Orbital Cellulitis

Orbital CellulitisInfections 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.
  • 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
  • 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!!

 

References

Sciarretta V1, Demattè M2, Farneti P3, Fornaciari M4, Corsini I5, Piccin O6, Saggese D7, Fernandez IJ8. Management of orbital cellulitis and subperiosteal orbital abscess in pediatric patients: A ten-year review. Int J Pediatr Otorhinolaryngol. 2017 May;96:72-76. PMID: 28390618. [PubMed] [Read by QxMD]

Marchiano E1, Raikundalia MD1, Carniol ET1, Echanique KA1, Kalyoussef E1, Baredes S1,2, Eloy JA1,2,3,4. Characteristics of patients treated for orbital cellulitis: An analysis of inpatient data. Laryngoscope. 2016 Mar;126(3):554-9. PMID: 26307941. [PubMed] [Read by QxMD]

Le TD1, Liu ES2, Adatia FA3, Buncic JR4, Blaser S5. The effect of adding orbital computed tomography findings to the Chandler criteria for classifying pediatric orbital cellulitis in predicting which patients will require surgical intervention. J AAPOS. 2014 Jun;18(3):271-7. PMID: 24924283. [PubMed] [Read by QxMD]

Smith JM1, Bratton EM1, DeWitt P2, Davies BW1, Hink EM1, Durairaj VD3. Predicting the need for surgical intervention in pediatric orbital cellulitis. Am J Ophthalmol. 2014 Aug;158(2):387-394. PMID: 24794092. [PubMed] [Read by QxMD]

Todman MS1, Enzer YR. Medical management versus surgical intervention of pediatric orbital cellulitis: the importance of subperiosteal abscess volume as a new criterion. Ophthal Plast Reconstr Surg. 2011 Jul-Aug;27(4):255-9. PMID: 21415801. [PubMed] [Read by QxMD]

Bedwell J1, Bauman NM. Management of pediatric orbital cellulitis and abscess. Curr Opin Otolaryngol Head Neck Surg. 2011 Dec;19(6):467-73. PMID: 22001661. [PubMed] [Read by QxMD]

Seltz LB1, Smith J, Durairaj VD, Enzenauer R, Todd J. Microbiology and antibiotic management of orbital cellulitis. Pediatrics. 2011 Mar;127(3):e566-72. PMID: 21321025. [PubMed] [Read by QxMD]

McKinley SH1, Yen MT, Miller AM, Yen KG. Microbiology of pediatric orbital cellulitis. Am J Ophthalmol. 2007 Oct;144(4):497-501. PMID: 17698020. [PubMed] [Read by QxMD]

Starkey CR1, Steele RW. Medical management of orbital cellulitis. Pediatr Infect Dis J. 2001 Oct;20(10):1002-5. PMID: 11642617. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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