Early CT Imaging in Severe Orbital Infections

Source: Yu WW, Borkhoff CM, Mahant S, et al. Factors associated with early computed tomography imaging in children hospitalized with severe orbital infections. Hosp Pediatr. 2025;15(1):28-36. doi: 10.1542/hpeds.2024-007990.Investigators from multiple institutions in Canada conducted a retrospective study to identify factors associated with early CT imaging in children hospitalized with severe orbital infections. Participants were patients 2 months to 18 years old hospitalized with periorbital or orbital cellulitis at 1 of 10 hospitals in Canada from 2009 to 2019. Study patients were identified using ICD-10 codes, and the medical records of those meeting eligibility criteria were reviewed. Data collected from the medical records included type of hospital (community or children’s), demographics, physical examination findings in the ED, prior antibiotic treatment, time and day of presentation (weekend, weekday, weekday evening), subspecialty consultation within 24 hours, laboratory findings including white blood cell (WBC) count and C-reactive protein (CRP), and whether a CT was obtained. The primary study outcome was receiving an early CT scan, defined as within 24 hours of ED presentation. Multivariate Poisson regression analysis was used to identify independent predictors or early CT. Variables in the model included hospital factors (type of hospital, time of day of presentation, subspecialty consultation), patient factors (age, prior antibiotics, fever), clinical findings (proptosis, eye swollen shut), and laboratory factors (WBC and CRP).Data were analyzed on 1,144 children with a median age of 4.8 years. Among the study participants, 769 (67.2%) had a diagnosis of periorbital cellulitis, and 66 (32.8%) were diagnosed with orbital cellulitis. Overall, 494 (43.2%) patients received a CT scan within 24 hours of ED presentation. In the multivariate model, hospital factors significantly associated with an early CT scan included presentation to a children’s hospital (adjusted relative risk [aRR], 1.80; 95% confidence interval [CI], 1.32, 2.45), ophthalmology consult (aRR, 2.19; 95% CI, 1.66, 2.90), and otolaryngology consult (aRR, 2.66; 95% CI, 1.84, 3.36). Compared to those 5 to 9 years old, children <5 years of age were less likely to receive a CT scan (aRR, 0.63; 95% CI, 0.53, 0.74). Proptosis was present in 31.4% of children with an early CT scan compared to 3.2% of those with no CT scan (aRR, 1.39; 95% CI, 1.24, 1.57), and having an eye swollen shut was noted in 36.2% and 22.7%, respectively, of patients receiving or not receiving an early CT scan (aRR, 1.27; 95% CI, 1.13, 1.43). Neither the presence of fever or previous antibiotic treatment were predictors of early CT scans. Among laboratory factors, there was no significant association between early CT scan and either WBC count or CRP level.The authors conclude that patient and hospital factors were associated with early CT scans in children with severe orbital infections, but inflammatory markers were not.Dr Loyal has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Investigators in the current study shed light on factors associated with early CT imaging in hospitalized Canadian children with periorbital or orbital cellulitis. Their findings build on work done in single-center settings1 and is strengthened by multiple participating hospitals and a decade of data. Acknowledging that severe orbital infections are largely a clinical diagnosis, previous investigators noted that laboratory markers such as WBC and CRP, previously associated with more severe outcomes, were not associated with early imaging. These investigators hypothesize that, perhaps, institutional clinical pathways that are being increasingly utilized to aid clinical decision-making2 have not yet incorporated WBC and CRP into their algorithms for severe orbital infections and more education is needed.A notable finding of the current study was that children under 5 years of age were less likely to undergo early CT imaging, potentially due to the need for sedation or clinician concern regarding radiation risk. In a previous study of orbital cellulitis, children >5 years were more likely to require surgery. (See AAP Grand Rounds. 2022;48[3]:33.)3 Reducing the number of unnecessary CT scans is important, to reduce the pediatric radiation dose.4 Pediatric clinicians, however, ought to avoid relying solely on radiation risk as a reason to delay or forgo imaging, especially when decision-making is further complicated by a high-risk, low-prevalence disease and the need to practice high-value care while prioritizing patient safety. Another area of opportunity is better understanding the utility and accuracy of ultrasound as an alternative imaging modality.5Children who had early CT imaging may have been sent to a children’s hospital for imaging because of suspected orbital infections. The retrospective nature of the current study makes this difficult to ascertain.In hospitalized children with severe orbital infections, established clinical factors (eg, proptosis) and hospital factors (community or children’s), rather than inflammatory markers (eg, CRP), are associated with early CT imaging.

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