Preseptal cellulitis . (a) Clinical appearance of a posttraumatic preseptal cellulitis in a 7-year-old child who scraped her eyelid on the corner of a bed frame. (b) Ocular exam on this patient shows absence of conjunctival inflammation, absence of proptosis, and normal motility. (c) The MRI scan of this patient shows thickening of the preseptal soft tissue, absence of sinus disease, and no evidence of a foreign body
Patients with preseptal cellulitis typically present with a short history of eyelid edema and erythema. The eyelid may be warm and tender to palpation. Predisposing factors, such as an insect bite, skin abrasion, hordeolum, chalazion, dacryocystitis, conjunctivitis, or traumatic foreign body , may be identified during the physical exam. Preseptal cellulitis may cause ocular signs such as chemosis and conjunctival erythema. However, proptosis, pupillary changes, and limited motility are signs of orbital involvement and are not included in the constellation of signs of preseptal disease. Fever and elevated white blood cell count are inconsistent features too. The differential diagnosis for preseptal cellulitis includes periocular allergic reactions, bug bites, angioneurotic edema, trauma, renal disease, thyroid eye disease, and early orbital cellulitis without orbital signs.
Preseptal cellulitis is typically treated with antibiotics. In addition, surgical drainage of collections of purulent material is required if an abscess is present. Antibiotic choice is governed by the suspected infective agent(s) and the age of the patient. Neonates and infants are hospitalized for intravenous antibiotics and monitoring. There are varied opinions on the age when outpatient treatment for preseptal cellulitis becomes appropriate. In children, and particularly infants, the immune system is less effective in defending against infection by encapsulated bacteria . An infant’s homeostatic mechanisms are also more fragile than those of a child or adult. We do not promote a dogmatic absolute age cutoff for outpatient versus inpatient management of preseptal cellulitis. Rather, we recommend utilization of clinical judgment with a degree of caution. Under the age of 1 year, it is often accepted that a preseptal cellulitis should be managed and monitored on an inpatient basis particularly if the child appears systemically ill or cannot be closely monitored. Between the age of 1 and 5 years, milder cases can be managed with outpatient treatment utilizing appropriate oral antibiotics and close follow-up. Sicker toddlers should be admitted for IV antibiotics. After age 5, it is acceptable to treat stable patients on an oral regimen.
The most common pathogens found in children with preseptal cellulitis are Staphylococcus aureus and Streptococcus species [7, 8, 12, 13]. Furthermore , methicillin-resistant S. aureus has become a more prominent factor in the past 10 years . Other bacteria, like Streptococcus pneumoniae and Haemophilus influenzae, used to be more prevalent; however, the introduction of the pneumococcal and H. flu vaccines has dramatically reduced the incidence of these infections over the past quarter century [15–18]. Cultures may be obtained by collecting purulent material at the site of the infection, while blood cultures should be obtained in children who are febrile. Culturing the conjunctiva or aspiration of the leading edge of the cellulitis is less rewarding in the yield of positive cultures. Initial selection of antibiotics may be guided by the Gram stain and then modified according to the results of the culture and sensitivities. Specific antibiotic regimens become rapidly outdated, but a suggested regimen is provided below. When available, consultation with a pediatric infectious disease specialist is recommended. When there is a superficial component to the infection, the periorbital skin may also be treated with a topical antibiotic. The preseptal cellulitis should be reevaluated 24–36 h into treatment, at which time improvement should be apparent. Failure to improve or worsening of the disease should initiate a reconsideration of imaging to rule out an abscess , foreign body, or postseptal disease. Antibiotic choices should also be reviewed when culture results are available or be reconsidered with the prevalence of antibiotic resistance that exists today. For routine imaging of a preseptal cellulitis, computed tomography scan (CT) better delineates the bone structure of the orbit, but in cases of a suspected nonmetallic foreign body, magnetic resonance imaging scan (MRI) may be more sensitive.
Surgery is indicated if an abscess or foreign body is identified. These should be drained or removed. The original site of the trauma may be used for surgical access, or an adjacent surgical landmark may be appropriate. Incisions placed in the lid crease in the upper eyelid, the subciliary area in the lower lid, or the lateral canthal angle will leave a cosmetically acceptable scar. After removal of the foreign body and drainage of the purulent material, the area is copiously irrigated with saline or antibiotic solution. The area of the wound or incision may be left open with a drain to prevent reaccumulation of the abscess .
Necrotizing fasciitis (Fig. 33.2) is a more acute and severe infection caused by aerobic or anaerobic microorganisms that is characterized by its rapid spread along and through the soft tissue, causing necrosis of the fascia, overlying skin, and subcutaneous soft tissue. This condition may occur in the eyelids and orbit [19, 20]. Mortality rates for this type of infection range from 30 to 76%. Patients develop systemic toxicity with sepsis, organ failure, respiratory failure, and death. The diagnosis should be considered in any soft tissue infection presenting with signs of systematic toxicity and marked edema, because the prognosis is closely linked with early recognition. In children, Streptococcus and polymicrobial culture results are reported . Therapy includes broad-spectrum antibiotics (penicillin, aminoglycoside, and metronidazole), early and aggressive surgical debridement, systemic support, and hyperbaric oxygen.
Necrotizing fasciitis . (a) This 4-year-old presented with a history of soft tissue trauma to the upper lid with rapidly progressing necrosis of the tissues over the next 2 days. (b) The CT scan shows marked soft tissue edema and subcutaneous gas. (c) Granulation tissue forming 2 weeks following surgical debridement. Note prolapsed upper cul-de-sac. (d) Postoperative appearance 5 months following excision of prolapsed tissue and repair by multiple mattress sutures of 5–0 chromic catgut. No skin grafting was necessary, only spontaneous granulation. (e) Downgaze with minimal lid lag
Antibiotic Treatment for Preseptal Cellulitis
Vancomycin 10–15 mg/kg IV Q 8 hours and clindamycin 15–25 mg/kg/day divided Q 8 h.
Trimethoprim/sulfamethoxazole 10 mg/kg/day TMP divided q12 h.
Clindamycin 10–25 mg/kg/day divided Q8 h.
Orbital cellulitis is differentiated from preseptal cellulitis by the presence and signs of the postseptal infectious disease process. Orbital cellulitis most commonly arises from spread of contiguous sinus disease but can also arise from traumatic violation of the orbit with implantation of infectious material, trans-septal spread of preseptal cellulitis, or metastatic hematogenous spread of infection to the orbit. The infection may also begin as a dental abscess that spreads to the orbit. Since the orbital process most often arises from spread of infection from the paranasal sinuses, it is helpful to have an ENT consultation involved early with these patients as sinus surgery is an integral part of successful management when surgery is required . Chronic sinusitis is identified as the cause of orbital infection in 75–85% of cases . Conversely, orbital involvement occurs in only 0.5–3% of patients with acute sinusitis . In children, the infected sinus cavities most often seen in association with orbital cellulitis are the ethmoid air cells.
The sinuses and orbit have several anatomic relationships that predispose to the communication of infection and inflammatory processes. Natural dehiscences are often present in the orbital walls, especially the lamina papyracea over the ethmoid sinuses . Bony dehiscences are also reported in the walls of the sphenoid sinus . These disruptions in the sphenoid bone put the optic nerve at risk for septic optic neuritis. The thin wall of the lamina papyracea may also erode in the face of infection, allowing direct communication of the purulent material within the sinus to the subperiosteal space of the orbit. Vascular flow of the valveless orbital veins will allow blood flow to occur from the sinuses to the orbit, another avenue for communication of the infection. The anterior and posterior ethmoidal foramina are additional natural conduits between the sinuses and orbit. All of these features of orbital and sinus anatomy create an avenue for transmission of sinus infection to the orbit.
Definitions of the clinical characteristics of orbital complications of sinusitis were described in a classification system developed by Hubert , Smith and Spencer , and, more recently, Chandler et al.  in the twentieth century. Although the classification system (below) should not be overemphasized as a stepwise progression of the disease process, the description of the clinical characteristics remains a valuable way of defining the severity and location of the infectious process. Orbital imaging is also helpful in staging orbital cellulitis . Nonetheless, it is the clinical exam, disease severity, and progression that are the paramount factors in determining treatment.
Class I (inflammatory edema, Fig. 33.3) is defined by the clinical characteristics of eyelid edema and erythema. This may occur because of congestion of the venous drainage system or transmission of inflammatory mediators from the infected sinuses into the periorbital soft tissue. This stage is sometimes called a preseptal cellulitis , but it is preferable not to use the same term that is used for a preseptal infectious process. In orbital cellulitis, this is an inflammatory response to the sinusitis. Orbital signs of decreased motility, proptosis, or alteration of the pupillary response are absent in the patients who fit the description of class I.
Sinusitis with preseptal inflammation. (a) This patient has edema and erythema of the left periocular region. (b) The CT scan demonstrates soft tissue edema of the eyelids, opacification of the ethmoid air cells, and normal orbital contents
Class II (orbital cellulitis, Fig. 33.4) is differentiated from class I by the presence of eyelid findings and signs of orbital involvement, such as proptosis, restriction of extraocular movements, pupillary defects, and alteration in vision. The diagnosis is confirmed with radiologic evidence of postseptal soft tissue changes. These changes are diffuse soft tissue thickening within the contents of the orbit. Localized collections of infectious material are described in the other classes.
Orbital cellulitis . (a) External photograph shows edema and erythema of the right periocular region. (b) This patient’s attempted upgaze with limitation of motility. (c) CT scan shows the soft tissue thickening of the orbital tissue. (d) The CT bone windows better demonstrate the extent of the sinus opacification
An additional class could be added to the Chandler classes to describe the clinical process of a subperiosteal effusion (Fig. 33.5). This effusion typically develops between the periosteum of the medial orbital and the underlying ethmoid sinuses. The effusion is an inflammatory elevation of the medial periosteum with sterile fluid found between the periosteum and the medial orbital bony wall. By imaging, it is difficult to assess whether this collection is an inflammatory process or whether it will be purulent material . A collection of purulent subperiosteal material is the next classic step in the Chandler classification system (class III subperiosteal abscess, Fig. 33.6). An effusion may resolve when the sinusitis is medically treated, but a subperiosteal abscess is more likely to be resistant to antibiotic treatment and require surgical intervention. Many papers have been written trying to determine what size subperiosteal abscess can be managed medically versus which larger ones require surgery [30–32].
Subperiosteal effusion . (a) This 11-year-old patient presented with a complaint of double vision. (b) The alteration in motility is seen in upgaze. (c) The coronal CT scan demonstrates his left-sided sinusitis and subperiosteal fluid collection. (d) Axial CT shows the medial subperiosteal fluid collection. Surgical drainage showed a clear effusion under the periosteum of the medial orbital wall
Subperiosteal abscess in orbital cellulitis. (a) Photograph in primary gaze demonstrating edema, erythema, and proptosis. (b) Photograph in upgaze demonstrating limitation of ocular motility in the left eye. (c) CT scan of this patient with ethmoidal sinusitis, a medial subperiosteal abscess , and orbital cellulitis
These subsets of patients with subperiosteal fluid collections are challenging to the clinician because the two groups will be similar by clinical appearance and radiologic imaging but will differ in the necessity for surgical drainage. The signs and symptoms of the subperiosteal fluid collections are often similar to class I or class II. At times a subperiosteal effusion or subperiosteal abscess will cause a nonaxial proptosis, whereas typically the proptosis caused by diffuse orbital cellulitis will move the globe anteriorly. In the case of a subperiosteal effusion or abscess, the globe is deviated away from the location of the fluid collection. The presence of a subperiosteal fluid collection is recognized only after imaging studies and then becomes a management issue. In a stable patient with good vision and no afferent pupillary defect, it is usually appropriate to initiate a trial of antibiotics rather than moving directly to surgical drainage . Antibiotics alone may clear the sinusitis and an inflammatory effusion may respond without surgical intervention. Patients with decreased vision, afferent pupillary defects, or other deteriorating clinical signs should have urgent drainage . At the time of surgery, the subperiosteal fluid may be cultured and smeared to determine whether it is an effusion or purulent fluid.
When the periosteum loses its integrity, or when there is inoculation of the infectious material directly into the orbit, an orbital abscess or collection of purulent material within the soft tissues of the orbit may occur (class IV, orbital abscess, Fig. 33.7). This direct continuity between the purulent material and the orbital tissue puts the orbital structures at higher risk for complications. The septic material and the inflammatory response arc toxic to the orbital tissues. The abscess must be drained, and it is not unusual for successful resolution of an intraorbital abscess to require more than one drainage attempt. However, as noted earlier, combined drainage of sinus infection and the orbital abscess has a lower incidence of reaccumulation of the infection . In the case of an intraconal abscess , it may be necessary to temporarily disinsert an extraocular muscle to access the abscess for drainage. As with any abscess , a pathway for postoperative drainage should be maintained. Sterile rubber bands or Penrose drains may be used for this purpose in the case of an intraorbital abscess .
Orbital abscess . (a) Intraoperative photo of right orbital abscess. (b) CT scan of this patient when the infection was confined to a subperiosteal abscess . (c) CT scan 4 days later when the infection has spread to the orbital tissues
When the infectious and inflammatory processes follow the venous system posteriorly, a cavernous sinus thrombosis may result (class V). When the infection begins as a unilateral problem, the spread of lid edema and skin discoloration to both sides is a clue to possible extension to the cavernous sinus. Another warning sign is identified when cranial nerve palsies become bilateral or when the motility deficit is identified as a paresis rather than orbital restriction. The physician should be alerted to this when abnormal findings in the extraocular motility are out of proportion with the degree of orbital edema and proptosis. Mental status changes or signs of meningeal irritation will often accompany the cavernous sinus thrombosis . An MRI will be used to diagnose the presence of cavernous sinus thrombosis . T2– and proton-weighted images with gadolinium will show high signal luminal narrowing or absence of flow. When a cavernous sinus thrombosis is confirmed, there are relatively few management changes that can be made if the patient has already been adequately treated with antibiotics and all abscesses drained. Heparin therapy has been described, but has not been shown to be helpful in properly controlled studies, and may be precarious in a patient who will need further acute surgical intervention. Ultimately, early suspicion and recognition, with aggressive multidisciplinary treatment, are the keys to managing this rare but devastating complication .
Regardless of age, the signs and symptoms of orbital cellulitis mandate hospital admission and intravenous antibiotics as well as dictate the potential need for surgery. The child is admitted and stabilized while intravenous antibiotics are started. As mentioned earlier, antibiotic choices quickly become outdated as the bacteriology of these infections evolve, but suggestions for preliminary choices relevant in 2016 are described below.
Antibiotic choices may be modified according to suspected or cultured bacterial agents. Blood cultures are taken before the antibiotics are started, and other focal lesions, such as conjunctivitis, should be cultured. Screening cultures of normal conjunctiva or the nasopharynx are rarely useful. The organisms responsible for orbital infections are often difficult to determine because of the polymicrobial nature of sinusitis and the abundance of normal bacterial flora on mucosal and skin surfaces. Cultures should be carefully interpreted. Previous antibiotic therapy may also cloud the culture results. In children with orbital cellulitis, the most common organisms isolated by sinus aspirate cultures are S. aureus, Streptococcus species, and anaerobic species [7, 8, 13, 35]. Particularly in younger children, bacteremia may also be present in cases of orbital cellulitis . Children younger than age 4 have impaired humoral immunity to bacteria with polysaccharide capsules such as H. influenzae , and bacteremia with these organisms is used to be seen more commonly in this age group. Thankfully, vaccination for H. influenzae had a dramatic reduction in these infections.