Preseptal and Orbital Cellulitis

Preseptal cellulitis is often a milder infection (and more common); while orbital cellulitis can present as a medical emergency; these can be differentiated with good clinical assessment.

 

Preseptal (periorbital) cellulitis= infection anterior to orbital septum (including the eyelid and surrounding soft tissue including cheek) with redness, tissue oedema, swollen eyelid.

Child is febrile but has normal eye movements and normal vision.

The infection is usually caused by Staph aureus or Gr A Strep; and generally extends from the skin injury externally or arises from deeper nasal sinus or teeth.

 

Orbital cellulitis = infection of the orbital tissues posterior to the orbital septum.

Bacteria from infected ethmoid sinus spreads to the orbital cavity- often Pneumococcus, Strep pyogenes, H influenza (less since vaccination), Anaerobes, Fungi or MRSA

 

Manifestations of orbital cellulitis include:

Orbital pain, Proptosis, Diplopia, painful / reduced eye movements (opthalmoplegia), cheimosis and reduced visual acuity (red-green differentiation is lost early).

Child may be irritable or drowsy; and may have vomiting, headache or seizures.

 

Complications include subperiosteal abscess, proptosis, ophthalmoplegia, cavernous sinus thrombosis, and vision loss (from ischaemic retinopathy). Intracranial spead of infection can cause meningitis and brain abcess.

 

Beware of differentials such as- neuroblastoma, rhabdomyosarcoma etc

 

Management:

Preseptal cellulitis:

If good clinical assessment was possible & there are no features of Orbital cellulitis, then treat with IV Co-Amoxyclav for 7 days (Oral only if early & mild case)

– Even in milder cases, review in 24 – 48 hours to review progress.

– May need Opthalmology assessment if unsure of assessment findings or moderate severity.

 

Orbital cellulitis:

If Unwell child with ‘orbital’ features or unable to do a good assessment, assume Orbital Infection

– Urgent senior review, including referrals to ENT and Ophthalmology teams required

– Treat with IV Ceftriaxone (may need to add Clindamycin if very unwell) for 7 days

– Antibiotics may be needed longer if bone infection present

– If improving, change to oral Co-Amoxyclav after 48h

– Take blood samples for FBC, U&E, CRP, Blood culture & Eye swab

– CT brain with orbital views- urgent

May require decongestant nose drops

May require surgical drainage of abscess

Monitor for intracranial complications

 

Indications for Urgent CT Brain with Orbital sections:

– Unable to assess eye movements/vision or if eyelid cannot be opened

– Orbital involvement suspected

– Focal neurological abnormality/ Central neurological signs

– Bilateral peri-orbital oedema

– Deterioration despite treatment

[Consider MRI brain if neurological signs & able to image urgently]