Topic Editor: Grant E. Fraser, M.D., FRACGP, FACRRM, ASTEM
Review Date: 10/15/2012
Definition
Orbital or postseptal cellulitis is a sight-threatening infection of the periocular structures posterior to the orbital septum. This condition is most commonly due to infection spreading from bacterial sinusitis.
Description
- Orbital cellulitis is an infection of the periocular structures posterior to the orbital septum, most commonly due to extension of infection from sinusitis (most commonly from the maxillary sinus)
- Streptococcus pneumoniae is the most common causative organism when orbital cellulitis is due to extension from sinusitis
- Less commonly, the source of infection can be local trauma or contiguous spread from infected teeth or facial structures or by hematogenous spread
- In cases of direct trauma, Staphylococcus aureus and Streptococcus pyogenes are the most common organisms involved
- Serious consequences of this condition can include cavernous sinus thrombosis, carotid occlusion, intracranial abscess, meningitis, or visual loss
Epidemiology
Incidence/prevalence
- Unknown prevalence
- Higher incidence in winter, probably due to the increased incidence of sinusitis
Age- More common in children than in adults
- Median age is 9 years
Gender
Risk factors
- Acute dacryocystitis/dacryoadenitis
- Facial skin infections (e.g., Impetigo, infected insect bite, acne, eczema)
- Infections (dental/intracranial)
- Male gender
- Ophthalmologic surgery
- Orbital trauma
- Orbital mucopyocele
- Preorbital or facial cellulitis
- Retained orbital foreign body
- Sinusitis
- Young age
Etiology
- Most commonly caused by extension of infection from adjacent maxillary or ethmoid sinuses, with the most common organism Streptococcus pneumoniae
- Other less common organisms are:
- Moraxella catarrhalis
- Group A ß-hemolytic streptococci, other streptococcal species, and anaerobes
- Haemophilus influenzae type B cases have markedly decreased due to vaccination
- Less commonly caused by direct infection due to local trauma (e.g., Bites from insects or animals or other penetrating injuries to the periocular region), contiguous spread of infection from the face or teeth, or by hematogenous spread. The most common causative organisms in such cases relates to the source of trauma or spread, but is more likely to be:
- Staphylococcus aureus
- Streptococcus pyogenes
- Streptococcus pneumoniae
- Other organisms depending upon the source
History
- The majority of patients present with local ocular symptoms such as erythema, pain and edema. Other symptoms include:
- Extending erythema around a swollen eyelid
- Foreign body sensation in the eye
- Headache
- Painful eye movements
- Rhinorrhea
- Visual disturbances such as declining vision or diplopia
- Fever, malaise, and a history of recent sinusitis or upper respiratory tract infection are common
- Rarely, there is a history of recent eyelid injury or orbital trauma
Physical findings on examination
- Proptosis and ophthalmoplegia are key findings in orbital cellulitis
- Other signs may include:
- Chemosis (swelling/edema of the conjunctiva)
- Decreased extraocular eye movements
- Elevated intraocular pressure
- Eyelid erythema
- Fever
- Impaired visual acuity
- Impaired or absent light reflex
- Purulent nasal discharge
- Tenderness around the eye
Blood test findings
Physical examination with supporting radiologic imaging usually confirms this diagnosis. Blood testing is usually of little value. In patients who are systemically unwell, basic blood evaluation (CBC, electrolytes, renal function) and potentially blood cultures, may be of some value.
- Complete blood count (CBC): CBC, if performed, may demonstrate normal or elevated leukocytes, with or without a left shift
- Blood and aspirate culture: Blood cultures should be obtained in patients who appear septic or bacteremic prior to administration of antibiotics. Blood cultures in nonseptic/bacteremic patients tend to be of little value. Some evidence exists for obtaining a blood culture in children 5 years of age
Other laboratory test findings
- Microbiology swab: A wound culture swab should be collected for culture if purulent material is draining from the nose or eye. In some cases, cultures may be obtained from sinus aspirate or abscess. Cultures from orbital or sinus abscesses are more likely to yield positive results
Radiographic findings
- CT orbits/sinuses (usually with IV contrast) is the study of choice both due to cost and availability. CT findings may include inflammation of orbital tissues deep to the septum. Additionally, if subperiosteal abscess or sinusitis is present, this should be evident on CT
- MRI head: May be used to evaluate the soft tissues, confirm abscess, and/or sinusitis
- Ultrasonography: Ultrasound may be helpful in following cases
- To rule out orbital myositis
- To identify foreign bodies or abscesses
- To track progress in drained abscesses
General treatment items
- Patients with orbital cellulitis should be hospitalized until they become afebrile and show clinical improvement
- Traditionally the treatment of subperiosteal or intraorbital abscess was with surgical drainage and antibiotic therapy. Surgical drainage is indicated in cases of complete ophthalmoplegia and/or significant visual impairment or in cases of large well-defined abscesses. In other cases, it is reasonable to provide intravenous antibiotics for 24–48 hours, with close monitoring and reassessment
- If there is no clinical improvement in 24-48 hours, consider repeat imaging (generally CT scan) and if abscess present, consider surgical drainage
- Treatment for brain abscess is usually surgical excision or drainage, plus 4-8 weeks of antibiotics
- The surgical approach consists of external/endoscopic ethmoidectomy, uncinectomy, antrostomy, and subperiosteal draining
- Empiric antibiotic therapy for all ages needs to provide coverage for pathogens associated with acute sinusitis (S. pneumoniae, H. influenzae, M. catarrhalis, S. pyogenes) in addition to S. aureus and anaerobes. If methicillin-resistant S aureus (MRSA) is prevalent in the community or shown on culture, appropriate therapy should be provided for this organism (e.g., Vancomycin, linezolid, daptomycin or telavancin)
- In cases of fungal orbital cellulitis, treatment is with appropriate antifungal agents, in consultation with an infectious disease expert. Amphotericin is often the initial choice
- Corticosteroids may be helpful in some cases, usually started after 2-3 days of antibiotics, and after any necessary surgical procedure is complete
- Provide tetanus prophylaxis in case of posttraumatic orbital cellulitis
Medications indicated with specific doses
Treatment requires adequate cover of all 3 of the following:
- Gram positive coverage (especially S. aureus) PLUS
- Gram negative coverage PLUS
- Anaerobic coverage
Gram positive Coverage (Choose 1 of the following):If MRSA not suspected:If MRSA suspected:- Vancomycin (drug of choice)
- Linezolid (less data supporting this and higher cost)
- Daptomycin
- Telavancin
- Clindamycin (with caution due to some resistance of MRSA)
Other agents such as doxycycline, trimethoprim/sulfamethoxazole, rifampin are generally not recommended, but can be considered in certain situations if a cultured MRSA shows sensitivity to the selected agent
- Doxycycline
- Trimethoprim/sulfamethoxazole
- Rifampin
Plus
Gram negative Coverage (Choose 1 of the following):- Ceftriaxone
- Adult Dosing
- Pediatric Dosing
- Cefotaxime
- Adult Dosing
- Pediatric Dosing
- Cefuroxime
- Adult Dosing
- Pediatric Dosing
- Ceftazidime
- Adult Dosing
- Pediatric Dosing
- Levofloxacin
- Adult Dosing
- Pediatric Dosing
Plus
Anaerobic coverage:
- Metronidazole
- Adult Dosing
- Pediatric Dosing
Note: If on Clindamycin as part of gram + coverage, this probably provides sufficient anaerobic coverage and metronidazole is likely unnecessary
Simplified Regimens:Staphylococcus aureus (MRSA if indicated or MSSA if not) coverage plus (choose 1)
- Ampicillin-sulbactam
- Adult Dosing
- Pediatric Dosing
- Ticarcillin-clavulanate
- Adult Dosing
- Pediatric Dosing
- Piperacillin-tazobactam
- Adult Dosing
- Pediatric Dosing
Disposition
Admission criteria
- Most patients require admission for IV antibiotics, particularly in cases of proptosis or ophthalmoplegia. In rare circumstances, a mild case could be considered for oral antibiotics with exceptionally close outpatient follow-up
Discharge criteria
- Afebrile and clinically improved
