- Compromised vision
- Symptoms of meningism
Why is this important?
- Permanent loss of vision can occur if periorbital cellulitis is not treated promptly. If the optic nerve is at risk and decompression is not achieved within hours, irreversible damage may occur.
- Intracranial complications may occur eg meningitis, cavernous sinus thrombosis
When to involve the ENT Registrar
- Urgently: Signs of severe disease with vision loss (proptosis, loss of colour vision etc.) - see classification below
- Soon: Signs of moderate disease eg pre-septal cellulitis
- Care is normally shared between ophthalmology and ENT (+/- paediatrics), with involvement of neurosurgery if indicated
Who to admit
- Any patient with red flags
- Any patient with worsening periorbital swelling or cellulitis whether on antibiotics or not
Always err on the side of caution. Many units would admit patients with any periorbital swelling for a minimum of overnight treatment and observation.
Assessment and recognition
- Arising from insect bites or periorbital trauma (including ENT/maxillofacial/ophthalmology procedures): likely to result in pre-septal cellulitis
- Arising from sinusitis; fronto-ethmoidal sinus pathology is the usual culprit: likely to result in orbital cellulitis or abscess
Chandler’s classification is used to communicate severity:
I. Pre-septal cellulitis - cellulitis confined to the eyelid ie anterior to the superior orbital septum
II. Orbital cellulitis without abscess - cellulitis involving the orbit
III. Orbital cellulitis with subperiosteal abscess - cellulitis with abscess confined to the orbital periosteum
IV. Intra-orbital abscess
V. Cavernous sinus thrombosis
The three crucial components of the examination are the eye, the nose and neurology.
Whilst the ophthalmologist will provide a more detailed examination, the ENT doctor should have performed a basic eye exam. Check for:
- Pain on eye movements
- Proptosis - look from above the brow
- Visual acuity - use a Snellen chart
- Colour vision and discrimination - loss of colour vision is a worrying sign and red reportedly goes first; use an Ishihara chart for red/green discrimination
- Fundoscopy - engorgement of retinal veins
- Nasendoscopy is essential: note the appearance of the nasal mucosa in general and middle meatus area specifically
- Any discharge should be swabbed and sent for culture
- A general neurological and cranial nerve examination is essential
Investigations aim 1) to assess the degree of sepsis and 2) to determine the cause of infection and severity of the condition.
Send bloods for FBC, CRP, U&E, blood cultures, ABG/lactate. You may wish to send a group & save in case there is a need for operative management.
A CT orbits/sinuses with contrast is the gold standard in the emergency setting. MRI head can give more detailed soft tissue information if a cavernous sinus thrombosis is suspected.
Immediate and overnight management
Bear in mind the Sepsis Resuscitation Bundle when managing septic patients.
- Broad spectrum IV antibiotics - consult your local microbiology guidance
- Nasal decongestants
- Steroid nasal drops
- Nasal douches
- Supportive: IV fluids, analgesia
You will need middle grade and senior input for the following:
- Drainage of abscess: endoscopic approach with functional endoscopic sinus surgery (common)
- Drainage of abscess: external approach (Lynch Howarth incision for medial abscesses) in urgent cases or when endonasal access is difficult
When to consider surgery
- Presence of an abscess (Chandler III or IV) with adverse eye signs such as propotosis, red desaturation or ophthalmoplegia
- No response to intravenous antibiotics within 24-36 hours (swelling unchanged; still pyrexial)
- No change in size of collection on repeat scan, despite surgical intervention
Post-operative scans are warranted when there is no resolution of symptoms.
Page last reviewed: 1 February 2018