Periorbital and Orbital Cellulitis

Ovid: 5-Minute Sports Medicine Consult, The

Periorbital and Orbital Cellulitis
COL. Mark D. Harris
Kevin deWeber
  • 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.
  • 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.
  • 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
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.
  • 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
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.
  • 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
  • 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.
  • 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


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
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.
376.01 Orbital cellulitis

This website uses cookies to improve your experience. We'll assume you're ok with this, but you can opt-out if you wish. Accept Read More