Cellulitis

Orbital and Preseptal Cellulitis

Orbital infections could be vision- and life-threatening, and prompt evaluation and treatment of patients with these infections is essential.

Preseptal cellulitis (periorbital cellulitis) is an infectious inflammation of {the} tissues anterior to {the} orbital septum, more often encountered in children with upper respiratory infections

.

• usually 2^o to trauma or skin infection in kids and adults
• EOM’s, pupils, visual acuity Hertels, are NORMAL
• teens and adults can be closely followed as outpatient with ORAL antibiotics (Augmentin) but if worsening then CT and admit for IV antibiotics
• under 5 year old could have bacteremia, especially from H flu (violaceous erythema w/marked lid swelling are classic) otitis media or pneumonia, more severe disease, need IV 3rd gen cephalosporin antibiotics after blood cultures taken
• surgical drainage of abscess could be necessary; do not violate septum and cause orb cellulitis

Orbital cellulitis is an infectious inflammatory process involving {the} orbital tissues posterior to {the} orbital septum and requires

• Etiologies include trauma, orbital fracture repair, strabismus surgery
• Extension of pre-existing infections of {the} face, lacrimal sac, and lacrimal gland which can extend into {the} orbit
• Pathophysiology: The most common bacterial pathogens in preseptal cellulitis include Haemophilus influenza, Staphylococcus aureus, and Streptococcus pneumoni
• Therapy: Subperiosteal abscess formation should be suspected if patients fail to improve or deteriorate on intravenous antibiotics .
  • Infants with preseptal cellulitis are usually admitted for intravenous therapy, whereas
  • older children and adults with preseptal infections could be treated with oral antibiotics. 7- to 10-days of intravenous therapy are required, followed by a course of oral antibiotics for 10 to 14 days
• infection posterior to orbital septum
• 90% from extension of acute or chronic bacterial sinusitis, remainder s/p trauma or surgery or 2^o to extension from other orbital or periorbital infection, or endogenous w/septic embolization
• fever, proptosis, restriction of EOM’s, pain on globe movement
• decreased visual acuity Afferent Pupillary Defect (APD), prolonged high Intraocular pressure (IOP) can be indications for aggressive management to prevent orbital apex syndrome or cavernous sinus thrombosis

• CT of orbit and sinuses to confirm sinus disease, rule out mass, rule out orbital foreign body if h/o trauma (even remote), rule out orbital or subperiosteal abscess which will require surgical drainage
• blood culture then broad spectrum IV antibiotics to cover gram cocci, H. influenzae (although less prevalent in kids 2^o to immunization), anaerobes, typically nafcillin and 3rd generation cephalosporin; ID consult if necessary; kids more often single organism
• progression of infection or no daily improvement on appropriate antibiotics can mean abscess: repeat CT as needed (prn) and drain w/concomitant sinus drainage as needed (prn)
• cavernous sinus thrombosis: rapid progression of proptosis and neurologic signs of intracranial dysfunction; could lead to meningitis; get neurosurgery consult