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Periorbital and Orbital Cellulitis

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Periorbital and Orbital Cellulitis
COL. Mark D. Harris
Kevin deWeber
Basics
Description
  • Periorbital (preseptal) cellulitis:
    • Inflammatory process, such as acute infection of the dermis and SC tissue anterior (superficial) to the orbital septum
  • Orbital (postseptal) cellulitis:
    • Inflammatory process, such as acute infection in the structures posterior (deep) to the orbital septum
  • Orbital septum: Connective tissue extension of the orbital periosteum into the upper and lower eyelids. It is nearly impervious to the spread of infection into the orbit.
  • Unlike what is commonly understood, periorbital cellulitis does not progress to orbital cellulitis.
Epidemiology
  • Mean age cited in many case studies of orbital cellulitis is 7.4 yrs.
  • Adults are more likely to be affected with periorbital cellulitis.
  • Rarely, recurrent periorbital cellulitis occurs.
Incidence
  • The incidence of periorbital cellulitis is roughly equal in males and females (1).
  • The incidence of orbital cellulitis is roughly 2:1 for Males: Females.
Risk Factors
Risk factors for periorbital and orbital cellulitis include (2):
  • Conjunctivitis
  • Infected wound or trauma
  • Insect bite
  • Sinusitis (acute or chronic)
  • Dacryostenosis, adenitis, and cystitis
  • Bacteremia
Genetics
No known genetic pattern
General Prevention
  • Immunization against H. influenzae provides good protection against periorbital and orbital cellulitis caused by H. influenzae. Children who have received at least 2 Hib immunizations are unlikely to have H. influenzae b infection.
  • Avoiding periorbital skin trauma is important for prevention. Protective goggles and other American National Standards Institute-approved eyewear may help decrease the risk.
Etiology
  • Prior to H. influenzae type b (Hib) immunization, H. influenzae accounted for 80% of bacteremic periorbital cellulitis cases. Now it is more common in younger and in nonvaccinated children.
  • Currently, both Staphylococcal (methicillin-sensitive Staphylococcus aureus [MSSA] and methicillin-resistant Staphylococcus aureus [MRSA]) and Streptococcal infections (group A and pneumococcus) are important causative organisms.
  • Consider M. catarrhalis, anaerobes, and nonbacteremic causes.
  • Infectious causes of preseptal cellulitis (3):
    • Localized infection of the eyelid or adjacent structures:
      • Conjunctivitis
      • Hordeolum
      • Chalazion
      • Dacryoadenitis
      • Dacryocystitis
      • Bacterial cellulitis from trauma
      • Surrounding skin disruptions (minor trauma, insect bites, dermatologic disorders)
  • Hematogenous dissemination:
    • Bacteremic periorbital cellulitis
  • Acute sinusitis:
    • Inflammatory edema
  • Infectious causes of orbital (postseptal) cellulitis:
    • Acute sinusitis
    • Hematogenous dissemination
    • Traumatic inoculation
Diagnosis
Clinical diagnosis is based on signs and symptoms and the neurological exam. It is very important to assess for orbital involvement because orbital cellulitis is much more dangerous than periorbital cellulitis.
History
  • Periorbital cellulitis:
    • Recent or current viral upper respiratory infection
    • Dermatologic trauma
    • Recent conjunctivitis
    • Fever
  • Orbital cellulitis:
    • Above, plus:
      • Recent sinusitis
      • Other serious infections
Physical Exam
  • Periorbital cellulitis:
    • Periorbital swelling, erythema, warmth, and tenderness
    • Unilateral
  • Orbital cellulitis:
    • Physical findings above, plus:
      • Proptosis
      • Ophthalmoplegia
      • Loss of visual acuity
      • Chemosis (bulbar conjunctival edema)
Diagnostic Tests & Interpretation
Lab
  • WBCs >15,000 can be associated with bacteremic periorbital cellulitis.
  • Blood culture if sepsis is suspected
  • Gram stain and culture of either a tissue aspirate or swab of draining purulent material. Specimens can be difficult to get, and specimens obtained during surgery often have the best results.
  • Lumbar puncture/cerebrospinal fluid evaluation if the child appears markedly ill, has insufficient Hib immunization, or meningitis must be ruled out.
Imaging
  • Sinus x-rays can be helpful to diagnose sinusitis.
  • Orbital/sinus/facial CT scan with contrast:
    • Should be strongly considered in most cases to differentiate between periorbital and orbital cellulitis
    • Definitely indicated if there is a concern for orbital cellulitis, traumatic penetration of the orbital septum, or if the patient fails to respond to parenteral antimicrobial therapy
    • Best confirmation of orbital cellulitis is by CT scan with contrast infusion of the orbit.
    • Can show sinusitis, proptosis, foreign body, and subperiosteal abscess

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Differential Diagnosis
  • Lack of fever and leukocytosis suggest noninfectious causes:
    • Trauma (including insect bite)
    • Local edema (hypoproteinemia, congestive heart failure)
    • Allergy (including angioneurotic edema and contact hypersensitivity)
    • Tumor (such as choroidal melanoma, retinoblastoma, rhabdomyosarcoma, neuroblastoma)
  • Early orbital cellulitis:
    • May have the same appearance as periorbital cellulitis
Treatment
ED Treatment
  • Establish IV access and administer oxygen for serious complications, including sepsis, meningitis, and cavernous sinus thrombosis.
  • Consider vancomycin in geographic areas with prevalent penicillin-resistant pneumococci or prevalent MRSA.
  • Children with orbital cellulitis require:
    • Parenteral antibiotics
    • CT scan
    • Ophthalmologic consultation
    • Prompt surgery may be necessary.
Medication
First Line
  • Periorbital cellulitis:
    • There is no evidence that IV antibiotics are generally better than oral antibiotics for periorbital cellulitis (1) [A].
    • Augmentin: 500 mg (peds: 45–90 mg/kg/24 hr) PO b.i.d.
    • Cephalexin: 500 mg (peds: 50–100 mg/kg/24 hr) PO q.i.d.
    • Clindamycin: 600 mg (peds: 40 mg/kg/24 hr) IV q6h; 300 mg (peds: 30 mg/kg/24 hr) PO q.i.d.
    • Dicloxacillin: 500 mg (peds: 100 mg/kg/24 hr) PO q6h
  • Orbital cellulitis:
    • MSSA:
      • Nafcillin: 2 g (peds: 150 mg/kg/24 hr) IV q4h or oxacillin: 2 g (peds: 150 mg/kg/24 hr) IV q4h
    • MRSA:
      • Vancomycin: 1 g IV q12h, PLUS
      • Ceftriaxone: 2 g IV (peds: 50–100 mg/kg/24 hr) q24h, PLUS
      • Metronidazole 1 g IV q12h
      • If penicillin/cephalexin allergy, vancomycin + levofloxacin 750 mg IV q24h + metronidazole IV
  • Symptomatic treatments:
    • Sinus decongestion
    • Nasal sprays
    • Oral decongestants
    • Oral antihistamines
Second Line
  • Immunocompromised patients: Gentamicin and piperacillin
  • Complicated or resistant cases: Linezolid (Zyvox)
Additional Treatment
Referral
Patients with orbital cellulitis should be referred for ophthalmologic consultation.
Surgery/Other Procedures
Orbital cellulitis patients with complete ophthalmoplegia, an abscess, or vision loss should undergo surgical drainage (2).
In-Patient Considerations
Most patients with orbital cellulitis should be admitted for 24–48 hr of IV antibiotics. If significant improvement occurs, switch to oral antibiotics. If no significant improvement results, consider repeat CT scan and surgical intervention.
Initial Stabilization
0.9% NS IV bolus (500 cc or 20 cc/kg) for dehydration, sepsis, hypotension
Admission Criteria
  • Toxicity
  • Orbital cellulitis should usually be treated in the hospital. Outpatient treatment should only be attempted if the eye is at least 50% open and very close follow-up can be guaranteed (2).
  • Progression of infection on oral antibiotics
  • Uncertainty that patient can get adequate care at home
Discharge Criteria
  • No more than modest swelling, tolerating oral antibiotics well with progressive improvement, nontoxic appearance, and reliable caregivers
  • Monitor for progressive swelling, irritability, increased fever, or vision changes.
Ongoing Care
Follow-Up Recommendations
Return-to-play guidance:
  • Athlete must be asymptomatic and the physical exam must be normal.
  • Athlete must pass sport-specific functional assessment.
  • Medical personnel should closely observe the athlete's performance in practice prior to clearing him or her for competition.
Patient Monitoring
Repeat imaging in patients with orbital cellulitis if there is any question about resolution after treatment.
Complications
Possible complications of orbital cellulitis include:
  • Blindness
  • Cavernous sinus thrombosis
  • Meningitis
  • Subdural empyema
  • Brain abscess
References
1. Goldman RD, Dolansky G, Rogovik AL. Predictors for admission of children with periorbital cellulitis presenting to the pediatric emergency department. Pediatr Emerg Care. 2008;24:279–283.
2. Nageswaran S, Woods CR, Benjamin DK, et al. Orbital cellulitis in children. Pediatr Infect Dis J. 2006;25:695–699.
3. Wald ER. Periorbital and orbital infections. Pediatr Rev. 2004;25:312–320.
Additional Reading
Robinson A, Beech T, McDermott A, et al. Investigation and management of adult periorbital and orbital cellulitis. J Laryng Otol. 2007;121:545–547.
Rimon A, Hoffer V, Prais D, et al. Periorbital cellulitis in the era of haemophils influenzae type B vaccine: predisposing factors and etiologic agents in hospitalized children. J Pediatr Ophthal Strabis. 2008;45:300–304.
Codes
ICD9
376.01 Orbital cellulitis


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