abstract/Text Orbital myositis is an inflammatory process that primarily involves the extraocular muscles and most commonly affects young adults in the third decade of life, with a female predilection. Clinical characteristics of orbital myositis include orbital and periorbital pain, ocular movement impairment, diplopia, proptosis, swollen eyelids, and conjunctival hyperemia. The most common presentation is acute and unilateral, which initially responds to systemic corticosteroid therapy. However, chronic and recurrent cases may involve both orbits. Many inflammatory, vascular, neoplastic, and infectious conditions that affect the extraocular muscles and other orbital tissue can mimic orbital myositis. The most important differential diagnoses include thyroid-related eye disease, other orbital inflammatory processes (unspecific idiopathic inflammation, vasculitis, and sarcoidosis), orbital cellulitis, and orbital tumors. In refractory, chronic, or recurrent cases, steroid-sparing agents, inmmunosuppressants, or radiation therapy may be indicated.

PMID 19656480  Curr Allergy Asthma Rep. 2009 Jul;9(4):316-23.
著者: J R Chandler, D J Langenbrunner, E R Stevens
雑誌名: Laryngoscope. 1970 Sep;80(9):1414-28. doi: 10.1288/00005537-197009000-00007.
Abstract/Text
PMID 5470225  Laryngoscope. 1970 Sep;80(9):1414-28. doi: 10.1288/0000・・・
著者: Aditya Mahalingam-Dhingra, Lina Lander, Diego A Preciado, Jonathan Taylormoore, Rahul K Shah
雑誌名: Arch Otolaryngol Head Neck Surg. 2011 Aug;137(8):769-73. doi: 10.1001/archoto.2011.118.
Abstract/Text OBJECTIVES: To describe the epidemiologic features of pediatric orbital and periorbital infections from a national perspective and to identify predictors of surgery.
DESIGN: Analysis of the Kids' Inpatient Database.
SETTING: Administrative data set.
PATIENTS: Pediatric inpatient admissions with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of orbital cellulitis.
MAIN OUTCOME MEASURES: Hospital admission, socioeconomic, and clinical variables were examined and predictors of surgical intervention were evaluated using logistic regression.
RESULTS: A total 5440 hospital admissions was noted for pediatric orbital cellulitis; of these, 672 patients (12.4%) underwent surgical intervention. Mean length of stay for all patients was 3.8 days; 90.4% were routinely discharged. Patients who had surgery were older, with a mean (SE) age of 10.1 (0.29) years compared with 6.1 (0.10) years for nonsurgical patients (P < .001). Surgical patients had a significantly longer mean hospital stay (7.1 vs 3.4 days, P < .001) and a higher mean cost of care ($41 009 vs $13 008, P < .001) compared with nonsurgical patients. Demographic predictors of surgical intervention included male sex, admitting characteristics, and hospital location. Except for sex, these variables remained significant in a multivariate model. Clinically, diplopia is a predictor of surgical intervention (odds ratio, 6.3; 95% confidence interval, 3.4-11.7).
CONCLUSIONS: This study describes the medical and surgical management of pediatric orbital and periorbital infections from a national perspective. Predictors of surgical intervention include older age, presentation with diplopia, and hospital admission via the emergency department. Knowledge of these variables facilitates analysis of resource utilization for pediatric orbital cellulitis and can be used to optimally triage patients, ultimately reducing costs and lengths of stay while preserving quality of care.

PMID 21844410  Arch Otolaryngol Head Neck Surg. 2011 Aug;137(8):769-73・・・
著者: A Weiss, D Friendly, K Eglin, M Chang, B Gold
雑誌名: Ophthalmology. 1983 Mar;90(3):195-203.
Abstract/Text The clinical features, microbiologic data, complications, and treatment in 137 children with periorbital cellulitis and 21 children with orbital cellulitis is presented. Periorbital cellulitis was more frequent (87%) than orbital cellulitis (13%). Periorbital cellulitis is a heterogeneous disease that may complicate trauma of the eyelids, external ocular infection, and upper respiratory infection. Children with periorbital cellulitis related to trauma or external infection tended to be less than 5 years old with negative blood cultures (99%) and positive cultures of percutaneous aspirates (42%); while children with periorbital cellulitis related to upper respiratory infection also tended to be less than 5 years of age, but blood cultures were frequently positive (42%) and cultures of percutaneous aspirates were usually negative (92%). Three children in the latter group developed meningitis. Intravenous antibiotic alone was effective treatment in most patients (90%). Orbital cellulitis was more frequent in children older than 5 years and frequently associated with sinusitis (90%). Blood and skin cultures were usually negative. Intravenous antibiotics alone were effective management in many patients (62%), but a significant proportion required paranasal sinus or orbital surgery (38%).

PMID 6866441  Ophthalmology. 1983 Mar;90(3):195-203.
著者: A Robinson, T Beech, A L McDermott, A Sinha
雑誌名: J Laryngol Otol. 2007 Jun;121(6):545-7. doi: 10.1017/S0022215106003434. Epub 2006 Dec 13.
Abstract/Text BACKGROUND: Orbital cellulitis has important complications. Despite this, there are few studies in the literature of large groups of cases of this condition.
METHODS: We performed a retrospective case analysis of all patients admitted with periorbital and orbital cellulitis between 2002 and 2004.
RESULTS: A total of 27 cases were included in the study. Of these, 25 had undergone a computed tomography scan, 19 of which had revealed significant sinus disease; 10 had had a microbiology result, with the most common organism being Streptococcus milleri; 20 had had a white cell count taken, with raised results in only 10; 12 had undergone surgery; and 25 had made a good recovery. One case had been found to be squamous cell carcinoma of the nasal cavity.
CONCLUSIONS: In this study, sinus disease was the commonest cause of orbital cellulitis, with the commonest organism being Streptococcus milleri. Only 50 per cent of cases with proven disease had had a raised white cell count; this is therefore not a very sensitive test.

PMID 17164026  J Laryngol Otol. 2007 Jun;121(6):545-7. doi: 10.1017/S0・・・
著者: D E C Baring, O J Hilmi
雑誌名: Clin Otolaryngol. 2011 Feb;36(1):57-64. doi: 10.1111/j.1749-4486.2011.02258.x.
Abstract/Text
PMID 21232022  Clin Otolaryngol. 2011 Feb;36(1):57-64. doi: 10.1111/j.・・・
著者: P S Cannon, D Mc Keag, R Radford, S Ataullah, B Leatherbarrow
雑誌名: Eye (Lond). 2009 Mar;23(3):612-5. doi: 10.1038/eye.2008.44. Epub 2008 Feb 29.
Abstract/Text AIMS/PURPOSE: Orbital cellulitis is conventionally managed by intravenous (i.v.) antibiotic therapy, followed by oral antibiotics once the infection shows signs of significant improvement. We report 4 years of experience using primary oral ciprofloxacin and clindamycin in cases of orbital cellulitis. Oral ciprofloxacin and clindamycin have a similar bioavailability to the i.v. preparations and provide an appropriate spectrum of antibiotic cover for the pathogens responsible for orbital cellulitis.
METHODS: A retrospective review was performed that identified all patients with orbital cellulitis and treated with primary oral antibiotic therapy admitted to the Manchester Royal Eye Hospital between March 2003 and March 2007. Age, stage of disease, surgical intervention, hospital duration, and complications were obtained. A comparison was made with patients admitted to our unit with orbital cellulitis and treated with primary i.v. antibiotics between March 2000 and March 2003.
RESULTS: Nineteen patients were included in the review for the period March 2003 to March 2007, which comprised of 7 children and 12 adults. Five patients required surgical intervention. All patients responded to the oral regimen, 18 patients had no change to their oral antibiotic therapy. Mean hospital stay was 4.4 days. There were no complications.
DISCUSSION: Empirical oral ciprofloxacin and clindamycin combination may be as safe and effective as i.v. therapy in the management of orbital cellulitis. Oral treatment can offer the advantages of rapid delivery of the first antibiotic dose, fewer interruptions in treatment, and simplified delivery of medication particularly in children.

PMID 18309335  Eye (Lond). 2009 Mar;23(3):612-5. doi: 10.1038/eye.2008・・・
著者: Imtiaz A Chaudhry, Farrukh A Shamsi, Elsanusi Elzaridi, Waleed Al-Rashed, Abdulrahman Al-Amri, Fahad Al-Anezi, Yonca O Arat, David E Holck
雑誌名: Ophthalmology. 2007 Feb;114(2):345-54. doi: 10.1016/j.ophtha.2006.07.059.
Abstract/Text PURPOSE: To describe risk factors predisposing patients to orbital cellulitis and potential complications in patients treated at a tertiary eye care referral center in the Middle East.
DESIGN: Noncomparative, interventional, retrospective case series.
PARTICIPANTS: Patients diagnosed with orbital cellulitis.
METHODS: A 15-year clinical review of patients with a diagnosis of orbital cellulitis referred to King Khaled Eye Specialist Hospital, an accredited (Joint Council on Accreditation of Healthcare Organizations, Washington, DC) tertiary care center in Riyadh, Saudi Arabia, was performed. Only those patients who had clinical signs and symptoms or radiologic evidence suggestive of orbital cellulitis were included in the study.
MAIN OUTCOME MEASURES: Patient demographics, factors predisposing to orbital cellulitis, and resulting complications.
RESULTS: A total of 218 patients (136 male, 82 female) fulfilling the diagnostic criteria for orbital cellulitis were identified. The average age of these patients was 25.7 years (range, 1 month-85 years). On imaging studies, there was evidence of inflammatory or infective changes to orbital structures; orbital abscesses were identified in 116 patients (53%). Sinus disease was the most common predisposing cause in 86 patients (39.4%), followed by trauma in 43 patients (19.7%). All patients received systemic antibiotic treatment before the identification of any responsible organisms. Of the 116 patients with orbital abscess, 101 patients (87%) required drainage. The results of cultures in patients in whom an orbital abscess was drained were positive for 91 patients (90%). The most common microorganisms isolated from the drained abscesses were Staphylococci and Streptococci species. Blood cultures were positive in only 4 patients from whom blood was drawn for cultures. Visual acuity improved in 34 eyes (16.1%) and worsened in 13 eyes (6.2%), including 9 (4.3%) eyes that sustained complete loss of vision, which was attributed to the delay in correct diagnosis and timely intervention (average 28 days vs. 9 days in patients with no loss of vision; P<0.05). There were 9 cases of intracranial extension of orbital abscesses that required either extended treatment with systemic antibiotics alone or in combination with neurosurgical intervention. Most patients received oral antibiotics on discharge for varying periods. There were 6 cases (2.7%) of strabismus and 4 cases (1.8%) of ptosis that persisted after treatment and resolution of orbital cellulitis.
CONCLUSIONS: Untreated sinusitis and prior history of orbital trauma were the 2 major causes of orbital cellulitis in patients referred to a tertiary care eye center in the Middle East. Although rare, severe visual loss still remains a serious complication of delayed detection and intervention in most cases of orbital cellulitis.

PMID 17270683  Ophthalmology. 2007 Feb;114(2):345-54. doi: 10.1016/j.o・・・
著者: Joseph V Vayalumkal, Tajdin Jadavji
雑誌名: Paediatr Drugs. 2006;8(2):99-111.
Abstract/Text Skin and soft tissue infections in children are an important cause for hospitalization. A thorough history and physical examination can provide clues to the pathogens involved. Collection of purulent discharge from lesions should be completed prior to initiating antimicrobial therapy, and results of bacteriologic studies (Gram stain and culture) should guide therapeutic decisions. The main pathogens involved in these infections are Staphylococcus aureus and group A beta-hemolytic streptococci, but enteric organisms also play a role especially in nosocomial infections. Increasing antibacterial resistance is becoming a major problem in the treatment of these infections worldwide. Specifically, the rise of methicillin-resistant S. aureus and glycopeptide-resistant S. aureus pose challenges for the future. Infections of the skin and soft tissues can be broadly classified based on the extent of tissue involvement. Superficial infections such as erysipelas, cellulitis, bullous impetigo, bite infections, and periorbital cellulitis may require hospitalization and parenteral antibacterials. Deeper infections such as orbital cellulitis, necrotizing fasciitis, and pyomyositis require surgical intervention as well as parenteral antibacterial therapy. Surgery plays a key role in the treatment of abscesses and for the debridement of necrotic tissue in deep infections. Intravenous immunoglobulin, as an adjunctive therapy, can be helpful in treating necrotizing fasciitis. For most infections an antistaphylococcal beta-lactam antibacterial is first-line therapy. Third-generation cephalosporins and beta-lactam/beta-lactamase inhibitor antibacterials as well as clindamycin or metronidazole are often required to provide broad-spectrum coverage for polymicrobial infections.Special populations, such as immunocompromised children, those with an allergy to penicillins, and those that acquire infections in hospitals, require specific antibacterial strategies. These usually involve broader antimicrobial coverage with increased Gram-negative (including antipseudomonal) and anerobic coverage. In patients with a true allergy to penicillins, clindamycin and vancomycin play an important role in treating Gram-positive infections. Newer antibacterial agents, such as linezolid and quinupristin/dalfopristin, are increasingly being studied in children for the treatment of skin and soft tissue infections. These agents hold promise for the future especially in the treatment of highly resistant, Gram-positive organisms such as methicillin-resistant S. aureus, vancomycin-resistant S. aureus, and vancomycin-resistant enterococci.

PMID 16608371  Paediatr Drugs. 2006;8(2):99-111.
著者: Dorothy J Reynolds, Sylvia R Kodsi, Steven E Rubin, I Rand Rodgers
雑誌名: J AAPOS. 2003 Dec;7(6):413-7. doi: 10.1016/S1091853103003069.
Abstract/Text PURPOSE: To identify risk factors in children admitted with preseptal or orbital cellulitis with associated intracranial infection.
METHODS: A retrospective chart review identified 10 patients (< or = 18 years) with a diagnosis of preseptal or orbital cellulitis and a concurrent or subsequent diagnosis of intracranial infection.
RESULTS: Diagnoses confirmed by imaging included sinusitis (n = 10), preseptal cellulitis (n = 4), orbital cellulitis (n = 6), orbital subperiosteal abscess (n = 5), Pott's puffy tumor (n = 4), epidural empyema (n = 2), epidural abscess (n = 6), and brain abscess (n = 2). The timing of diagnosis of intracranial infection ranged from hospital day 1 to 21. All but 1 patient had positive microbial cultures. Seven of 10 patients had positive microbial cultures from two or more sites, 70% of which were polymicrobial; Streptococcus species and Staphylococcus species were the most commonly isolated bacterial pathogens. All patients required both medical and surgical therapy; all 10 patients underwent sinus surgery; 8 patients required neurosurgical craniotomy; and 5 patients underwent orbital surgery. There were no deaths.
CONCLUSION: Intracranial involvement should be suspected in any patient age > or = 7 years with preseptal or orbital cellulitis associated with orbital subperiosteal abscess, Pott's puffy tumor, concurrent sinusitis, complaints of headache, and continuing fever despite intravenous antibiotics. Given the high incidence of polymicrobial infection found on cultures in this series, broad-spectrum antibiotics are strongly indicated. When imaging the orbits and sinuses in such patients, we recommend including the brain to rule out intracranial involvement.

PMID 14730294  J AAPOS. 2003 Dec;7(6):413-7. doi: 10.1016/S10918531030・・・
著者: Michael T Yen, Kimberly G Yen
雑誌名: Ophthal Plast Reconstr Surg. 2005 Sep;21(5):363-6; discussion 366-7.
Abstract/Text PURPOSE: To determine the effect of intravenous corticosteroids in the acute management of pediatric orbital cellulitis with subperiosteal abscess.
METHODS: The inpatient records of all patients treated for orbital cellulitis with subperiosteal orbital abscess between January 2001 and August 2003 were reviewed. The use of corticosteroids, length of hospital stay, need for surgical drainage, treatment course, and clinical outcomes were reviewed. A t test and Fisher exact test analysis were calculated to evaluate statistical significance.
RESULTS: Twelve patients received intravenous corticosteroids and 11 patients did not receive corticosteroids. All patients had complete resolution of their abscess without complications. Length of hospitalization between the patients treated with and without intravenous corticosteroids was not significantly different (p = 0.26). Four of 12 patients treated with intravenous corticosteroids underwent orbitotomy for drainage of the abscess, and 6 of 11 patients treated without intravenous corticosteroids underwent surgical drainage (p = 0.20). Two of 12 patients treated with corticosteroids received intravenous antibiotics after discharge, whereas 7 of 11 in the group not treated with corticosteroids received intravenous antibiotics after discharge (p = 0.03).
CONCLUSIONS: The use of intravenous corticosteroids does not appear to adversely affect clinical outcomes and may be beneficial in the treatment of pediatric orbital cellulitis with subperiosteal abscess. Review of our data suggests that a prospective, randomized trial is warranted to further clarify the role of corticosteroids in the acute management of pediatric orbital cellulitis with subperiosteal abscess.

PMID 16234700  Ophthal Plast Reconstr Surg. 2005 Sep;21(5):363-6; disc・・・

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