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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.

Cellulitis Periorbital & Orbital

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

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