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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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Rosen, Peter, et al., editors. "Periorbital and Orbital Cellulitis." 5-Minute Emergency Consult, 5th ed., Lippincott Williams & Wilkins, 2016. Emergency Central, emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307324/all/Periorbital_and_Orbital_Cellulitis.
Periorbital and Orbital Cellulitis. In: Rosen P, Shayne P, Barkin AZ, et al, eds. 5-Minute Emergency Consult. 5th ed. Lippincott Williams & Wilkins; 2016. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307324/all/Periorbital_and_Orbital_Cellulitis. Accessed April 26, 2019.
Periorbital and Orbital Cellulitis. (2016). In Rosen, P., Shayne, P., Barkin, A. Z., Wolfe, R. E., Hayden, S. R., Barkin, R. M., & Schaider, J. J. (Eds.), 5-Minute Emergency Consult. Available from https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307324/all/Periorbital_and_Orbital_Cellulitis
Periorbital and Orbital Cellulitis [Internet]. In: Rosen P, Shayne P, Barkin AZ, Wolfe RE, Hayden SR, Barkin RM, Schaider JJ, editors. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2016. [cited 2019 April 26]. Available from: https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307324/all/Periorbital_and_Orbital_Cellulitis.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Periorbital and Orbital Cellulitis ID - 307324 ED - Rosen,Peter, ED - Shayne,Philip, ED - Barkin,Adam Z, ED - Wolfe,Richard E, ED - Hayden,Stephen R, ED - Barkin,Roger M, ED - Schaider,Jeffrey J, BT - 5-Minute Emergency Consult UR - https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307324/all/Periorbital_and_Orbital_Cellulitis PB - Lippincott Williams & Wilkins ET - 5 DB - Emergency Central DP - Unbound Medicine ER -