Periorbital and Orbital Cellulitis

Periorbital and Orbital Cellulitis is a topic covered in the 5-Minute Emergency Consult.

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Periorbital Cellulitis
  • An inflammatory, typically infectious condition affecting the eyelid(s)
  • It is anatomically distinguished by its location, isolated to the tissues anterior to the orbital septum:
    • Orbital septum is the connective tissue extension of the orbital periosteum that is reflected into the upper and lower eyelids
    • Extension to the deep tissues is rare because the septum represents a nearly impenetrable barrier but it may be incomplete
  • Most commonly presents as a complication of upper respiratory tract infection (URTI) and sinusitis:
    • Swelling is caused by inflammatory edema from vascular and lymphatic congestion
  • May occur as a complication of a localized inflammation/infection in the eyelid or adjacent structures:
    • Blepharitis
    • Hordeolum
    • Dacryocystitis
    • Surrounding skin disruptions:
  • Insect bites
  • Minor trauma
  • Impetigo or other dermatologic disorders

Orbital Cellulitis
  • Inflammatory process in the structures deep to the orbital septum
  • Typically occurs secondary to extension from an adjacent structure:
    • Sinusitis:
      • Most commonly ethmoiditis penetrating through the thin lamina papyracea
    • Dental abscess
    • Retained foreign body in the orbit
    • Puncture wounds
    • Orbital fracture
    • Postoperative infection
    • Hematogenous spread from a remote source due to valveless orbital veins
    • Rare cause—direct extension of periorbital cellulitis


Periorbital Cellulitis
  • Streptococcus pneumoniae
  • Staphylococcus aureus
  • Streptococcus pyogenes
  • Moraxella catarrhalis
  • Haemophilus influenzae
  • Gonococcus – rare
  • Consider nonbacterial cause

Orbital Cellulitis
  • Currently streptococcal and staphylococcal infections are the most common causes:
    • S. pneumoniae, Streptococcus viridans, S. pyogenes, Streptococcus anginosus, S. aureus
    • Anaerobes, Bacteroides, and gram-negatives may also be seen
  • All forms of orbital cellulitis carry a risk of severe morbidity and possible mortality and are therefore a true emergency:
    • Permanent visual loss may occur
    • May extend to subperiosteal space with abscess formation
    • Cavernous sinus thrombosis and CNS infections may be life threatening
  • Fungal infections are an uncommon but an even more lethal form particularly in the immunocompromised:
    • Cerebrorhino-orbital phycomycosis (CROP)
    • Rapidly fatal in 75% of cases:
      • 80% of cases occur in patients with a recent episode of diabetic ketoacidosis
      • Predisposing factor: Severe metabolic acidosis and immunocompromise
      • Begins in the paranasal sinuses and proliferates in the blood vessels causing thrombosis and necrosis
      • Bloody nasal discharge is common
      • May present with evidence of necrosis of the palate and/or nasal mucosa

Pediatric Considerations
  • Routine vaccinations including Hib and Pneumococcus have dramatically decreased periorbital and orbital cellulitis, but infections may still occur with these organisms particularly in younger children and those without at least 2 Hib vaccines
  • Periorbital cellulitis is overall 5 times more common and typically occurs in children <5 yr whereas orbital cellulitis is more common in children over 5 yr

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