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Cellulitis

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Orbital and Preseptal Cellulitis

Orbital infections might possibly be vision- and life-threatening, and prompt evaluation and treatment of patients with these infections is essential.

Preseptal cellulitis (periorbital cellulitis) is an infectious inflammation of the tissues anterior to the orbital septum, more often encountered in children with upper respiratory infections

• usually 2^o to trauma or skin infection in kids and adults
• EOM’s, pupils, visual acuity Hertels, are NORMAL
• teens and adults can be closely followed as outpatient with ORAL antibiotics (Augmentin) but if worsening then CT and admit for IV antibiotics
• under 5 year old might possibly have bacteremia, especially from H flu (violaceous erythema w/marked lid swelling are classic) otitis media or pneumonia, more severe disease, need IV 3rd gen cephalosporin antibiotics after blood cultures taken
• surgical drainage of abscess might possibly be necessary; do not violate septum and cause orb cellulitis

Orbital cellulitis is an infectious inflammatory process involving the orbital tissues posterior to the orbital septum and requires

• Etiologies include trauma, orbital fracture repair, strabismus surgery
• Extension of pre-existing infections of the face, lacrimal sac, and lacrimal gland which can extend into the orbit
• Pathophysiology: The most common bacterial pathogens in preseptal cellulitis include Haemophilus influenza, Staphylococcus aureus, and Streptococcus pneumoni
• Therapy: Subperiosteal abscess formation should be suspected if patients fail to improve or deteriorate on intravenous antibiotics.
  • Infants with preseptal cellulitis are usually admitted for intravenous therapy, whereas
  • older children and adults with preseptal infections might possibly be treated with oral antibiotics. 7- to 10-days of intravenous therapy are required, followed by a course of oral antibiotics for 10 to 14 days
• infection posterior to orbital septum
• 90% from extension of acute or chronic bacterial sinusitis, remainder s/p trauma or surgery or 2^o to extension from other orbital or periorbital infection, or endogenous w/septic embolization
• fever, proptosis, restriction of EOM’s, pain on globe movement
• decreased visual acuity Afferent Pupillary Defect (APD), prolonged high Intraocular pressure (IOP) can be indications for aggressive management to prevent orbital apex syndrome or cavernous sinus thrombosis

• CT of orbit and sinuses to confirm sinus disease, rule out mass, rule out orbital foreign body if h/o trauma (even remote), rule out orbital or subperiosteal abscess which will require surgical drainage.
• blood culture then broad spectrum IV antibiotics to cover gram cocci, H. influenzae (although less prevalent in kids 2^o to immunization), anaerobes, typically nafcillin and 3rd generation cephalosporin; ID consult if necessary; kids more often single organism.
• progression of infection or no daily improvement on appropriate antibiotics can mean abscess: repeat CT as needed (prn) and drain w/concomitant sinus drainage as needed (prn).
• cavernous sinus thrombosis: rapid progression of proptosis and neurologic signs of intracranial dysfunction; might possibly lead to meningitis; get neurosurgery consult.