Preseptal and Orbital Cellulitis

Presentation by Khang Lu, MS4, 2dLt USAF

Case Study HPI: 2 yo girl presents with left eye swelling and fever that began 2
days ago. The patient was seen at the ED and given Ibuprofen and
Benadryl for a suspected allergic process. Yesterday, the patient was
brought back to the ED for worsening left eyelid swelling with
decreased appetite.

VS: T 98.6, RR 24, BP 119/97, SpO2 100% RA, HR 137

PE: WDWN, fussy and ill, but otherwise non-toxic. Left upper and
lower eyelids appear significantly edematous, erythematous, and
tender to palpation. EOM appeared intact but exam limited due to
pain. No apparent chemosis, proptosis, or purulent discharge
present.

CT was obtained, patient admitted to peds ward.

Optho and ENT consulted.

Objectives
1. Understand the pathogenesis of preseptal and orbital cellulitis

2. Distinguish between preseptal and orbital cellulitis from H&P

3. Review medical treatment

4. Know the indications for CT scan and surgical intervention

 Anatomy of the Orbit
Orbit: horizontal cone-shaped structure with apex in the skull

Orbital septum: membrane separating eyelid from deeper

structures

Preseptal cellulitis: infection of soft tissues anterior to septum

Orbital cellulitis: infection of structures posterior to septum

Orbit is surrounded by paranasal sinuses: frontal, ethmoid, maxillary

Noma et al. TOOPHTJ The Open Ophthalmology Journal 4.1 (2010): 71-75; Uptodate
 Etiology of Orbital Cellulitis
1. Extension of primary infection from paranasal sinuses

a. Most common cause: extension from ethmoid sinusitis

b. Sinusitis Narrowing of ostia Drainage Bacterial Proliferation

Spread through lamina papyracea and Zuckerkandls dehiscences

2. Direct inoculation secondary to trauma

a. Orbital fracture or surgical trauma bacteria directly into orbit

3. Hematogenous spread secondary to bacteremia via valveless orbital veins

a. Can also allow infection to pass from orbit to cavernous sinus

Hauser, A., and S. Fogarasi. "Periorbital and Orbital Cellulitis." Pediatrics in Review 31.6 (2010): 242-49
 Epidemiology
Preseptal cellulitis is more common that orbital cellulitis

More common in young children

Uncommon complication of bacterial rhinosinusitis, but rhinosinusitis is the source of

infection for most cases of orbital cellulitis

Staphylococcus aureus and streptococci species are most common organisms

Streptococcus anginosus 15%

Staphylococcus aureus 9%

Group A -hemolytic strep 6%

Streptococcus pneumoniae 4%
Botting et al International Journal of Pediatric Otorhinolaryngology 72.3 (2008): 377-83; Seltz et al Pediatrics 127.3 (2011)
 Clinical Presentation

Preseptal Cellulitis Orbital Cellulitis

Unilateral eyelid erythema, swelling, Unilateral erythema, swelling, warmth,

warmth, and tenderness tenderness of eyelid

Fever, systemic signs, leukocytosis Fever, systemic signs, leukocytosis

Chemosis is rare Ophthalmoplegia

Proptosis

Chemosis

Visual impairment
Hauser, A., and S. Fogarasi. "Periorbital and Orbital Cellulitis." Pediatrics in Review 31.6 (2010): 242-49
 Chandlers Classification

Group I: Preseptal cellulitis

Group II: Orbital cellulitis

Group III: Subperiosteal abscess

Group IV: Orbital abscess

Group V: Cavernous sinus thrombosis

Bedwell and Bauman "Management of Pediatric Orbital Cellulitis and Abscess." Current Opinion in Otolaryngology & Head and Neck Surgery 19.6 (2011) 467-73
 Medical Management

Most preseptal and orbital cellulitis can be managed medically

Empirically treat to cover streptococcus, staphylococcus, and MRSA

Preseptal cellulitis: Clindamycin with outpatient follow up in 24-48 hours

Or: TMP-SMX + Amoxicillin, Amoxicillin-clavulanic acid, Cefpodoxime, or Cefdinir

Orbital cellulitis: IV Vancomycin + Piperacillin-tazobactam

Or: Vancomycin + Ceftriaxone or Cefotaxime or Ampicillin-sulbactam

Switch to PO Clindamycin + Amoxicillin-clavulanate when symptoms improve (3-5 days)

Adjuvants: Intranasal oxymetazoline, PO steroids

Liu et al IDSA Guideline. Clinical Infectious Diseases 52.3 (2011)

 Indications for CT

Eyelid edema preventing complete examination

Suspecting Chandler Classification II or greater

Deteriorating visual acuity, proptosis, or ophthalmoplegia

CNS involvement (focal neurologic deficit, seizure, AMS)

Systemic signs: fever or leukocytosis

Worsening/no improvement after 24-48 hrs of antibiotics

Bedwell and Bauman "Management of Pediatric Orbital Cellulitis and Abscess." Current Opinion in Otolaryngology & Head and Neck Surgery 19.6 (2011) 467-73
 Surgical Management
Indications

Poor response to appropriate antibiotics after 24-48 hours

Evidence of impaired visual acuity, elevated IOP, opthalmoplegia, proptosis 5 mm, abscess > 10 mm

Goals: drain abscess, release pressure on orbit, obtain cultures to guide antibiotics

Surgical interventions:

Endoscopic sinus surgery to drain affected sinuses and obtain cultures

Endoscopic ethmoidectomy to drain medial subperiosteal abscesses

Lynch incision to drain medial subperiosteal abscesses

External orbitotomy for drainage of lateral, superior, or inferior abscesses

Johnson, Jonas T., Clark A. Rosen, and Byron J. Bailey. "Chapter 33: Acute Rhinosinusitis." Bailey's Head and Neck Surgery--otolaryngology.
Case

CT scan in ED showed evidence of orbital cellulitis (Chandler II)

Patient was admitted to the pediatric ward

Empiric treatment with IV Vancomycin + Piperacillin-Tazobactam on HD#1

Patient clinically improved, tolerated PO clindamycin + amoxicillin + clavulanate,

and discharged on HD#3

Continue PO antibiotics for 10 days and f/u in ENT clinic

Conclusion
Most common etiology of orbital cellulitis is rhinosinusitis

Key distinguishing features for orbital cellulitis: opthalmoplegia, proptosis, chemosis,

visual impairment

Most cases respond well to antibiotic therapy (PO Clindamycin; IV Vanc + Zosyn

Indications for CT is low: Chandler Class II or greater

Several indications for surgery including poor response to antibiotic therapy,

worsening symptoms, or severe symptoms
Questions?
 Works Cited
1. Bedwell, Joshua, and Nancy M. Bauman. "Management of Pediatric Orbital Cellulitis and Abscess." Current Opinion in Otolaryngology & Head and Neck Surgery

19.6 (2011): 467-73. Web.

2. Botting, A.m., D. Mcintosh, and M. Mahadevan. "Paediatric Pre- and Post-septal Peri-orbital Infections Are Different Diseases." International Journal of Pediatric

Otorhinolaryngology 72.3 (2008): 377-83. Web.

3. Hauser, A., and S. Fogarasi. "Periorbital and Orbital Cellulitis." Pediatrics in Review 31.6 (2010): 242-49.

4. Johnson, Jonas T., Clark A. Rosen, and Byron J. Bailey. "Chapter 33: Acute Rhinosinusitis." Bailey's Head and Neck Surgery--otolaryngology. Philadelphia: Wolters

Kluwer Health /Lippincott Williams & Wilkins, 2014

5. Liu, C., A. Bayer, S. E. Cosgrove, R. S. Daum, S. K. Fridkin, R. J. Gorwitz, S. L. Kaplan, A. W. Karchmer, D. P. Levine, B. E. Murray, M. J. Rybak, D. A. Talan, and

H. F. Chambers. "Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus Aureus

Infections in Adults and Children." Clinical Infectious Diseases 52.3 (2011): n. pag. Web.

6. Noma, Kazunami, Yasuhiro Takahashi, Igal Leibovitch, and Hirohiko Kakizaki. "Transcutaneous Blepharoptosis Surgery: Simultaneous Advancement of the Levator

Aponeurosis and Mllers Muscle (Levator Resection)." TOOPHTJ The Open Ophthalmology Journal 4.1 (2010): 71-75. Web.

7. Seltz, L. B., J. Smith, V. D. Durairaj, R. Enzenauer, and J. Todd. "Microbiology and Antibiotic Management of Orbital Cellulitis." Pediatrics 127.3 (2011): n. pag.