CT scan helps predict need for surgery in pediatric orbital cellulitis

This retrospective review shows that using both radiological signs on orbital computerized tomography (CT) and Chandler criteria can more accurately predict which patients will require surgery for orbital cellulitis.

The authors reviewed the radiological features of 101 patients with orbital cellulitis in an effort to develop a staging system that includes these findings, and then evaluated whether this classification system increases the ability to predict which patients will need surgery.

They found that bony destruction was significantly associated with surgical intervention, and that subperiosteal abscess size was significantly correlated with management outcome. Additionally, applied to this series, the Chandler classification system did not predict when surgical intervention is likely.

Based on their data, they propose a modification of the Chandler classification system for children with orbital cellulitis utilizing both clinical and radiological information:

• Stage I: prespetal cellulitis that has not yet compromised the postseptal space of the orbit
• Stage II: signs of postseptal inflammation, such as orbital fat edema/stranding and scleral thickening
• Stage III: phlegmon or subperiosteal abscess formation \3.8 mL
• Stage IV: abscess or phlegmon collection .3.8 mL
• Stage V: extraorbital complications, including cavernous sinus thrombosis and intracranial extension

Patients in stage IV are six times more likely to require surgical intervention than those in stage III.

The authors conclude that deciding whether and when to perform subperiosteal abscess surgical drainage is complex, and involves factors such as the patient’s clinical response to systemic antibiotic treatment, the size and location of the fluid collection, as well as the surgeon’s skill and experience. In this series, decision to treat surgically was greatly influenced by the child’s clinical deterioration or lack of improvement (such as persistent fever or decreasing visual acuity) on systemic antibiotics, which is usually corroborated by worsening of radiological signs on CT.