Periorbital Cellulitis

Red flags

  • Compromised vision  
  • Symptoms of meningism
  • Sepsis

 

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

Pathophysiology

  Photo: right pre-septal (Chandler I) cellulitis. Note how the erythema is clearly confined to the eye lid.

 

Photo: right pre-septal (Chandler I) cellulitis. Note how the erythema is clearly confined to the eye lid.

  • 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

 

  Photo: left post-septal (Chandler II) or orbital cellulitis. Note how the erythema involves the brow, orbit and maxilla.

 

Photo: left post-septal (Chandler II) or orbital cellulitis. Note how the erythema involves the brow, orbit and maxilla.

The three crucial components of the examination are the eye, the nose and neurology.

Eye examination

Whilst the ophthalmologist will provide a more detailed examination, the ENT doctor should have performed a basic eye exam. Check for:

  1. Opthalmoplegia/diplopia
  2. Pain on eye movements
  3. Proptosis - look from above the brow
  4. Visual acuity - use a Snellen chart
  5. 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 
  6. Fundoscopy - engorgement of retinal veins

Nose examination

  1. Nasendoscopy is essential: note the appearance of the nasal mucosa in general and middle meatus area specifically
  2. Any discharge should be swabbed and sent for culture

Neurological examination

  1. A general neurological and cranial nerve examination is essential

Investigations

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. 

Non-surgical options

  1. Broad spectrum IV antibiotics - consult your local microbiology guidance
  2. Nasal decongestants
  3. Steroid nasal drops
  4. Nasal douches
  5. Supportive: IV fluids, analgesia

 

Further management

You will need middle grade and senior input for the following:

Surgical options

  1. Drainage of abscess: endoscopic approach with functional endoscopic sinus surgery (most common)
  2. 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)
  • Visual compromise and/or propotosis
  • No response to intravenous antibiotics within 24-48 hours
  • No change in size of collection on repeat scan, despite treatment 

Post-operative scans are warranted when there is no resolution of symptoms.

 

 

Page last reviewed: 23 September 2016