How Common is Orbital Cellulitis?

Patient Presentation
A 9-year-old female came to clinic with swelling of the left eye for 1 day and 4 days of fever. She had previously been evaluated in a walk-in medical care office and treated for conjunctivitis with antibiotic drops two days previously. She currently had photophobia, blurred vision, headache above both eyes, but no oral, facial or ear pain. She had had rhinorrhea for the past week and denied trauma or insect bites. The past medical history and family history were non-contributory. The review of systems was otherwise negative.

The pertinent physical exam showed a female with obvious facial swelling. Her vital signs were normal except for a temperature of 101.5&deg F. Her growth parameters were 10-25%. She could not open her left eye and the swelling and erythema extended above the eyebrow, into the cheek about 2 cm and laterally about 1 cm from the eye. With lid retraction, she had marked bulbar and palpebral conjunctival injection, photophobia, painful extraocular movements and proptosis. She had some limitations to inward gaze but it was difficult to assess because of pain. She was tender over the ethmoid sinuses with purulent rhinorrhea. She had no dental pain and the rest of her examination was normal. The diagnosis of orbital cellulitis was made. The radiologic evaluation of computed tomography of the orbits showed a medial wall, retrobulbar abscess formation and ethmoid sinusitis. The patient’s clinical course showed that Ophthalmology was consulted who placed her on intravenous broad-spectrum antibiotics and eye rinses. A respiratory culture grew Haemophilus influenza type B and the patient was placed on Ciprofloxacin for a 2-3 week antibiotic course. Outpatient follow-up at 12 days showed no opthalmological deficits and the patient was otherwise doing well.

Case Image
Figure 92 – Axial image from a CT scan of the orbits performed with intravenous contrast demonstrates sinusitis of the left ethmoid sinus and both sphenoid sinuses. There is left sided prespetal cellulitis anterior to the left orbit. Furthermore, there is a left sided subperiosteal abscess between the medial wall of the left orbit and the left medial rectus muscle.

Discussion
Orbital cellulitis is a serious infection whose complications can include meningitis, intracranial abscess, cavernous sinus thrombosis, carotid artery occlusion and vision loss. Orbital cellulitis itself is usually a complication of rhinosinusitis particularly of the ethmoid sinuses but also trauma.

Haemophilus influenza type B usually has been the prevalent causative organism with Staphlococcus aureus and viridins streptococcus also being common causes. The microbiology appears to be changing though. A 25-year study shows that although immunization against Haemophilus influenza type B and pneumococcus have decreased the cases of invasive infections such as meningitis, epiglottitis and bacteremia, immunization does not appear to decrease the cases of orbital cellulitis. Yet a recent 5 year review of patients at a children’s hospital found that Streptococcus anginosus was an emerging pathogen in pediatric orbital infections. See To Learn More below.

To learn more about the physical characteristics distinguishing periorbital (preseptal) cellulitis from orbital cellulitis click here.

Learning Point
Overall orbital cellulitis is generally an uncommon pediatric problem, especially in contrast to periorbital cellulitis. Exactly how uncommon depends on the research study but it is important to consider its possibility in any child presenting with swelling around the orbit. Some recent studies are abstracted below.

  • In a 10-year retrospective study of 52 patients less than 2 years of age with rhinosinusitis, orbital complications were evaluated and none had orbital cellulititis. This would be ~0 patients/year.

  • In another 10-year retrospective review, 6 patients with orbital complications secondary to acute sinusitis were evaluated and 1 had orbital cellulitis. This would be ~0.1 patients/year.

  • In a third 10-year retrospective review, 83 patients with preseptal or orbital cellulitis were evaluated and 14 had orbital cellulitis. This would be ~1.4 patients/year.

  • In a cross-sectional 3-year study, ~260 patients (adult and pediatric) with preseptal and orbital cellulitiis, 11 pediatric patients had orbital cellulitis. This would be ~3.6 patients/year.

  • In a 5-year retrospective review, a total of 94 patients were admitted to a large referral children’s hospital with confirmed orbital cellulitis. This would be ~18.8 patients/year.
  • In a 25-year retrospective review for admitted children < 7 years within the United States military healthcare system, there was no change in the incidence of orbital cellulitis during 5 consecutive 5-year time periods. The incidence of orbital cellulitis was stable at ~4/1000 admissions.

    Questions for Further Discussion
    1. What clinical features help to distinguish orbital cellulitis from periorbital cellulitis?
    2. What are indications for surgical treatment of orbital cellulitis?
    3. What are the complications of sinusitis?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Eye Infections

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Cieslak TJ, Rajnik M, Roscelli JD. Immunization against Haemophilus influenzae type B fails to prevent orbital and facial cellulitis: results of a 25-year study among military children. Mil Med. 2008 Oct;173(10):941-4.

    Eviatar E, Gavriel H, Pitaro K, Vaiman M, Goldman M, Kessler A. Conservative treatment in rhinosinusitis orbital complications in children aged 2 years and younger. Rhinology. 2008 Dec;46(4):334-7.

    Babar TF, Zaman M, Khan MN, Khan MD. Risk factors of preseptal and orbital cellulitis. J Coll Physicians Surg Pak. 2009 Jan;19(1):39-42.

    Suhaili DN, Goh BS, Gendeh BS. A ten year retrospective review of orbital complications secondary to acute sinusitis in children. Med J Malaysia. 2010 Mar;65(1):49-52.

    Georgakopoulos CD, Eliopoulou MI, Stasinos S, Exarchou A, Pharmakakis N, Varvarigou A. Periorbital and orbital cellulitis: a 10-year review of hospitalized children. Eur J Ophthalmol. 2010 Nov-Dec;20(6):1066-72.

    Seltz LB, Smith J. Durairai VD, Enzenauer R, Todd J. Microbiology and Antibiotic Management of Orbital Cellulitis. Pediatrics. 2011;127;e566-e572.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital