A Teenager With Right-Eye Swelling

Honey H. Herce, MD; Kimberly G. Yen, MD


August 07, 2014


Orbital cellulitis involves the structures posterior to the orbital septum. It can be related to acute or chronic sinus disease in 90% of cases. Most commonly found in children, the focus of the disease comes from the ethmoid sinus and spreads to the orbit through the lamina papyracea. Other causes of orbital cellulitis to consider are trauma, foreign body, post-surgical, dacryoadenitis, dacryocystitis, panophthalmitis, and endogenous septicemia.

Orbital cellulitis in children is more often caused by a single gram-positive organism, such as Staphylococcus and Streptococcus.[1] In adults, however, antibiotic treatment should provide broad-spectrum coverage because infections tend to involve multiple organisms that may include gram-negative cocci (eg, Haemophilus influenzae, Moraxella catarrhalis) and anaerobes.[2]

Orbital cellulitis requires prompt diagnosis and treatment to prevent both vision- and life-threatening complications. Clinical signs include fever, leukocytosis (75%), proptosis, chemosis, ptosis, restriction of and pain with ocular movements, decreased vision, and headache. Decreased visual acuity, pupil abnormalities, impaired color vision, and restricted visual fields are clinical signs that suggest involvement of the orbital apex and require aggressive treatment. Delayed treatment may result in an orbital apex syndrome, cavernous sinus thrombosis, cranial nerve palsy, brain abscess, or even death. CT or MRI can show orbital involvement, location, and extent.

Subperiosteal abscess formation involves the collection of purulent material between the periorbita and bony walls of the orbit. They usually localize adjacent to the infected sinus, but may extend through the periosteum into the orbital soft tissue. Abscess formation is suggested by progressive proptosis, globe displacement, or failure to show clinical improvement despite antibiotic treatment. Abscesses within the orbital tissue can extend posteriorly, resulting in life-threatening consequences, such as cavernous sinus thrombosis, meningitis, and intracranial process.

Isolated medial or inferior subperiosteal abscesses in children younger than 9 years with underlying ethmoid sinusitis, intact vision, and moderate proptosis usually do not require surgical drainage.[3] Management of orbital cellulitis in children younger than 9 years usually includes intravenous antibiotics and careful observation.

Surgical drainage coupled with appropriate antibiotic therapy is recommended for older patients or patients with a more severe presentation.

Management can consist of careful observation unless the following criteria are present[3]:

  • Patient is 9 years of age or older;

  • Presence of frontal sinusitis;

  • Nonmedial location of subperiosteal abscess;

  • Large subperiosteal abscess;

  • Suspicion of anaerobic infection (presence of gas in abscess on CT);

  • Recurrence of subperiosteal abscess after prior drainage;

  • Evidence of chronic sinusitis;

  • Acute optic nerve or retinal compromise; or

  • Infection of dental origin (anaerobic infection more likely).


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