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Orbital Cellulitis as a Complication of Sinusitis
Orbital Cellulitis as a Complication of Sinusitis Shannon Munro Cohen, PhD, APRN, BC, FNP
Image appears courtesy of VisualDx. © Logical Images, Inc. All rights reserved. ABSTRACT Orbital cellulitis is an uncommon but serious infection involving the soft tissues behind the orbital septum that generally spreads from the sinuses. With prompt recognition and appropriate intravenous antibiotic use, mortality rates have declined from 17% to less than 2.5%, but blindness still occurs in 11% of cases. Nurse practitioners need to be aware of the diagnosis and management of this potentially lifethreatening disorder. Keywords: complications, orbital cellulitis, sinusitis © 2011 American College of Nurse Practitioners
O
rbital cellulitis is an uncommon but serious infection involving the soft tissues behind the orbital septum that generally spreads from the sinuses. It is associated with significant risk of blindness, meningitis, and death, thus nurse practitioners (NPs) need to be aware of prevention strategies, diagnosis, and management of this disorder.1 Before antibiotics, 17% of patients with orbital cellulitis died, and 20% lost their sight in the affected eye.2 Mortality rates have declined to less than 2.5%, but blindness still occurs in 11% of cases.3-4 It is often difficult to distinguish between preseptal (or periorbital) and orbital (or postseptal) cellulitis on initial presentation, thus the NP should maintain a high degree of suspicion for the latter.5 The orbit is usually spared infection by the orbital septum. Preseptal cellulitis involves the eyelid and external structures. Orbital cellulitis is a deeper infection behind the orbital septum. Preseptal cellulitis occasionally progresses to orbital cellulitis, and this spread is more likely to occur in children.2,5-6 The prevalence of 38
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preseptal and orbital cellulitis is not widely reported but is more common during the winter months as a result of increased respiratory and sinus infections.2,7 In 1995, 5,000 US patients were discharged with a diagnosis of deep inflammation of the eyelid.8 Preseptal and orbital cellulitis is more common among pediatric patients, with an average age of 7.5 years, and 73% of reported cases occurred in boys.2,9 The advent of the Haemophilus influenzae B (Hib) vaccine in 1985 significantly reduced the incidence of both of these disorders. Amabati et al.10 reported a decline from 27 cases of Hib-related cellulitis (11.7% of total cases) to 3 cases (3.5% of cases, p ⫽ 0.028) after 1990 when the Hib vaccine was extended to children as young as 2 months old. PRESEPTAL VERSUS ORBITAL CELLULITIS Preseptal cellulitis is an infection of the eyelid and surrounding soft tissue with an acute onset of erythema and edema of the eyelid.8 Preseptal cellulitis is less severe than Volume 7, Issue 1, January 2011
CLINICAL PRESENTATION AND PHYSICAL EXAMINATION With both preseptal and orbital cellulitis, patients may present with unilateral periorbital erythema and edema, leukocytosis, and fever; these findings alone cannot be used to distinguish one disorder from the other.8 Patients ETIOLOGY with preseptal cellulitis may report a recent history of Preseptal cellulitis is commonly associated with local skin abrasions or insect bites to the eyelid, but the trauma, sinusitis, and upper respiratory tract eye is relatively uninvolved.2 Patients with either disorder infections.8,10 The majority of may complain of rhinorrhea, cases of orbital cellulitis are epiphora (excessive tearing), associated with sinusitis, of and difficulty opening the which 98% involve the etheye.8,11 Sinus pain, headache, Nearly half of patients with 2-3,9,10 moid sinuses. Other fever, painful eye movement, intracranial complications causes include extension of blurred or double vision, and of sinusitis present with infection from the lacrimal generalized malaise are seen in orbital cellulitis or sac, dental infection, eyebrow patients with orbital cellulitis.2 piercing, eyelid surgery, straThe patient’s eyelids should abscess. bismus correction surgery, be inspected for trauma, and retinal and intraocular surgery, the patient should be examretained foreign objects, or ined for cervical, submandibublunt trauma to the orbit.2,3 The most common organlar, and preauricular lymphadenopathy.8 The presence isms include Staphylococcus aureus, staphylococcus epiderand quality of eye drainage should be noted, as well as midis, streptococcus, and anaerobes, which are commonly testing for gross visual acuity, pupillary response to light, seen on the skin or cause respiratory tract infections and extraocular movements. Presence of proptosis (eye 8 and sinusitis. protrusion, usually laterally or downward), chemosis (conjunctiva swelling), eye pain, and reduced or loss of PATHOPHYSIOLOGY trigeminal nerve sensation should be noted.8,11 Abnormal Orbital cellulitis occurs when infection extends from the pupillary response to light suggests optic nerve compresparanasal sinuses and face, direct inoculation from trauma sion, necessitating immediate surgical and ophthalmology or surgery, or spread of bacteria through the blood referral.8 The presence of optic disc edema and intraocu3 stream. The thin medial wall of the orbit allows bacteria lar pressure is also assessed by an ophthalmologist.2 3 to spread from the ethmoid and maxillary sinuses. In addition, the orbital veins do not have valves, which DIAGNOSIS allows infection to spread in both directions.3 In addition to a thorough history and physical examination, Microorganisms found in the sinuses and upper respiraa complete blood count (CBC) and blood cultures should tory tract multiply and invade the swollen tissue of the be drawn before antibiotic administration. Conjunctival culorbit, and this effect is enhanced by blockage of flow tures are generally unrevealing, but culture of eyelid through the sinus cavities.3 When orbital cellulitis is abscesses may be useful.8,15 Nasal cultures may be appropricaused by infection in the sphenoid sinuses, there is risk ate when there is a lot of drainage with suspected sinusitis.15 of optic nerve compression, vision loss, and infection in Needle aspiration of the orbit is contraindicated.3 the brain.6 Retinal and optic nerve ischemia leads to A high resolution axial and coronal CT scan of the blindness within 2-3 hours.12 In addition to orbital celorbit and sinuses is essential to determine the extent of lulitis, sinusitis may lead to epidural, subdural, and intraceye involvement. Coronal views may be difficult to 13 erebral abscesses and meningitis. Nearly half of patients obtain in young children because of the need to hyperwith intracranial complications of sinusitis present with extend or hyperflex the neck for imaging.3 MRI is used orbital cellulitis or abscess.14 to evaluate orbital abscess and rule out cavernous sinus orbital cellulitis but has been known to progress to a more serious infection, especially in children.2 Orbital cellulitis is a potentially life-threatening infection involving the soft tissues behind the orbital septum, which progresses rapidly.2,11
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disease or thrombosis.16 Orbital ultrasound has been used by some researchers to follow the resolution of orbital cellulitis, but it is not the gold standard for diagnosis.17 A CT scan of the brain and a lumbar puncture are performed in neonates and patients with signs or symptoms of meningitis.8
subperiosteal abscess, orbital abscess, cavernous sinus thrombosis, exposure keratopathy, increased intraocular pressure, central retinal artery or vein occlusion, optic neuropathy, blindness, meningitis, brain abscess, and death.2,3,8 Severe fungal infections may be seen among the immunocompromised, and infection with methicillin-resistant Staphylococcus aureus has been reported, with both infections rapidly becoming fatal.8
DIFFERENTIAL DIAGNOSES On initial presentation, healthcare providers may believe eyelid swelling is a result of allergies, but these patients STAGING OF ORBITAL INFECTIONS need sufficient evaluation to rule out cellulitis or In the literature preseptal cellulitis has been reported as abscess.18 Patients with orbital cellulitis present with unistage one orbital cellulitis.1,2 Other authors argue that the lateral involvement, fever, altered visual acuity, painful eye orbital septum provides an effective barrier to prevent the movements, chemosis, proptosis, and no specific history spread of infection, and the conditions are not synonyof allergy.5 mous.6,20,21 Orbital infections were classified into five In contrast, patients with allergic conjunctivitis have a stages in 1970 by Chandler, Langenbrunner, and Stevens, more sudden onset of bilateral eye itching with mild and this tool is still used today.22 Each stage does not inflammation of the eyelid, and normal visual acuity, necessarily progress to the next one. pupillary response to light, and eye movement; these signs • Stage 1: Preseptal Cellulitis and symptoms respond rapidly to oral antihistamines, • Stage 2: Orbital Cellulitis 5,19 antihistamine eyedrops, and/or prednisone. See Figure • Stage 3: Subperiosteal Abscess 1 for an algorithm developed by Papier, Tuttle, and • Stage 4: Orbital Abscess Mahar that may be used in diagnosing a patient with a • Stage 5: Cavernous Sinus Thrombosis 19 swollen red eyelid. The differential diagnoses for preseptal and orbital TREATMENT cellulitis are extensive and include angioedema, allergic The key to successful treatment is early recognition of eyelid swelling, bacterial or viral conjunctivitis, dacryoadorbital cellulitis, targeting of antibiotics to the most likely enitis or dacryocystitis, contact dermatitis, herpes zoster organisms, and appropriate, timely referral. Acute sinusitis or simplex, hordeolum, chalazion, necrotizing fasciitis, is associated with Streptococcus pneumoniae, Haemophilus cavernous sinus thrombosis, orbital tumors or pseudotuinfluenzae, and Moraxella catarrhalis.1,23 Patients with eye mors, orbital vasculitis, and trauma may be infected with 2,8 maxillary osteomyelitis. Staphylococcus aureus, group A Orbital inflammation may also hemolytic streptococci, or Each stage of orbital be seen with amyloidosis, thymethicillin-resistant roid eye disease, Wegener’s granStaphylococcus aureus.1 Patients infection does not ulomatosis, sarcoidosis, with chronic sinusitis may be necessarily progress to the Churg-Strauss, Sjögren’s syninfected with anaerobes.1 next one. drome, malignancy, and idioPreseptal cellulitis is treated pathic orbital inflammatory with oral antibiotics (such as syndrome.15 Renal disease, dicloxacillin, cephalexin, clinmyxedema, congestive heart failure, and superior vena damycin, or erythromycin) and close observation.1 If cava syndrome cause periorbital edema as well.19 patients do not improve or worsen within 24-48 hours, they need to be admitted for intravenous (IV) antibiotics, COMPLICATIONS OF PRESEPTAL AND ORBITAL such as nafcillin plus ceftriaxone and metronidazole.1 For CELLULITIS patients allergic to penicillin, IV vancomycin plus levPreseptal cellulitis can progress to orbital cellulitis, eyelid ofloxacin and metronidazole may be used.1 Patients susabscess, or eyelid necrosis.2 Orbital cellulitis may lead to pected of orbital cellulitis need immediate IV antibiotics 40
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Figure 1. Algorithm for diagnosing a patient with a swollen red eyelid19.
Reprinted with permission. Copyright 2007. American Academy of Family Physicians. All rights reserved.
Patient presents with swollen red eyelid
Bilateral?
Yes
No
Abrupt onset?
Yes
No
Danger signs present (e.g., proptosis, pain with eye movement, limitation of eye movement, decreased visual acuity, afferent papillary defect*)?
Scaling? Yes Yes Contact dermatitis
Orbital cellulitis
No
No Discrete lid lesion?
Angioedema Yes Vesicles?
Yes History of atopy?
Yes Atopic dermatitis
Pain?
Yes
Blepharitis Systemic disorder
Preseptal cellulitis No
Herpes simplex Herpes zoster No
No
Hordeolum
No Chalazion Tumor
*__Afferent papillary defect refers to an interference with the input of light to the pupillomotor system resulting in a symmetrical decrease in contraction of both pupils to light given to the damaged eye, compared with light given to the less damaged or normal eye.
(after blood cultures are drawn) for 1-2 weeks, followed by oral antibiotics for an additional 2-3 weeks.3 Severe cases of preseptal cellulitis and all cases of orbital cellulitis should be admitted to the hospital for close monitoring and IV antibiotics.1,8 Pediatric patients are best admitted for observation. If the patient does not improve within 24-48 hours after IV antibiotics, resistant organisms may be the culprit.8 After 48-72 hours of IV antibiotics, if there is significant clinical improvement, the patient may be continued on oral antibiotics.8 Surgical intervention is warranted when the patient experiences a visual impairment, has a well-defined abscess, or shows no clinical improvement after 24 hours www.npjournal.org
of IV therapy or gas is seen in an abscess on CT (suggesting an anaerobic etiology).1,15 Surgical intervention is not usually necessary in children under age 9 because the infection generally is caused by a single gram-positive organism.15 The ICD 9 diagnosis code for orbital cellulitis is 376.01 and preseptal cellulitis is 373.13. CASE STUDY A 5-year-old white boy presented to his pediatrician’s office with redness, swelling, and matting of the right eye previously treated with Neosporin eyedrops (containing neomycin, gramicidin, and polymyxin). On initial examination, he was found to have a moderately The Journal for Nurse Practitioners - JNP
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severe, right conjunctivitis but was afebrile without eye eye or surrounding structures.Visual acuity was pain, visual impairment, or lymphadenopathy. maintained at 20/20 in both eyes. There was no Gentamicin sulfate (Garamycin) ophthalmic eyedrops proptosis. Slit lamp exam by ophthalmologist showed were added to his current regimen, plus oral Cefaclor a normal cornea. The anterior chamber was deep (Ceclor) 375 mg by mouth and clear. Pupils were 4 mm twice a day. with a brisk, equal pupillary Two days later he returned response. The fundus appeared Prompt referral is required to the office with worsening normal. The external auditory conjunctivitis with a hemorcanals and tympanic membranes for suspected orbital rhagic component, headaches, were clear. His nasal mucosa was cellulitis and and a fever of 102 degrees erythematous, injected with recommended for preseptal Fahrenheit. He had no commildly engorged turbinates. The cellulitis as well. plaints of eye pain or visual nasal septum was straight and disturbance but found it diffiintact. The oropharynx and poscult to open his right eyelid. terior pharynx were clear with His CBC showed a white blood cell count of 20,000 and no postnasal drainage noted. There was no tendera left shift with 78% granulocytes (polymorphonuclear ness to percussion over frontal sinuses. His maxillary leukocytes). His platelet count was 350,000, and his sinuses were slightly tender to palpation. hematocrit was 41.6. He was admitted for possible orbital • Neck: supple without masses or adenopathy cellulitis and intravenous antibiotic administration. • Chest: normal unlabored respiratory effort, breath His other medical information was as follows: sounds clear to auscultation, excursions normal. Past medical history: Significant for frequently He had a regular heart rate and rhythm without recurrent upper respiratory tract infections. He had a murmur or rub. normal prenatal and birth history, and his vaccinations • Abdomen: revealed no organomegaly, masses, or were up to date. He had no known perennial or seasonal tenderness allergies. He had no medication or food allergies. • Skin: clear without cyanosis or rash (See eye assessSocial history: Lived with his parents and younger ment above) brother. He was not exposed to secondhand tobacco • Neurologic exam: appropriate for age and degree smoke. He had a dog who resided outdoors. of illness. Trigeminal nerve sensation was intact, Medications: Gentamicin sulfate (Garamycin) ophtested by light touch. thalmic eyedrops, Cefaclor (Ceclor) 375 mg twice a day • Initial diagnosis: severe, right-sided conjunctivitis, by mouth elevated white blood cell count suggestive of bactePhysical examination rial infection. No evidence of other eye, ear, nose, • Temperature 101 degrees F or throat infection; however, sinusitis and orbital • Pulse 95 cellulitis must be ruled out. • Respirations 22 Stat sinus CT scan results: A sinus CT scan obtained • Blood pressure 92/52 after admission showed underdeveloped frontal sinuses. • Weight 43 lbs. There was right maxillary sinus mucosal thickening, with • Height 44” mild sclerosis and indistinctness of the posterior wall and • He appeared mildly ill, tearful and clinging to his orbital floor (which forms the superior margin of the maxmother, but in no acute distress. illary sinus). There were no air fluid levels within the sinus, • EENT: severe, right-sided conjunctivitis with and no significant inflammatory changes in the adjacent chemosis, the skin surrounding the right eye was right orbit. The posterior ethmoid air cells were partially edematous and erythematous, his extraocular moveopacified. The sphenoid sinuses were clear. ments were difficult to evaluate from the amount of Impression: evidence of right maxillary sinusitis, swelling and hemorrhagic involvement of the conopacification of the posterior ethmoid sinuses, and projunctiva. There was no evidence of trauma to the gression to the right orbital floor 42
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Labs: Blood cultures were obtained and were reported negative. A CBC was obtained each day. Erythrocyte sedimentation rate on admission was 2 but rose to a high of 61 over the course of his hospital stay. Plan: Laboratory studies, stat CT scan of the sinuses and orbits, and stat ophthalmologic consultation were obtained as noted above. IV cefuroxime sodium (Zinacef) at 50 mg/kg/dose every 8 hours was begun on admission after blood cultures were drawn. The patient’s eyedrops were changed by the ophthalmologist to ciprofloxacin hydrochloride (Ciloxan) 2 drops in affected eye every 2 hours after application of warm compresses. ENT referral was initiated as the patient had evidence of significant sinusitis, but surgical intervention was not thought to be warranted at that time. As his fever did not abate and his overall appearance deteriorated over the next few days, his IV antibiotic was changed to ticarcillin disodium/clavulanate potassium (Timentin). Addition of an intravenous antifungal medication was considered but decided against by the ENT. After another 24 hours his fever began to resolve, his sense of well-being improved, and his orbital cellulitis showed slow and steady improvement. He was discharged to home after 7 days, with IV antibiotics for a total of 10 days, followed by oral antibiotics for another 14 days. He was examined by his pediatrician the day after discharge and weekly for a month, with close telephone contact. Follow-up Sinus CT Scan and Physical Examination 1 Month Later The mucosal thickening seen on sinus CT scan in the right maxillary sinus was largely resolved, with minimal mucosal change persisting along the roof of the right maxillary antrum. No fluid levels were seen. The ethmoid, frontal, and sphenoid sinuses were clear. The scans through the orbits revealed no orbital mass or intraorbital inflammatory change. The optic nerves and extraocular muscles were normal in size. On physical examination, the child’s eyelid edema had essentially resolved, but mild bruising and discoloration around the orbit were still resolving. His extraocular movements were intact, as was his gross visual acuity. Examination by his ophthalmologist was reported to be normal other than mild residual hemorrhagic involvement of the conjunctiva. His maxillary sinus discomfort was resolved, and he denied any symptoms of illness. His parents were very pleased with his progress and said they were thankful that he did not lose his vision in that eye. www.npjournal.org
PREVENTION AND CLINICAL PEARLS Orbital cellulitis has a sudden onset with no foolproof method of prevention.3 When a patient is determined to have preseptal cellulitis, dental disease, or bacterial sinusitis, it should be treated appropriately to prevent spread to the orbit.8,23 Patients with traumatic lid laceration benefit from prophylactic topical antibiotics and re-examination 48-72 hours after treatment.8 Key findings that need to be assessed and documented in any patient with suspected orbital cellulitis include restriction of ocular movement, eye pain, proptosis, visual impairment, altered sensorium, and involvement of the trigeminal nerve.3 Prompt ophthalmology referral is required for all patients suspected of having orbital cellulitis and is recommended for patients with preseptal cellulitis as well. Pediatric patients should be admitted for observation and treatment of preseptal or orbital cellulitis with timely referral to ophthalmology. CONCLUSION In summary, early recognition of orbital cellulitis is essential to preventing blindness, meningitis, and death. Orbital cellulitis is often difficult to distinguish from preseptal cellulitis on initial presentation and is strongly associated with sinusitis. NPs need to be aware of the diagnosis and management of this uncommon but potentially lifethreatening infection. Patients with orbital cellulitis need to be admitted with prompt imaging studies, cultures, and IV antibiotics, as well as appropriate referral in a timely manner. References 1. Hennemann S, Nguygen L. What is the best initial treatment for orbital cellulitis in children? J Fam Med. 2007;56(8):662-664. 2. Scott O. Orbital cellulitis. 2009. http://www.patient.co.uk/printer.asp? doc⫽40025295 Accessed May 7, 2010. 3. Harrington JN. Orbital cellulitis. 2009. http://emedicine.medscape.com/ article/1217858-print. Accessed May 5, 2010. 4. Younis RT, Lazar RH, Bustillo A, Anand VK. Orbital infection as a complication of sinusitis: Are diagnostic and treatment trends changing? Ear Nose Throat J. 2002;81(11):771-775. 5. Bethel J. Distinguishing features of preseptal and orbital cellulitis. Emerg Nurs. 2010;22(2):28-30. 6. Carlisle RT, Fredrick GT. Preseptal and orbital cellulitis. Hosp Physician. 2006;42(10):15-19. 7. Rodriguez FL, Puigarnau VR, Fasheh YW, Ribo AJ, Luaces CC, Pou FJ. Orbital and periorbital cellulitis: Review of 107 cases. An Esp Pediatr. 2000;53(6):567-572. 8. Sobol AL, Hutcheson KA. Preseptal cellulitis. 2009. http://emedicine.medscape.com/article/1218009-print. Accessed May 8, 2010. 9. Nageswaran S, Woods CR., Benjamin DK, Givner LB, Shetty A. Orbital cellulitis in children. Pediatr Infect Dis J. 2006;25(8):695-699. 10. Ambati BK, Ambati J, Azar N, Stratton L, Schmidt EV. Periorbital and orbital cellulitis before and after the advent of Haemophilus influenzae type B vaccination. Ophthalmology. 2000;107(8):1450-1453. 11. Armstrong PA, Nichol NM. An eye for trouble: Orbital cellulitis. Emerg Med J. 2006;23. http://www.emjonline.com/cgi/content/full/23/12/e66. Accessed January 31, 2010.
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12. Hytonen M, Atula T, Pitkaranta A. Complications of acute sinusitis in children. Acta Otolaryngol. 2000;543:154-157. 13. DelGaudio JM, Evans SH, Sobol SE, Parikh SL. Intracranial complications of sinusitis: What is the role of endoscopic sinus surgery in the acute setting? Am J Otolaryngol. 2010;31:25-28. 14. Howe L, Jones NS. Guidelines for the management of periorbital cellulitis/abscess. Clin Otolaryngol. 2004;29:725-728. 15. Hong ES, Allen RC. Orbital cellulitis in a child. 2010. http://www.EyeRounds.org/cases/103-Pediatric-Orbital-Cellulitis.htm. Accessed May 7, 2010. 16. Wilkerson RG, Sinert R, Kassutto Z, Fiedler E. Periorbital infections. 2008. http://emedicine.medscape.com/article/798397-print. Accessed January 31, 2010. 17. Mair MH, Geley T, Judmaier W, Gabner I. Using orbital sonography to diagnose and monitor treatment of acute swelling of the eyelids in pediatric patients. Am J Roentgenol. 2002;179:1529-1534. 18. Goodyear PW, Firth AL, Strachan DR, Dudley M. Periorbital swelling: The important distinction between allergy and infection. Emerg Med J. 2004;21:240-242. 19. Papier A, Tuttle DJ, Mahar TJ. Differential diagnosis of the swollen red eyelid. Am Fam Physician. 2007;76:1815-1824. 20. Clark WN. Periorbital and orbital cellulitis in children. Paediatric Child Health. 2004;9(7):471-472. 21. Givner LB. Periorbital versus orbital cellulitis. Pediatr Infect Dis J. 2002;21(12):1157-1158. 22. Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of orbital complications in acute sinusitis. Laryngoscope 1970;80:1414-1428. 23. Brook I. Microbiology of acute sinusitis of odontogenic origin presenting with periorbital cellulitis in children. Ann Otol Rhinol Laryngol. 2007;116(5):386-388.
Shannon Munro Cohen, PhD, APRN, BC, FNP, is a family nurse practitioner working in an asthma, allergy, and immunology practice in Roanoke, VA. She can be reached at [email protected]. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest. 1555-4155/10/$ see front matter © 2011 American College of Nurse Practitioners doi:10.1016/j.nurpra.2010.06.009
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Image appears courtesy of VisualDx. © Logical Images, Inc. All rights reserved. ABSTRACT Orbital cellulitis is an uncommon but serious infection involving the soft tissues behind the orbital septum that generally spreads from the sinuses. With prompt recognition and appropriate intravenous antibiotic use, mortality rates have declined from 17% to less than 2.5%, but blindness still occurs in 11% of cases. Nurse practitioners need to be aware of the diagnosis and management of this potentially lifethreatening disorder. Keywords: complications, orbital cellulitis, sinusitis © 2011 American College of Nurse Practitioners
O
rbital cellulitis is an uncommon but serious infection involving the soft tissues behind the orbital septum that generally spreads from the sinuses. It is associated with significant risk of blindness, meningitis, and death, thus nurse practitioners (NPs) need to be aware of prevention strategies, diagnosis, and management of this disorder.1 Before antibiotics, 17% of patients with orbital cellulitis died, and 20% lost their sight in the affected eye.2 Mortality rates have declined to less than 2.5%, but blindness still occurs in 11% of cases.3-4 It is often difficult to distinguish between preseptal (or periorbital) and orbital (or postseptal) cellulitis on initial presentation, thus the NP should maintain a high degree of suspicion for the latter.5 The orbit is usually spared infection by the orbital septum. Preseptal cellulitis involves the eyelid and external structures. Orbital cellulitis is a deeper infection behind the orbital septum. Preseptal cellulitis occasionally progresses to orbital cellulitis, and this spread is more likely to occur in children.2,5-6 The prevalence of 38
The Journal for Nurse Practitioners - JNP
preseptal and orbital cellulitis is not widely reported but is more common during the winter months as a result of increased respiratory and sinus infections.2,7 In 1995, 5,000 US patients were discharged with a diagnosis of deep inflammation of the eyelid.8 Preseptal and orbital cellulitis is more common among pediatric patients, with an average age of 7.5 years, and 73% of reported cases occurred in boys.2,9 The advent of the Haemophilus influenzae B (Hib) vaccine in 1985 significantly reduced the incidence of both of these disorders. Amabati et al.10 reported a decline from 27 cases of Hib-related cellulitis (11.7% of total cases) to 3 cases (3.5% of cases, p ⫽ 0.028) after 1990 when the Hib vaccine was extended to children as young as 2 months old. PRESEPTAL VERSUS ORBITAL CELLULITIS Preseptal cellulitis is an infection of the eyelid and surrounding soft tissue with an acute onset of erythema and edema of the eyelid.8 Preseptal cellulitis is less severe than Volume 7, Issue 1, January 2011
CLINICAL PRESENTATION AND PHYSICAL EXAMINATION With both preseptal and orbital cellulitis, patients may present with unilateral periorbital erythema and edema, leukocytosis, and fever; these findings alone cannot be used to distinguish one disorder from the other.8 Patients ETIOLOGY with preseptal cellulitis may report a recent history of Preseptal cellulitis is commonly associated with local skin abrasions or insect bites to the eyelid, but the trauma, sinusitis, and upper respiratory tract eye is relatively uninvolved.2 Patients with either disorder infections.8,10 The majority of may complain of rhinorrhea, cases of orbital cellulitis are epiphora (excessive tearing), associated with sinusitis, of and difficulty opening the which 98% involve the etheye.8,11 Sinus pain, headache, Nearly half of patients with 2-3,9,10 moid sinuses. Other fever, painful eye movement, intracranial complications causes include extension of blurred or double vision, and of sinusitis present with infection from the lacrimal generalized malaise are seen in orbital cellulitis or sac, dental infection, eyebrow patients with orbital cellulitis.2 piercing, eyelid surgery, straThe patient’s eyelids should abscess. bismus correction surgery, be inspected for trauma, and retinal and intraocular surgery, the patient should be examretained foreign objects, or ined for cervical, submandibublunt trauma to the orbit.2,3 The most common organlar, and preauricular lymphadenopathy.8 The presence isms include Staphylococcus aureus, staphylococcus epiderand quality of eye drainage should be noted, as well as midis, streptococcus, and anaerobes, which are commonly testing for gross visual acuity, pupillary response to light, seen on the skin or cause respiratory tract infections and extraocular movements. Presence of proptosis (eye 8 and sinusitis. protrusion, usually laterally or downward), chemosis (conjunctiva swelling), eye pain, and reduced or loss of PATHOPHYSIOLOGY trigeminal nerve sensation should be noted.8,11 Abnormal Orbital cellulitis occurs when infection extends from the pupillary response to light suggests optic nerve compresparanasal sinuses and face, direct inoculation from trauma sion, necessitating immediate surgical and ophthalmology or surgery, or spread of bacteria through the blood referral.8 The presence of optic disc edema and intraocu3 stream. The thin medial wall of the orbit allows bacteria lar pressure is also assessed by an ophthalmologist.2 3 to spread from the ethmoid and maxillary sinuses. In addition, the orbital veins do not have valves, which DIAGNOSIS allows infection to spread in both directions.3 In addition to a thorough history and physical examination, Microorganisms found in the sinuses and upper respiraa complete blood count (CBC) and blood cultures should tory tract multiply and invade the swollen tissue of the be drawn before antibiotic administration. Conjunctival culorbit, and this effect is enhanced by blockage of flow tures are generally unrevealing, but culture of eyelid through the sinus cavities.3 When orbital cellulitis is abscesses may be useful.8,15 Nasal cultures may be appropricaused by infection in the sphenoid sinuses, there is risk ate when there is a lot of drainage with suspected sinusitis.15 of optic nerve compression, vision loss, and infection in Needle aspiration of the orbit is contraindicated.3 the brain.6 Retinal and optic nerve ischemia leads to A high resolution axial and coronal CT scan of the blindness within 2-3 hours.12 In addition to orbital celorbit and sinuses is essential to determine the extent of lulitis, sinusitis may lead to epidural, subdural, and intraceye involvement. Coronal views may be difficult to 13 erebral abscesses and meningitis. Nearly half of patients obtain in young children because of the need to hyperwith intracranial complications of sinusitis present with extend or hyperflex the neck for imaging.3 MRI is used orbital cellulitis or abscess.14 to evaluate orbital abscess and rule out cavernous sinus orbital cellulitis but has been known to progress to a more serious infection, especially in children.2 Orbital cellulitis is a potentially life-threatening infection involving the soft tissues behind the orbital septum, which progresses rapidly.2,11
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disease or thrombosis.16 Orbital ultrasound has been used by some researchers to follow the resolution of orbital cellulitis, but it is not the gold standard for diagnosis.17 A CT scan of the brain and a lumbar puncture are performed in neonates and patients with signs or symptoms of meningitis.8
subperiosteal abscess, orbital abscess, cavernous sinus thrombosis, exposure keratopathy, increased intraocular pressure, central retinal artery or vein occlusion, optic neuropathy, blindness, meningitis, brain abscess, and death.2,3,8 Severe fungal infections may be seen among the immunocompromised, and infection with methicillin-resistant Staphylococcus aureus has been reported, with both infections rapidly becoming fatal.8
DIFFERENTIAL DIAGNOSES On initial presentation, healthcare providers may believe eyelid swelling is a result of allergies, but these patients STAGING OF ORBITAL INFECTIONS need sufficient evaluation to rule out cellulitis or In the literature preseptal cellulitis has been reported as abscess.18 Patients with orbital cellulitis present with unistage one orbital cellulitis.1,2 Other authors argue that the lateral involvement, fever, altered visual acuity, painful eye orbital septum provides an effective barrier to prevent the movements, chemosis, proptosis, and no specific history spread of infection, and the conditions are not synonyof allergy.5 mous.6,20,21 Orbital infections were classified into five In contrast, patients with allergic conjunctivitis have a stages in 1970 by Chandler, Langenbrunner, and Stevens, more sudden onset of bilateral eye itching with mild and this tool is still used today.22 Each stage does not inflammation of the eyelid, and normal visual acuity, necessarily progress to the next one. pupillary response to light, and eye movement; these signs • Stage 1: Preseptal Cellulitis and symptoms respond rapidly to oral antihistamines, • Stage 2: Orbital Cellulitis 5,19 antihistamine eyedrops, and/or prednisone. See Figure • Stage 3: Subperiosteal Abscess 1 for an algorithm developed by Papier, Tuttle, and • Stage 4: Orbital Abscess Mahar that may be used in diagnosing a patient with a • Stage 5: Cavernous Sinus Thrombosis 19 swollen red eyelid. The differential diagnoses for preseptal and orbital TREATMENT cellulitis are extensive and include angioedema, allergic The key to successful treatment is early recognition of eyelid swelling, bacterial or viral conjunctivitis, dacryoadorbital cellulitis, targeting of antibiotics to the most likely enitis or dacryocystitis, contact dermatitis, herpes zoster organisms, and appropriate, timely referral. Acute sinusitis or simplex, hordeolum, chalazion, necrotizing fasciitis, is associated with Streptococcus pneumoniae, Haemophilus cavernous sinus thrombosis, orbital tumors or pseudotuinfluenzae, and Moraxella catarrhalis.1,23 Patients with eye mors, orbital vasculitis, and trauma may be infected with 2,8 maxillary osteomyelitis. Staphylococcus aureus, group A Orbital inflammation may also hemolytic streptococci, or Each stage of orbital be seen with amyloidosis, thymethicillin-resistant roid eye disease, Wegener’s granStaphylococcus aureus.1 Patients infection does not ulomatosis, sarcoidosis, with chronic sinusitis may be necessarily progress to the Churg-Strauss, Sjögren’s syninfected with anaerobes.1 next one. drome, malignancy, and idioPreseptal cellulitis is treated pathic orbital inflammatory with oral antibiotics (such as syndrome.15 Renal disease, dicloxacillin, cephalexin, clinmyxedema, congestive heart failure, and superior vena damycin, or erythromycin) and close observation.1 If cava syndrome cause periorbital edema as well.19 patients do not improve or worsen within 24-48 hours, they need to be admitted for intravenous (IV) antibiotics, COMPLICATIONS OF PRESEPTAL AND ORBITAL such as nafcillin plus ceftriaxone and metronidazole.1 For CELLULITIS patients allergic to penicillin, IV vancomycin plus levPreseptal cellulitis can progress to orbital cellulitis, eyelid ofloxacin and metronidazole may be used.1 Patients susabscess, or eyelid necrosis.2 Orbital cellulitis may lead to pected of orbital cellulitis need immediate IV antibiotics 40
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Figure 1. Algorithm for diagnosing a patient with a swollen red eyelid19.
Reprinted with permission. Copyright 2007. American Academy of Family Physicians. All rights reserved.
Patient presents with swollen red eyelid
Bilateral?
Yes
No
Abrupt onset?
Yes
No
Danger signs present (e.g., proptosis, pain with eye movement, limitation of eye movement, decreased visual acuity, afferent papillary defect*)?
Scaling? Yes Yes Contact dermatitis
Orbital cellulitis
No
No Discrete lid lesion?
Angioedema Yes Vesicles?
Yes History of atopy?
Yes Atopic dermatitis
Pain?
Yes
Blepharitis Systemic disorder
Preseptal cellulitis No
Herpes simplex Herpes zoster No
No
Hordeolum
No Chalazion Tumor
*__Afferent papillary defect refers to an interference with the input of light to the pupillomotor system resulting in a symmetrical decrease in contraction of both pupils to light given to the damaged eye, compared with light given to the less damaged or normal eye.
(after blood cultures are drawn) for 1-2 weeks, followed by oral antibiotics for an additional 2-3 weeks.3 Severe cases of preseptal cellulitis and all cases of orbital cellulitis should be admitted to the hospital for close monitoring and IV antibiotics.1,8 Pediatric patients are best admitted for observation. If the patient does not improve within 24-48 hours after IV antibiotics, resistant organisms may be the culprit.8 After 48-72 hours of IV antibiotics, if there is significant clinical improvement, the patient may be continued on oral antibiotics.8 Surgical intervention is warranted when the patient experiences a visual impairment, has a well-defined abscess, or shows no clinical improvement after 24 hours www.npjournal.org
of IV therapy or gas is seen in an abscess on CT (suggesting an anaerobic etiology).1,15 Surgical intervention is not usually necessary in children under age 9 because the infection generally is caused by a single gram-positive organism.15 The ICD 9 diagnosis code for orbital cellulitis is 376.01 and preseptal cellulitis is 373.13. CASE STUDY A 5-year-old white boy presented to his pediatrician’s office with redness, swelling, and matting of the right eye previously treated with Neosporin eyedrops (containing neomycin, gramicidin, and polymyxin). On initial examination, he was found to have a moderately The Journal for Nurse Practitioners - JNP
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severe, right conjunctivitis but was afebrile without eye eye or surrounding structures.Visual acuity was pain, visual impairment, or lymphadenopathy. maintained at 20/20 in both eyes. There was no Gentamicin sulfate (Garamycin) ophthalmic eyedrops proptosis. Slit lamp exam by ophthalmologist showed were added to his current regimen, plus oral Cefaclor a normal cornea. The anterior chamber was deep (Ceclor) 375 mg by mouth and clear. Pupils were 4 mm twice a day. with a brisk, equal pupillary Two days later he returned response. The fundus appeared Prompt referral is required to the office with worsening normal. The external auditory conjunctivitis with a hemorcanals and tympanic membranes for suspected orbital rhagic component, headaches, were clear. His nasal mucosa was cellulitis and and a fever of 102 degrees erythematous, injected with recommended for preseptal Fahrenheit. He had no commildly engorged turbinates. The cellulitis as well. plaints of eye pain or visual nasal septum was straight and disturbance but found it diffiintact. The oropharynx and poscult to open his right eyelid. terior pharynx were clear with His CBC showed a white blood cell count of 20,000 and no postnasal drainage noted. There was no tendera left shift with 78% granulocytes (polymorphonuclear ness to percussion over frontal sinuses. His maxillary leukocytes). His platelet count was 350,000, and his sinuses were slightly tender to palpation. hematocrit was 41.6. He was admitted for possible orbital • Neck: supple without masses or adenopathy cellulitis and intravenous antibiotic administration. • Chest: normal unlabored respiratory effort, breath His other medical information was as follows: sounds clear to auscultation, excursions normal. Past medical history: Significant for frequently He had a regular heart rate and rhythm without recurrent upper respiratory tract infections. He had a murmur or rub. normal prenatal and birth history, and his vaccinations • Abdomen: revealed no organomegaly, masses, or were up to date. He had no known perennial or seasonal tenderness allergies. He had no medication or food allergies. • Skin: clear without cyanosis or rash (See eye assessSocial history: Lived with his parents and younger ment above) brother. He was not exposed to secondhand tobacco • Neurologic exam: appropriate for age and degree smoke. He had a dog who resided outdoors. of illness. Trigeminal nerve sensation was intact, Medications: Gentamicin sulfate (Garamycin) ophtested by light touch. thalmic eyedrops, Cefaclor (Ceclor) 375 mg twice a day • Initial diagnosis: severe, right-sided conjunctivitis, by mouth elevated white blood cell count suggestive of bactePhysical examination rial infection. No evidence of other eye, ear, nose, • Temperature 101 degrees F or throat infection; however, sinusitis and orbital • Pulse 95 cellulitis must be ruled out. • Respirations 22 Stat sinus CT scan results: A sinus CT scan obtained • Blood pressure 92/52 after admission showed underdeveloped frontal sinuses. • Weight 43 lbs. There was right maxillary sinus mucosal thickening, with • Height 44” mild sclerosis and indistinctness of the posterior wall and • He appeared mildly ill, tearful and clinging to his orbital floor (which forms the superior margin of the maxmother, but in no acute distress. illary sinus). There were no air fluid levels within the sinus, • EENT: severe, right-sided conjunctivitis with and no significant inflammatory changes in the adjacent chemosis, the skin surrounding the right eye was right orbit. The posterior ethmoid air cells were partially edematous and erythematous, his extraocular moveopacified. The sphenoid sinuses were clear. ments were difficult to evaluate from the amount of Impression: evidence of right maxillary sinusitis, swelling and hemorrhagic involvement of the conopacification of the posterior ethmoid sinuses, and projunctiva. There was no evidence of trauma to the gression to the right orbital floor 42
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Labs: Blood cultures were obtained and were reported negative. A CBC was obtained each day. Erythrocyte sedimentation rate on admission was 2 but rose to a high of 61 over the course of his hospital stay. Plan: Laboratory studies, stat CT scan of the sinuses and orbits, and stat ophthalmologic consultation were obtained as noted above. IV cefuroxime sodium (Zinacef) at 50 mg/kg/dose every 8 hours was begun on admission after blood cultures were drawn. The patient’s eyedrops were changed by the ophthalmologist to ciprofloxacin hydrochloride (Ciloxan) 2 drops in affected eye every 2 hours after application of warm compresses. ENT referral was initiated as the patient had evidence of significant sinusitis, but surgical intervention was not thought to be warranted at that time. As his fever did not abate and his overall appearance deteriorated over the next few days, his IV antibiotic was changed to ticarcillin disodium/clavulanate potassium (Timentin). Addition of an intravenous antifungal medication was considered but decided against by the ENT. After another 24 hours his fever began to resolve, his sense of well-being improved, and his orbital cellulitis showed slow and steady improvement. He was discharged to home after 7 days, with IV antibiotics for a total of 10 days, followed by oral antibiotics for another 14 days. He was examined by his pediatrician the day after discharge and weekly for a month, with close telephone contact. Follow-up Sinus CT Scan and Physical Examination 1 Month Later The mucosal thickening seen on sinus CT scan in the right maxillary sinus was largely resolved, with minimal mucosal change persisting along the roof of the right maxillary antrum. No fluid levels were seen. The ethmoid, frontal, and sphenoid sinuses were clear. The scans through the orbits revealed no orbital mass or intraorbital inflammatory change. The optic nerves and extraocular muscles were normal in size. On physical examination, the child’s eyelid edema had essentially resolved, but mild bruising and discoloration around the orbit were still resolving. His extraocular movements were intact, as was his gross visual acuity. Examination by his ophthalmologist was reported to be normal other than mild residual hemorrhagic involvement of the conjunctiva. His maxillary sinus discomfort was resolved, and he denied any symptoms of illness. His parents were very pleased with his progress and said they were thankful that he did not lose his vision in that eye. www.npjournal.org
PREVENTION AND CLINICAL PEARLS Orbital cellulitis has a sudden onset with no foolproof method of prevention.3 When a patient is determined to have preseptal cellulitis, dental disease, or bacterial sinusitis, it should be treated appropriately to prevent spread to the orbit.8,23 Patients with traumatic lid laceration benefit from prophylactic topical antibiotics and re-examination 48-72 hours after treatment.8 Key findings that need to be assessed and documented in any patient with suspected orbital cellulitis include restriction of ocular movement, eye pain, proptosis, visual impairment, altered sensorium, and involvement of the trigeminal nerve.3 Prompt ophthalmology referral is required for all patients suspected of having orbital cellulitis and is recommended for patients with preseptal cellulitis as well. Pediatric patients should be admitted for observation and treatment of preseptal or orbital cellulitis with timely referral to ophthalmology. CONCLUSION In summary, early recognition of orbital cellulitis is essential to preventing blindness, meningitis, and death. Orbital cellulitis is often difficult to distinguish from preseptal cellulitis on initial presentation and is strongly associated with sinusitis. NPs need to be aware of the diagnosis and management of this uncommon but potentially lifethreatening infection. Patients with orbital cellulitis need to be admitted with prompt imaging studies, cultures, and IV antibiotics, as well as appropriate referral in a timely manner. References 1. Hennemann S, Nguygen L. What is the best initial treatment for orbital cellulitis in children? J Fam Med. 2007;56(8):662-664. 2. Scott O. Orbital cellulitis. 2009. http://www.patient.co.uk/printer.asp? doc⫽40025295 Accessed May 7, 2010. 3. Harrington JN. Orbital cellulitis. 2009. http://emedicine.medscape.com/ article/1217858-print. Accessed May 5, 2010. 4. Younis RT, Lazar RH, Bustillo A, Anand VK. Orbital infection as a complication of sinusitis: Are diagnostic and treatment trends changing? Ear Nose Throat J. 2002;81(11):771-775. 5. Bethel J. Distinguishing features of preseptal and orbital cellulitis. Emerg Nurs. 2010;22(2):28-30. 6. Carlisle RT, Fredrick GT. Preseptal and orbital cellulitis. Hosp Physician. 2006;42(10):15-19. 7. Rodriguez FL, Puigarnau VR, Fasheh YW, Ribo AJ, Luaces CC, Pou FJ. Orbital and periorbital cellulitis: Review of 107 cases. An Esp Pediatr. 2000;53(6):567-572. 8. Sobol AL, Hutcheson KA. Preseptal cellulitis. 2009. http://emedicine.medscape.com/article/1218009-print. Accessed May 8, 2010. 9. Nageswaran S, Woods CR., Benjamin DK, Givner LB, Shetty A. Orbital cellulitis in children. Pediatr Infect Dis J. 2006;25(8):695-699. 10. Ambati BK, Ambati J, Azar N, Stratton L, Schmidt EV. Periorbital and orbital cellulitis before and after the advent of Haemophilus influenzae type B vaccination. Ophthalmology. 2000;107(8):1450-1453. 11. Armstrong PA, Nichol NM. An eye for trouble: Orbital cellulitis. Emerg Med J. 2006;23. http://www.emjonline.com/cgi/content/full/23/12/e66. Accessed January 31, 2010.
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12. Hytonen M, Atula T, Pitkaranta A. Complications of acute sinusitis in children. Acta Otolaryngol. 2000;543:154-157. 13. DelGaudio JM, Evans SH, Sobol SE, Parikh SL. Intracranial complications of sinusitis: What is the role of endoscopic sinus surgery in the acute setting? Am J Otolaryngol. 2010;31:25-28. 14. Howe L, Jones NS. Guidelines for the management of periorbital cellulitis/abscess. Clin Otolaryngol. 2004;29:725-728. 15. Hong ES, Allen RC. Orbital cellulitis in a child. 2010. http://www.EyeRounds.org/cases/103-Pediatric-Orbital-Cellulitis.htm. Accessed May 7, 2010. 16. Wilkerson RG, Sinert R, Kassutto Z, Fiedler E. Periorbital infections. 2008. http://emedicine.medscape.com/article/798397-print. Accessed January 31, 2010. 17. Mair MH, Geley T, Judmaier W, Gabner I. Using orbital sonography to diagnose and monitor treatment of acute swelling of the eyelids in pediatric patients. Am J Roentgenol. 2002;179:1529-1534. 18. Goodyear PW, Firth AL, Strachan DR, Dudley M. Periorbital swelling: The important distinction between allergy and infection. Emerg Med J. 2004;21:240-242. 19. Papier A, Tuttle DJ, Mahar TJ. Differential diagnosis of the swollen red eyelid. Am Fam Physician. 2007;76:1815-1824. 20. Clark WN. Periorbital and orbital cellulitis in children. Paediatric Child Health. 2004;9(7):471-472. 21. Givner LB. Periorbital versus orbital cellulitis. Pediatr Infect Dis J. 2002;21(12):1157-1158. 22. Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of orbital complications in acute sinusitis. Laryngoscope 1970;80:1414-1428. 23. Brook I. Microbiology of acute sinusitis of odontogenic origin presenting with periorbital cellulitis in children. Ann Otol Rhinol Laryngol. 2007;116(5):386-388.
Shannon Munro Cohen, PhD, APRN, BC, FNP, is a family nurse practitioner working in an asthma, allergy, and immunology practice in Roanoke, VA. She can be reached at [email protected]. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest. 1555-4155/10/$ see front matter © 2011 American College of Nurse Practitioners doi:10.1016/j.nurpra.2010.06.009
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