A 12-year-old male with a history of autism spectrum disorder and chronic sinusitis presented for forehead swelling. His mother reported that she noticed progressive forehead swelling for about one month. She had followed up with the patient’s pediatrician and ENT and was given oral cephalexin and fluticasone nasal spray which did not make any changes in his symptoms. The patient denied any fevers or headaches.
A 5-year-old generally healthy fully immunized boy presented to the ED with worsening left ear redness, swelling, and tenderness that his family noticed the day before presentation. His family had also recently noticed an abrasion over that ear. The patient was on amoxicillin for strep throat, which was diagnosed a week before the onset of his symptoms and was improving.
A 32-year-old man with a history of traumatic globe rupture from a stab wound two months ago, status post repair, presented to the emergency department for worsening right eye pain and green malodorous drainage for the past three days. These symptoms started when he got a fleck of sawdust in the right eye about four days prior to presentation, which he was able to brush out with his finger. He described the pain as severe, throbbing, constant, and non-radiating. He had been unable to open the right eyelid for three days, both due to pain and from the thick sticky discharge that adhered his eyelids together. He reported that his vision had been normal before these symptoms started. On review of systems, he reported nausea that started on the day of presentation but otherwise denied any vision loss or pain in the other eye.
General: Nontoxic appearing but seemed quite uncomfortable.
Eye: On inspection, he had substantial right upper and lower eyelid swelling and erythema, with a green discharge dripping from the palpebral fissure. There was a well-healed scar on the bottom eyelid. The lateral canthus appeared inferiorly displaced. The patient was unable to open his right eye actively, and was unable to tolerate passive opening due to severe discomfort, despite pain medication.
White blood cell (WBC) count: 9.1 x 10^3 /uL with 80.4% neutrophils
Complete metabolic panel (CMP): Within normal limits
Procalcitonin:<0.05 ng/mL
Lactate: 1.4 mmol/L
Cultures from the eye revealed penicillin-sensitive Streptococcus pneumoniae.
Pain with extraocular movements should be present in orbital cellulitis due to inflammation of the structures deep within the orbit. Although not sensitive, proptosis, leukocytosis & fever, chemosis, or any visual impairment should raise concern for orbital cellulitis.
In this patient, displacement of the lateral canthus likely represents a mass effect from his orbital abscess. This abscess is seen lateral to the globe on imaging. On ultrasound, it appears as a heterogeneous isoechoic collection that abuts the right globe. A hyperechoic structure between the orbit and this collection with shadowing raises the possibility of a foreign body. Debris is also visible throughout the right globe and within the anterior chamber. On CT scan, the abscess is described as a rim-enhancing fluid collection that adheres to the lateral rectus muscle. The hyperdense foreign body is again seen on CT, as well as a small focus of air within the anterior chamber.
An otherwise healthy 34-year-old male presented to the Emergency Department with two weeks of anterior neck pain. Symptoms began with several days of pain in his mandibular molars, progressing to pain and swelling in the neck. In the last several days, the patient developed warmth and redness in the chest wall associated with subjective fever and chills. Additionally, the patient reports difficulty swallowing solid foods secondary to odynophagia associated with intermittent globus sensation. He has no history of immunocompromise and denies any drug or alcohol use. Of note, he has not seen a dentist in many years.
Vitals: BP 115/80; HR 120; T 101°F; RR 16; O2 sat 97%
General: Well appearing in no acute distress
HEENT: Poor dentition, mild trismus. No gingival inflammation or swelling or induration to suggest abscess. The floor of the mouth is unremarkable.
Skin: The neck and upper chest demonstrate erythema and tenderness with an enlarged area of fluctuance on the superior aspect of the left breast (Figure 1).
White blood cell (WBC) count: 6.3 k/uL
Lactate: 1.6 mmol/L
Glucose: 95 mg/dL
Creatinine: 0.72 mg/dL
Lemierre Syndrome, also known as septic thrombophlebitis of the internal jugular vein, is a rare condition with an incidence of 3-15 cases per million people. This condition occurs when an oropharyngeal or odontogenic infection spreads locally from pharyngeal tissue to the internal jugular vein. The pathogens classically arise from normal oral flora, most commonly Fusobacterium necrophorum. The presentation may be associated with trismus and/or dysphagia. Subsequent complications, including localized abscess formation and bacteremia, stem from a combination of surrounding tissue invasion and systemic septic embolization.
Given the potential for regional lymphatic spread and septic embolization, patients may present with both local and systemic findings. Skin exam may reveal regionalized cellulitic or infectious changes overlying the neck or chest (Figure 1).
Respiratory signs and symptoms may suggest the presence of pulmonary septic emboli or mediastinitis.
Constitutional symptoms including fever, chills, and fatigue are common though nonspecific. The differential is broad and includes a number of infectious, lymphatic, endocrine, and neoplastic conditions.
It is essential for the clinician to consider the alternative diagnosis of Ludwig’s Angina through careful evaluation of the oral floor.
Given the potential for oropharyngeal and respiratory compromise, emergency clinicians must maintain a high index of suspicion for this condition. Diagnostics should include laboratory studies with blood cultures, as well as CT imaging of the neck and chest to evaluate for filling defects of the internal jugular vein.
When entertaining the diagnosis, early antibiosis is prudent. Treatment should include both an extended course of antibiotic therapy as well as surgical source control of abscesses. Given the propensity for thrombus development (Figure 2), anticoagulation may be considered, but its indication here remains controversial. Patients with Lemierre Syndrome will require surgical consultation and hospital admission.
A 44-year-old female presented to the emergency department with the complaint of a “stone under [her] tongue.” She reported that the “stone” had been present and painless for two years. The day prior, she began experiencing pain at this site while brushing her teeth. She squeezed the area in an attempt to expel it, but this action only increased her pain.
Vitals: BP 156/92; Pulse 80; Temp 98.4°F; Resp 14; SpO2 100%
General: Sitting on chair, no acute distress
HEENT: Localized swelling to the inferior lingual frenulum at Wharton’s duct with associated erythema. Partially visualized white calculus, palpable through the mucosal membrane.
None
Sialolith in Wharton’s Duct. There was visual and tactile evidence of a calculus under the patient’s tongue. It had slowly grown and was associated with increased pain and swelling while brushing her teeth.
The majority of sialoliths can be managed conservatively with hydration, moist heat application, massaging of the gland, milking the duct, and advising the patient to suck on tart candies to promote salivation. Larger, more superficial sialoliths may benefit from excision in the emergency department. In the case above, local anesthetic was injected, and manual expulsion was attempted but was unsuccessful. The emergency physician made a single 1 cm incision over the calculus and a 0.5 cm x 0.75 cm sialolith was removed with minimal bleeding. The patient was discharged on a course of amoxicillin-clavulanic acid.
A 29 year-old-male with a past medical history of left eye enucleation secondary to a gunshot wound several years prior presents to the Emergency Department (ED) for blurry vision, redness, and concern for a deformity to his right eye. The patient states symptoms started 2-3 months ago and he initially thought symptoms were due to allergies and recalls rubbing his eye a lot. Over the past 3-4 days, he noticed an acute decline in his vision with what the patient describes as a “cloudy bump” appearing during that time. The patient normally does not wear contacts or corrective lenses but states his vision is very blurry and he is now having difficulty reading. He also reports photophobia and mild eye pain. Review of systems is negative for any fevers, headache, eye discharge, or any recent falls or trauma.
Vitals: BP 125/83; Pulse 70; Temp 97.6 F (36.4 C); Resp 17; SpO2 100%
Constitutional: No acute distress, lying in stretcher comfortably.
Head: No visible traumatic injuries. No peri-orbital edema or facial swelling.
Eyes:
Nose: No foreign bodies.
Mouth/Throat: Oropharynx is clear and moist and mucous membranes are normal.
Neck: Normal range of motion.
None
Corneal hydrops secondary to keratoconus.
Keratoconus is a degenerative, multifactorial, non-inflammatory disorder of the cornea that causes bilateral thinning of the cornea and distorted vision. The corneal thinning leads to a structural weakness in the collagen fibers that causes the characteristic bulging, “cone-shaped” cornea. If the thinning is significant enough, a break in collagen fibers and Descemet’s membrane lead to sudden edema which appears as a corneal opacification. This complication is known as corneal hydrops and causes sudden eye pain and decreased visual acuity. Patients with keratoconus present in young adulthood with progressive blurry or distorted vision. Risk factors include connective tissue disorders and Down syndrome as well as a familial history of keratoconus. There is also a risk in patients with a history of eye rubbing as was the case with this patient. The initial treatment for keratoconus is corrective eyewear for refractive correction.
The clinical hallmark of keratoconus is the cone-like protrusion of the cornea. The bulging may eventually lead to “Munson’s sign”, a v-shaped indentation of the lower eyelid on downward gaze as the cornea bulges outward that is seen in advanced keratoconus.
A 5-year-old male with a history of recent frontal sinusitis associated with preseptal cellulitis requiring surgery presented with facial swelling. Swelling developed in the 24 hours prior to presentation without facial pain, nausea, or emesis. Denied facial trauma as well as any neurologic deficits, loss of consciousness, headaches, or fever/chills. At the time of his prior surgery, he presented with swelling localized to the left eye along with worsening pain, nausea, and emesis. After surgery, he was discharged in stable condition on antibiotics for 10 days. He has been in his usual state of health since that time.
Vitals: BP 93/59 (Sitting); HR 84; Temp 37.3 °C (99.1 °F) (Oral); Resp 12; Wt 20.6 kg (45 lb 6.6 oz)
General: Active, alert, normal development, and in no acute distress
HEENT: Swelling over the forehead and nasal bridge. Tenderness to palpation over the forehead. No erythema or overlying skin changes.
Nose: Normal appearance. No congestion or rhinorrhea.
Mouth/Throat: Mucous membranes are moist. Oropharynx is clear.
White blood cell (WBC) count: 8.9 x 10^3/uL
Hemoglobin: 11.5 g/dL
Platelets: 365 x 10^3/uL
ANC: 4.490 x 10^3/uL
ESR: 15 mm
CRP: <0.5 mg
In the initial management of this patient, CT imaging of the head with contrast should be used to characterize the lesion and evaluate for intracranial involvement. In our patient, the CT scan showed frontal bone osteomyelitis with possible extension into the subdural space. He was admitted on broad-spectrum antibiotics and surgical washout was performed the following day.
Pott’s Puffy Tumor is a rare but serious complication of sinusitis with potential intracranial involvement. Complications include orbital cellulitis, intracranial abscess, meningitis, and cavernous sinus thrombosis.
