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Ugeskrift For Laeger Dec 2023In this case report, two patients were initially presented with orbital symptoms due to undiagnosed sinonasal disease. An eight-year-old girl was suspected of preseptal...
In this case report, two patients were initially presented with orbital symptoms due to undiagnosed sinonasal disease. An eight-year-old girl was suspected of preseptal cellulitis due to swelling and redness around the right eye for a month. MRI of the orbit showed a change in the orbit suspected to be a tumour. Regression in symptoms was seen after three months and a mucocele was suspected. The other patient was a 57-year-old woman suspected of left-side acute dacryocystitis with a palpable mass above the medial canthus for a month. MRI was performed due to atypical presentation and showed tumour changes originating from the ethmoid sinus.
Topics: Female; Humans; Middle Aged; Child; Orbit; Head; Neoplasms
PubMed: 38105733
DOI: No ID Found -
Journal of Neurosurgery Sep 2023A reluctance to monitor extraocular cranial nerve (EOCN) function has restricted skull base surgery worldwide. Spontaneous and triggered electromyography (EMG)...
OBJECTIVE
A reluctance to monitor extraocular cranial nerve (EOCN) function has restricted skull base surgery worldwide. Spontaneous and triggered electromyography (EMG) monitoring can be recorded intraoperatively to identify and assess potential cranial nerve injury. Determining the conductive function of EOCNs requires the collection of clear, reliable, and repeatable compound muscle action potentials (CMAPs) secondary to stimulation. EOCN EMG needle electrodes can, although infrequently, cause ocular morbidity including hematoma, edema, and scleral laceration. The aim of this study was to ascertain if minimally invasive 7-mm superficial needle electrodes would record CMAPs as well as standard 13-mm intraorbital electrodes.
METHODS
Conventionally, the authors have monitored EOCN function with intraorbital placement of paired 13-mm needle electrodes into three extraocular muscles: medial rectus, superior oblique, and lateral rectus. A prospective case-control study was performed using shorter (7-mm) needle electrodes. A single minimally invasive electrode was placed superficially near each extraocular muscle and coupled with a common reference. CMAPs were recorded from the minimally invasive electrodes and compared with CMAPs recorded from the paired intraorbital electrodes. The presence or absence of CMAPs was analyzed and compared among EMG recording techniques.
RESULTS
A total of 429 CMAPs were analyzed from 71 EOCNs in 25 patients. The experimental setup yielded 167 true-positive (39%), 106 false-positive (25%), 17 false-negative (4%), and 139 true-negative (32%) responses. These values were used to calculate the sensitivity (91%), specificity (57%), positive predictive value (61%), and negative predictive value (89%). EOCN electrodes were placed in 82 total eyes in 58 patients (CMAPs were obtained in 25 patients). Twenty-six eyes showed some degree of edema, bruising, or bleeding, which was transient and self-resolving. Three eyes in different patients had complications from needle placement or extraction including conjunctival hemorrhage, periorbital ecchymosis, and corneal abrasion, ptosis, and upper eyelid edema.
CONCLUSIONS
Because of artifact contamination, 106 false-positive responses (25%), and 17 false-negative responses (4%), the minimally invasive EMG technique cannot reliably record CMAP responses intraoperatively as well as the intraorbital technique. Less-invasive techniques can lead to an inaccurate EOCN assessment and potential postoperative morbidity. EOCN palsies can be debilitating and lifelong; therefore, the benefits of preserving EOCN function outweigh the potential risks of morbidity from electrode placement. EMG monitoring with intraorbital electrodes remains the most reliable method of intraoperative EOCN assessment.
Topics: Humans; Electromyography; Case-Control Studies; Cranial Nerves; Electrodes; Oculomotor Muscles
PubMed: 36840739
DOI: 10.3171/2023.1.JNS221690 -
Archivos de La Sociedad Espanola de... Oct 2023VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is a newly described autoinflammatory entity caused by a UBA-1 gene mutation. Among the most...
VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is a newly described autoinflammatory entity caused by a UBA-1 gene mutation. Among the most frequent symptoms it produces fever, cytopenias, polychondritis, pulmonary infiltrates and up to 40% ocular involvement such as periorbital edema, uveitis, episcleritis, scleritis and retinal vasculitis. Patients respond to high doses of corticosteroids, however, many end up being refractory to them and to the classic immunosuppressants. We described the case of a 77-year-old male patient with ocular involvement in the form of episcleritis and periorbital edema who was later diagnosed with VEXAS Syndrome. The patient, after failing treatment with immunosuppressants, is currently receiving treatment with oral steroids and tocilizumab. Ophthalmologist must be aware of the ophthalmological affectation of autoinflammatory diseases and especially of this new entity described as the VEXAS Syndrome.
Topics: Male; Humans; Aged; Scleritis; Eye Diseases; Eye; Cellulitis; Edema
PubMed: 37595794
DOI: 10.1016/j.oftale.2023.07.004 -
Cureus May 2024Periorbital necrotizing fasciitis (NF) is a devastating bacterial infection associated with irreversible inflammatory destruction of soft tissues. Outcomes include...
Periorbital necrotizing fasciitis (NF) is a devastating bacterial infection associated with irreversible inflammatory destruction of soft tissues. Outcomes include disfigurement, vision loss, septic shock, and death within hours to days. We describe two cases of periorbital NF that presented to our unit within a three-month period. We aim to highlight the key clinical features of periorbital NF, demonstrate the rapid progression of the disease, and the need for prompt identification and decisive intervention. Both patients presented with fever and left-sided periorbital swelling and showed rapid progression of swelling and gangrenous changes to the periorbital skin with worsening proptosis. They were treated with broad-spectrum intravenous antibiotics and underwent emergency surgical debridement of necrotic tissue followed by reconstruction. We propose a formal protocol that we recommend to aid the diagnosis and management of periorbital NF in an acute setting.
PubMed: 38826916
DOI: 10.7759/cureus.59501 -
Survey of Ophthalmology 2023Streptococcus is a diverse bacterial genus that is part of the ocular surface microbiome implicated in conjunctivitis, keratitis, endophthalmitis, dacryocystitis, and... (Review)
Review
Streptococcus is a diverse bacterial genus that is part of the ocular surface microbiome implicated in conjunctivitis, keratitis, endophthalmitis, dacryocystitis, and orbital cellulitis that can lead to decreased visual acuity and require surgical intervention. The pathophysiology of S. pneumoniae is well-established and the role of the polysaccharide capsule, pneumolysin, neuraminidases, and zinc metalloproteinases in ocular infections described. Additionally, key virulence factors of the viridans group streptococci such as cytolysins and proteases have been outlined, but there is a paucity of research on the remaining streptococcus species. These virulence factors tend to result in aggressive disease. Clinically, S. pneumoniae is implicated in 2.7-41.2% of bacterial conjunctivitis cases, more predominant in the pediatric population, and is implicated in 1.8-10.7% of bacterial keratitis isolates. Streptococcus bacteria are significantly implicated in acute postoperative, postintravitreal, and bleb-associated endophthalmitis, responsible for 10.3-37.5, 29.4, and 57.1% of cases, respectively. Group A and B streptococcus endogenous endophthalmitis is rare, but has a very poor prognosis. Inappropriate prescription of antibiotics in cases of nonbacterial aetiology has contributed to increasing resistance, and a clinical index is needed to more accurately monitor this. Furthermore, there is an increasing need for prospective, surveillance studies of antimicrobial resistance in ocular pathogens, as well as point-of-care testing using molecular techniques.
Topics: Child; Humans; Prospective Studies; Streptococcus; Anti-Bacterial Agents; Endophthalmitis; Streptococcal Infections; Eye Infections, Bacterial; Streptococcus pneumoniae; Keratitis
PubMed: 36764397
DOI: 10.1016/j.survophthal.2023.02.001 -
Aesthetic Plastic Surgery May 2024The main causes of ecchymosis and edema are osteotomy (bone manipulation), dissection of subcutaneous tissue, and skin manipulation in the rhinoplasty procedure. Eyelid...
The main causes of ecchymosis and edema are osteotomy (bone manipulation), dissection of subcutaneous tissue, and skin manipulation in the rhinoplasty procedure. Eyelid edema following surgery can potentially affect visual acuity, particularly during the initial twenty-four hours after the procedure. These may also delay the patient's return to their normal social life therefore hampering their quality of life. Various surgical and medical methods have been reported to address these issues. This study aimed to compare the effects of using cold saline (0-4 °C) versus room temperature saline (20-25 °C) irrigation throughout the surgery on postoperative edema, ecchymosis, and pain. Fifty patients who underwent open-approach primary rhinoplasty between August 2022 and August 2023 at a tertiary academic center were included. Fifty patients were randomly divided into two groups depending on using cold saline (0-4 °C) (group 1) or room temperature saline (20-25 °C) (group 2) during surgical site irrigation. Patients were assessed for pain, edema, and bruising using a VAS (Visual Analog Scale) on the second and seventh postoperative days. Visual analog score (VAS) was used for subjective outcome analyses. Each patient scored the severity of their periorbital ecchymosis on day two and seven. Periorbital ecchymosis was also evaluated on the second and seventh postoperative days using the SPREE (Surgeon Periorbital Rating of Edema and Ecchymosis) scale. On the second postoperative day, the VAS pain score in group 1, where cold water was used, was found to be statistically and significantly different from the control group (group 2) (p < 0.05). However, there was no statistically significant difference between both groups when comparing the VAS pain scores on the seventh postoperative day. Regarding the VAS ecchymosis score on the seventh postoperative day, there was a statistically significant difference favoring group 1 (p < 0.05). The SPREE scale data also indicated that group 1 had significantly lower scores on the seventh day (p < 0.05). While the SPREE scores on the second day were lower in group 1 than in group 2, this difference did not reach statistical significance (p = 0.061). The findings from our study show that cold saline irrigation may contribute to intraoperative hemostasis by inducing local vasoconstriction. We observed that intraoperative bleeding decreased with the use of cold saline. This approach has the potential to improve patient satisfaction and overall quality of life by reducing postoperative ecchymosis without significantly increasing the cost of the surgical procedure.Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
PubMed: 38806826
DOI: 10.1007/s00266-024-04105-y -
Journal of General Internal Medicine Aug 2023Cellulitis is a clinical diagnosis with several mimics and no gold standard diagnostic criteria. Misdiagnosis is common. This review aims to quantify the proportion of... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Cellulitis is a clinical diagnosis with several mimics and no gold standard diagnostic criteria. Misdiagnosis is common. This review aims to quantify the proportion of cellulitis misdiagnosis in primary or unscheduled care settings based on a second clinical assessment and describe the proportion and types of alternative diagnoses.
METHODS
Electronic searches of Medline, Embase and Cochrane library (including CENTRAL) using MeSH and other subject terms identified 887 randomised and non-randomised clinical trials, and cohort studies. Included articles assessed the proportion of cellulitis misdiagnosis in primary or unscheduled care settings through a second clinical assessment up to 14 days post initial diagnosis of uncomplicated cellulitis. Studies on infants and patients with (peri-)orbital, purulent and severe or complex cellulitis were excluded. Screening and data extraction was conducted independently in pairs. Risk of bias was assessed using a modified risk of bias tool from Hoy et al. Meta-analyses were undertaken where ≥ 3 studies reported the same outcome.
RESULTS
Nine studies conducted in the USA, UK and Canada, including a total of 1600 participants, were eligible for inclusion. Six studies were conducted in the inpatient setting; three were in outpatient clinics. All nine included studies provided estimates of the proportion cellulitis misdiagnosis, with a range from 19 to 83%. The mean proportion misdiagnosed was 41% (95% CI 28 to 56% for random effects model). Heterogeneity between studies was very high both statistically (I 96%, p-value for heterogeneity < 0.001) and clinically. Of the misdiagnoses, 54% were attributed to three conditions (stasis dermatitis, eczematous dermatitis and edema/lymphedema).
DISCUSSION
The proportion of cellulitis misdiagnosis when reviewed within 14 days was substantial though highly variable, with the majority attributable to three diagnoses. This highlights the need for timely clinical reassessment and system initiatives to improve diagnostic accuracy of cellulitis and its most common mimics.
TRIAL REGISTRATION
Open Science Framework ( https://osf.io/9zt72 ).
Topics: Humans; Cellulitis; Diagnostic Errors; Canada
PubMed: 37231210
DOI: 10.1007/s11606-023-08229-w -
Ophthalmic Plastic and Reconstructive...A 66-year-old immunocompromised man presented with cellulitis around the left eye that was initially concerning for necrotizing fasciitis. Exam findings were remarkable...
A 66-year-old immunocompromised man presented with cellulitis around the left eye that was initially concerning for necrotizing fasciitis. Exam findings were remarkable for exquisite periocular tenderness with rigid, immobile eyelids resulting from severe erythema, edema, and induration. Given the concern for orbital compartment syndrome and a necrotizing infection, the patient was taken urgently to the operating room for debridement of the eyelid skin as well as an urgent lateral canthotomy and cantholysis. His eye exam revealed 360° of hemorrhagic chemosis, no relative afferent pupillary defect, and an ipsilateral elevated intraocular pressure of 35 mm Hg. No visual acuity measurement could be obtained secondary to the patient's altered mental status. His intraocular pressure normalized after treatment with antihypertensive drops and further extension of the canthotomy. Histopathological analysis showed extensive neutrophilic infiltrate of the dermis which was compatible with a diagnosis of Sweet's syndrome.
Topics: Male; Humans; Aged; Intraocular Pressure; Sweet Syndrome; Orbit; Cellulitis; Eyelids
PubMed: 36893059
DOI: 10.1097/IOP.0000000000002373