Periorbital cellulitis

Background

Periorbital anatomy.

• Also known as preseptal cellulitis — infection anterior to the orbital septum
• Most often due to contiguous spread from sinusitis, skin infection, insect bite, or local trauma
• Most patients are <10 years old
• Rarely progresses to orbital cellulitis, but must be distinguished from it (see table below)
• Common organisms: S. aureus, S. pneumoniae, S. pyogenes, H. influenzae (in unvaccinated)

Periorbital vs Orbital Cellulitis

• Orbital cellulitis may mimic periorbital cellulitis early in its course
• Orbital cellulitis
  • Ocular emergency
  • Most often due to ethmoid sinusitis
  • May also be due to orbital trauma, endophthalmitis, infection from teeth / middle ear
  • Not caused by extension of periorbital cellulitis
• Periorbital cellulitis
  • Usually benign
  • Most often due to contiguous infection of soft tissues of face and eyelids

Clinical Features

Periorbital cellulitis

.

• Eyelid swelling, erythema, tenderness, warmth
• +/- fever
• Key distinguishing features from orbital cellulitis (all ABSENT in preseptal):
  • Proptosis
  • Chemosis
  • Globe displacement
  • Limitation of extraocular movements
  • Pain with eye movement
  • Diplopia
  • Vision loss

Differential Diagnosis

Periorbital swelling

Proptosis

• Normal IOP
  • Orbital cellulitis
  • Orbital pseudotumor
  • Orbital tumor
• Increased IOP
  • Retrobulbar abscess
  • Retrobulbar emphysema
  • Retrobulbar hemorrhage
  • Ocular compartment syndrome
  • Orbital tumor

No proptosis

• Periorbital cellulitis/erysipelas
• Dacryocystitis (lacrimal duct)
• Dacryocele/Dacryocystocele
• Dacryostenosis
• Dacryoadenitis (lacrimal gland)
• Allergic reaction
• Nephrotic Syndrome (pediatrics)

Lid Complications

• Blepharitis (crusts)
• Chalazion (meibomian gland)
• Stye (hordeolum) (eyelash folicle)

Other

• Subperiosteal abscess
• Orbital abscess
• Cavernous sinus thrombosis
• Conjunctivitis
• Contact dermatitis
• Herpes zoster
• Herpes simplex
• Sarcoidosis
• Granulomatosis with polyangiitis

Evaluation

Periorbital cellulitis caused by a dental infection (also causing maxillary sinusitis).

• Visual acuity, pupil exam, extraocular movement assessment — essential to distinguish from orbital cellulitis
• CT orbit with IV contrast if:
  • Equivocal exam (unable to fully assess proptosis, EOM, or pain with eye movement)
  • Unable to accurately assess vision (e.g. age <1 year)
  • Toxic-appearing or not improving on antibiotics
  • Concern for orbital abscess (subperiosteal or orbital)
• Blood cultures if febrile or toxic-appearing

Management

Antibiotics

Outpatient

Treatment recommended for 5-7 days. If signs of cellulitis persist at the end of this period, treatment should be continued until the eyelid erythema and swelling have resolved or nearly resolved.

• TMP/SMX 1-2 double-strength tablets BID OR

- In children: TMP/SMX 8 to 12 mg/kg QD of the TMP component divided every 12 hours

• Clindamycin 300mg Q8H - In children: Clindamycin 30 to 40 mg/kg per day in three to four equally divided doses, maximum 1.8 grams per day

PLUS one of the following agents:

• Amoxicillin 875 mg BID OR

- In children: Amoxicillin 45-90 mg/kg per day divided every 12 hours

• Cefpodoxime 400mg BID OR

- In children: Cefpodoxime 10 mg/kg per day divided every 12 hours, max 200 mg

• Cefdinir 300 mg BID - In children: Cefdinir 14 mg/kg per day, divided every 12 hours, max daily 600 mg

Inpatient

• Vancomycin 15-20mg/kg IV BID + (one of the following)
  • Ampicillin/Sulbactam 3 g IV q6hr OR
  • Ticarcillin/Clavulanate 3.1 g IV q4h OR
  • Piperacillin/Tazobactam 4.5 g IV q6h OR
  • Ceftriaxone 2 g IV q12hr OR
  • Cefotaxime 2 g IV q4h

Pediatric:

• Vancomycin 15mg/kg IV q6hrs + (one of the following)
  • Ampicillin/Sulbactam 50mg/kg IV q6hrs (max 3g/dose) OR
  • Piperacillin/Tazobactam 100mg/kg IV q8hrs (max 4.5g) OR
  • Ceftriaxone 50mg/kg IV q12hrs (max 2g/dose) OR
  • Cefotaxime 50mg/kg IV q6hrs (max 2g/dose)

Disposition

• Outpatient: Well-appearing, afebrile, mild disease, reliable follow-up in 24 hours
• Admit: Age <1 year, toxic-appearing, febrile, unable to tolerate PO, failed outpatient therapy, concern for orbital involvement
• Return precautions: Worsening swelling, fever, vision changes, pain with eye movement, inability to open eye

See Also

• Periorbital swelling
• Orbital cellulitis