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Monday, Monday ( lalalalala …)

Monday, Monday ( lalalalala …). AM Report July 18, 2011. Left orbital cellulitis secondary to paranasal sinus disease. CT Orbits with Contrast. Infections anterior to orbital septum= PERIORBITAL Infections posterior to the orbital septum= ORBITAL.

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Monday, Monday ( lalalalala …)

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  1. Monday, Monday (lalalalala…) AM Report July 18, 2011

  2. Left orbital cellulitis secondary to paranasal sinus disease CT Orbits with Contrast

  3. Infections anterior to orbital septum= PERIORBITALInfections posterior to the orbital septum= ORBITAL Anatomic Considerations (Courtesy of PIR “Periorbital and Orbital Cellulitis”)

  4. Epidemiology • Periorbitalcellulitis • Pts <5yrs • 3 times more common than orbital cellulitis • Orbital cellulitis • Average age 6.8 yrs (1wk to 18 months) • 2:1 male predominance • Occurs more often in winter months (URI, sinusitis)

  5. Pathogenesis • Periorbtial • Extension of external ocular infection • Hordeolum (stye) • Dacrocystitis/dacroadenitis • Superficial break in the skin • Orbital • RHINOSINUSITIS • URI • Dental abscess • Direct penetrating injury to the orbit • Hematogenous spread

  6. Microbiology • Periorbital • S. aureus, S. epidermidis, S. pyogenes • Orbital • Staphylococcus (MRSA), Streptococcus • Less commonly (dental, sinus dz): Haemophilus, Neisseria, Bacteroides, Veillonella, Provetella, Peptostreptococcus, Moraxellacatarrhalis • Consider Hib in unimmunized children

  7. Clinical Presentation • Periorbital • Unilateral erythema, swelling, warmth, and tenderness of the eyelid • Fever, systemic signs (toxicity?) • Orbital • All signs/Sx above • Blurred vision, ophthalmoplegia (pain with EOM), proptosis, chemosis

  8. Periorbitalcellulitis due to insect bite (arrow) PeriorbitalCellulitis (Courtesy of PIR “Periorbital and Orbital Cellulitis”)

  9. Periorbitalcellulitis due to dental abscess PeriorbitalCellulitis (Courtesy of PIR “Periorbital and Orbital Cellulitis”)

  10. Orbital cellulitis due to pan-sinusitis Orbital Cellulitis (Courtesy of PIR “Periorbital and Orbital Cellulitis”)

  11. Differential Diagnosis • Allergic reaction • Edema due to hypoproteinemia • Orbital wall infarction and subperiosteal hematomas in pts with SS dz

  12. Evaluation • Periorbital • Dx on clinical findings (no routine labs or imaging necessary) • Wound Cx • Blood Cx (only if hematogenous spread is suspected) • Orbital • High WBC ct, ESR/CRP suggestive • Blood Cx (only if hematogenous spread is suspected)

  13. Evaluation (con’t) • Orbital • Wound Cx • CT scan with contrast of head and sinuses • Incomplete exam due to edema/pain • Presence of CNS involvement • Decrease in visual acuity, color vision, gross proptosis, ophthalmoplegia • Clinical deterioration or no improvement after 24-48h of appropriate Abx

  14. Treatment • Periorbital • Empiric coverage for Staph and Strep • Dicloxicillin • First generation cephalosporin • Clindamycin or Bactrim if MRSA is suspected • Improvement should be evident in 24-48h • Periorbitalcellulitis due to hematogenous spread should be treated with IV Abx (both gram+&- coverage) • Length of treatment 7-10 days

  15. Treatment • Orbital • Admit with ENT and Ophthalmology consults • Empiric coverage for Staph, Strep and organisms associated with sinusitis (IV) • Clindamycin and 3rd generation cephalosporin • Surgical drainage if indicated • Length of treatment 10-14 days • Transition to oral abx after significant clinical improvement is made

  16. Potential Complications • Recurrent periorbialcellulitis • Atopy • HSV/HIV • Atypical Mycobacteria • Collagen vascular diseases • Structural/anatomic abnormalities • Cavernous sinus thrombosis • Intracranial infections • Loss of vision

  17. Recurrent PeriorbitalCellulitis due to HSV (also the happiest child that ever had periorbitalcellulitis) Recurrent PeriorbitalCellulitis (Courtesy of PIR “Periorbital and Orbital Cellulitis”)

  18. Periorbital and Orbital Cellulitis

  19. Noon Conference: Intern Clinical Reasoning with Dr. English (Everyone else is free for lunch!) Thanks for your Attention!

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