Doctor123.org

Periorbital Cellulitis, Pediatric

Basics

Description

- Infectious - Early orbital cellulitis, dacryocystitis, stye, severe viral conjunctivitis - Orbital cellulitis is an ophthalmologic emergency and requires prompt therapy.

  • Periorbital or preseptal cellulitis is an acute infection characterized by pain, erythema, and edema to the anterior eyelid and surrounding tissue.
  • The infection lies superficial to orbital septum, a thin fascial layer forming the anterior boundary of the orbital compartment.
  • In contrast, orbital cellulitis is an infection involving the deeper structures of the orbit and requires emergent intervention.

Epidemiology

  • Often occurs in young children, commonly <5 years of age, but can occur at any age
  • Periorbital cellulitis is at least three times more common than orbital cellulitis.

Risk Factors

Predisposing factors that may lead to infection include skin trauma and lacrimal/eyelid injury.

Pathophysiology

  • Often, extension from an external source including trauma (insect bite, recent surgery, foreign body) or adjacent infection (sinusitis, dacryocystitis, hordeola, dental abscess)

Etiology

  • Variable depending on mechanismMost common pathogens are Staphylococcus aureus (increasingly methicillin-resistant) and Streptococci species.Anaerobic infections can extend from dental source.Haemophilus influenza type B was historically the most common pathogen; consider in unimmunized child younger than 5 years of age.

Commonly Associated Conditions

  • Rarely associated with bacteremia; however, consider this condition in children younger than 3 years of age or in immunocompromised patients.

Diagnosis

History

  • Onset, time course of symptom progression, and any predisposing factors
  • A history of trauma is suggestive of periorbital cellulitis.
  • The presence of pain supports cellulitis, whereas complaints of pruritus are more suggestive of an allergic etiology.
  • Diplopia and visual changes are more suggestive of orbital cellulitis.
  • Quantify systemic symptoms such as fever and lethargy.These indicate a more severe, disseminated infection.

Physical Exam

  • Superficial orbital tissues and lids will be edematous, erythematous, warm to the touch, and typically tender on palpation.Often unilateral, the findings can start in one eyelid, but both the upper and lower eyelids are usually involved.May be signs of previous trauma, cutaneous injury, etc.
  • Occasionally, the eyelids are so swollen that it is difficult to examine the globe. To do so, place anesthetic eyedrops on the eye and use ocular speculum or fashion a paperclip into a lid retractor to lift the eyelid.
  • The globe should be carefully examined.In periorbital cellulitis, the ocular exam is often normal. The sclera is usually white, although patients can have some conjunctival erythema but rarely chemosis.Any change in vision, pupillary function, or limitations in eye motility suggests orbital involvement.
  • The presence of proptosis and/or pain with eye movement suggests deep orbital involvement.
  • Neurologic findings, such as cranial nerve deficit, are suggestive of deep space involvement.
  • Evaluate for signs of fever, respiratory infection, and sepsis.

Diagnostic Tests & Interpretation

Lab

  • Lab tests are usually not helpful or indicated.
  • CBC is warranted only if bacteremia is suspected.Leukocytosis has no value in differentiating periorbital and orbital cellulitis.
  • Skin cultures and blood cultures have a low yield.Blood cultures are obtained only when the child is febrile or appears septic.Wound cultures can be obtained if there is an abscess.

Imaging

  • Periorbital cellulitis is a clinical diagnosis and radiologic confirmation is only indicated if the diagnosis is unclear. Imaging may be required in the following circumstances:If orbital cellulitis is suspectedCases that do not respond to medical treatmentNeurologic symptoms are present.
  • Serial CT scanning should be done only if the child is not improving with treatment.

Differential Diagnosis

  • InfectiousEarly orbital cellulitis, dacryocystitis, stye, severe viral conjunctivitisOrbital cellulitis is an ophthalmologic emergency and requires prompt therapy.
  • AllergicPeriocular allergic reaction: insect bite, angioedema, contact dermatitis
  • OtherPeriocular traumaRhabdomyosarcomaIdiopathic orbital inflammatory syndrome (IOIS)Cavernous venous thrombosisHypoproteinemia

Treatment

General Measures

  • Simple periorbital cellulitis should be empirically treated based on local prevalence of Staphylococcus and Streptococcus species.Consider MRSAExamples include second-generation cephalosporins or ²-lactamase " resistant penicillins.
  • There is no evidence to suggest that intravenous are better than oral antibiotics; however, younger children need close observation and/or follow-up.
  • For children <1 year of age, strongly consider hospitalization for IV therapy and very close observation.
  • Children between the ages of 1 and 5 years should either be hospitalized or arranged for close follow-up after initiating antibiotics.
  • Children >5 years of age can usually be treated with an oral regimen as long as they do not appear toxic or have orbital involvement.
  • Any patient with symptoms suggestive of deep space involvement or hematogenous involvement should be hospitalized.

Medication

  • In nontoxic children, oral antibiotics: amoxicillin/clavulanate, cefalexin, clindamycin (if MRSA is a concern), etc. are started on an outpatient basis; the child should be seen again within 24 " 48 hours.
  • Consider admission for IV antibiotics (clindamycin, ampicillin/sulbactam, etc.) for those patients younger than 1 year of age, ill appearing, have bacteremia, or symptoms suggestive of orbital involvement.

Surgery/Other Procedures

Surgical intervention is usually required when an abscess or a foreign body is present.

Ongoing Care

  • Patients should have close follow-up 24 " 48 hours after initiating outpatient treatment.
  • Patients who do not improve after close follow-up should be admitted for IV antibiotics and imaging.
  • Patients should be seen daily until a definite improvement is noted.

Prognosis

Excellent, with minimal incidence of long-term sequelae, unless a complication is encountered

Complications

  • Orbital extension (2.5 " 17%)
  • Skin abscess (8%)
  • Eyelid necrosis (1 " 2%)
  • Sepsis
  • Intracranial extension (2 " 3%)

Patient Monitoring

  • Watch patients closely for signs of orbital extension, bacteremia, or other forms of disseminated infection.
  • Neonates and infants can become septic very quickly, so they need to be closely monitored.

Additional Reading

  • Bedwell J, Bauman N. Management of pediatric orbital cellulitis and abscess. Curr Opin Otolaryngol Head Neck Surg. 2011;19(6);467 " 473. [View Abstract]
  • Donahue SP, Schwartz G. Preseptal and orbital cellulitis in childhood: a changing microbiologic spectrum. Ophthalmology. 1998;105(10):1902 " 1905. [View Abstract]
  • Foster JA, Katowitz JA. Pediatric orbital and periocular infections. In: Katowitz JA, ed. Pediatric Oculoplastic Surgery. New York, NY: Springer-Verlag; 2001:407 " 420.
  • Georgakopoulos CD, Eliopoulou MI, Stasinos S, et al. Periorbital and orbital cellulitis: a 10-year review of hospitalized children. Eur J Ophthalmol. 2010;20(6):1066 " 1072. [View Abstract]
  • Hauser A, Fogarasi S. Periorbital and orbital cellulitis. Pediatr Rev. 2010;31(6);242 " 249. [View Abstract]
  • Lessner A, Stern GA. Preseptal and orbital cellulitis. Infect Dis Clin North Am. 1992;6(4):933 " 952. [View Abstract]
  • Powell KR. Orbital and periorbital cellulitis. Pediatr Rev. 1995;16(5):163 " 167. [View Abstract]
  • Rutar T, Chambers HF, Crawford JB, et al. Ophthalmic manifestations of infections caused by the USA300 clone of community-associated methicillin-resistant Staphylococcus aureus. Ophthalmology. 2006;113(8):1455 " 1462. [View Abstract]
  • Wald ER. Periorbital and orbital infections. Pediatr Rev. 2004;25(9):312 " 320. [View Abstract]
  • Vayalumkal JV, Jadavji T. Children hospitalized with skin and soft tissue infections: a guide to antibacterial selection and treatment. Paediatr Drugs. 2006;8(2):99 " 111. [View Abstract]

Codes

ICD09

  • 376.01 Orbital cellulitis
  • 373.13 Abscess of eyelid

ICD10

  • H05.019 Cellulitis of unspecified orbit
  • H00.039 Abscess of eyelid unspecified eye, unspecified eyelid
  • H05.012 Cellulitis of left orbit
  • H05.011 Cellulitis of right orbit

SNOMED

  • 109245003 Cellulitis of periorbital region
  • 109242000 Abscess of periorbital region (disorder)