Hot Seat Case # 117 Denouement: 7 yo female with facial swelling
Posted on: September 27, 2018, by : Haroon Shaukat MD
Nadira Ramkellawan, MD INOVA Fairfax Children’s Hopital
Case: 7 yo female with tactile fever and unilateral eye swelling diagnosed with sinusitis with possible subperiosteal involvement on imaging. ENT was consulted and advised outpatient management and follow up. The patient ultimately returned with acute onset new seizures found to have intracranial involvement and progression of disease.
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Discussion:
Much of the debate in this case was in the early management of this child, both around potential diagnosis and management. Some of the red flags in the history for this patient were rapid evolution of symptoms, however, more so the forehead tenderness to palpation and lack of significant URI symptoms leading one down the road of sinusitis or orbital cellulitis.
The other point that was brought up and is an art taught by the more experienced staff is what to do with opposing views with the consultant. In the ED, we often ask our colleagues for their consultation as they are the experienced providers. However, we are often the ones with the child in front of us and may be unable to appropriately express the subtleties in the case or examination that may make us feel uncomfortable. Much of the group disagreed with ENT, and felt that although surgical intervention was not necessary at this time, if there is a clinical suspicion for osteomyelitis, a medical admission for early and aggressive IV therapy is.
In regards to imaging we had significant discussion regarding what types of CT to obtain. Is a CT maxofacial with contrast enough?- we all seemed to disagree with what was done. We discussed if orbit was necessary- maybe not seemed to be the consensus. We did feel that brain/forehead should have maybe been considered. We discussed having a discussion with radiology since we only have a few different ordering options but they have several different ordering protocols on their end.
In regards to labs: even though CBC, ESR, CRP does not change our management in the ED significantly ID may use it to trend response to IV abx.
In regards to bounce back we decided neurosurgery involvement, IV AED prophylaxis and abx should all be given promptly.
Denouement:
At the first visit, ENT was consulted who advised no further imaging as long as the patient looked well. Aggressive treatment with Afrin and antibiotics were advised. However, her sinusitis evolved and worsened. She returned with a Pott’s Puffy Tumor, which is osteomyelitis of the frontal bone with associated intracranial, subperiosteal abscess. Neurosurgery was consulted. She was given Vancomycin, Ceftriaxone and Flagyl in the ED and loaded with Keppra as well, although she had no return of seizures while in the ED. The patient was taken to the OR with ENT for endoscopic sinus surgery revealing right sided pansinusitis with significantly edematous nasal and sinus mucosa throughout. Purulence in R maxillary and R frontal sinus drained. Cultures showed light growth of Staph epidermidis and strep intermedius. Repeat MRI several weeks later showed no abscess with improved frontal bone enhancement and dural enhancement.
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