periorbital and orbital cellulitis adaobi okobi, m.d. pediatrics chief resident st. barnabas...
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Periorbital and Orbital Cellulitis
Adaobi Okobi, M.D.Pediatrics Chief ResidentSt. Barnabas Hospital
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
Copyright ©2010 American Academy of Pediatrics
Hauser, A. et al. Pediatrics in Review 2010;31:242-249
Simplified anatomy of the eye, paranasal sinuses, and venous drainage
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
Organisms
Haemophilus influenza type b (before Hib vaccine in 1985)
Staphylococcus aureus (including MRSA)
S. epidermidis Streptococcus pyogenes
History
Past sinus disease? Past dental disease? Previous eye surgery? History of trauma?
Physical Exam
Observe for degree of ocular swelling
Assess extraocular movement Evaluate for foreign body Assess visual acuity
Clinical Signs and Symptoms
Unilateral erythema of eyelid
Swelling of eyelid Warmth of eyelid Tenderness of
eyelid Blurred vision Ophthalmoplegia Proptosis Chemosis
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 24-48 hours
Copyright ©2010 American Academy of Pediatrics
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
Copyright ©2010 American Academy of Pediatrics
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
Differential Diagnosis
Allergic reaction Edema from hypoproteinemia Orbital wall infarction Subperiosteal hematoma Orbital pseudotumor Orbital myositis Retinoblastoma Metastatic carcinoma Exophthalmos secondary to thyroid
dysfunction
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
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 10-14 days for orbital cellulitis If no improvement in 24-48 hours
consider consulting Infectious Disease, ophthalmology, ENT and/or neurosurgery
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
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
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 24-48 hours with antibiotics
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
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
References
Hauser, A and Fogarasi, S. Periorbital and Orbital Cellulitis. Pediatrics in Review. 2010;31:242-249