DESCRIPTION

• An acute bacterial infection of the skin and subcutaneous tissue anterior to the orbital septum; does not involve the orbital structures (globe, fat, and ocular muscles)
• Synonym(s): preseptal cellulitis

EPIDEMIOLOGY

• Occurs more commonly in children; mean age 21 months
• 3 times more common than orbital cellulitis

ETIOLOGY AND PATHOPHYSIOLOGY

• The anatomy of the eyelid distinguishes periorbital (preseptal) from orbital cellulitis:
  • A connective tissue sheet (orbital septum) extends from the orbital bones to the margins of the upper and lower eyelids; it acts as a barrier to infection of deeper orbital structures.
  • Infection of tissues anterior to the orbital septum is periorbital (preseptal) cellulitis.
  • Infection deep to the orbital septum is orbital (postseptal) cellulitis.
• Periorbital cellulitis typically arises from a contiguous infection of soft tissues of the face.
  • Sinusitis (via lamina papyracea) extension
  • Local trauma; insect or animal bites
  • Foreign bodies
  • Dental abscess extension
  • Hematogenous seeding
• Common organisms
  • Staphylococcus aureus, typically MSSA (MRSA is increasing.)
  • Staphylococcus epidermidis
  • Streptococcus pyogenes
  • Streptococcus pneumonia (1)
• Atypical organisms
  • Acinetobacter spp.; Nocardia brasiliensis
  • Bacillus anthracis; Pseudomonas aeruginosa
  • Neisseria gonorrhoeae; Proteus spp.
  • Pasteurella multocida; Mycobacterium tuberculosis; Trichophyton sp. (ringworm)
• Since vaccine introduction, the incidence of Haemophilus influenzae disease has decreased (should still be suspected in unimmunized or partially immunized patients).

RISK FACTORS

• Contiguous spread from upper respiratory infection
• Acute sinusitis
• Conjunctivitis
• Blepharitis
• Dental infection
• Local skin trauma/puncture wound
• Insect bite
• Bacteremia

GENERAL PREVENTION

• Avoid trauma around the eyes.
• Avoid swimming in fresh or salt water with facial skin abrasions.
• Routine vaccination: particularly H. influenzae type B and Streptococcus pneumoniae

HISTORY

• Induration, erythema, warmth, and/or tenderness of periorbital soft tissue, usually with normal vision and normal eye movements
• Chemosis (conjunctival swelling), proptosis; pain with extraocular eye movements can occur in severe cases of periorbital cellulitis and are concerning for orbital cellulitis.
• Fever (not always present)
• History of recent upper respiratory illness, sinusitis, or insect bite/local trauma (2)

PHYSICAL EXAM

• Vital signs and general appearance (Patients with orbital cellulitis often appear systemically ill.)
• Inspect eyes and surrounding structures—eyelids, lashes, conjunctiva, and skin.
  • Erythema, swelling, and tenderness of lids without orbital congestion
  • Violaceous discoloration of eyelid is more commonly associated with H. influenzae.
• Evaluate for skin breakdown.
• Look for vesicles to rule out herpetic infection.
• Inspect nasal vaults and palpate sinuses for signs of acute sinusitis.
• Examine oral cavity for dental abscesses.
• Test ocular motility and visual acuity.

DIFFERENTIAL DIAGNOSIS

• Orbital cellulitis
  • Orbital cellulitis may have the same signs and symptoms as periorbital cellulitis, with fever, proptosis, chemosis, ophthalmoplegia, decreased visual acuity, pain with ocular movement.
• Abscess
• Dacryocystitis
• Hordeolum (stye)
• Angioedema (allergic inflammation) (2)
• Orbital or periorbital trauma
• Idiopathic inflammation from orbital pseudotumor
• Orbital myositis
• Rapidly progressive tumors
  • Rhabdomyosarcoma
  • Retinoblastoma
  • Lymphoma
• Leukemia

DIAGNOSTIC TESTS & INTERPRETATION

MEDICATION

• Treat periorbital cellulitis with oral antibiotics and ensure close follow-up.
• Empiric antibiotic treatment should cover the most likely organisms (Staphylococcus and Streptococcus).
• Observe local prevalence of MRSA to determine need for coverage.
• No evidence that IV antibiotics are more effective than PO in reducing recovery time or preventing secondary complications in simple periorbital cellulitis
• Insufficient evidence for benefit of steroid use (3)

ISSUES FOR REFERRAL

Consult ENT and ophthalmology if there is concern for orbital cellulitis or if patients do not respond quickly to first-line treatment.

SURGERY/OTHER PROCEDURES

• Usually not indicated in uncomplicated cases
• If there is an abscess or potential compromise of critical structures, orbital surgery is indicated.
• Diplopia is the strongest clinical predictor for surgery.

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

• If the patient is stable and there are no systemic signs of toxicity, mild cases in adults and children >1 year of age can be safely managed on an outpatient basis.
• Consider hospitalization and IV antibiotics:
  • If patient appears systemically ill
  • Children <1 year of age
  • Patients not immunized against S. pneumoniae or H. influenzae
  • If patients do not improve or deteriorate within 24 hours of oral antibiotics
  • High suspicion for orbital cellulitis (eyelid swelling with reduced vision, diplopia, abnormal light reflexes, or proptosis)
• No strict guidelines indicate when to switch from parenteral to PO therapy. In general, a switch from IV to oral antibiotics is reasonable once eyelid edema and erythema have significantly improved.
• A 10- to 14-day course of antibiotics is indicated.

FOLLOW-UP RECOMMENDATIONS

PATIENT EDUCATION

• Maintain good skin hygiene.
• Avoid skin trauma.
• Report early skin changes (swelling, redness, and pain) if recurrent after a course of therapy.

PROGNOSIS

• With timely treatment, patients do well.
• Recurrent periorbital cellulitis occurs with ≥3 periorbital infections in 1 year with at least 1 month of in between episodes; must be differentiated from treatment failure due to antibiotic resistance

COMPLICATIONS

• Orbital cellulitis; orbital abscess formation
• Scarring
• Vision loss
• Cavernous sinus thrombosis
• Osteomyelitis

ICD10

L03.211 Cellulitis of face

SNOMED

109245003 Cellulitis of periorbital region