Cellulitis, Periorbital

Cellulitis, Periorbital is a topic covered in the 5-Minute Clinical Consult.

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Basics

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

ALERT
It is essential to distinguish periorbital cellulitis from orbital cellulitis. Orbital cellulitis is a potentially life-threatening condition. Orbital cellulitis is posterior to the orbital septum; symptoms include restricted eye movement, pain with eye movement, proptosis, and vision changes.

Epidemiology

  • Occurs more commonly in children; mean age 21 months
  • 3 times more common than orbital cellulitis (1)[C]

Incidence
Increased incidence in the winter months (due to increased cases of sinusitis) (1)[C]

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 (1)[C]
    • Staphylococcus aureus, typically MSSA (MRSA is increasing.)
    • Staphylococcus epidermidis
    • Streptococcus pyogenes
  • Atypical organisms
    • Acinetobacter sp.; Nocardia brasiliensis
    • Bacillus anthracis; Pseudomonas aeruginosa
    • Neisseria gonorrhoeae; Proteus sp.
    • Pasteurella multocida; Mycobacterium tuberculosis; Trichophyton sp. (ringworm)
  • Since vaccine introduction, the incidence of Haemophilus influenzae disease has decrease (should still be suspected in unimmunized or partially immunized patients).

Genetics
No known genetic predisposition

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

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