Cellulitis, Orbital

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Basics

Description

  • Acute, severe, vision-threatening infection of orbital contents posterior to the orbital septum.
  • Preseptal (previously referred to as periorbital) cellulitis is anterior to the septum. Location determines the appropriate workup and treatment.
  • Synonym(s): postseptal cellulitis

Epidemiology

  • No difference in frequency between genders in adults. Higher incidence in boys in childhood.
  • More common in children
  • Orbital cellulitis is much less common than preseptal cellulitis (1)

Incidence
The incidence of orbital cellulitis has declined since introduction of routine Haemophilus influenzae type b (Hib) vaccination.

Etiology and Pathophysiology

  • Sinusitis is classically associated with orbital cellulitis. Local skin conditions are typically associated with preseptal cellulitis.
  • The ethmoid sinus is separated from the orbit by the lamina papyracea (“layer of paper”), a thin bony separation, and is often the source of contiguous spread of infection to the orbit. The ethmoid sinus is present at birth.
  • The orbital septum is a connective tissue barrier that extends from the skull into the lid and separates the preseptal from the orbital space.
  • Cellulitis in the closed bony orbit causes proptosis, globe displacement, orbital apex syndrome (mass effect on the cranial nerves), optic nerve compression, and vision loss.
  • Cultures of surgical specimens in adults often grow multiple organisms. In over 1/3 of cases, no pathogen is recovered (2)[B]. Blood cultures typically do not grow an organism.
  • Most common organisms (3)[C],(4)[C]:
    • Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus anginosus
  • Less common organisms:
    • Moraxella catarrhalis, H. influenzae, group A β-hemolytic Streptococcus, Pseudomonas aeruginosa, anaerobes, phycomycosis (mucormycosis), aspergillosis, Mycobacterium tuberculosis, Mycobacterium avium complex, trichinosis, Echinococcus
  • Haemophilus is no longer the leading cause of orbital cellulitis (3)[B],(4)[B]. Methicillin-resistant Staphylococcus aureus (MRSA) is increasingly a clinical consideration.

Genetics
No known genetic predisposition

Risk Factors

  • Sinusitis is present in 80–100% of cases (3)[C]. Pansinusitis is often observed in adults (1).
  • Orbital trauma, retained orbital FB, ophthalmic surgery, and/or history of sinus surgery (1)
  • Dental, periorbital, skin, or intracranial infection; acute dacryocystitis (inflammation of the lacrimal sac) and acute dacryoadenitis (inflammation of the lacrimal gland)
  • Immunosuppressed patients are at increased risk of adverse outcomes.

General Prevention

  • Routine Hib vaccination
  • Appropriate treatment of bacterial sinusitis
  • Proper wound care and perioperative monitoring of orbital surgery and trauma
  • Avoid trauma to the sinus and orbital regions.

Commonly Associated Conditions

  • Sinusitis, especially pansinusitis in adults
  • Trauma and intraorbital FB
  • Preseptal cellulitis
  • Adverse outcomes include orbital apex syndrome, vision loss, ophthalmoplegia, abscess, meningitis, or cavernous sinus thrombosis

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Basics

Description

  • Acute, severe, vision-threatening infection of orbital contents posterior to the orbital septum.
  • Preseptal (previously referred to as periorbital) cellulitis is anterior to the septum. Location determines the appropriate workup and treatment.
  • Synonym(s): postseptal cellulitis

Epidemiology

  • No difference in frequency between genders in adults. Higher incidence in boys in childhood.
  • More common in children
  • Orbital cellulitis is much less common than preseptal cellulitis (1)

Incidence
The incidence of orbital cellulitis has declined since introduction of routine Haemophilus influenzae type b (Hib) vaccination.

Etiology and Pathophysiology

  • Sinusitis is classically associated with orbital cellulitis. Local skin conditions are typically associated with preseptal cellulitis.
  • The ethmoid sinus is separated from the orbit by the lamina papyracea (“layer of paper”), a thin bony separation, and is often the source of contiguous spread of infection to the orbit. The ethmoid sinus is present at birth.
  • The orbital septum is a connective tissue barrier that extends from the skull into the lid and separates the preseptal from the orbital space.
  • Cellulitis in the closed bony orbit causes proptosis, globe displacement, orbital apex syndrome (mass effect on the cranial nerves), optic nerve compression, and vision loss.
  • Cultures of surgical specimens in adults often grow multiple organisms. In over 1/3 of cases, no pathogen is recovered (2)[B]. Blood cultures typically do not grow an organism.
  • Most common organisms (3)[C],(4)[C]:
    • Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus anginosus
  • Less common organisms:
    • Moraxella catarrhalis, H. influenzae, group A β-hemolytic Streptococcus, Pseudomonas aeruginosa, anaerobes, phycomycosis (mucormycosis), aspergillosis, Mycobacterium tuberculosis, Mycobacterium avium complex, trichinosis, Echinococcus
  • Haemophilus is no longer the leading cause of orbital cellulitis (3)[B],(4)[B]. Methicillin-resistant Staphylococcus aureus (MRSA) is increasingly a clinical consideration.

Genetics
No known genetic predisposition

Risk Factors

  • Sinusitis is present in 80–100% of cases (3)[C]. Pansinusitis is often observed in adults (1).
  • Orbital trauma, retained orbital FB, ophthalmic surgery, and/or history of sinus surgery (1)
  • Dental, periorbital, skin, or intracranial infection; acute dacryocystitis (inflammation of the lacrimal sac) and acute dacryoadenitis (inflammation of the lacrimal gland)
  • Immunosuppressed patients are at increased risk of adverse outcomes.

General Prevention

  • Routine Hib vaccination
  • Appropriate treatment of bacterial sinusitis
  • Proper wound care and perioperative monitoring of orbital surgery and trauma
  • Avoid trauma to the sinus and orbital regions.

Commonly Associated Conditions

  • Sinusitis, especially pansinusitis in adults
  • Trauma and intraorbital FB
  • Preseptal cellulitis
  • Adverse outcomes include orbital apex syndrome, vision loss, ophthalmoplegia, abscess, meningitis, or cavernous sinus thrombosis

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