- Email: [email protected]
Bilateral orbital preseptal cellulitis after combined adenotonsillectomy and strabismus surgery—Case report and pathogenetic hypothesis
International Journal of Pediatric Otorhinolaryngology 77 (2013) 1209–1211
Contents lists available at SciVerse ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Case report
Bilateral orbital preseptal cellulitis after combined adenotonsillectomy and strabismus surgery—Case report and pathogenetic hypothesis E. Muzzi a,*, F. Parentin b, G. Pelos a, D.L. Grasso a, L. Lora a, F. Trabalzini c, S. Pensiero b, E. Orzan a a
Audiology and ENT Unit, Department of Pediatrics, Institute for Maternal and Child Health – IRCCS ‘‘Burlo Garofolo’’, Via dell’Istria 65/1, 34137 Trieste, Italy Ophthalmology Unit, Department of Pediatrics, Institute for Maternal and Child Health – IRCCS ‘‘Burlo Garofolo’’, Via dell’Istria 65/1, 34137 Trieste, Italy c Department of Sense Organs, Otology and Skull Base Surgery Unit, Siena University Hospital, Siena, Italy b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 6 November 2012 Received in revised form 6 April 2013 Accepted 9 April 2013 Available online 7 May 2013
The first case of bilateral orbital preseptal cellulitis complicating combined adenotonsillectomy and strabismus surgery is reported. The issues of antimicrobial prophylaxis are discussed. The authors speculate about the possible routes of surgical site infection. Transient bacteraemia secondary to adenotonsillectomy may be theoretically a source of distant surgical site infection to the orbit, raising the issue of distant surgical site contamination during multidisciplinary surgery. Combined adenotonsillectomy and eye surgery might benefit from prophylactic systemic antibiotic administration. ß 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Periorbital cellulitis Adenoidectomy Tonsillectomy Eye surgery Postoperative complications Surgical site infection
1. Introduction Adenotonsillectomy and strabismus surgery are the most common procedures performed in children by ENT surgeons and ophthalmologists respectively. Antimicrobial prophylaxis is not strictly recommended for these operations [1,2]. Periocular infections are rare complications of strabismus surgery [3]. Orbital cellulitis can be classified as preseptal and postseptal cellulitis based on the anatomical landmark, the orbital septum. The septum forms a barrier, preventing the spread of superficial infection into the deeper orbit. Infection of the soft tissues anterior to the orbital septum is also named periorbital cellulitis. Clinical distinction between preseptal and postseptal cellulitis is important as the ocular morbidity and prognosis differ. Actual orbital infection is marked by proptosis and ophtalmoplegia, is rare and is due either to advanced purulent sinusitis or to penetrating orbital trauma [4]. Bacteraemia can be induced by a variety of procedures involving manipulation of heavily colonized mucous membranes of the upper airways, in particular when the integrity of the pharyngeal mucosa is breached. Although this usually does not cause any problems in healthy individuals, it may lead to infective complications, e.g. in high-risk cardiac patients or patients with joint prostheses. Antibiotic prophylaxis is still recommended in
* Corresponding author. Tel.: +39 3393653679; fax: +39 0403785537. E-mail addresses: [email protected], [email protected] (E. Muzzi). 0165-5876/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijporl.2013.04.007
these high-risk patients before any invasive procedure that may cause bacteraemia [5]. To the best of our knowledge, this is the first case report of bilateral orbital preseptal cellulitis occurring after combined adenotonsillectomy and strabismus surgery. 2. Case report A 3-year-old boy with a history of adenotonsillar hypertrophy with posterior nasal obstruction, recurrent tonsillitis and essential infantile esotropia with ‘‘V’’ pattern underwent combined ENT and eye surgery. The procedures were carried out under general anaesthesia with endotracheal intubation. The patient underwent a 5-mm right medial rectus recession through limbal approach and bilateral inferior oblique recession through an infero-temporal approach. Muscle-scleral sutures were performed using 6-0 Vicryl stitches (Ethicon Inc., Somerville, NJ), while conjunctival incisions were closed with 8-0 Vicryl stitches. Instillation of a single drop of povidone-iodine in the fornix of the eyes was done before starting surgery. Topical medication with combined dexamethasone 0.1% and tobramicine 0.3% ointment was performed at the end of the operation. Eyes were then covered with sterile pad dressings and a sterile operative field was prepared for adenotonsillectomy. A McIvor mouth gag was inserted. Adenoidectomy was performed by curettage. Cold dissection was used for the bilateral extracapsular tonsillectomy. Moderate bleeding occurred. Haemostasis was rapidly achieved by bismuth subgallate added to gauze swabs. There were no intra-operative complications. The patient was
1210
E. Muzzi et al. / International Journal of Pediatric Otorhinolaryngology 77 (2013) 1209–1211
3. Discussion
Fig. 1. Right eye.
discharged the day next to the operation on acetaminophen 200 mg plus codeine 5 mg suppositories and combined dexamethasone 0.1% and tobramicine 0.3% eye-drops three times per day. On the second postoperative day, mild congestion and redness were noted in both eyes. On the fourth day after surgery, the boy was readmitted for fever up to 38 8C and increasing conjunctival redness with chemosis and palpebral swelling. No proptosis was noted; visual acuity was normal and extraocular movements could not be fully tested because of severe pain. A mild limitation of abduction and elevation in his right eye was pointed out. Fundal examination was normal. Eye and periorbital tissue examination was therefore consistent with bilateral anteroseptal orbital cellulitis without endophtalmitis. Computed tomography imaging was judged not costeffective for supporting the clinical diagnosis, due to the risks of radiation exposure in children. No bacterial growths from conjunctival swabs were observed. A nasal swab grew Moraxella catarrhalis, which was considered as a commensal organism of the respiratory tract because no signs of rhinosinusitis were found at endoscopic examination, and the pharynx was healing well. A full blood count showed a leucocytosis of 16.55 103 per mL, predominantly neutrophils. Intravenous ceftriaxone 80 mg/kg/die, topical dexamethasone 0.1% and tobramicine 0.3% eyedrops and topical ofloxacine 0.3% ointment were administered for 7 days, resulting in prompt clinical improvement (Figs. 1 and 2). No postoperative haemorrhage occurred from the pharynx. Patient was discharged 7 days after re-admission. One month postoperatively, a minimal residual esotropia is noticeable, without ‘‘V’’ pattern. Nasal breathing is markedly improved and no further episodes of sore throat are reported.
Fig. 2. Left eye.
According to Shapiro et al. [4], the causes of periorbital cellulitis can be classified in secondary to sinusitis, secondary to disruption of local skin integrity and cases associated with bacteraemia with no apparent predisposing factors. The haematogenous spread of microorganisms from distant sources to the orbit is well recognized. Argelich et al. [6] reported the case of orbital cellulitis and endogenous endophtalmitis secondary to calculus cholecystitis. Bilateral orbital cellulitis with negative blood and throat cultures has been also reported as a consequence of periorbital botox injection [7]. A transient bacteraemia has been observed in patients who undergo tonsillectomy and adenoidectomy. The rate of bacteraemia has been reported to range from 13% to 41% during tonsillectomy and from 6.25% to 40% during adenoidectomy. It does not seem that transient bacteraemia is related to the presence of bacterial colonization of the tonsils or adenoids. Moreover, several studies have demonstrated the absence of bacteraemia before oral cavity and pharyngeal procedures [5]. The pathogenesis of this kind of bacteraemia is unknown, but it has been proposed that it may be related to traction of the tonsils during dissection or retrograde flow of bacteria from exposed vessels. Patients with greater amount of bleeding during tonsillectomy are at higher risk of developing bacteraemia [8]. Bacteraemia during adenoidectomy may be a result of manipulation of the operative site, in particular digital examination, compression, and gauze application [9]. Kocaturk et al. [10] suggested that cold dissection techniques might be at higher risk of transient bacteraemia after tonsillectomy. Adenoidectomy techniques, either suction diathermy or curettage, do not differ in terms of the incidence of bacteraemia [5]. Transient bacteraemia usually lasts no more than 15–30 min and is generally harmless in healthy individuals. The microorganisms associated with this bacteraemia are usually completely eliminated by the host defence mechanisms within 1 h [5]. On the basis of a systematic review, including meta-analyses, Dhiwakar et al. [1] advocate against the routine prescription of antibiotic prophylaxis to patients undergoing tonsillectomy. Although bacteraemia does not have clinical significance in otherwise healthy children, it may have consequences for high-risk patients. The incidence of periocular infection after strabismus surgery accounts for less than 1 in 1000 cases [2]. Routine instillation of a single drop of povidone-iodine in the fornix of the operated eye at the conclusion of the operation is accepted for prophylaxis by many authors [3]. Others do not recommend antibiotic prophylaxis for strabismus surgery at all [2]. Patients having limbal incision approach are 2.73 times more likely than those having fornix incision to develop pain and discharge after surgery. When antibiotic plus steroid drops are used, limbal-incision surgery is followed by a 3.6% incidence of pain and discharge. When only povidone-iodine is administered, the incidence of these complications raises to 10.7%. This may indicate the need for more antiinflammatory medications, with or without antibiotic, in this subset of patients [2]. Surgery of the medial rectus muscle involves orbital tissues close to the ethmoid cells. A damage of this area can result in the spread of virulent bacteria from the paranasal sinuses to the orbital tissues [3]. However, the endoscopic examination of the nose and the culture swabs were not consistent with this route of infection in the present report. Surgical site infection from local damage can be advocated as the cause of the orbital complication, but appropriate prophylaxis of eye surgery was performed, and conjunctival swabs were negative for bacterial growth. Although it is impossible to be certain of the cause of the infection, we hypothesize that bacteraemia after adenotonsillectomy may be involved in the pathogenesis of this case, according to the theory of bacteraemia from unapparent
E. Muzzi et al. / International Journal of Pediatric Otorhinolaryngology 77 (2013) 1209–1211
sources [4]. The inflammation of eye tissues after strabismus surgery and the transient bacteraemia after adenotonsillectomy could have favoured the onset of bilateral orbital preseptal cellulitis. This is actually a striking hypothesis, which should be explored in future research. Whether a subgroup of patients undergoing adenotonsillectomy might benefit from selective administration of antibiotics is unknown and needs to be investigated [1]. Combined multidisciplinary surgery during a single session of general anaesthesia can be offered to reduce the risks, the costs and the parental concerns related to multiple anaesthesia procedures in children. However, no informations are available on specific safety issues of this practice. 4. Conclusion The occurrence of bilateral orbital preseptal cellulitis as a complication of combined adenotonsillectomy and strabismus surgery is reported for the first time in the literature. The possible causes of surgical site infection are direct inoculation during surgery, contiguous paranasal sinus infection, and bacteraemia after adenotonsillectomy. Despite current evidence is elusive about the indications of antibiotic prophylaxis in adenotonsillectomy and strabismus surgery, these procedures might benefit from prophylactic systemic antibiotic administration to avoid infectious complications. The safety of combined surgery, which reduces the risks, the costs and the parental concerns related to multiple anaesthesia procedures, should be maximized as much as possible.
1211
The issue of distant surgical site contamination during combined multidisciplinary surgery needs further investigation. Conflict of interest statement Nothing to disclose. References [1] M. Dhiwakar, W.A. Clement, M. Supriya, W. McKerrow, Antibiotics to reduce posttonsillectomy morbidity, Cochrane Database Syst. Rev. 12 (2010) CD005607. [2] M.E. Wilson, Topical antibiotic/steroid medication for infection prophylaxis after strabismus surgery: is it custom or science? J. AAPOS 12 (2008) 321. [3] A. Basheikh, R. Superstein, A child with bilateral orbital cellulitis one day after strabismus surgery, J. AAPOS 13 (2009) 488–490. [4] E.D. Shapiro, E.R. Wald, B.A. Brozanski, Periorbital cellulitis and paranasal sinusitis: a reappraisal, Pediatr. Infect. Dis. 1 (1982) 91–94. [5] P. Casserly, S. Kieran, E. Phelan, E. Smyth, P. Lacy, Bacteremia during adenoidectomy: a comparison of suction diathermy adenoid ablation and adenoid curettage, Ann. Otol. Rhinol. Laryngol. 119 (2010) 526–529. [6] R. Argelich, N. Iba´n˜ez-Flores, J. Bardavio, A. Bure´s-Jelstrup, G. Garcı´a-Segarra, R. Coll-Colell, et al., Orbital cellulitis and endogenous endophthalmitis secondary to Proteus mirabilis cholecystitis, Diagn. Microbiol. Infect. Dis. 64 (2009) 442–444. [7] J. Diel, J. Zaky, From botulism to blindness, Proc. UCLA Healthc. 16 (2012) 1–3. [8] S. Koc, L. Gu¨rbu¨zler, G. Yenis¸ehirli, A. Eyibilen, I. Aladag˘, K. Yelken, et al., The comparison of bacteremia and amount of bleeding during adenotonsillectomy, Int. J. Pediatr. Otorhinolaryngol. 75 (2011) 12–14. [9] E. Okur, M. Aral, I. Yildirim, M.A. Kilic¸, P. Ciragil, Bacteremia during adenoidectomy, Int. J. Pediatr. Otorhinolaryngol. 66 (2002) 149–153. [10] S. Kocaturk, A. Yildirim, T. Demiray, G. Bahar, M.Z. Bakici, Cold dissection versus bipolar cauterizing tonsillectomy for bacteriemia, Am. J. Otolaryngol. 26 (2005) 51–53.
Contents lists available at SciVerse ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Case report
Bilateral orbital preseptal cellulitis after combined adenotonsillectomy and strabismus surgery—Case report and pathogenetic hypothesis E. Muzzi a,*, F. Parentin b, G. Pelos a, D.L. Grasso a, L. Lora a, F. Trabalzini c, S. Pensiero b, E. Orzan a a
Audiology and ENT Unit, Department of Pediatrics, Institute for Maternal and Child Health – IRCCS ‘‘Burlo Garofolo’’, Via dell’Istria 65/1, 34137 Trieste, Italy Ophthalmology Unit, Department of Pediatrics, Institute for Maternal and Child Health – IRCCS ‘‘Burlo Garofolo’’, Via dell’Istria 65/1, 34137 Trieste, Italy c Department of Sense Organs, Otology and Skull Base Surgery Unit, Siena University Hospital, Siena, Italy b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 6 November 2012 Received in revised form 6 April 2013 Accepted 9 April 2013 Available online 7 May 2013
The first case of bilateral orbital preseptal cellulitis complicating combined adenotonsillectomy and strabismus surgery is reported. The issues of antimicrobial prophylaxis are discussed. The authors speculate about the possible routes of surgical site infection. Transient bacteraemia secondary to adenotonsillectomy may be theoretically a source of distant surgical site infection to the orbit, raising the issue of distant surgical site contamination during multidisciplinary surgery. Combined adenotonsillectomy and eye surgery might benefit from prophylactic systemic antibiotic administration. ß 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Periorbital cellulitis Adenoidectomy Tonsillectomy Eye surgery Postoperative complications Surgical site infection
1. Introduction Adenotonsillectomy and strabismus surgery are the most common procedures performed in children by ENT surgeons and ophthalmologists respectively. Antimicrobial prophylaxis is not strictly recommended for these operations [1,2]. Periocular infections are rare complications of strabismus surgery [3]. Orbital cellulitis can be classified as preseptal and postseptal cellulitis based on the anatomical landmark, the orbital septum. The septum forms a barrier, preventing the spread of superficial infection into the deeper orbit. Infection of the soft tissues anterior to the orbital septum is also named periorbital cellulitis. Clinical distinction between preseptal and postseptal cellulitis is important as the ocular morbidity and prognosis differ. Actual orbital infection is marked by proptosis and ophtalmoplegia, is rare and is due either to advanced purulent sinusitis or to penetrating orbital trauma [4]. Bacteraemia can be induced by a variety of procedures involving manipulation of heavily colonized mucous membranes of the upper airways, in particular when the integrity of the pharyngeal mucosa is breached. Although this usually does not cause any problems in healthy individuals, it may lead to infective complications, e.g. in high-risk cardiac patients or patients with joint prostheses. Antibiotic prophylaxis is still recommended in
* Corresponding author. Tel.: +39 3393653679; fax: +39 0403785537. E-mail addresses: [email protected], [email protected] (E. Muzzi). 0165-5876/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijporl.2013.04.007
these high-risk patients before any invasive procedure that may cause bacteraemia [5]. To the best of our knowledge, this is the first case report of bilateral orbital preseptal cellulitis occurring after combined adenotonsillectomy and strabismus surgery. 2. Case report A 3-year-old boy with a history of adenotonsillar hypertrophy with posterior nasal obstruction, recurrent tonsillitis and essential infantile esotropia with ‘‘V’’ pattern underwent combined ENT and eye surgery. The procedures were carried out under general anaesthesia with endotracheal intubation. The patient underwent a 5-mm right medial rectus recession through limbal approach and bilateral inferior oblique recession through an infero-temporal approach. Muscle-scleral sutures were performed using 6-0 Vicryl stitches (Ethicon Inc., Somerville, NJ), while conjunctival incisions were closed with 8-0 Vicryl stitches. Instillation of a single drop of povidone-iodine in the fornix of the eyes was done before starting surgery. Topical medication with combined dexamethasone 0.1% and tobramicine 0.3% ointment was performed at the end of the operation. Eyes were then covered with sterile pad dressings and a sterile operative field was prepared for adenotonsillectomy. A McIvor mouth gag was inserted. Adenoidectomy was performed by curettage. Cold dissection was used for the bilateral extracapsular tonsillectomy. Moderate bleeding occurred. Haemostasis was rapidly achieved by bismuth subgallate added to gauze swabs. There were no intra-operative complications. The patient was
1210
E. Muzzi et al. / International Journal of Pediatric Otorhinolaryngology 77 (2013) 1209–1211
3. Discussion
Fig. 1. Right eye.
discharged the day next to the operation on acetaminophen 200 mg plus codeine 5 mg suppositories and combined dexamethasone 0.1% and tobramicine 0.3% eye-drops three times per day. On the second postoperative day, mild congestion and redness were noted in both eyes. On the fourth day after surgery, the boy was readmitted for fever up to 38 8C and increasing conjunctival redness with chemosis and palpebral swelling. No proptosis was noted; visual acuity was normal and extraocular movements could not be fully tested because of severe pain. A mild limitation of abduction and elevation in his right eye was pointed out. Fundal examination was normal. Eye and periorbital tissue examination was therefore consistent with bilateral anteroseptal orbital cellulitis without endophtalmitis. Computed tomography imaging was judged not costeffective for supporting the clinical diagnosis, due to the risks of radiation exposure in children. No bacterial growths from conjunctival swabs were observed. A nasal swab grew Moraxella catarrhalis, which was considered as a commensal organism of the respiratory tract because no signs of rhinosinusitis were found at endoscopic examination, and the pharynx was healing well. A full blood count showed a leucocytosis of 16.55 103 per mL, predominantly neutrophils. Intravenous ceftriaxone 80 mg/kg/die, topical dexamethasone 0.1% and tobramicine 0.3% eyedrops and topical ofloxacine 0.3% ointment were administered for 7 days, resulting in prompt clinical improvement (Figs. 1 and 2). No postoperative haemorrhage occurred from the pharynx. Patient was discharged 7 days after re-admission. One month postoperatively, a minimal residual esotropia is noticeable, without ‘‘V’’ pattern. Nasal breathing is markedly improved and no further episodes of sore throat are reported.
Fig. 2. Left eye.
According to Shapiro et al. [4], the causes of periorbital cellulitis can be classified in secondary to sinusitis, secondary to disruption of local skin integrity and cases associated with bacteraemia with no apparent predisposing factors. The haematogenous spread of microorganisms from distant sources to the orbit is well recognized. Argelich et al. [6] reported the case of orbital cellulitis and endogenous endophtalmitis secondary to calculus cholecystitis. Bilateral orbital cellulitis with negative blood and throat cultures has been also reported as a consequence of periorbital botox injection [7]. A transient bacteraemia has been observed in patients who undergo tonsillectomy and adenoidectomy. The rate of bacteraemia has been reported to range from 13% to 41% during tonsillectomy and from 6.25% to 40% during adenoidectomy. It does not seem that transient bacteraemia is related to the presence of bacterial colonization of the tonsils or adenoids. Moreover, several studies have demonstrated the absence of bacteraemia before oral cavity and pharyngeal procedures [5]. The pathogenesis of this kind of bacteraemia is unknown, but it has been proposed that it may be related to traction of the tonsils during dissection or retrograde flow of bacteria from exposed vessels. Patients with greater amount of bleeding during tonsillectomy are at higher risk of developing bacteraemia [8]. Bacteraemia during adenoidectomy may be a result of manipulation of the operative site, in particular digital examination, compression, and gauze application [9]. Kocaturk et al. [10] suggested that cold dissection techniques might be at higher risk of transient bacteraemia after tonsillectomy. Adenoidectomy techniques, either suction diathermy or curettage, do not differ in terms of the incidence of bacteraemia [5]. Transient bacteraemia usually lasts no more than 15–30 min and is generally harmless in healthy individuals. The microorganisms associated with this bacteraemia are usually completely eliminated by the host defence mechanisms within 1 h [5]. On the basis of a systematic review, including meta-analyses, Dhiwakar et al. [1] advocate against the routine prescription of antibiotic prophylaxis to patients undergoing tonsillectomy. Although bacteraemia does not have clinical significance in otherwise healthy children, it may have consequences for high-risk patients. The incidence of periocular infection after strabismus surgery accounts for less than 1 in 1000 cases [2]. Routine instillation of a single drop of povidone-iodine in the fornix of the operated eye at the conclusion of the operation is accepted for prophylaxis by many authors [3]. Others do not recommend antibiotic prophylaxis for strabismus surgery at all [2]. Patients having limbal incision approach are 2.73 times more likely than those having fornix incision to develop pain and discharge after surgery. When antibiotic plus steroid drops are used, limbal-incision surgery is followed by a 3.6% incidence of pain and discharge. When only povidone-iodine is administered, the incidence of these complications raises to 10.7%. This may indicate the need for more antiinflammatory medications, with or without antibiotic, in this subset of patients [2]. Surgery of the medial rectus muscle involves orbital tissues close to the ethmoid cells. A damage of this area can result in the spread of virulent bacteria from the paranasal sinuses to the orbital tissues [3]. However, the endoscopic examination of the nose and the culture swabs were not consistent with this route of infection in the present report. Surgical site infection from local damage can be advocated as the cause of the orbital complication, but appropriate prophylaxis of eye surgery was performed, and conjunctival swabs were negative for bacterial growth. Although it is impossible to be certain of the cause of the infection, we hypothesize that bacteraemia after adenotonsillectomy may be involved in the pathogenesis of this case, according to the theory of bacteraemia from unapparent
E. Muzzi et al. / International Journal of Pediatric Otorhinolaryngology 77 (2013) 1209–1211
sources [4]. The inflammation of eye tissues after strabismus surgery and the transient bacteraemia after adenotonsillectomy could have favoured the onset of bilateral orbital preseptal cellulitis. This is actually a striking hypothesis, which should be explored in future research. Whether a subgroup of patients undergoing adenotonsillectomy might benefit from selective administration of antibiotics is unknown and needs to be investigated [1]. Combined multidisciplinary surgery during a single session of general anaesthesia can be offered to reduce the risks, the costs and the parental concerns related to multiple anaesthesia procedures in children. However, no informations are available on specific safety issues of this practice. 4. Conclusion The occurrence of bilateral orbital preseptal cellulitis as a complication of combined adenotonsillectomy and strabismus surgery is reported for the first time in the literature. The possible causes of surgical site infection are direct inoculation during surgery, contiguous paranasal sinus infection, and bacteraemia after adenotonsillectomy. Despite current evidence is elusive about the indications of antibiotic prophylaxis in adenotonsillectomy and strabismus surgery, these procedures might benefit from prophylactic systemic antibiotic administration to avoid infectious complications. The safety of combined surgery, which reduces the risks, the costs and the parental concerns related to multiple anaesthesia procedures, should be maximized as much as possible.
1211
The issue of distant surgical site contamination during combined multidisciplinary surgery needs further investigation. Conflict of interest statement Nothing to disclose. References [1] M. Dhiwakar, W.A. Clement, M. Supriya, W. McKerrow, Antibiotics to reduce posttonsillectomy morbidity, Cochrane Database Syst. Rev. 12 (2010) CD005607. [2] M.E. Wilson, Topical antibiotic/steroid medication for infection prophylaxis after strabismus surgery: is it custom or science? J. AAPOS 12 (2008) 321. [3] A. Basheikh, R. Superstein, A child with bilateral orbital cellulitis one day after strabismus surgery, J. AAPOS 13 (2009) 488–490. [4] E.D. Shapiro, E.R. Wald, B.A. Brozanski, Periorbital cellulitis and paranasal sinusitis: a reappraisal, Pediatr. Infect. Dis. 1 (1982) 91–94. [5] P. Casserly, S. Kieran, E. Phelan, E. Smyth, P. Lacy, Bacteremia during adenoidectomy: a comparison of suction diathermy adenoid ablation and adenoid curettage, Ann. Otol. Rhinol. Laryngol. 119 (2010) 526–529. [6] R. Argelich, N. Iba´n˜ez-Flores, J. Bardavio, A. Bure´s-Jelstrup, G. Garcı´a-Segarra, R. Coll-Colell, et al., Orbital cellulitis and endogenous endophthalmitis secondary to Proteus mirabilis cholecystitis, Diagn. Microbiol. Infect. Dis. 64 (2009) 442–444. [7] J. Diel, J. Zaky, From botulism to blindness, Proc. UCLA Healthc. 16 (2012) 1–3. [8] S. Koc, L. Gu¨rbu¨zler, G. Yenis¸ehirli, A. Eyibilen, I. Aladag˘, K. Yelken, et al., The comparison of bacteremia and amount of bleeding during adenotonsillectomy, Int. J. Pediatr. Otorhinolaryngol. 75 (2011) 12–14. [9] E. Okur, M. Aral, I. Yildirim, M.A. Kilic¸, P. Ciragil, Bacteremia during adenoidectomy, Int. J. Pediatr. Otorhinolaryngol. 66 (2002) 149–153. [10] S. Kocaturk, A. Yildirim, T. Demiray, G. Bahar, M.Z. Bakici, Cold dissection versus bipolar cauterizing tonsillectomy for bacteriemia, Am. J. Otolaryngol. 26 (2005) 51–53.