Periorbital and orbital infections in children

              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.
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