Rosen & Barkin's 5-Minute Emergency Medicine Consult (531 page)

• Currently streptococcal and staphylococcal infections are the most common causes:
  
  • S. pneumoniae
    ,
    Streptococcus viridans
    ,
    S. pyogenes
    ,
    Streptococcus anginosus, S. aureus
    
  • Anaerobes, Bacteroides, and gram-negatives may also be seen
    
• All forms of orbital cellulitis carry a risk of severe morbidity and possible mortality and are therefore a true emergency:
  
  • Permanent visual loss may occur
    
  • May extend to subperiosteal space with abscess formation
    
  • Cavernous sinus thrombosis and CNS infections may be life threatening
    
• Fungal infections are an uncommon but an even more lethal form particularly in the immunocompromised:
  
  • Cerebrorhino-orbital phycomycosis (CROP)
    
  • Rapidly fatal in 75% of cases:
    
    • 80% of cases occur in patients with a recent episode of diabetic ketoacidosis
      
    • Predisposing factor: Severe metabolic acidosis and immunocompromise
      
    • Begins in the paranasal sinuses and proliferates in the blood vessels causing thrombosis and necrosis
      
    • Bloody nasal discharge is common
      
    • May present with evidence of necrosis of the palate and/or nasal mucosa
      

• Routine vaccinations including Hib and Pneumococcus have dramatically decreased periorbital and orbital cellulitis, but infections may still occur with these organisms particularly in younger children and those without at least 2 Hib vaccines
  
• Periorbital cellulitis is overall 5 times more common and typically occurs in children <5 yr whereas orbital cellulitis is more common in children over 5 yr
  

DIAGNOSIS

• Both present with a unilateral, red, swollen eye:
  
  • Lid swelling may be profound in both
    
• Differences include:
  
  • Source of inciting infection
    
  • Single vs. both lids involved
    
  • Toxicity, systemic and neurologic symptoms
    

• Preceded by sinusitis in 60–90%, dental infection, trauma, puncture wound, or recent operation
  
• Swelling and redness surrounding eye in addition to eye pain, visual impairment, loss of color vision, restricted eye movements
  
• Headache, meningismus, and symptoms of systemic illness may occur
  
• Identify complicating medical problems:
  
  • Immunocompromise
    
  • Diabetes
    

• Toxic appearance:
  
  • Fever >39°C
    
• Restricted, painful extraocular movements (EOM)
  
• Afferent pupillary defect
  
• Conjunctival injection
  
• Chemosis
  
• Decreased visual acuity
  
• Diplopia
  
• Proptosis
  
• Meningismus and neurologic findings may be seen.
  

• Preceded by local skin injury, insect bite, URTI, or superficial ocular infection
  
• Ask about vaccination status in young children
  
• Low-grade fever
  
• Subacute presentation
  

• Red, swollen eyelid
  
• Often single lid involvement but can involve both
  
• Conjunctival injection common
  
• Low-grade fever common:
  
  • Rare systemic symptoms
    
• Normal visual acuity
  
  • No symptoms of deep ocular involvement
    

• Complete eye exam:
  
  • External exam
    
  • Visual acuity
    
  • EOM
    
  • Pupillary exam
    
  • Fundoscopic exam
    
  • Intraocular pressure measurement
    
• Complete neurologic exam
  

Supportive but not diagnostic:

• CBC:
  
  • WBC <15,000 for periorbital cellulitis
    
  • WBC >15,000 may suggest bacteremic periorbital cellulitis or orbital cellulitis
    
• Blood culture
  
• Gram stain and culture of tissue aspirate or swab of draining purulent material:
  
  • Chocolate agar plate when gonorrhea suspected
    

CT scan orbits with contrast:

• Indicated if:
  
  • CNS or systemic signs
    
  • Visual disturbances
    
  • Proptosis; restricted or painful EOM
    
  • Ophthalmoplegia
    
  • Bilateral edema
    
  • No improvement or deterioration at 24 hr
    
• Demonstrates extent of:
  
  • Orbital cellulitis
    
  • Sinusitis
    
  • Orbital emphysema
    
  • Subperiosteal abscess
    
  • Presence of foreign body
    
  • Cavernous sinus thrombosis
    

Lumbar puncture:

• Rule out CNS involvement in patients who appear toxic or manifest meningismus
  
• Surgery:
  
  • Evacuate abscess
    
  • Relieve sinusitis
    
  • Decompress optic nerve
    

• Allergic reaction
  
• Dacryoadenitis
  
• Dacryocystitis
  
• Graves disease
  
• Hordeolum
  
• Inflammatory orbital pseudotumor
  
• Insect bite
  
• Orbital rhabdosarcoma
  
• Periorbital ecchymosis
  
• Retrobulbar hemorrhage
  

TREATMENT

IV fluids for vomiting, dehydration, toxic appearance, clinical need for parenteral antibiotics

• Antipyretics
  
• Pain medication as needed
  
• Antibiotics
  

• Typically responds to oral antibiotics unless appears bacteremic or toxic:
  
  • Augmentin: 500 mg (peds: 45 mg/kg/24 h) PO TID
    
  • Cephalexin: 500 mg (peds: 100 mg/kg/24 h) PO QID
    
  • Clindamycin: 300 mg (peds: 20 mg/kg/24 h) PO QID
    
  • Dicloxacillin: 500 mg (peds: 100 mg/kg/24 h) PO QID
    
• Parenteral antibiotics:
  
  • Cefotaxime: 1–2 g (peds: 150 mg/kg/24 h) IV q6–8h
    
  • Clindamycin: 600 mg (peds: 40 mg/kg/24 h) IV q6h
    

• Early administration of parenteral antibiotics
  
• Ophthalmologic consultation for any intraocular manifestations
  
• If sinusitis is the source, consider ENT consultation, and add decongestants to the treatment
  
• Emergent surgical intervention may be necessary:
  
  • If
    Bacteroides
    is suspected organism:
    
    • Surgical débridement
      
    • Vancomycin
      
    • Tetanus toxoid when appropriate
      
• If proptosis leaves the cornea exposed:
  
  • Lubricating drops (Lacri-Lube: 2 drops q2–4h PRN)
    
• If you suspect CROP:
  
  • Amphotericin B IV at highest tolerated dose
    
  • Topical amphotericin B (1 mg/mL) irrigation or nasal packing
    
  • Local debridement
    

• Ceftriaxone: 1–2 g (peds: 100 mg/kg/24 h) IV q12–24h
  
• Erythromycin ophthalmologic ointment: Applied q4h to lower cul-de-sac
  

Depending on suspected organism:

• Gentamicin: 5 mg/kg/24 h IV
  
• Metronidazole: 15 mg/kg IV load, then 7.5 mg/kg q6h
  
• Nafcillin: 1–2 g (peds: 100 mg/kg/24 h) IV q4h
  
• Vancomycin: 1 g (peds: 40 mg/kg/24 h) q12h
  

FOLLOW-UP

Discharge with oral antibiotics and prompt follow-up unless:

• Evidence of systemic toxicity, neurologic, visual or orbital findings
  
• Unable to tolerate PO antibiotics
  
• Progression of infection on oral antibiotics
  
• Unable to arrange follow up within 24–48 hr
  
• High-risk
  H. influenzae
  type B
  
• Complicating medical problems
  

Admit for:

• IV antibiotics
  
• Observation for progression
  
• Specialist consultation
  
• Surgical incision and drainage
  

• Anytime a patient presents with a red swollen eye, consider the possibility of orbital cellulitis
  
• Take a careful history for:
  
  • Recent sinusitis
    
  • Recent puncture, history of trauma or surgical procedure
    
  • Recent dental infection—particularly a canine space abscess
    
  • History of immunocompromise or recent or current episode of DKA
    
  • Determine vaccination status in children
    
• Pay careful attention to exclude:
  
  • Systemic toxicity
    
  • Eye pain or visual impairment
    
  • Restriction of eye movements
    
  • Signs and symptoms of neurologic involvement
    

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  Int J Pediatr Otorhinolaryngol
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