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Periorbital and Orbital Cellulitis, Emergency Medicine

Basics

Description

- Dental abscess - Retained foreign body in the orbit - Puncture wounds - Orbital fracture - Postoperative infection - Hematogenous spread from a remote source due to valveless orbital veins - Rare cause " ”direct extension of periorbital cellulitis

- All forms of orbital cellulitis carry a risk of severe morbidity and possible mortality and are therefore a true emergency: - Permanent visual loss may occur - May extend to subperiosteal space with abscess formation - Cavernous sinus thrombosis and CNS infections may be life threatening

- Fungal infections are an uncommon but an even more lethal form particularly in the immunocompromised: - Cerebrorhino-orbital phycomycosis (CROP) - Rapidly fatal in 75% of cases: - 80% of cases occur in patients with a recent episode of diabetic ketoacidosis - Predisposing factor: Severe metabolic acidosis and immunocompromise - Begins in the paranasal sinuses and proliferates in the blood vessels causing thrombosis and necrosis - Bloody nasal discharge is common - May present with evidence of necrosis of the palate and/or nasal mucosa

- Indicated if: - CNS or systemic signs - Visual disturbances - Proptosis; restricted or painful EOM - Ophthalmoplegia - Bilateral edema - No improvement or deterioration at 24 hr

- Rule out CNS involvement in patients who appear toxic or manifest meningismus - Surgery: - Evacuate abscess - Relieve sinusitis - Decompress optic nerve

- Typically responds to oral antibiotics unless appears bacteremic or toxic: - Augmentin: 500 mg (peds: 45 mg/kg/24 h) PO TID - Cephalexin: 500 mg (peds: 100 mg/kg/24 h) PO QID - Clindamycin: 300 mg (peds: 20 mg/kg/24 h) PO QID - Dicloxacillin: 500 mg (peds: 100 mg/kg/24 h) PO QID

- If you suspect CROP: - Amphotericin B IV at highest tolerated dose - Topical amphotericin B (1 mg/mL) irrigation or nasal packing - Local debridement

- Anytime a patient presents with a red swollen eye, consider the possibility of orbital cellulitis - Take a careful history for: - Recent sinusitis - Recent puncture, history of trauma or surgical procedure - Recent dental infection " ”particularly a canine space abscess - History of immunocompromise or recent or current episode of DKA - Determine vaccination status in children

Periorbital Cellulitis

  • An inflammatory, typically infectious condition affecting the eyelid(s)
  • It is anatomically distinguished by its location, isolated to the tissues anterior to the orbital septum:Orbital septum is the connective tissue extension of the orbital periosteum that is reflected into the upper and lower eyelidsExtension to the deep tissues is rare because the septum represents a nearly impenetrable barrier but it may be incomplete
  • Most commonly presents as a complication of upper respiratory tract infection (URTI) and sinusitis:Swelling is caused by inflammatory edema from vascular and lymphatic congestion
  • May occur as a complication of a localized inflammation/infection in the eyelid or adjacent structures:BlepharitisHordeolumDacryocystitisSurrounding skin disruptions:
  • Insect bites
  • Minor trauma
  • Impetigo or other dermatologic disorders

Orbital Cellulitis

  • Inflammatory process in the structures deep to the orbital septum
  • Typically occurs secondary to extension from an adjacent structure:Sinusitis:Most commonly ethmoiditis penetrating through the thin lamina papyraceaDental abscessRetained foreign body in the orbitPuncture woundsOrbital fracturePostoperative infectionHematogenous spread from a remote source due to valveless orbital veinsRare cause " ”direct extension of periorbital cellulitis

Etiology

Periorbital Cellulitis

  • Streptococcus pneumoniae
  • Staphylococcus aureus
  • Streptococcus pyogenes
  • Moraxella catarrhalis
  • Haemophilus influenzae
  • Gonococcus " “ rare
  • Consider nonbacterial cause

Orbital Cellulitis

  • Currently streptococcal and staphylococcal infections are the most common causes:S. pneumoniae, Streptococcus viridans, S. pyogenes, Streptococcus anginosus, S. aureusAnaerobes, Bacteroides, and gram-negatives may also be seen
  • All forms of orbital cellulitis carry a risk of severe morbidity and possible mortality and are therefore a true emergency:Permanent visual loss may occurMay extend to subperiosteal space with abscess formationCavernous sinus thrombosis and CNS infections may be life threatening
  • Fungal infections are an uncommon but an even more lethal form particularly in the immunocompromised:Cerebrorhino-orbital phycomycosis (CROP)Rapidly fatal in 75% of cases:80% of cases occur in patients with a recent episode of diabetic ketoacidosisPredisposing factor: Severe metabolic acidosis and immunocompromiseBegins in the paranasal sinuses and proliferates in the blood vessels causing thrombosis and necrosisBloody nasal discharge is commonMay present with evidence of necrosis of the palate and/or nasal mucosa
  • Routine vaccinations including Hib and Pneumococcus have dramatically decreased periorbital and orbital cellulitis, but infections may still occur with these organisms particularly in younger children and those without at least 2 Hib vaccines
  • Periorbital cellulitis is overall 5 times more common and typically occurs in children <5 yr whereas orbital cellulitis is more common in children over 5 yr

Diagnosis

Signs and Symptoms

Periorbital Cellulitis/Orbital Cellulitis

  • Both present with a unilateral, red, swollen eye:Lid swelling may be profound in both
  • Differences include:Source of inciting infectionSingle vs. both lids involvedToxicity, systemic and neurologic symptoms

Orbital CelluLItis

History

  • Preceded by sinusitis in 60 " “90%, dental infection, trauma, puncture wound, or recent operation
  • Swelling and redness surrounding eye in addition to eye pain, visual impairment, loss of color vision, restricted eye movements
  • Headache, meningismus, and symptoms of systemic illness may occur
  • Identify complicating medical problems:

Physical Exam

  • Toxic appearance:
  • Restricted, painful extraocular movements (EOM)
  • Afferent pupillary defect
  • Conjunctival injection
  • Chemosis
  • Decreased visual acuity
  • Diplopia
  • Proptosis
  • Meningismus and neurologic findings may be seen.

Periorbital Cellulitis

History

  • Preceded by local skin injury, insect bite, URTI, or superficial ocular infection
  • Ask about vaccination status in young children
  • Low-grade fever
  • Subacute presentation

Physical Exam

  • Red, swollen eyelid
  • Often single lid involvement but can involve both
  • Conjunctival injection common
  • Low-grade fever common:
  • Normal visual acuityNo symptoms of deep ocular involvement

Essential Workup

  • Complete eye exam:External examVisual acuityEOMPupillary examFundoscopic examIntraocular pressure measurement
  • Complete neurologic exam

Diagnosis Tests & Interpretation

Lab

Supportive but not diagnostic: ‚

  • CBC:WBC <15,000 for periorbital cellulitisWBC >15,000 may suggest bacteremic periorbital cellulitis or orbital cellulitis
  • Blood culture
  • Gram stain and culture of tissue aspirate or swab of draining purulent material:Chocolate agar plate when gonorrhea suspected

Imaging

CT scan orbits with contrast: ‚

  • Indicated if:CNS or systemic signsVisual disturbancesProptosis; restricted or painful EOMOphthalmoplegiaBilateral edemaNo improvement or deterioration at 24 hr
  • Demonstrates extent of:Orbital cellulitisSinusitisOrbital emphysemaSubperiosteal abscessPresence of foreign bodyCavernous sinus thrombosis

Diagnostic Procedures/Surgery

Lumbar puncture: ‚

  • Rule out CNS involvement in patients who appear toxic or manifest meningismus
  • Surgery:Evacuate abscessRelieve sinusitisDecompress optic nerve

Differential Diagnosis

  • Allergic reaction
  • Dacryoadenitis
  • Dacryocystitis
  • Graves disease
  • Hordeolum
  • Inflammatory orbital pseudotumor
  • Insect bite
  • Orbital rhabdosarcoma
  • Periorbital ecchymosis
  • Retrobulbar hemorrhage

Treatment

Initial Stabilization/Therapy

IV fluids for vomiting, dehydration, toxic appearance, clinical need for parenteral antibiotics ‚

Ed Treatment/Procedures

  • Antipyretics
  • Pain medication as needed
  • Antibiotics

Periorbital Cellulitis

  • Typically responds to oral antibiotics unless appears bacteremic or toxic:Augmentin: 500 mg (peds: 45 mg/kg/24 h) PO TIDCephalexin: 500 mg (peds: 100 mg/kg/24 h) PO QIDClindamycin: 300 mg (peds: 20 mg/kg/24 h) PO QIDDicloxacillin: 500 mg (peds: 100 mg/kg/24 h) PO QID
  • Parenteral antibiotics:Cefotaxime: 1 " “2 g (peds: 150 mg/kg/24 h) IV q6 " “8hClindamycin: 600 mg (peds: 40 mg/kg/24 h) IV q6h

Orbital Cellulitis

  • Early administration of parenteral antibiotics
  • Ophthalmologic consultation for any intraocular manifestations
  • If sinusitis is the source, consider ENT consultation, and add decongestants to the treatment
  • Emergent surgical intervention may be necessary:If Bacteroides is suspected organism:Surgical debridementVancomycinTetanus toxoid when appropriate
  • If proptosis leaves the cornea exposed:Lubricating drops (Lacri-Lube: 2 drops q2 " “4h PRN)
  • If you suspect CROP:Amphotericin B IV at highest tolerated doseTopical amphotericin B (1 mg/mL) irrigation or nasal packingLocal debridement

Medication

First Line

  • Ceftriaxone: 1 " “2 g (peds: 100 mg/kg/24 h) IV q12 " “24h
  • Erythromycin ophthalmologic ointment: Applied q4h to lower cul-de-sac

Second Line

Depending on suspected organism: ‚

  • Gentamicin: 5 mg/kg/24 h IV
  • Metronidazole: 15 mg/kg IV load, then 7.5 mg/kg q6h
  • Nafcillin: 1 " “2 g (peds: 100 mg/kg/24 h) IV q4h
  • Vancomycin: 1 g (peds: 40 mg/kg/24 h) q12h

Follow-Up

Disposition

Periorbital Cellulitis

Discharge with oral antibiotics and prompt follow-up unless: ‚

  • Evidence of systemic toxicity, neurologic, visual or orbital findings
  • Unable to tolerate PO antibiotics
  • Progression of infection on oral antibiotics
  • Unable to arrange follow up within 24 " “48 hr
  • High-risk H. influenzae type B
  • Complicating medical problems

Orbital Cellulitis

Admit for: ‚

  • IV antibiotics
  • Observation for progression
  • Specialist consultation
  • Surgical incision and drainage

Pearls and Pitfalls

  • Anytime a patient presents with a red swollen eye, consider the possibility of orbital cellulitis
  • Take a careful history for:Recent sinusitisRecent puncture, history of trauma or surgical procedureRecent dental infection " ”particularly a canine space abscessHistory of immunocompromise or recent or current episode of DKADetermine vaccination status in children
  • Pay careful attention to exclude:Systemic toxicityEye pain or visual impairmentRestriction of eye movementsSigns and symptoms of neurologic involvement

Additional Reading

  • Hauser ‚ A, Fogarasi ‚ S. Periorbital and orbital cellulitis. Pediatr Rev. 2010;31:242 " “249.
  • Potter ‚ NJ, Brown ‚ CL, McNab ‚ AA, Orbital cellulitis: Medical and surgical management. J Clinic Experiment Ophthalmol. 2011;S:2.
  • Rudloe ‚ TF, Harper ‚ MB, Prabhu ‚ SP, et al. Acute periorbital infections: Who needs emergent imaging? Pediatrics. 2010;125(4):e719 " “e726.
  • Upile ‚ NS, Munir ‚ N, Leong ‚ SC, et al. Who should manage acute periorbital cellulitis in children? Int J Pediatr Otorhinolaryngol. 2012;76:1073 " “1077.
  • Wald ‚ E. Periorbital and orbital infections. Infect Dis Clin North Am. 2007;21(2):392 " “408.

See Also (Topic, Algorithm, Electronic Media Element)

  • Dacryoadenitis
  • Dacryocystitis
  • Hyperthyroidism
  • Hordeolum and Chalazion
  • Pseudotumor Cerebri

Codes

ICD9

  • 373.13 Abscess of eyelid
  • 682.0 Cellulitis and abscess of face

ICD10

  • H05.012 Cellulitis of left orbit
  • H05.019 Cellulitis of unspecified orbit
  • H00.039 Abscess of eyelid unspecified eye, unspecified eyelid
  • H05.011 Cellulitis of right orbit
  • H00.031 Abscess of right upper eyelid
  • H00.032 Abscess of right lower eyelid
  • H00.033 Abscess of eyelid right eye, unspecified eyelid
  • H00.034 Abscess of left upper eyelid
  • H00.035 Abscess of left lower eyelid
  • H00.036 Abscess of eyelid left eye, unspecified eyelid
  • H00.03 Abscess of eyelid
  • H05.013 Cellulitis of bilateral orbits
  • H05.01 Cellulitis of orbit

SNOMED

  • 109245003 Cellulitis of periorbital region
  • 194005002 orbital cellulitis (disorder)