Monday, Monday (lalalalala…) AM Report July 18, 2011

Left orbital cellulitis secondary to paranasal sinus disease Extensive paranasal sinus congestion with complete opacification of the ethmoid air cells; apparent break through the lamina papyracea with stranding of the retro-orbital fat and opacification along the medial rectus muscle; preseptal inflammation; mild proptosis CT Orbits with Contrast

Infections anterior to orbital septum= PERIORBITAL Infections posterior to the orbital septum= ORBITAL Anatomic considerationsorbital infections: orbital septum may be incomplete, spread from paranasal sinuses, valveless orbital vv allow passage of hematogenous infection Anatomic Considerations (Courtesy of PIR “Periorbital and Orbital Cellulitis”)

Epidemiology Periorbital cellulitis Orbital cellulitis Pts <5yrs 3 times more common than orbital cellulitis Orbital cellulitis Average age 6.8 yrs (1wk to 18 months) 2:1 male predominance Occurs more often in winter months (URI, sinusitis)

Pathogenesis Periorbtial Orbital Extension of external ocular infection Hordeolum (stye) Dacrocystitis/dacroadenitis Superficial break in the skin Orbital RHINOSINUSITIS URI Dental abscess Direct penetrating injury to the orbit Hematogenous spread Dental abscess and hematogenous spread can also cause periorbital cellulitis

Microbiology Periorbital Orbital Consider Hib in unimmunized children S. aureus, S. epidermidis, S. pyogenes Orbital Staphylococcus (MRSA), Streptococcus Less commonly (dental, sinus dz): Haemophilus, Neisseria, Bacteroides, Veillonella, Provetella, Peptostreptococcus, Moraxella catarrhalis Consider Hib in unimmunized children

Clinical Presentation Periorbital Unilateral erythema, swelling, warmth, and tenderness of the eyelid Fever, systemic signs (toxicity?) Orbital All signs/Sx above Blurred vision, ophthalmoplegia (pain with EOM), proptosis, chemosis If not able to do a complete exam due to eyelid swelling/pain, imaging and Ophtho consult needed (with likely admission for IV Abx)

Periorbital cellulitis due to insect bite (arrow) Periorbital Cellulitis (Courtesy of PIR “Periorbital and Orbital Cellulitis”)

Periorbital cellulitis due to dental abscess Periorbital Cellulitis (Courtesy of PIR “Periorbital and Orbital Cellulitis”)

Orbital cellulitis due to pan-sinusitis Note limited adduction in the left eye Orbital Cellulitis (Courtesy of PIR “Periorbital and Orbital Cellulitis”)

Differential Diagnosis Allergic reaction Edema due to hypoproteinemia Orbital wall infarction and subperiosteal hematomas in pts with SS dz

Evaluation Periorbital Orbital Dx on clinical findings (no routine labs or imaging necessary) Wound Cx Blood Cx (only if hematogenous spread is suspected) Orbital High WBC ct, ESR/CRP suggestive

Evaluation (con’t) Orbital Wound Cx CT scan with contrast of head and sinuses Incomplete exam due to edema/pain Presence of CNS involvement Decrease in visual acuity, color vision, gross proptosis, ophthalmoplegia Clinical deterioration or no improvement after 24-48h of appropriate Abx On CT, may see diffuse fat infiltration, subperiosteal abscess, and true orbital abscess

Treatment Periorbital Empiric coverage for Staph and Strep Dicloxicillin First generation cephalosporin Clindamycin or Bactrim if MRSA is suspected Improvement should be evident in 24-48h Periorbital cellulitis due to hematogenous spread should be treated with IV Abx (both gram+&- coverage) Length of treatment 7-10 days No evidence suggests that IV Abx are better than oral for simple periorbital cellulitis. So, choice of route is based on the general appearance of the patient, ability to take PO meds, compliance, and clinical progression of disease

Treatment Orbital Admit with ENT and Ophthalmology consults Empiric coverage for Staph, Strep and organisms associated with sinusitis (IV) Clindamycin and 3rd generation cephalosporin Surgical drainage if indicated Length of treatment 10-14 days Transition to oral abx after significant clinical improvement is made Surgical drainage with significant abscess formation (with increase in intraoccular pressure) or with nonresponsiveness to Abx therapy

Potential Complications Recurrent periorbial cellulitis Atopy HSV/HIV Atypical Mycobacteria Collagen vascular diseases Structural/anatomic abnormalities Cavernous sinus thrombosis Intracranial infections Loss of vision Cavernous sinus thrombosis difficult to dx, b/c it presents with similar Sx to orbital cellulitis Loss of vision from septic emboli to the optic nerve or ischemia due to compression

Recurrent Periorbital Cellulitis due to HSV (also the happiest child that ever had periorbital cellulitis) Recurrent Periorbital Cellulitis (Courtesy of PIR “Periorbital and Orbital Cellulitis”)

Periorbital and Orbital Cellulitis Periorbital Cellulitis Orbital Cellulitis Anatomy Infxn anterior to orbital septum (eyelid and surrounding tissues) Infxn posterior to orbital septum Epidemiology Usually pts<5 yo, 3x more common than orbital cellulitis Avg age 6.8 yrs (1wk-16 yrs); 2:1 male: female Pathogenesis Extension of external ocular infxn or superficial break in skin (hematogenous spread) Extension of rhinosinusitis, URI, dental abscess, hematogenous spread Microbiology Hib (un/ partially immunized kids), S. aureus, S. epi, S. pyogenes Hib, Staph and Strep species Presentation Unilat. erythema, swelling, warmth and tenderness of the eyelid Same, along with blurred vision, opthalmoplegia, proptosis, chemosis Diagnosis Clinical (+/- wound cx, blood cx) CT: diffuse fat infiltation, subperiosteal abscess and true orbital abscess; BCx, WCx Treatment Oral Abx: empiric coverage of staph and strep (dicloxacillin, Bactrim); LOT 7-10 d IV Abx: good gram + and – coverage (Clinda + 2nd or 3rd generation cephalosporin); ?surgery; LOT 10-14d

Thanks for your Attention! Noon Conference: Intern Clinical Reasoning with Dr. English (Everyone else is free for lunch!) Thanks for your Attention!