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

2. 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

3. 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”)

4. 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)

5. 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

6. 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

7. 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)

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

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

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

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

12. 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

13. 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

14. 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

15. 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 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

16. 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

17. 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”)

18. 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

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