Periorbital cellulitis

Basics

Description

  • An acute, spreading infection of the skin and subcutaneous tissue of the area surrounding the eye, usually secondary to external inoculation, but the inflammation does not extend into the bony orbit
  • Synonym(s): Preseptal cellulitis

Alert

It is important to distinguish periorbital cellulitis from orbital cellulitis (restricted extraocular mobility, diplopia, proptosis, and globe displacement vision loss), which is a potentially life-threatening condition.

Epidemiology

Occurs more commonly in children, with mean age 21 months

Incidence

Increased incidence in the winter months (due to increased number of cases of sinusitis)

Risk Factors

  • Contiguous spread from upper respiratory infection
  • Sinusitis
  • Local skin trauma
  • Insect bite
  • Puncture wound
  • Bacteremia

Genetics

No known genetic predisposition

General Prevention

  • Avoid dermatologic trauma.
  • Avoid swimming in fresh or salt water with skin abrasion.

Pathophysiology

  • Contiguous spread from upper respiratory infection Sinusitis Local skin trauma Insect bite Puncture wound BacteremiaAn understanding of the anatomy of the eyelid is important in distinguishing preseptal from orbital cellulitis. The orbital septum is a sheet of connective tissue that extends from the orbital bones to the margins of the upper and lower eyelids, and it acts as a barrier to infection deep in the orbital structures. Infection of the tissues superficial to the orbital septum is called preseptal cellulitis, whereas infection deep in the orbital septum is termed orbital cellulitis.
  • Periorbital cellulitis classically arises from a contiguous infection of soft tissues of the face, secondary to:
    • Sinusitis (via lamina papyracea)
    • Local trauma
    • Insect or animal bites
    • Foreign bodies

Etiology

  • Common organisms:
    • Streptococcus pneumoniae
    • Staphylococcus aureus
    • Streptococcus pyogenes
  • Atypical organisms:
    • Acinetobacter sp.
    • Nocardia brasiliensis
    • Bacillus anthracis
    • Pseudomonas aeruginosa
    • Neisseria gonorrhoeae
    • Proteus sp.
    • Pasteurella multocida
    • Mycobacterium tuberculosis
    • Trichophyton sp. (ringworm)
  • Since the introduction of routine vaccination in 1990, Haemophilus influenzae B is no longer a leading cause of orbital cellulitis.

Diagnosis

History

  • Induration, erythema, warmth, and/or tenderness of periorbital soft tissues
  • Chemosis (conjunctival swelling), proptosis, pain with extraocular eye movements
  • Fever (although not necessary for diagnosis)

Alert

Pain with eye movement and conjunctival swelling can occur, although both should raise the suspicion for orbital cellulitis.

Physical Exam

  • Pain with eye movement and conjunctival swelling can occur, although both should raise the suspicion for orbital cellulitis. Thorough inspection of the eye and surrounding structures is key part in physical exam.
  • Erythema, swelling, and tenderness of lids without orbital congestion. Violaceous discoloration of eyelid is more commonly associated with Haemophilus influenza.
  • Also look for any break in skin if history of trauma causing periorbital cellulitis. Look for vesicle to rule out herpetic infection.
  • Inspection of nasal vaults and sinus palpation for signs of acute sinusitis
  • Ocular motility and visual acuity testing to rule out orbital cellulitis

Diagnostic Tests & Interpretation

Lab

  • Complete blood count with differential
  • Blood cultures

Follow-Up & Special Considerations

Children with periorbital or orbital cellulitis often have underlying sinusitis. If the child is febrile and appears toxic, blood cultures should be performed and lumbar puncture considered.

Imaging

If suspicious for orbital involvement, computed tomography (CT) scan can be used to evaluate the extent of infection and detect orbital inflammation or abscess (1)[B]. The classic sign of orbital cellulitis on CT scan is bulging of the medial rectus. CT should be performed with contrast, thin sections (2 mm), coronal and axial views with bone windows.

Differential Diagnosis

  • Orbital cellulitis: Orbital cellulitis may have the same signs and symptoms in the periorbital tissue, but also results in proptosis, edema of the conjunctiva, ophthalmoplegia, or decreased visual acuity.
  • Abscess
  • Dacryocystitis
  • Hordeolum
  • Allergic inflammation
  • Orbital or periorbital trauma
  • Idiopathic orbital inflammatory syndrome
  • Rapidly progressive tumors:
    • Rhabdomyosarcoma
    • Retinoblastoma
    • Lymphoma
  • Leukemia

Treatment

Medication

  • Orbital cellulitis: Orbital cellulitis may have the same signs and symptoms in the periorbital tissue, but also results in proptosis, edema of the conjunctiva, ophthalmoplegia, or decreased visual acuity. Empiric antibiotic treatment regimens are based on coverage of the most likely organisms, paying attention to local resistance patterns and the pathogens usually associated with sinusitis.
  • Uncomplicated post-traumatic:
    • Usually due to skin flora, including Staphylococcus and Streptococcus
    • Cephalexin, dicloxacillin, clindamycin
  • Extension from sinusitis:
    • Amoxicillin, clavulanate, 3rd-generation cephalosporin
  • Bacteremic cellulitis:
    • May be associated with meningitis
    • Ceftriaxone plus vancomycin to cover methicillin-resistant Staphylococcus aureus
  • Duration of therapy should be 7–10 days:
    • If symptoms do not improve within 24 hours, IV antibiotic therapy is indicated (2)[B].

Additional Treatment

Issues for Referral

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Although treatment may consist of intravenous antibiotics alone, management should be in consultation with otolaryngologists and ophthalmologists, especially when there is concern of orbital cellulitis.

Surgery/Other Procedures

Orbital surgery is indicated if the patient:

  • Fails to respond
  • No improvement by 24–48 hours
  • Visual impairment
  • Complete ophthalmoplegia
  • Well-defined periosteal abscess (1,2)
  • Deteriorates clinically despite treatment
  • Has worsening visual acuity or pupillary changes
  • Develops an abscess, except in selected pediatric cases of medial subperiosteal abscess, which may be successfully treated medically. Abscess formation necessitates incision and drainage.
  • Endoscopic and transcaruncular surgery has been successfully employed to treat subperiosteal and intraorbital abscesses.

In-Patient Considerations

  • Mild cases in adults and children >1 year can be managed on an outpatient basis, provided the patient is stable and without systemic signs of toxicity.
  • Preseptal cellulitis in children <4 years may warrant hospitalization and the use of intravenous antibiotics.

Admission Criteria

Consider hospitalization and IV antibiotics:

  • For children <1 year
  • Patients who have not been immunized for S. pneumoniae or H. influenza
  • If no signs of clinical improvement are apparent after 24 hours of oral antibiotics

Discharge Criteria

  • There are no strict guidelines to indicate when to switch therapy from parenteral to oral agents.
  • Generally, we switch to oral therapy after the patient is afebrile and the skin findings have begun to resolve, which usually takes 3–5 days. Once we switch to oral therapy, it should be continued for 2–3 weeks. The longer duration is recommended for those patients with severe ethmoid sinusitis associated with bony destruction.

Ongoing Care

Follow-Up Recommendations

Patient Monitoring

The patient should be monitored for signs of orbital involvement, including decreased visual acuity or painful/limited ocular motility.

Patient Education

  • Maintain good skin hygiene.
  • Avoid skin trauma.
  • Report early skin changes to health care professional.

Prognosis

With adequate antibiotic treatment, outlook is good. Response to antibiotics in children with periorbital cellulitis usually is rapid, and a 10-day course of treatment generally is sufficient.

Complications

  • Orbital cellulitis
  • Abscess formation
  • Scarring
  • Delay in diagnosis and adequate treatment may result in serious complications, including blindness.

References

1. Beech T, Robinson A, McDermott AL, et al. Paediatric periorbital cellulitis and its management. Rhinology. 2007;45:47–9.

2. Hennemann S, et al. Clinical inquiries. What is the best initial treatment for orbital cellulitis in children? J Fam Prac. 2007;56(8):662–4.

3. Georgakopoulos CD, Eliopoulou MI, Stasinos S, Exarchou A, Pharmakakis N, Varvarigou A et al. Periorbital and orbital cellulitis: a 10-year review of hospitalized children. European journal of ophthalmology. 2010.

Additional Reading

Br J Ophthalmol. 2008;92:1337–41 doi:10.1136/bjo.2007.128975.

Goldstein SM, Shelsta HN. Community-acquired Methicillin-resistant Staphylococcus aureus Periorbital Cellulitis: A Problem Here to Stay. Ophthal Plast Reconstr Surg. 2009;25:77.

http://emedicine.medscape.com/article/798397-overview.

Codes

ICD9

682.0 Cellulitis and abscess of face

Snomed

109245003 Cellulitis of periorbital region (disorder)

Clinical Pearls

  • Preseptal and orbital cellulitis occur most commonly in children.
  • A multidisciplinary approach is needed in managing children with this condition, and CT scan of the patient’s sinuses is essential to differentiate from orbital cellulitis.
  • Early detection of periorbital cellulitis is important to prevent complications.
  • The 2 most important factors for periorbital cellulitis are upper respiratory infection and eyelid trauma; sinusitis is more associated with orbital cellulitis (3)[C].

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