Fifteen-minute consultation: Preseptal and orbital cellulitis

Abstract

'It is midnight and you are called to see a thirteen-year-old boy who has been brought to the paediatric emergency department with a 24-hour history of swelling and redness of his left eye. He has had a 'runny nose' for a couple of days. He is systemically well. His upper and lower lids are red and swollen such that his eye is not open fully, though you elicit normal eye movements when you open his eye. Pupils are equal and reactive with no afferent pupillary defect. Visual acuity and colour vision are normal on examination.' In this article, we consider the approach to preseptal and orbital cellulitis in children including the initial assessment and management options.

Sinonasal-Related Orbital Infections in Children: A Clinical and Therapeutic Overview

“…Fundoscopy should also be considered in the case of suspected optic nerve impairment. Children with pre-septal involvement are generally systemically well, but signs of systemic involvement (including fever) may occur more frequently if the infection spreads beyond the orbital septum [26].…”

“…A local examination generally reveals unilateral eyelid and peri-orbital swelling, tenderness, erythema, and warmth. The clinical signs suggesting possible intra-orbital involvement are an inability to open the eye sufficiently to allow examination, proptosis, ophthalmoplegia, and diplopia, impaired vision (reduced acuity or the loss of perception of the colour red), asymmetrical pupillary reactivity, chemosis, or injection of the conjunctiva or sclera [26]. An otolaryngological examination using nasal fibre endoscopy is useful for exploring the nasal cavities, the middle and superior meatus and osteomeatal complex, and the sphenoethmoidal recess, in order to detect any sign of sinus disease (including mucosal edema and purulent secretion) and guide the collection of samples for microbiological analysis.…”

“…Children with uncomplicated POC do not need to undergo routine baseline imaging [27], but if available and provided that it does not delay any further treatment, urgent magnetic resonance imaging (MRI) with gadolinium enhancement is the method of choice for localising and diagnosing an abscess in the case of suspected intra-orbital involvement (or if the impossibility of inspecting the eye during a bedside examination cannot rule it out), clinical deterioration, no response to intravenous antibiotic treatment after >48 h, or suspected intracranial extension. The alternative is contrast-enhanced computed tomography (CT) of the orbit, the maxillo-facial unit, and the brain [26,28]. The diagnostic accuracy of CT in detecting OC, OA, or SPA ranges from 91% to 100% [29,30], and its pre-surgical use is essential to plan the treatment of the primary sinonasal focus and guide the surgical drainage of any intra-orbital or sub-periosteal collection.…”

Trauma and sinusitis induce orbital cellulitis in an 11-year-old boy

“…signs of clinical and laboratory improvement are present, a transition from initial intravenous treatment to oral treatment can be considered. The total treatment duration of these infections has decreased considerably in recent years to approximately two weeks, even in cases of orbital or subperiosteal infections [23][24][25][26]. After CT examination for diagnosis con rmation, children with orbital honeycomb in ammation combined with sinusitis are usually treated with systemic antibiotics, nasal glucocorticoids, nasal cavity washing, agents promoting mucosal dissolution, negative pressure to attract nasal secretions, etc.…”

“…CT scans were necessary for the following conditions in patients with orbital cellulitis: inability to perform a complete eye evaluation, exophthalmos, ophthalmoplegia, and pain in external eye movements, decreased vision, or central symptoms (seizures, focal neurological de cits, or a change in the mental state). In clinical cases of intracranial complications or cavernous sinus thrombosis or such suspected on the basis of CT ndings, such as changes in the mental status, persistent fever after appropriate treatment, or CT ndings suggesting intracranial expansion, MRI should be considered [25,31]. When the clinical manifestations support orbital cellulitis, but the CT examination results are normal, MRI examination is recommended to be performed to facilitate the diagnosis [33].…”