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Periorbital and orbital infections in children JOHN D. SIDDENS, DO GEOFFREY J. GLADSTONE, MD Bacterial infections of the peri-orbital and orbital tissues range in sever-ity from minor to life-threatening. Presep-tal (periorbital) cellulitis is more common than orbital cellulitis and occurs quite fre-quently in children. A history of antece-dent trauma or upper respiratory tract in-fection is present in more than half of all cases. Evaluation by computed tomogra-phy scans is an indispensable part of the diagnostic procedure. All cultures should be obtained before institution of antibiotic therapy. Initial therapy should begin with administration of broad-spectrum antibi-otics with adjustments made in response to positive culture results. Response to an-tibiotics is usually prompt and the inci-dence of complications is low. If clinical improvement is slow, surgery should be performed early in the course of the dis-ease to minimize the potential for sig-nificant complications such as cavernous sinus thrombosis. (Key words: Periorbital cellulitis, or-bital cellulitis, orbital septum, subperios-teal abscess, cavernous sinus thrombosis) At the time this article was written, Dr Siddens was a fellow, oculoplastic, orbital, and reconstructive surgery, Wayne State University School of Medicine, Kresge Eye Institute, Detroit, Mich. Dr Gladstone is co-director, Ocu-loplastics Service, William Beaumont Hospital, Royal Oak, Mich. Dr Siddens is currently clinical instructor, ophthalmology, Department of Ophthalmology, Univer-sity of South Carolina School of Medicine, Columbia, SC. Reprint requests to John D. Siddens, DO, Greenville Eye Associates, 50 Bear Dr, Greenville, SC 29605. Periorbital infections are common in chil-dren and usually resolve promptly with appro-priate therapy. Orbital infections are less com-mon in this population and are frequently as-sociated with serious complications. We review the classification, etiology, diagnosis, and ther-apy of these infections. A thorough understand-ing of their pathophysiology will help to avoid the potential morbidity associated with these conditions. Anatomy The anatomic development of the sinuses in children may play a part in the relative fre-quency of periorbital and orbital infections. The ethmoid sinuses are proportionally nor-mal at birth, whereas the maxillary sinuses are small and poorly formed. The frontal si-nuses are not formed at all at birth.' Congeni-tal dehiscences of the orbital walls are com-mon in newborn infants. 2 These factors may predispose the child to an increased risk of peri-orbital infection. As the child grows, the orbital cavity be-comes separated from the sinuses by thin bony plates. An example is the lamina papyracea, an extremely thin segment of bone that forms a portion of the medial wall of the orbit and the lateral wall of the ethmoid sinus. The ve-nous system of the orbit and the paranasal si-nuses have free communications through valveless channels. No lymphatic system ex-ists within the orbit. These factors make the spread of infection relatively easy within the periorbital tissues. The orbital periosteum, also known as the 226 • JAOA • Vol 92 • No 2 • February 1992 Clinical practice • Siddens and Gladstone Figure 1. Cross section of orbit. Note relationship of or-bital septum to preseptal and postseptal ( orbital) lamel-lae. periorbita, is a thin tissue barrier lining the orbital walls. The periorbita acts as an obsta-cle to the spread of infection into or out of the orbit. The orbital septum is a fibrous tissue structure extending from each eyelid's tarsal plate to the orbital periosteum (Fig 1). This fascial plane separates the anterior eyelid la-mella from the posterior lamella, or orbit con-tents. The septum provides a barrier to the spread of infection from one lamella to the other. Classification These infections are classified by a system es-tablished by Smith and Spencer 3 and later modi-fied by Chandler and colleagues4 according to the location of the infection with particular ref-erence to the orbital septum. Classification is as follows: • Class I. Periorbital or preseptal cellulitis is the most common pediatric adnexal infection in this class. One study reported 94% of chil-dren with orbital or periorbital infections as having preseptal cellulitis. Preseptal celluli-tis is confined to the anterior lamellar tis-sues. Lid edema and erythema may be mild or severe (Fig 2). Typically, the globe re-mains uninvolved, with normal function and vision. • Class II. Orbital cellulitis results from ex-tension of infection through the septum into the orbital fat and other tissues. Manifesta-tions of this infection include proptosis, limi-tation of retropulsion, impaired or painful motility, and periocular pain. Visual acuity may be impaired late in the course of orbital cellulitis, and septicemia may become appar-ent. • Class III. Subperiosteal abscess may occur if pus collects between the periosteum and the orbital wall. Medial wall involvement (Fig 3) is most common, causing globe dis-placement inferiorly or laterally. Symptoms may be mild at first, or they may become severe and resemble orbital cellulitis. • Class IV. Orbital abscess occurs when pus accumulates within orbital tissue. The in-fectious process may become localized and encapsulated, unlike orbital cellulitis which infiltrates the tissues diffusely. Proptosis, che-mosis, ophthalmoplegia, and visual impair-ment are generally associated with this in-fection. • Class V. Cavernous sinus thrombosis results from extension of the orbital infection to the intracranial space. Headache, nausea, vom-iting, fever, pupillary dilation, and other se-vere systemic symptoms herald cavernous si-nus thrombosis (CST). Optic nerve edema Figure 2. Left: Preseptal cellulitis with complete ptosis. Right: Note marked periorbital swelling of upper eyelid as well as brow. Clinical practice • Siddens and Gladstone JAOA • Vol 92 • No 2 • February 1992 • 227 and involvement of the ophthalmic and max-illary branches of the trigeminal nerve may occur. It is interesting to note that tender-ness and pain on extraocular motion may be absent with CST. Etiology Upper respiratory tract infections, sinusitis, and conjunctivitis may predispose a patient to preseptal cellulitis. However, this infection typi-cally results from traumatic inoculation of infec-tious agents into tissues. Nasolacrimal duct obstruction and dacryocystitis may cause pre-septal cellulitis in newborn infants. Posttrau-matic infections are usually caused by Staphy-lococcus species or Streptococcus species, whereas Haemophilus influenzae or Pneumo-coccus species are responsible for most postrespi-ratory or sinus infections.5,6 Orbital cellulitis and the other postseptal infections are usually caused by Staphylococ-cus aureus, Streptococcus pneumoniae, H in-fluenzae, Propionibacterium, or anaerobic agents. Because of a lack of antibodies to the capsular antigens, children younger than 3 years are particularly susceptible to H influ-enzae. Extension of infection from the parana-sal sinuses as well as facial infection and den-tal infection may cause most cases of orbital cellulitis. Trauma or perioperative factors may predispose to orbital cellulitis, as may lacri-mal, systemic, or intraocular infection. Orbital fungal infections are uncommon in children. A steady, indolent course of orbital swelling in children, with vomiting or diar-rhea and dehydration, may indicate mucormy-cosis. Immunocompromised patients may also be predisposed to fungal infections. Localization of infection within the perios-teal space can result in a subperiosteal abscess; if the process extends to the tissues within the orbit, an orbital abscess may develop. Migra-tion of infection intracranially will increase the likelihood of CST. Diagnosis Suspicion of a periorbital or orbital infection should prompt a thorough investigation. Im-mediate recognition and therapy are impor-tant in preventing the spread of infection and Figure 3. Computed tomography scan demonstrates subperiosteal abscess along medial orbital wall. Note in-volvement of ethmoid sinus. Figure 4. Top: Computed tomography scan shows marked soft tissue involvement with early postseptal spread of infection. Bottom: Coronal view of same pa-tient. the potential morbidity associated with these infections. Obtaining a thorough patient his-tory is important to identify the onset and du-ration of symptoms, predisposing factors, and the medical condition of the patient. Physical examination may reveal a child or 228 • JAOA • Vol 92 • No 2 • February 1992 Clinical practice • Siddens and Gladstone Figure 5. Left: Left orbital cellulitis in 2 -year-old patient Right: Clinical im-provement after antibiotics had been ad-ministered intravenously for 2 days. young adult with a relatively sudden onset of unilateral chemosis, lid swelling, erythema, and proptosis. Ocular motility may be reduced or painful. Visual acuity and intraocular pres-sure must be recorded. Fundus evaluation will reveal the status of the optic nerve and the retina. Systemic evaluation may show pyrexia, malaise, irritability, or other signs of menin-geal inflammation. Conjunctival scrapings and cultures along with nasopharyngeal cultures may be obtained but are not mandatory because the results rarely correlate with blood and abscess cul-tures. 7 If taken, blood agar and chocolate agar should be included as inoculum media. A com-plete blood cell count may reveal leukocyto-sis; blood cultures should be obtained in all cases. Radiologic evaluation helps to assess the lo-cation and extent of the infection. Because in most instances sinus studies of children are difficult to interpret, computed tomograms (CT) of the orbits should be obtained (Fig 4). In the future, magnetic resonance imaging may play a part in the evaluation of periocu-lar infection. However, high contrast orbital CT remains the sine qua non at this time. Ul-trasonography is useful in evaluating the or-bit for abscesses or foreign bodies, but lesions adjacent to the globe or at the orbital apex may be difficult to interpret. A strong suspicion of preseptal or orbital cel-lulitis requires the immediate hospitalization of the patient. Prompt recognition, thorough evaluation, and appropriate therapy prevent exacerbation of the infection and the onset of potentially deadly complications such as men-ingitis, cavernous sinus thrombosis, or brain abscess. The most common ocular complication is partial or complete loss of vision as a result of CST, septic optic neuritis, occlusion of the ocular blood supply, or sustained high intraocu-lar pressure. Once vision is lost, the process is usually irreversible. Although proptosis is a major sign of orbital cellulitis, it is not unique to this type of infec-tion. A study conducted by the Toronto Hospi-tal for Sick Children separated proptosis into five major etiologic categories. Periorbital in-fections fell under inflammatory causes, along with sinus infections, and accounted for more than 30% of the children in the study. Hyper-thyroidism was named as a common cause un-der metabolic and systemic diseases, and neo-plastic causes included rhabdomyosarcoma and optic nerve glioma. Orbital hemorrhage secondary to trauma was a major cause of vas-cular proptosis. Developmental anomalies, such as craniostenosis, were grouped in a fi-nal etiologic category.8 Therapy All cultures should be obtained before institu-tion of antibiotics. The rapidity with which pre-septal infections can spread should prompt an aggressive approach to antibiotic therapy. Em-piric therapy with intravenous antibiotics should begin as soon as possible. More defini-tive therapy may be instituted as cultures iden-tify the offending organism.9 Broad-spectrum coverage with cefuroxime, 200 mg/kg of body weight, may be instituted in three divided doses per day. 1° Nafcillin so-dium may also be given intravenously at a daily dose of 200 mg/kg of body weight if de-sired. Clindamycin or vancomycin hydrochlo-ride may be substituted if the patient is aller-gic to penicillin. The clinical response to antibiotic therapy may take up to 72 hours. Chandler and col-leagues4 stated that more serious infections should show a reversal of fever within 8 hours Clinical practice • Siddens and Gladstone JAOA • Vol 92 • No 2 • February 1992 • 229 with aggressive intravenous antibiotics; oth-erwise, surgical intervention may be consid-ered. If the patient improves, intravenous an-tibiotics should be maintained for a minimum of 7 to 10 days (Fig 5). The patient may then be discharged and given 10 days of oral amoxicillin/clavulanate potassium, cefadroxil, or other broad-spectrum cephalosporins. The patient is then followed up closely for several weeks to monitor for recurrence. Surgery is indicated when clinical deteri-oration occurs, or if a foreign body can be shown to be the cause of the infection." Intra-venous antibiotics will not penetrate suffi-ciently into an orbital or subperiosteal abscess. In this case, surgery is mandatory. Up to 50% of more serious infections may require drain-age of the sinuses, subperiosteal space, or or-bits in addition to intravenously administered antibiotics.5 The antibiotics should be contin-ued for 10 to 14 days after surgery. The possi-bility of osteomyelitis or a retained foreign body must be considered if recurrence or exac-erbation of symptoms occurs.12 Summary Bacterial infection of the periorbital or orbital tissues is a common clinical entity in children. The severity of the infection can range from mild to life-threatening; therefore, aggressive workup and therapy are paramount. Orbital and periorbital infections may be classified into groups based on location in tissues, with the orbital septum and orbital periosteum as distinguishing factors. Preseptal cellulitis is common in the younger age groups and is typically caused by trauma or by upper respiratory tract infection. Orbital cellulitis, subperiosteal abscess, orbital abscess, and cavernous sinus thrombosis are less common but potentially more severe in-fections. Aggressive therapy is critical to pre-vent serious and often life-threatening concomi-tant complications. Computed tomography scanning of the or-bits is required for the diagnosis and classifi-cation of the infection and provides a basis on which to begin therapy. Conjunctival and naso-pharyngeal cultures can be obtained, but blood cultures are more helpful. Cultures and Gram staining of visible pus may be beneficial. Broad-spectrum antibiotics are necessary for a prompt clinical response. As organisms are cultured, therapy may be adjusted accord-ing to sensitivities. Clinical improvement should be apparent soon after initiation of an-tibiotic therapy; otherwise, surgical interven-tion may be indicated. Surgical drainage of the infected tissues may be required to provide com-plete resolution. Prompt recognition, thorough evaluation, and appropriate therapy are nec-essary to prevent exacerbation of the infection and the onset of potentially deadly complica-tions such as meningitis, cavernous sinus thrombosis, or brain abscess. References 1.Duke-Elder S, Cooke C: Normal and abnormal development: Embryology, in Duke-Elder S (ed): System in Ophthalmology Part 2: Congenital Deformities. St Louis, The CV Mosby Co, 1963, vol 3, pp 827-976. 2. MacDonald D, Schneider K, Della Rocca RC: Childhood dis-orders of the orbit and ocular adnexa, in Ophthalmic Plastic and Reconstructive Surgery. St Louis, CV Mosby Co, 1987, vol 1, pp 331-332. 3. Smith AT, Spencer JT: Orbital complications resulting from lesions of the sinuses. Ann Otol Rhinol Laryngol 1948;57:5-27. 4. Chandler JR, Langenbrunner DJ, Stevens ER: The patho-genesis of orbital complications in acute sinusitis. Laryngoscope 1970;80:1414-1428. 5. Spires JR, Smith RJH: Bacterial infections of the orbital and periorbital tissues in children. Laryngoscope 1986;96:763-767. 6. Israele V, Nelson JD: Periorbital and orbital cellulitis. Pe-diatr Infect Dis J 1987;6:404-410. 7. Watters EC, Wallar PH, Hiles DA, et al: Evaluation of or-bital cellulitis and results of treatment. Arch Ophthalmol 1976;94:785-788. 8. Crawford JS: Diseases of the orbit, in Toronto Hospital for Sick Children Department of Ophthalmology: The Eyes in Chil-dren. New York, Grune & Stratton Inc, 1983, pp 361-394. 9. Jackson K, Baker SR: Periorbital cellulitis. Head Neck Surg 1987;9:227-243. 10.Nelson JD: Cefuroxime: A cephalosporin with unique ap-plicability to pediatric practice. Pediatr Infect D is J 1983;2:394- 396. 11.Schramm VL, Curtin HD, Kennerdell JS: Evaluation of or-bital cellulitis and results of treatment. Laryngoscope 1982;92:732-738. 12.Rootman J, Robertson W, Lapoint JS: Inflammatory dis-eases, in Rootman J (ed): Diseases of the Orbit. Philadelphia, JB Lippincott Co, pp 143-159. 230 • JAOA • Vol 92 • No 2 • February 1992 Clinical practice • Siddens and Gladstone
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Title | Periorbital and orbital infections in children |
Description | Bacterial infections of the periorbital and orbital tissues range in severity from minor to life-threatening. Preseptal (periorbital) cellulitis is more common than orbital cellulitis and occurs quite frequently in children. A history of antecedent trauma or upper respiratory tract infection is present in more than half of all cases. Evaluation by computed tomography scans is an indispensable part of the diagnostic procedure. All cultures should be obtained before institution of antibiotic therapy. Initial therapy should begin with administration of broad-spectrum antibiotics with adjustments made in response to positive culture results. Response to antibiotics is usually prompt and the incidence of complications is low. If clinical improvement is slow, surgery should be performed early in the course of the disease to minimize the potential for significant complications such as cavernous sinus thrombosis. (Key words: Periorbital cellulitis, orbital cellulitis, orbital septum, subperiosteal abscess, cavernous sinus thrombosis) |
Creator | Siddens, John D. |
Date | 1992 |
Transcript | Periorbital and orbital infections in children JOHN D. SIDDENS, DO GEOFFREY J. GLADSTONE, MD Bacterial infections of the peri-orbital and orbital tissues range in sever-ity from minor to life-threatening. Presep-tal (periorbital) cellulitis is more common than orbital cellulitis and occurs quite fre-quently in children. A history of antece-dent trauma or upper respiratory tract in-fection is present in more than half of all cases. Evaluation by computed tomogra-phy scans is an indispensable part of the diagnostic procedure. All cultures should be obtained before institution of antibiotic therapy. Initial therapy should begin with administration of broad-spectrum antibi-otics with adjustments made in response to positive culture results. Response to an-tibiotics is usually prompt and the inci-dence of complications is low. If clinical improvement is slow, surgery should be performed early in the course of the dis-ease to minimize the potential for sig-nificant complications such as cavernous sinus thrombosis. (Key words: Periorbital cellulitis, or-bital cellulitis, orbital septum, subperios-teal abscess, cavernous sinus thrombosis) At the time this article was written, Dr Siddens was a fellow, oculoplastic, orbital, and reconstructive surgery, Wayne State University School of Medicine, Kresge Eye Institute, Detroit, Mich. Dr Gladstone is co-director, Ocu-loplastics Service, William Beaumont Hospital, Royal Oak, Mich. Dr Siddens is currently clinical instructor, ophthalmology, Department of Ophthalmology, Univer-sity of South Carolina School of Medicine, Columbia, SC. Reprint requests to John D. Siddens, DO, Greenville Eye Associates, 50 Bear Dr, Greenville, SC 29605. Periorbital infections are common in chil-dren and usually resolve promptly with appro-priate therapy. Orbital infections are less com-mon in this population and are frequently as-sociated with serious complications. We review the classification, etiology, diagnosis, and ther-apy of these infections. A thorough understand-ing of their pathophysiology will help to avoid the potential morbidity associated with these conditions. Anatomy The anatomic development of the sinuses in children may play a part in the relative fre-quency of periorbital and orbital infections. The ethmoid sinuses are proportionally nor-mal at birth, whereas the maxillary sinuses are small and poorly formed. The frontal si-nuses are not formed at all at birth.' Congeni-tal dehiscences of the orbital walls are com-mon in newborn infants. 2 These factors may predispose the child to an increased risk of peri-orbital infection. As the child grows, the orbital cavity be-comes separated from the sinuses by thin bony plates. An example is the lamina papyracea, an extremely thin segment of bone that forms a portion of the medial wall of the orbit and the lateral wall of the ethmoid sinus. The ve-nous system of the orbit and the paranasal si-nuses have free communications through valveless channels. No lymphatic system ex-ists within the orbit. These factors make the spread of infection relatively easy within the periorbital tissues. The orbital periosteum, also known as the 226 • JAOA • Vol 92 • No 2 • February 1992 Clinical practice • Siddens and Gladstone Figure 1. Cross section of orbit. Note relationship of or-bital septum to preseptal and postseptal ( orbital) lamel-lae. periorbita, is a thin tissue barrier lining the orbital walls. The periorbita acts as an obsta-cle to the spread of infection into or out of the orbit. The orbital septum is a fibrous tissue structure extending from each eyelid's tarsal plate to the orbital periosteum (Fig 1). This fascial plane separates the anterior eyelid la-mella from the posterior lamella, or orbit con-tents. The septum provides a barrier to the spread of infection from one lamella to the other. Classification These infections are classified by a system es-tablished by Smith and Spencer 3 and later modi-fied by Chandler and colleagues4 according to the location of the infection with particular ref-erence to the orbital septum. Classification is as follows: • Class I. Periorbital or preseptal cellulitis is the most common pediatric adnexal infection in this class. One study reported 94% of chil-dren with orbital or periorbital infections as having preseptal cellulitis. Preseptal celluli-tis is confined to the anterior lamellar tis-sues. Lid edema and erythema may be mild or severe (Fig 2). Typically, the globe re-mains uninvolved, with normal function and vision. • Class II. Orbital cellulitis results from ex-tension of infection through the septum into the orbital fat and other tissues. Manifesta-tions of this infection include proptosis, limi-tation of retropulsion, impaired or painful motility, and periocular pain. Visual acuity may be impaired late in the course of orbital cellulitis, and septicemia may become appar-ent. • Class III. Subperiosteal abscess may occur if pus collects between the periosteum and the orbital wall. Medial wall involvement (Fig 3) is most common, causing globe dis-placement inferiorly or laterally. Symptoms may be mild at first, or they may become severe and resemble orbital cellulitis. • Class IV. Orbital abscess occurs when pus accumulates within orbital tissue. The in-fectious process may become localized and encapsulated, unlike orbital cellulitis which infiltrates the tissues diffusely. Proptosis, che-mosis, ophthalmoplegia, and visual impair-ment are generally associated with this in-fection. • Class V. Cavernous sinus thrombosis results from extension of the orbital infection to the intracranial space. Headache, nausea, vom-iting, fever, pupillary dilation, and other se-vere systemic symptoms herald cavernous si-nus thrombosis (CST). Optic nerve edema Figure 2. Left: Preseptal cellulitis with complete ptosis. Right: Note marked periorbital swelling of upper eyelid as well as brow. Clinical practice • Siddens and Gladstone JAOA • Vol 92 • No 2 • February 1992 • 227 and involvement of the ophthalmic and max-illary branches of the trigeminal nerve may occur. It is interesting to note that tender-ness and pain on extraocular motion may be absent with CST. Etiology Upper respiratory tract infections, sinusitis, and conjunctivitis may predispose a patient to preseptal cellulitis. However, this infection typi-cally results from traumatic inoculation of infec-tious agents into tissues. Nasolacrimal duct obstruction and dacryocystitis may cause pre-septal cellulitis in newborn infants. Posttrau-matic infections are usually caused by Staphy-lococcus species or Streptococcus species, whereas Haemophilus influenzae or Pneumo-coccus species are responsible for most postrespi-ratory or sinus infections.5,6 Orbital cellulitis and the other postseptal infections are usually caused by Staphylococ-cus aureus, Streptococcus pneumoniae, H in-fluenzae, Propionibacterium, or anaerobic agents. Because of a lack of antibodies to the capsular antigens, children younger than 3 years are particularly susceptible to H influ-enzae. Extension of infection from the parana-sal sinuses as well as facial infection and den-tal infection may cause most cases of orbital cellulitis. Trauma or perioperative factors may predispose to orbital cellulitis, as may lacri-mal, systemic, or intraocular infection. Orbital fungal infections are uncommon in children. A steady, indolent course of orbital swelling in children, with vomiting or diar-rhea and dehydration, may indicate mucormy-cosis. Immunocompromised patients may also be predisposed to fungal infections. Localization of infection within the perios-teal space can result in a subperiosteal abscess; if the process extends to the tissues within the orbit, an orbital abscess may develop. Migra-tion of infection intracranially will increase the likelihood of CST. Diagnosis Suspicion of a periorbital or orbital infection should prompt a thorough investigation. Im-mediate recognition and therapy are impor-tant in preventing the spread of infection and Figure 3. Computed tomography scan demonstrates subperiosteal abscess along medial orbital wall. Note in-volvement of ethmoid sinus. Figure 4. Top: Computed tomography scan shows marked soft tissue involvement with early postseptal spread of infection. Bottom: Coronal view of same pa-tient. the potential morbidity associated with these infections. Obtaining a thorough patient his-tory is important to identify the onset and du-ration of symptoms, predisposing factors, and the medical condition of the patient. Physical examination may reveal a child or 228 • JAOA • Vol 92 • No 2 • February 1992 Clinical practice • Siddens and Gladstone Figure 5. Left: Left orbital cellulitis in 2 -year-old patient Right: Clinical im-provement after antibiotics had been ad-ministered intravenously for 2 days. young adult with a relatively sudden onset of unilateral chemosis, lid swelling, erythema, and proptosis. Ocular motility may be reduced or painful. Visual acuity and intraocular pres-sure must be recorded. Fundus evaluation will reveal the status of the optic nerve and the retina. Systemic evaluation may show pyrexia, malaise, irritability, or other signs of menin-geal inflammation. Conjunctival scrapings and cultures along with nasopharyngeal cultures may be obtained but are not mandatory because the results rarely correlate with blood and abscess cul-tures. 7 If taken, blood agar and chocolate agar should be included as inoculum media. A com-plete blood cell count may reveal leukocyto-sis; blood cultures should be obtained in all cases. Radiologic evaluation helps to assess the lo-cation and extent of the infection. Because in most instances sinus studies of children are difficult to interpret, computed tomograms (CT) of the orbits should be obtained (Fig 4). In the future, magnetic resonance imaging may play a part in the evaluation of periocu-lar infection. However, high contrast orbital CT remains the sine qua non at this time. Ul-trasonography is useful in evaluating the or-bit for abscesses or foreign bodies, but lesions adjacent to the globe or at the orbital apex may be difficult to interpret. A strong suspicion of preseptal or orbital cel-lulitis requires the immediate hospitalization of the patient. Prompt recognition, thorough evaluation, and appropriate therapy prevent exacerbation of the infection and the onset of potentially deadly complications such as men-ingitis, cavernous sinus thrombosis, or brain abscess. The most common ocular complication is partial or complete loss of vision as a result of CST, septic optic neuritis, occlusion of the ocular blood supply, or sustained high intraocu-lar pressure. Once vision is lost, the process is usually irreversible. Although proptosis is a major sign of orbital cellulitis, it is not unique to this type of infec-tion. A study conducted by the Toronto Hospi-tal for Sick Children separated proptosis into five major etiologic categories. Periorbital in-fections fell under inflammatory causes, along with sinus infections, and accounted for more than 30% of the children in the study. Hyper-thyroidism was named as a common cause un-der metabolic and systemic diseases, and neo-plastic causes included rhabdomyosarcoma and optic nerve glioma. Orbital hemorrhage secondary to trauma was a major cause of vas-cular proptosis. Developmental anomalies, such as craniostenosis, were grouped in a fi-nal etiologic category.8 Therapy All cultures should be obtained before institu-tion of antibiotics. The rapidity with which pre-septal infections can spread should prompt an aggressive approach to antibiotic therapy. Em-piric therapy with intravenous antibiotics should begin as soon as possible. More defini-tive therapy may be instituted as cultures iden-tify the offending organism.9 Broad-spectrum coverage with cefuroxime, 200 mg/kg of body weight, may be instituted in three divided doses per day. 1° Nafcillin so-dium may also be given intravenously at a daily dose of 200 mg/kg of body weight if de-sired. Clindamycin or vancomycin hydrochlo-ride may be substituted if the patient is aller-gic to penicillin. The clinical response to antibiotic therapy may take up to 72 hours. Chandler and col-leagues4 stated that more serious infections should show a reversal of fever within 8 hours Clinical practice • Siddens and Gladstone JAOA • Vol 92 • No 2 • February 1992 • 229 with aggressive intravenous antibiotics; oth-erwise, surgical intervention may be consid-ered. If the patient improves, intravenous an-tibiotics should be maintained for a minimum of 7 to 10 days (Fig 5). The patient may then be discharged and given 10 days of oral amoxicillin/clavulanate potassium, cefadroxil, or other broad-spectrum cephalosporins. The patient is then followed up closely for several weeks to monitor for recurrence. Surgery is indicated when clinical deteri-oration occurs, or if a foreign body can be shown to be the cause of the infection." Intra-venous antibiotics will not penetrate suffi-ciently into an orbital or subperiosteal abscess. In this case, surgery is mandatory. Up to 50% of more serious infections may require drain-age of the sinuses, subperiosteal space, or or-bits in addition to intravenously administered antibiotics.5 The antibiotics should be contin-ued for 10 to 14 days after surgery. The possi-bility of osteomyelitis or a retained foreign body must be considered if recurrence or exac-erbation of symptoms occurs.12 Summary Bacterial infection of the periorbital or orbital tissues is a common clinical entity in children. The severity of the infection can range from mild to life-threatening; therefore, aggressive workup and therapy are paramount. Orbital and periorbital infections may be classified into groups based on location in tissues, with the orbital septum and orbital periosteum as distinguishing factors. Preseptal cellulitis is common in the younger age groups and is typically caused by trauma or by upper respiratory tract infection. Orbital cellulitis, subperiosteal abscess, orbital abscess, and cavernous sinus thrombosis are less common but potentially more severe in-fections. Aggressive therapy is critical to pre-vent serious and often life-threatening concomi-tant complications. Computed tomography scanning of the or-bits is required for the diagnosis and classifi-cation of the infection and provides a basis on which to begin therapy. Conjunctival and naso-pharyngeal cultures can be obtained, but blood cultures are more helpful. Cultures and Gram staining of visible pus may be beneficial. Broad-spectrum antibiotics are necessary for a prompt clinical response. As organisms are cultured, therapy may be adjusted accord-ing to sensitivities. Clinical improvement should be apparent soon after initiation of an-tibiotic therapy; otherwise, surgical interven-tion may be indicated. Surgical drainage of the infected tissues may be required to provide com-plete resolution. Prompt recognition, thorough evaluation, and appropriate therapy are nec-essary to prevent exacerbation of the infection and the onset of potentially deadly complica-tions such as meningitis, cavernous sinus thrombosis, or brain abscess. References 1.Duke-Elder S, Cooke C: Normal and abnormal development: Embryology, in Duke-Elder S (ed): System in Ophthalmology Part 2: Congenital Deformities. St Louis, The CV Mosby Co, 1963, vol 3, pp 827-976. 2. MacDonald D, Schneider K, Della Rocca RC: Childhood dis-orders of the orbit and ocular adnexa, in Ophthalmic Plastic and Reconstructive Surgery. St Louis, CV Mosby Co, 1987, vol 1, pp 331-332. 3. Smith AT, Spencer JT: Orbital complications resulting from lesions of the sinuses. Ann Otol Rhinol Laryngol 1948;57:5-27. 4. Chandler JR, Langenbrunner DJ, Stevens ER: The patho-genesis of orbital complications in acute sinusitis. Laryngoscope 1970;80:1414-1428. 5. Spires JR, Smith RJH: Bacterial infections of the orbital and periorbital tissues in children. Laryngoscope 1986;96:763-767. 6. Israele V, Nelson JD: Periorbital and orbital cellulitis. Pe-diatr Infect Dis J 1987;6:404-410. 7. Watters EC, Wallar PH, Hiles DA, et al: Evaluation of or-bital cellulitis and results of treatment. Arch Ophthalmol 1976;94:785-788. 8. Crawford JS: Diseases of the orbit, in Toronto Hospital for Sick Children Department of Ophthalmology: The Eyes in Chil-dren. New York, Grune & Stratton Inc, 1983, pp 361-394. 9. Jackson K, Baker SR: Periorbital cellulitis. Head Neck Surg 1987;9:227-243. 10.Nelson JD: Cefuroxime: A cephalosporin with unique ap-plicability to pediatric practice. Pediatr Infect D is J 1983;2:394- 396. 11.Schramm VL, Curtin HD, Kennerdell JS: Evaluation of or-bital cellulitis and results of treatment. Laryngoscope 1982;92:732-738. 12.Rootman J, Robertson W, Lapoint JS: Inflammatory dis-eases, in Rootman J (ed): Diseases of the Orbit. Philadelphia, JB Lippincott Co, pp 143-159. 230 • JAOA • Vol 92 • No 2 • February 1992 Clinical practice • Siddens and Gladstone |
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