Periorbital cellulitis

Background

• Most often due to contiguous infection of soft tissues of face and eyelids
• Most patients are <10yr
• Rarely leads to orbital cellulitis

Periorbital vs Orbital Cellulitis

• Orbital cellulitis may mimic periorbital cellulitis early in its course
• Orbital cellulitis
  • Ocular emergency
  • Most often due to ethmoid sinusitis
  • May also be due to orbital trauma, endophthalmitis, infection from teeth / middle ear
  • Not caused by extension of periorbital cellulitis
• Periorbital cellulitis
  • Usually benign
  • Most often due to contiguous infection of soft tissues of face and eyelids

Clinical Features

• Swelling and erythema of tissues surrounding the orbit
• +/- pain with eye movement
• +/- fever
• Lack of:
  • Proptosis
  • Chemosis
  • Globe displacement
  • Limitation of eye movements
  • Double vision
  • Vision loss (indicates orbital apex involvement)

Differential Diagnosis

Periorbital swelling

Proptosis

• Normal IOP
  • Orbital cellulitis
  • Orbital pseudotumor
  • Orbital tumor
• Increased IOP
  • Retrobulbar abscess
  • Retrobulbar emphysema
  • Retrobulbar hemorrhage
  • Orbital tumor

No proptosis

• Periorbital cellulitis/erysipelas
• Dacryocystitis (lacrimal duct)
• Dacryocele/Dacryocystocele
• Dacryostenosis
• Dacryoadenitis (lacrimal gland)
• Allergic reaction
• Nephrotic Syndrome (pediatrics)

Lid Complications

• Blepharitis (crusts)
• Chalazion (meibomian gland)
• Stye (hordeolum) (eyelash folicle)

Other

• Subperiosteal abscess
• Orbital abscess
• Cavernous sinus thrombosis
• Conjunctivitis
• Contact dermatitis
• Herpes zoster
• Herpes simplex
• Sarcoidosis
• Granulomatosis with polyangiitis

Evaluation

• CT Orbit with IV contrast if:
  • Concern for orbital cellulitis
  • Unable to accurately assess vision (e.g. age <1yr)

Management

Antibiotics

Outpatient

• Amoxicillin/Clavulanate 875mg BID x7-10 days OR
• Cefpodoxime 200mg BID x7-10d OR
• Cephalexin 450mg PO three times daily OR
• Cefdinir 600mg PO once daily x7-10 days

Inpatient

Vancomycin 15-20mg/kg IV BID + (one of the following)

• Ampicillin/Sulbactam 3 g IV q6hr OR
• Ticarcillin/Clavulanate 3.1 g IV q4h OR
• Piperacillin-Tazobactam 4.5 g IV q6h OR
• Ceftriaxone 2 g IV q12hr OR
• Cefotaxime 2 g IV q4h

Disposition

• If well-appearing and afebrile consider discharge

See Also

• Periorbital Swelling
• Periorbital vs Orbital Cellulitis
• Orbital Cellulitis

References

Authors

Ross Donaldson, Jordan Swartz, Yos Yachivev, Daniel Ostermayer, Neil Young