Periorbital & Orbital Cellulitis

See also neck lumps and hearing loss for other paediatric ENT/ infective presentations.

Periorbital (preseptal) cellulitis

Infection of the eyelid and tissues anterior to the orbital septum — common in children, often arising with sinusitis, local trauma, facial/ dental procedures, insect bites, impetigo, conjunctivitis or a chalazion. Causative organisms: Streptococcus pneumoniae, Staphylococcus aureus, Streptococcus pyogenes, Staphylococcus epidermidis, Haemophilus species.

Identifying mild disease (safe for oral treatment)

All of: age >3 months; not immunocompromised; able to fully open the eye; white sclera with non-injected conjunctiva; normal, pain-free eye movements; intact vision (including colour vision); no fever; normal WCC (if tested).

Note: eyelid swelling without pain or fever can occur without infection (e.g. after an insect bite) — a trial of antihistamines may be reasonable if cellulitis isn’t suspected, but review within 24 hours to confirm improvement.

Management

• Mild: oral antibiotics (e.g. cefalexin 33 mg/kg, max 1 g, PO TDS for 7–10 days) — with medical review within 24 hours regardless.
• Moderate–severe: IV antibiotics for at least 48 hours (often longer).
• Do not classify as mild if: age <3 months, an adequate eye exam can’t be performed, or Hib immunisation is inadequate.
• Severe cellulitis, or any concern for orbital cellulitis, needs inpatient otolaryngology and ophthalmology review.

Orbital cellulitis

Infection posterior to the orbital septum — sight- and life-threatening, with potential complications including vision loss, cavernous sinus thrombosis, meningitis and intracranial abscess. Predisposing factors: sinusitis, orbital trauma, dental infection.

Signs suggesting orbital (not just periorbital) cellulitis

Moderate swelling impairing eyelid opening (limiting pupil/eye-movement exam); conjunctival injection, chemosis, discharge; proptosis; reduced eye movements; pain on eye movement; diplopia; reduced visual acuity; visual field defects; asymmetric pupil size or abnormal pupillary reflexes; evidence of rhinosinusitis or odontogenic infection; impaired red colour perception (an early sign of optic nerve injury — check with Ishihara plates); severe headache or other signs of intracranial involvement.

Management

Any child with suspected orbital cellulitis needs immediate hospital referral for prompt ENT and ophthalmology input. Likely to include:

• CT orbits/sinuses ± brain, plus routine pathology including blood culture.
• IV antibiotics — the Paediatric Improvement Collaborative guideline recommends a third-generation cephalosporin (cefotaxime or ceftriaxone) plus flucloxacillin.
• Possible surgical drainage (e.g. of a subperiosteal abscess) if not responding to medical management alone.