OVERVIEW: What every practitioner needs to know

Are you sure your patient has periorbital/orbital cellulitis? What are the typical findings for this disease?

Periorbital and orbital cellulitis are serious infections that can affect children of any age. The infection generally starts as sinusitis with rapid spread to the orbit. Orbital cellulitis can cause rapid proptosis, limitation of motility, and optic nerve damage. Children generally need admission to the hospital with IV antibiotics.

What is the difference between preseptal and orbital cellulitis?

Preseptal (also known as periorbital) cellulitis is a soft tissue infection of the eyelids located anterior to the orbital septum. Orbital cellulitis is an infection located posterior to the orbital septum. Because of its orbital location, it is associated with potentially serious complications, such as ocular motility deficits, vision loss, intracranial spread, and death.

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Preseptal cellulitis does not typically spread to the orbit, but both pre- and post-septal cellulitis have a similar appearance. It can be difficult to differentiate the two conditions. Orbital cellulitis affects the extraocular muscles, leading to limitation of ocular movement. Asking about double vision and looking carefully for a restriction of movement is a key part of the exam. A second important differentiating factor is that orbital cellulitis will produce proptosis.

Typical findings:

  • Lid and periorbital swelling

  • Erythema

  • Ptosis

  • Diplopia

  • Proptosis or globe displacement

  • Pain

  • Fever

  • Blurred vision

What other disease/condition shares some of these symptoms?

Conjunctivitis or “pink eye:” Inflammation secondary to an infection of the conjunctiva can produce edema and erythema of the lids. The most prominent signs of conjunctivitis, however, are the eye redness and discharge.

Stye/Hordeolum/Chalazion: A stye can mimic cellulitis by causing rapid swelling and erythema of the lids. It may also become secondarily infected, causing preseptal cellulitis.

Malignancies, such as retinoblastoma or rhabdomycosarcoma, can involve the orbit and cause rapid proptosis, lid edema and erythema.

What caused this disease to develop at this time?

Preseptal cellulitis is caused by a stye or chalazion, animal scratch or bug bite, and other eyelid trauma. A discrete cause should be sought and if not identified, an orbital etiology should always be investigated with orbital imaging.

Sinusitis is the source of orbital cellulitis 90% of the time. The ethmoid sinus is most commonly involved, with extension through the thin lamina papyrecea (lateral wall of the ethmoid sinus) to the medial orbit. Evidence of “pansinusitis,” affecting the ethmoid, maxillary, sphenoid and frontal sinuses may also be found on imaging.

Other predisposing factors include dental abscess, recent ocular or orbital surgery, dacryocystitis, and trauma or foreign body.

What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?

  • A complete blood count (CBC) should be ordered to assess for systemic signs of infection (elevated white blood count and polymorphonucleocytes) and inflammation (elevated platelets).

  • An erythrocyte sedimentation rate (ESR) and c-reactive protein (CRP) may also be ordered to assess systemic signs of inflammation.

  • A basic metabolic panel (BMP) may help to determine electrolyte balance if IV fluids are needed for hydration.

  • Blood cultures should be considered when signs of sepsis are present.

  • Nasal cultures may help guide therapy if discharge is present. Conjunctival cultures are usually not helpful.

Would imaging studies be helpful? If so, which ones?

Computed tomography (CT) with thin cuts through the orbits and sinuses is useful to rule out the presence of an orbital abscess. A CT is not strictly necessary to treat periorbital/orbital cellulitis. Clinical exam should be used to rule out the presence of orbital involvement when possible. To reduce radiation exposure and health care costs, imaging should be reserved for patients with proptosis, globe displacement, edema extending beyond the eyelids, diplopia, pain with or limitation of extraocular motility, a decompensating clinical picture, or stagnation of response to treatment.

If you are able to confirm that the patient has periorbital/orbital cellulitis, what treatment should be initiated?

Children should be admitted for observation and broad-spectrum IV antibiotics. Other supportive treatments include head elevation, nasal decongestant, mucolytics, and nasal saline irrigation.

Consider double coverage of Staph aureus (See Table I) and other gram-positive and gram-negative bacteria (See Table II).

Drug Dose Notes
Vancomycin 10-15 mg/kg IV every 6 h; maximum daily dose 4 grams empiric therapy due to risk of MRSA
Nafcillin 200 mg/kg/day IV divided in 4-6 doses; maximum daily dose 12 grams for methicillin-sensitive Staph aureus; better CNS penetration than vancomycin
Drug Dose Notes
ampicillin-sulbactam 300 mg/kg/day divided in 4 doses maximum daily dose 8 g ampicillin component
ticarcillin-clavulanate 200-300 mg/kg/day ticarcillin divided in 4-6 doses maximum daily dose 18 g ticarcillin component
piperacillin-tazobactam 240 mg/kg/day piperacillin divided in 3 doses maximum daily dose 16 g piperacillin component
ceftriaxone 80-100 mg/kg/day divided in 2 doses maximum daily dose 4 g
cefotaxime 150-200 mg/kg/day divided in 3-4 doses maximum daily dose 12 g

No standard exists for treatment length. IV antibiotics are often continued for 3 to 5 days before discharging the patient home on oral antibiotics. The choice of oral antibiotics is guided by culture results. If unknown, choose a broad-spectrum antibiotic (See Table III). Treatment is switched when the patient is afebrile and clinical improvement is noted. Total treatment length is 2 to 3 weeks.

Drug Dose Notes
amoxicillin-clavulanate 45 mg/kg/day divided every 12 hours for children >3 mon and <40 kg  
linezolid 600 mg twice daily for children >12 years; 10 mg/kg 3 times daily for children <11 years choose if MRSA suspected

Otolaryngology and Ophthalmology should be consulted. Daily ophthalmic examinations include visual acuity, color vision, pupillary reaction, and extraocular motility. Surgical drainage is indicated with progression of signs and symptoms, lack of improvement despite treatment, visual acuity of 20/60 or worse on initial evaluation, severe orbital complications such as afferent pupillary reflex, and CT evidence of abscess formation. Drainage may be performed through the sinuses via endoscopic approach or by eyelid or transcaruncular incision. Subperiosteal abscesses may respond to antibiotics alone, particularly in children <9 years with a single-organism medial subperiosteal abscess.

What are the possible outcomes of periorbital/orbital cellulitis?

In 1970, Chandler presented a classification of 5 levels of severity in periorbital cellulitis, indicating the most frequent complications (See Table IV).


Chandler’s classification of periorbital cellulitis

Preseptal cellulitis does not carry the inherent risk of vision loss and mortality of orbital cellulitis. The difficulty lies in distinguishing preseptal cellulitis from postseptal (orbital) cellulitis. These children can usually be managed as outpatients, as long as they are well systemically. Daily follow-up is required until clinical improvement is made. Vision loss and mortality is extremely rare.

Orbital cellulitis can spread rapidly along the posterior orbit, leading to vision loss and intracranial involvement. The child requires close follow-up in the hospital until significant improvement is made. Ophthalmology and Otolaryngology should be consulted to monitor the condition and consider surgical intervention. Decreased visual acuity, a visual field defect, or afferent pupillary defect are signs of compressive optic neuropathy, and must be managed urgently. Intracranial extension must be considered if meningeal symptoms develop. The risk of vision loss is low (<10%) and the risk of death is 1-2%. With timely management, most patients will make a full recovery.

What causes this disease and how frequent is it?

Periorbital or Preseptal Cellulitis:

  • The most common cause of periorbital cellulitis is contiguous spread of local infection of the face or eyelids due to trauma, insect or animal bites, or foreign objects.

  • Streptococcus pneumoniae, Staphylococcus aureus, other streptococcus, and anaerobes are the most common microorganisms.

Orbital Cellulitis:

  • The most common cause of orbital cellulitis is acute sinusitis, typically ethmoid sinusitis or pansinusitis.

  • Surgery is another important risk factor, including strabismus surgery, blepharoplasty, and retinal surgery.

  • Orbital trauma, especially fractures or foreign objects, dacryocystitis, dental infections, and other facial infections are other causative factors.

    The causative bacteria include: Streptococcus species, Staphylococcus aureus, and anaerobes.

    Less common organisms include: Pseudomonas aeruginosa, Pasteurella multocida, Enterococcus, Klebsiella, Mycobacterium tuberculosis, and Neisseria gonorrhea.

    Haemophilus influenzae type b was the leading organism prior to 1990 when the Hib vaccine became widely available, and is now much less common.

    Fungal species, including Mucor and Aspergillus species, are generally associated with an immunocompromised state.

How do these pathogens/genes/exposures cause the disease?

Preseptal Cellulitis: Organisms cause infection via a breakdown of the skin barrier with subsequent subcutaneous spread.

Orbital Cellulitis: Organisms spread from infected deep tissue: the sinus, oral cavity, or by trauma or surgery of the orbit.

Other clinical manifestations that might help with diagnosis and management

A single gram positive organism is usually causative in children under age 9 years. These younger children usually respond to IV antibiotics. Older children and adults are more likely to have polymicrobial infections with a lower incidence of response to IV antibiotics alone. Anaerobic infections, often of dental origin, also carry a higher risk of poor response to IV antibiotics alone.

What complications might you expect from the disease or treatment of the disease?

Vision loss, cranial nerve defects, intracranial spread, and death can occur if the infection spreads posteriorly.

How can periorbital/orbital cellulitis be prevented?

The Hib vaccine has greatly lowered the incidence of Haemophilus influenzae type b as a causative factor in periorbital cellulitis.

What is the evidence?

Chandler, JR, Langenbrunner, DJ, Stevens, ER. “The pathogenesis of orbital complications in acute sinusitis”. Laryngoscope. vol. 80. 1970. pp. 1414-28. (This landmark paper describes a review of the literature, case reports and a proposed modification of the classification of orbital cellulitis by severity level. Treatment of orbital cellulitis today is still based on the “Chandler Criteria.”)

Garcia, GH, Harris, GJ. “Criteria for nonsurgical management of subperiosteal abscess of the orbit: analysis of outcomes 1988-1998”. Ophthalmology. vol. 107. 2000. pp. 1454-6. (This prospective, comparative case series examined 40 children who were treated for subperiosteal abscess. The following nine management criteria determined a medical treatment plan: age less than 9 years, absence of frontal sinusitis, medial location of the subperiosteal abscess, small or moderate size of the subperiosteal abscess, absence of gas within the abscess on CT scan, absence of previous drainage, no evidence of chronic sinusitis, no evidence of acute optic nerve or retinal compromise, absence of dental infection. 3 patients were treated outside the guidelines. 8/37 underwent immediate surgical drainage. Of the 29 remaining patients treated medically, 27 (93.1%) were successfully treated with antibiotics alone. The authors conclude that in children <9 years without certain surgical criteria, orbital subperiosteal abscess can be treated medically.)

Rahbar, R, Robson, CD, Petersen, RA. “Management of orbital subperiosteal abscess in children”. Arch Otolaryngol Head Neck Surg. vol. 127. 2001. pp. 281-6. (This retrospective review of 19 patients treated for orbital subperiosteal abscess (SPA) between 1997 and 1999 sought to determine guidelines for management. All patients were treated initially with IV antibiotics. Surgery was performed for worsening ophthalmologic examination. 11 patients underwent transnasal endoscopic drainage of medial SPA and 3 patients underwent external drainage of a superior SPA. Patients with a superior SPA who underwent external drainage had a longer hospital stay [median, 7 days] compared to those treated with transnasal endoscopic drainage or IV antibiotics [median, 5 days].)

Rudloe, TF, Harper, MB, Prabhu, SP. “Acute periorbital infections: who needs emergent imaging?”. Pediatrics. vol. 125. 2010. pp. 7e719-e726. (This retrospective study of emergency department visits from 1995 to 2008 sought to identify predictors for intraorbital or intracranial abscess among children with signs or symptoms of periorbital infection, and thus determine a target group for emergent CT. 918 patients were studied, of which 298 underwent CT imaging. 111 were found to have an abscess. Although proptosis, pain with eye movement, and motility deficit were associated with the presence of an abscess, only 50.5% of patients with an abscess had these findings. On multivariate analysis, significant edema extending beyond the eyelids, blood neutrophil count >10,000, age >3 years, and previous antibiotics were other high risk factors for abscess. The authors conclude that using these criteria can identify high risk patients who should undergo emergent CT imaging.)

Seltz, LB, Smith, J, Durairaj, VD. “Microbiology and antibiotic management of orbital cellulitis”. Pediatrics. vol. 127. 2011. pp. e566-e572. (This study was a retrospective chart review of 94 patients admitted between 2004-2009 with orbital infection confirmed by CT scan. The authors sought to review microbiology data in regard the apparent increase in methicillin-resistant Staphylococcus aureus (MRSA) infections. A pathogen was identified in 31% of patients. 15% had Streptococcus anginosus. 9% had Staphylococcus aureus (only 1 patient with MRSA). Less common organisms were group A beta-hemolytic streptococci, Streptococcus pneumoniae, and Haemophilus influenzae. Combination antibiotics were used in 62% of patients. Vancomycin use increased from 14% to 57% during the study period. When started on a single antibiotic, patients were likely to be discharged on a single antibiotic. The authors conclude that the incidence of MRSA orbital infections is low and combination antibiotics, including vancomycin use, may contribute to the development of resistant organisms.)