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Periorbital and Orbital Cellulitis

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1 Periorbital and Orbital Cellulitis
Adaobi Okobi, M.D. Pediatrics Chief Resident St. Barnabas Hospital

2 Objectives Differentiate between periorbital and orbital cellulitis based on history and physical exam Discuss the causes and treatments of periorbital and orbital cellulitis Review the indications for imaging and ophthalmology consultation for eyelid swelling Recognize the complications of periorbital and orbital cellulitis

3 Simplified anatomy of the eye, paranasal sinuses, and venous drainage
Orbital septum- thin membrane separating the superficial eyelid from the deeper orbital structures; anterior to the septum= periorbital and posterior to the septum=orbital Hauser, A. et al. Pediatrics in Review 2010;31: Copyright ©2010 American Academy of Pediatrics

4 Pathogenesis Sinusitis
Extension of external ocular infection (ie hordeolum, dacryocystitis/dacroadenitis) Dental abscess Superficial break in the skin (ie infected bug bite, acne, eczema, periocular surgery or direct penetrating trauma) Hematogenous spread More prevalent in children younger than 5 years; periorbital 3x more common than orbital Sinuses surround the orbit on 3 sides and an infection could affect the orbit Dacryocystitis/dacroadenitis- infection of the lacrimal system Valveless orbital veins can allow for hematogenous infection in either antegrade or retrograde direction

5 Organisms Haemophilus influenza type b (before Hib vaccine in 1985)
Staphylococcus aureus (including MRSA) S. epidermidis Streptococcus pyogenes

6 History Past sinus disease? Past dental disease? Previous eye surgery?
History of trauma?

7 Physical Exam Observe for degree of ocular swelling
Assess extraocular movement Evaluate for foreign body Assess visual acuity

8 Clinical Signs and Symptoms
Unilateral erythema of eyelid Swelling of eyelid Warmth of eyelid Tenderness of eyelid Blurred vision Ophthalmoplegia Proptosis Chemosis Signs of increased intraocular pressure

9 Imaging: Indications Eyelid edema that makes a complete examination impossible Presence of CNS involvement (ie seizures, focal neurologic deficits, or altered mental status) Deteriorated visual acuity or color vision Proptosis Ophthalmoplegia Clinical worsening or no improvement after hours

10 Periorbital cellulitis

11 Hauser, A. et al. Pediatrics in Review 2010;31:242-249
A 15-month-old girl who has periorbital cellulitis and fever following infection of an insect bite to her lower right eyelid despite treatment with several days of cephalexin Hauser, A. et al. Pediatrics in Review 2010;31: Copyright ©2010 American Academy of Pediatrics

12 Hauser, A. et al. Pediatrics in Review 2010;31:242-249
An 11-year-old boy who has pan-sinusitis and left orbital cellulitis and presented with fever, severe left eye pain, proptosis, chemosis, and limitation of extraocular movements Hauser, A. et al. Pediatrics in Review 2010;31: Copyright ©2010 American Academy of Pediatrics

13 Differential Diagnosis
Allergic reaction Edema from hypoproteinemia Orbital wall infarction Subperiosteal hematoma Orbital pseudotumor Orbital myositis Retinoblastoma Metastatic carcinoma Exophthalmos secondary to thyroid dysfunction Orbital pseduotumor- presents with pain, proptosis, local swelling, conjunctival injection; may have diplopia, visual loss, ptosis and limited extraocular movements; CT demonstrates inflammatory changes and an abnormal mass density of the intraorbital soft tissues; tx: corticosteroids

14 Admission Criteria Patients with orbital cellulitis presenting with:
Eyelid edema Diplopia Reduced visual acuity Abnormal light reflexes Ophthalmoplegia Proptosis Appears toxic Eye exam is unable to be completely performed Signs of CNS involvement: Lethargy Vomiting Seizures Headache Cranial nerve deficit

15 Management Depends on the patient’s appearance, ability to take oral medications, compliance and clinical progression of the disease Empiric antibiotics should cover Staphylococcus and Streptococcus species, particularly MRSA Treat for 7-10 days for periorbital cellulitis Treat for days for orbital cellulitis If no improvement in hours consider consulting Infectious Disease, ophthalmology, ENT and/or neurosurgery

16 Management Obtain blood culture in younger patients or those that appear systemically ill Culture ocular discharge Obtain orbital, epidural absces or sinus fluid if patient requires surgery Include a sepsis evaluation if the patient appears toxic or has neurologic involvement

17 Complications Local abscess formation Orbital cellulitis
Intracranial extension of infection (eg subdural empyema, intracerebral abscess, extradural abscess and meningitis) Cavernous venous sinus thrombosis Septic emboli of the optic nerve Optic nerve ischemia (due to compression) may result in visual loss

18 Summary Orbital cellulitis is an emergency that requires prompt diagnosis and evaluation by ophthalmology Periorbital cellulitis and orbital cellulitis have distinct differences that can be elicited by careful history and physical examination If the physical exam cannot be fully completed for any reason, radiologic imaging is required Patients with systemic illness or evidence of orbital cellulitis or neurologic involvement require inpatient admission Improvement should occur within hours with antibiotics

19 Questions A 6 year old child is brought to the emergency department by his parents because of upper respiratory tract symptoms, a progressively swollen left eye, and altered mental status. He has been otherwise healthy and is fully immunized. Upon examination, he is difficult to arouse. Local signs include a markedly swollen left eye with proptosis. Eye movements are difficult to assess because of the boy’s poor neurologic status. He is febrile, but hemodynamically stable. The most likely pathogenesis is: A. Acute bacterial meningitis, with secondary infection of the left orbit B. Bacteremia causing both ocular and intracranial illness C. Head trauma, with ocular and intraocular manifestations D. Intracranial mass causing ocular and neurologic manifestations E. Orbital cellulitis, with the neurologic complication of bacterial meningitis

20 Questions A father calls your office to report that his 2 year old daughter has had nasal congestion and fever for the past 2 days. She received a nonprescription medication this morning, and today her right eye is “swollen shut”. When she arrives in your office, she is febrile but nontoxic. Her right eyelids are swollen and erythematous. It is nearly impossible to determine whether her extraocular movements are normal, but she exhibits increased tearing of the affected eye. Of the following, the most reasonable diagnosis and plan of treatment are: A. Allergic reaction and trial of antihistamine at home B. Periorbital cellulitis and IV antibiotics and CT scan of the orbits C. Periorbital cellulitis and ophthalmology consultation and IV antibiotics D. Periorbital cellulitis and oral antibiotics at home E. Reactive periorbital swelling from sinusitis and nasal decongestant at home

21 References Hauser, A and Fogarasi, S. Periorbital and Orbital Cellulitis. Pediatrics in Review. 2010;31:

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