Cellulitis Periorbital & Orbital

Description of Medical Condition

An acute, spreading infection of the dermis and subcutaneous tissue. Several entities are recognized. Cellulitis around the eyes is a potentially dangerous periorbital and orbital infection.

System(s) affected: Skin/Exocrine, Nervous

Genetics: No known genetic pattern

Incidence/Prevalence in USA: Unknown

Predominant age: N/A

Predominant sex: Male = Female

Medical Symptoms and Signs of Disease

• Lid edema
• Rhinorrhea
• Orbital pain, tenderness
• Headache
• Conjunctival hyperemia
• Chemosis
• Ptosis
• Limitation to ocular motion
• Increase intraocular pressure
• Disease in corneal sensation
• Congestion of retinal veins
• Chorioretinal stria
• Gangrene and sloughing of lids

What Causes Disease?

Cellulitis around the eye in adult

• Staphylococcus aureus most common
• Streptococcus pyogenes
• Streptococcus pneumonia
• Mixed infection

Cellulitis around the eye in children less than five years OH. influenzae most common

Risk Factors

• Trauma
• Chronic sinusitis (anaerobic)
• Acute sinusitis (aerobic)
• Retained orbital foreign bodies
• Puncture wound
• Surgical procedure: Exploration of orbital tumor, retinal detachment procedure, strabismus operation
• Acute dacryocystitis
• Dental or intracranial infection
• BacteremiaDiagnosis of Disease

Differential Diagnosis

Retro-orbital cellulitis/abscess

Laboratory

• Aspiration of fluid from the orbit is contraindicated
• Blood culture more likely to be positive in children < 5 years
• Culture of discharge from nasal mucosa, nasopharynx and conjunctiva

Drugs that may alter lab results: Previous antibiotic therapy Disorders that may alter lab results: N/A

Pathological Findings

N/A

Special Tests

Serial serological testing with antistreptolysin, anti-deoxyribonuclease B, and antihyaluronidase tests may be successful in diagnosing cellulitis caused by group A, C, or G hemolytic streptococci

Imaging

• B-scan ultrasound
• Plain orbital and sinus films
• Computerized tomography (CT) is the most accurate and provides the most important information
• Magnetic resonance imaging is the imaging modality of choice in diagnosing suspected cases of cavernous sinus thrombosis

Diagnostic Procedures

• Skin biopsy
• Lumbar puncture should be considered for all children with H. influenzae type B cellulitis

Treatment (Medical Therapy)

Appropriate Health Care

Outpatient for mild cases, inpatient for severe infections

General Measures

N/A

Surgical Measures

• Surgical debridement and/or drainage is needed if abscess develops or if clinical situation deteriorates despite adequate therapy in 24-48 hours or if visual acuity decreases
• In orbital mucormycosis, surgical debridement of devitalized tissue is extremely important

Activity

• Ambulatory in mild infection
• Bedrest in severe infection

Diet

Regular diet

Patient Education

• Good skin hygiene
• Avoid skin traumas
• Report early skin changes to health professional

Medications (Drugs, Medicines)

Drug(s) of Choice

• In adults, nafcillin or oxacillin 1.5 g every 4 hours
• In children, ampidllin 200 mg/kg/day in divided doses intravenously plus nafcillin or oxacillin (100 mg/kg/day)
• Sinus decongestion — nasal sprays, oral decongestants. oral antihistamines

Contraindications:

• Allergies to the antibiotic
• Previous history of allergy to the drug

Precautions: Renal failure, other organ failure Significant possible interactions: Refer to manufacturer’s literature

Alternative Drugs

• In adults, cefotaxime or clindamycin or chloramphenicol orvancomycin
• In children, influenzae resistant to ampicillin third generation cephalosporin, cefotaxime or chloramphenicol
• In immunocompromised — piperacillin and gentamicin
• Fluoroquinolones (adults)
• Linezolid (Zyvox)

Patient Monitoring

Repeat imaging in patients with orbital cellulitis

Prevention / Avoidance

• Avoid trauma
• Avoid swimming in fresh water or salt water in the presence of skin abrasion
•  In influenzae cellulitis — rifampin prophylaxis for the entire family of an index case. Rifampin prophylaxis in day-care classroom in which one or two children exposed. Dosage — 20 mg/kg/24 h (maximum of 600 mg a day) for 4 days.

Possible Complications

• Osteomyelitis
• Strabismus
• Afferent pupillary defect
• Chronic draining sinus
• Scarred upper eyelid
• Profound visual loss
• Blindness
• Ophthalmoplegia
• Cavernous sinus thrombosis
• Meningitis
• Intracranial abscess
• Acute infarction of retina and choroid

Expected Course / Prognosis

With adequate antibiotic treatment, outlook is good

Miscellaneous

Associated Conditions

Sinusitis ethmoiditis in children in 84% of patients

Age-Related Factors

Pediatric: Newborn may acquire orbital cellulitis secondary to intrauterine infection Geriatric: N/A

Pregnancy

N/A

International Classification of Diseases

376.01 Orbital cellulitis

See Also

Cellulitis Erysipelas Animal bites Thrombophlebitis, superficial