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Periorbital and orbital cellulitis

Specialties > Child health

Background knowledge 🧠

Definition

  • Periorbital cellulitis: Infection of the eyelid and periorbital soft tissues anterior to the orbital septum.
  • Orbital cellulitis: Infection involving the orbital tissues posterior to the orbital septum.
  • Both conditions are distinct but can be clinically similar.
  • Orbital cellulitis is more severe and can lead to serious complications.

Epidemiology

  • More common in children than adults, especially under 10 years old.
  • Periorbital cellulitis is more common than orbital cellulitis.
  • Orbital cellulitis more common in males.
  • Increased incidence in winter months due to higher rates of sinusitis.

Aetiology and pathophysiology

  • Periorbital cellulitis often secondary to local skin trauma, insect bites, or spread from adjacent infection (e.g., conjunctivitis).
  • Orbital cellulitis typically arises from spread of infection from the paranasal sinuses (especially ethmoid sinusitis).
  • Common pathogens: Staphylococcus aureus, Streptococcus species, Haemophilus influenzae.
  • Orbital involvement leads to inflammation and potential abscess formation, increased intraorbital pressure.
  • Complications include cavernous sinus thrombosis and vision loss.

Types

  • Periorbital (Preseptal) Cellulitis: Infection confined anterior to the orbital septum.
  • Orbital Cellulitis: Infection posterior to the orbital septum, involving orbital contents.
  • Subperiosteal abscess: Collection of pus between the orbital bone and periosteum, can be a complication of orbital cellulitis.
  • Orbital abscess: Collection of pus within the orbit, requires prompt intervention.

Clinical Features 🌡️

Symptoms

  • Pain around the eye, often worse with eye movements (more common in orbital cellulitis).
  • Swelling and redness of the eyelids.
  • Reduced vision (suggestive of orbital cellulitis).
  • Fever, malaise, and systemic symptoms more common in orbital cellulitis.
  • Periorbital cellulitis: absence of proptosis, no restriction of eye movements.
  • Orbital cellulitis: possible proptosis, ophthalmoplegia, and diplopia.

Signs

  • Eyelid erythema and oedema.
  • Periorbital cellulitis: normal visual acuity, no proptosis, normal eye movements.
  • Orbital cellulitis: proptosis, restricted eye movements, reduced visual acuity, afferent pupillary defect.
  • Chemosis (conjunctival oedema) in severe cases of orbital cellulitis.
  • Systemic signs: fever, tachycardia, lethargy (more common in orbital cellulitis).

Investigations 🧪

Tests

  • Clinical examination: Distinguish between periorbital and orbital cellulitis.
  • Blood tests: FBC (raised WBC), CRP (raised).
  • Blood cultures: Identify causative organisms.
  • CT scan of orbits: Necessary if orbital cellulitis is suspected; look for abscess, sinusitis, intracranial involvement.
  • MRI: Used if intracranial complications are suspected.
  • Swabs from the conjunctiva or any discharge if present.

Management 🥼

Management

  • Periorbital cellulitis: Oral antibiotics (e.g., co-amoxiclav), outpatient management in mild cases.
  • Orbital cellulitis: IV antibiotics (e.g., ceftriaxone + metronidazole), admission to hospital.
  • Surgical drainage if abscess formation is present.
  • Consider ENT referral if sinusitis is the underlying cause.
  • Monitor visual acuity and eye movements regularly.

Complications

  • Vision loss due to optic nerve involvement in orbital cellulitis.
  • Cavernous sinus thrombosis.
  • Intracranial abscess formation.
  • Meningitis.
  • Sepsis.

Prognosis

  • Periorbital cellulitis: Excellent prognosis with timely treatment.
  • Orbital cellulitis: Good prognosis if treated early, but risk of permanent vision loss if delayed.
  • Complications are more common in delayed or untreated cases.

Key points

  • Differentiate between periorbital and orbital cellulitis early in clinical assessment.
  • Orbital cellulitis is a medical emergency requiring prompt treatment to prevent complications.
  • CT imaging is crucial in diagnosing orbital cellulitis and assessing for complications.
  • Empirical broad-spectrum IV antibiotics should be started immediately in suspected orbital cellulitis.

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Child health