Periorbital and orbital cellulitis (pediatrics): Clinical sciences

Periorbital and orbital cellulitis are bacterial infections of the soft tissues within or around the orbit. Based on the relation of the infection to the orbital septum and the presence or absence of increased intraorbital pressure, you can differentiate orbital from periorbital cellulitis.

Orbital cellulitis occurs posterior to the orbital septum and is associated with increased intraorbital pressure, while periorbital cellulitis occurs in the soft tissues anterior to the orbital septum and is not associated with increased intraorbital pressure.

Now, if your patient presents with a chief concern suggesting orbital or periorbital cellulitis, you should first perform an ABCDE assessment to determine whether the patient is unstable or stable.

If unstable, stabilize their airway, breathing, and circulation. Next, obtain IV access, consider IV fluids, and put the patient on continuous vital sign monitoring, including blood pressure, heart rate, and pulse oximetry. Finally, if needed, don’t forget to provide supplemental oxygen. Now, let’s go back and discuss stable patients.

First, obtain a focused history and physical examination. History typically reveals unilateral eye pain and swelling. In some cases, the patient or their caregiver may report fever, a recent sinus or dental infection, or a recent trauma to the eye or surrounding skin, like an insect bite or even impetigo. The physical exam reveals unilateral erythema around the orbit, as well as warmth, tenderness to palpation, and swelling of the upper or lower eyelid.

Now, here’s a clinical pearl to keep in mind! If your patient has severe pain or swelling, you might not be able to visualize the eye well enough to obtain a thorough exam. In this case, you should order a CT scan of the orbit to establish a diagnosis.

At this point, you should suspect orbital or periorbital cellulitis, so your next step is to assess your patient for signs of increased intraorbital pressure.

These include blurred vision or reduced visual acuity, ophthalmoplegia, proptosis, chemosis, and abnormal corneal light reflex.

If your patient presents with no signs of increased intraorbital pressure, diagnose periorbital cellulitis, which can result from minor skin trauma like abrasions or insect bites.

In most cases, this is a clinical diagnosis, so you won’t need labs or imaging. In other words, you can proceed straight to treatment, which primarily relies on penicillin combined with oral beta-lactamase inhibitors, such as amoxicillin-clavulanate, which cover Staphylococcus, Streptococcus, and other gram-positive skin flora.

Now, let’s go back and take a look at patients who present with signs of increased intraorbital pressure.