Monday, Monday (lalalalala…)AM Report July 18, 2011

Left orbital cellulitis secondary to paranasal sinus disease

CT Orbits with Contrast

Infections anterior to orbital septum= PERIORBITALInfections posterior to the orbital septum= ORBITAL

Anatomic Considerations (Courtesy of PIR “Periorbital and Orbital Cellulitis”)

EpidemiologyPeriorbital cellulitis

◦Pts <5yrs◦3 times more common than orbital

cellulitisOrbital cellulitis

◦Average age 6.8 yrs (1wk to 18 months)

◦2:1 male predominance ◦Occurs more often in winter months

(URI, sinusitis)

PathogenesisPeriorbtial

◦Extension of external ocular infection Hordeolum (stye) Dacrocystitis/dacroadenitis Superficial break in the skin

Orbital◦RHINOSINUSITIS◦URI◦Dental abscess◦Direct penetrating injury to the orbit◦Hematogenous spread

MicrobiologyPeriorbital

◦S. aureus, S. epidermidis, S. pyogenes

Orbital◦Staphylococcus (MRSA),

Streptococcus◦Less commonly (dental, sinus dz):

Haemophilus, Neisseria, Bacteroides, Veillonella, Provetella, Peptostreptococcus, Moraxella catarrhalis

Consider Hib in unimmunized children

Clinical PresentationPeriorbital

◦Unilateral erythema, swelling, warmth, and tenderness of the eyelid

◦Fever, systemic signs (toxicity?)Orbital

◦All signs/Sx above◦Blurred vision, ophthalmoplegia

(pain with EOM), proptosis, chemosis

Periorbital cellulitis due to insect bite (arrow)

Periorbital Cellulitis (Courtesy of PIR “Periorbital and Orbital Cellulitis”)

Periorbital cellulitis due to dental abscess

Periorbital Cellulitis (Courtesy of PIR “Periorbital and Orbital Cellulitis”)

Orbital cellulitis due to pan-sinusitis

Orbital Cellulitis (Courtesy of PIR “Periorbital and Orbital Cellulitis”)

Differential DiagnosisAllergic reactionEdema due to hypoproteinemia Orbital wall infarction and

subperiosteal hematomas in pts with SS dz

EvaluationPeriorbital

◦Dx on clinical findings (no routine labs or imaging necessary)

◦Wound Cx ◦Blood Cx (only if hematogenous

spread is suspected)Orbital

◦High WBC ct, ESR/CRP suggestive◦Blood Cx (only if hematogenous

spread is suspected)

Evaluation (con’t)Orbital

◦Wound Cx◦CT scan with contrast of head and

sinuses Incomplete exam due to edema/pain Presence of CNS involvement Decrease in visual acuity, color vision,

gross proptosis, ophthalmoplegia Clinical deterioration or no improvement

after 24-48h of appropriate Abx

TreatmentPeriorbital

◦Empiric coverage for Staph and Strep Dicloxicillin First generation cephalosporin Clindamycin or Bactrim if MRSA is suspected

◦Improvement should be evident in 24-48h

◦Periorbital cellulitis due to hematogenous spread should be treated with IV Abx (both gram+&- coverage)

◦Length of treatment 7-10 days

TreatmentOrbital

◦Admit with ENT and Ophthalmology consults

◦Empiric coverage for Staph, Strep and organisms associated with sinusitis (IV) Clindamycin and 3rd generation

cephalosporin ◦Surgical drainage if indicated◦Length of treatment 10-14 days

Transition to oral abx after significant clinical improvement is made

Potential ComplicationsRecurrent periorbial cellulitis

◦Atopy◦HSV/HIV◦Atypical Mycobacteria◦Collagen vascular diseases◦Structural/anatomic abnormalities

Cavernous sinus thrombosisIntracranial infectionsLoss of vision

Recurrent Periorbital Cellulitis due to HSV (also the happiest child that ever had periorbital cellulitis)

Recurrent Periorbital Cellulitis (Courtesy of PIR “Periorbital and Orbital Cellulitis”)

Periorbital and Orbital Cellulitis Periorbital Cellulitis Orbital CellulitisAnatomy Infxn anterior to orbital

septum (eyelid and surrounding tissues)

Infxn posterior to orbital septum

Epidemiology Usually pts<5 yo, 3x more common than orbital cellulitis

Avg age 6.8 yrs (1wk-16 yrs); 2:1 male: female

Pathogenesis Extension of external ocular infxn or superficial break in skin (hematogenous spread)

Extension of rhinosinusitis, URI, dental abscess, hematogenous spread

Microbiology Hib (un/ partially immunized kids), S. aureus, S. epi, S. pyogenes

Hib, Staph and Strep species

Presentation Unilat. erythema, swelling, warmth and tenderness of the eyelid

Same, along with blurred vision, opthalmoplegia, proptosis, chemosis

Diagnosis Clinical (+/- wound cx, blood cx)

CT: diffuse fat infiltation, subperiosteal abscess and true orbital abscess; BCx, WCx

Treatment Oral Abx: empiric coverage of staph and strep (dicloxacillin, Bactrim); LOT 7-10 d

IV Abx: good gram + and – coverage (Clinda + 2nd or 3rd generation cephalosporin); ?surgery; LOT 10-14d

THANKS FOR YOUR ATTENTION!

Noon Conference: Intern Clinical Reasoning with Dr. English(Everyone else is free for lunch!)