Orbital Cellulitis
- Oct 25th, 2019
- Sean M. Fox
- categories:
Originally published at Pediatric EM Morsels on September 28, 2017. Reposted with permission.
Follow Dr. Sean M. Fox on twitter @PedEMMorsels
Infections are common topics considered when evaluating children in the ED. We have covered MANY (108 as of this Morsel). Often, we consider infections as being on a spectrum of simple to complicated. Acute Otitis Media can be simple, or it can become complex (Mastoiditis or Gradenigo’s Syndrome). Pharyngitis can be simple, or it can become complicated (Peritonsillar Abscess). Infections in the head and neck region can start simple, but given the location, can become complicated. Sinusitis is a relatively common and simple infection that may become complicated. In diagnosing sinusitis, we need to remember to be vigilant for the more complex entity: Orbital Cellulitis.
Orbital Cellulitis: Basics
- Orbital cellulitis is an infection of the orbit that involves the tissues posterior to the orbital septum.
- Also referred to as Post-Septal Cellulitis.
- The orbital septum divides the orbit into pre-septal and post-septal regions.
- The orbital septum is a fascial extension of the orbital periosteum and extends to the tarsal plates.
- It is often caused by extension from local infection, like Sinusitis (Ethmoid Sinusitis is the most common predisposing factor). [Marchiano, 2016]
- The bacterial that are most often associated with orbital cellulitis are:
- Streptococcus pneumoniae
- Steptococcus anginosus group [Seltz, 2011]
- Haemophilus influenzae
- Historically, it was predominant cause of pre-septal disease.
- Becoming less common due to vaccination.
- Moraxella catarrhalis
- Group A beta-hemolytic streptococci
- Staphylococcus aureus
- MRSA has been found in cases, but is still uncommon [Seltz, 2011]
- Anaerobes
- Can lead to (badness):
- Vision loss
- Cavernous Sinus Thrombosis
- Brain Abscess
- Meningitis
- Carotid Artery Occlusion
- Intracranial Abscess
Orbital Cellulitis: Staging
- Evaluation and management often based upon Chandler Classification: [Marchiano, 2016; Bedwell, 2011; Starkey, 2001]
- Stage I
- Eyelid swelling and sinusitis.
- No abscess or cellulitis in post-septal space.
- Consistent with Periorbitial Cellulitis.
- Can be treated antibiotics (mild cases can be treated with oral antibiotics.)
- Stage II
- Cellulitis of the post-septal region – edema of the orbital lining, chemosis, proptosis, limitation of extra ocular movement.
- No abscess formation on CT.
- Can be treated with IV antibiotics.
- Stage III
- Occasional visual loss
- Subperiosteal abscess, globe displacement
- Intraconal involvement of the extra ocular muscles
- IV antibiotics for 24-48 hours. Surgery if not improving after that.
- Stage IV
- Ophthalmoplegia and visual loss.
- Periosteal rupture and extension of abscess formation into the orbit.
- Proptosis.
- IV antibiotics and surgical drainage.
- Stage V
- Retorgrade phlebitis extending to the cavernous sinus.
- Leads to bilateral eye findings -> Cavernous Sinus Thrombosis.
- Stage I
- Initial assessment often aims at distinguishing periorbitial / pre-septal infection from orbital / post-septal infection. [Starkey, 2001]
- Can be difficult to differentiate especially in the young child.
- CT scan with contrast is the recommended imaging modality.
- Contrast can help differentiate true abscess from phlegmon. [Starkey, 2001]
Orbital Cellulitis: Surgery vs Medical
- Traditionally, orbital cellulitis is taught to be a surgical emergency… or at least one that requires prompt surgical drainage… but there has been debate over the timing of surgery. [Bedwell, 2011; Starkey, 2001]
- The role for medical management has steadily increased. [Bedwell, 2011]
- Between the extremes of presentations, it can be difficult to predict the need for early surgical intervention. [Bedwell, 2011]
- Some risk factors for requiring surgery: [Smith, 2014; Bedwell, 2011]
- Size of subperiosteal abscess matters.
- Greater the 10 mm is more likely to require surgery.
- Volume of abscess found to be predictive (> 1,250 mm^3 needed surgery). [Todman, 2011]
- Location of subperiosteal abscess matters.
- Nonmedially is more likely to require surgery.
- Age matters.
- Kids > 9 years are more likely to require surgery.
- Older children are predisposed to more complex, polymicrobial infections. [Marchiano, 2016]
- Presence of proptosis.
- Extraocular muscle restriction
- Increased intraocular pressure
- Size of subperiosteal abscess matters.
- Patients, even with these risk factors, may still have successful medical therapy.
- Management, in the end, must be tailored for the individual. [Bedwell, 2011]
- The initial exam is very important!
- It can help determine if there is concerns for mobility or proptosis.
- Management is often predicated on response to initial medical therapy… so knowledge of the initial exam is necessary for comparison.
Moral of the Morsel
- Periorbital and Orbital Cellulitis can be difficult to distinguish from initially. Know that both have a good chance of improving with IV antibiotics.
- Not every child with preseptal/periorbital cellulitis requires a CT in the ED to rule-out orbital involvement.
- If there is no proptosis and normal eye movement, IV antibiotics may be sufficient.
- Hospitalization for close reassessments and eye exam can help determine if CT is eventually required.
- Not every child with CT proven orbital cellulitis requires surgery! So don’t be mad when the ENT doctor recommends that the child be admitted for IV antibiotics to the Pediatric Service.
- Bilateral is Bad! Think Cavernous Sinus Thrombosis!!