Periorbital vs Orbital Cellulitis

Background

• Must distinguish between these two conditions
  • Orbital cellulitis may mimic periorbital cellulitis early in its course
• Orbital cellulitis most often 2/2 ethmoid sinusitis
  • May also be 2/2 orbital trauma, endophthalmitis, infectious infection from teeth / middle ear
• Periorbital cellulitis most often 2/2 contiguous infection of soft tissues of face and eyelids
• Periorbital cellulitis does not lead to orbital cellulitis

ORBITAL CELLULITIS (vs. Periorbital)

Any of the following:

1. Fever
2. Ill appearance
3. Blurred vision
4. Proptosis
5. Painful/limited EOM
6. Diplopia
7. Edema of optic disk
8. Venous engorgement of retina

Diagnosis

Signs/Symptoms

1. Periorbital Cellulitis
   1. Swelling and erythema of tissues surrounding the orbit
   2. +/- pain with eye movement
   3. +/- fever
2. Orbital Cellulitis
   1. All of the above plus:
      1. Proptosis
      2. Chemosis (conj. swelling)
      3. Globe displacement
      4. Limitation of eye movements
      5. Double vision
      6. Vision loss (indicates orbital apex involvement)

Imaging

1. CT Orbit with IV contrast
   1. Indicated for suspected orbital cellulitis or in pts who cannot accurately assess vision (e.g. age <1yr)
   2. Findings c/w orbital cellulitis:
      1. Proptosis
      2. Inflammation of ocular muscles
      3. Subperiosteal or orbital abscess

Complications

1. Subperiosteal Abscess
   1. Must be distinguished from orbital cellulitis based on CT
2. Orbital Abscess
   1. Pts tend to have severe proptosis, globe displacement, and appear systemically ill
   2. May be clinically indistinguishable from orbital cellulitis; requires CT
3. Meningitis
4. Cavernous sinus thrombosis

Treatment

1. Periorbital Cellulitis
   1. Most cases (except for pts < 1yr) can be managed as outpatient w/ oral abx and daily f/u
   2. Treatment (7-10 days)
      1. Augmentin 875mg BID OR
      2. Cefpodoxime 200mg BID OR
      3. Cefdinir 600mg qd
2. Orbital Cellulitis
   1. Vancomycin +
      1. Ampicillin-sulbactam 3 g IV q6hr OR
      2. Ticarcillin-clavulanate 3.1 g IV q4h OR
      3. Piperacillin-tazobactam 4.5 g IV q6h OR
      4. Ceftriaxone 2 g IV q12hr OR
      5. Cefotaxime 2 g IV q4h

Disposition

• Periorbital Cellulitis
  • If well-appearing and afebrile consider discharge
  • If concern of hematogenous cause consider admission
• Orbital Cellulitis
  • Admit

See Also

Periorbital Swelling

Source

UpToDate

Tintinalli