Dermatology Book

Bacterial Infections

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Orbital Cellulitis

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  1. Epidemiology
    1. Mean age: 12 years old
  2. Pathophysiology
    1. Bacterial ethmoid Sinusitis extension to involve orbit
      1. Extends via thin medial bony wall into orbit
      2. Extends via retrobulbar veins (no valves) into lids
    2. Organisms
      1. Streptococcus Pneumoniae
      2. Group A Streptococcus
      3. Staphylococcus aureus
      4. Moraxella catarrhalis
      5. Haemophilus Influenzae (under age 3 years, decreasing due to Immunization)
      6. Mixed bacterial infection including Anaerobes
  3. Stages
    1. Inflammatory Edema
    2. Orbital Cellulitis
      1. Proptosis
      2. Reduced ocular mobility
    3. Subperiosteal Abscess
    4. Frank Orbital Abscess
    5. Cavernous Sinus Thrombosis
  4. Signs
    1. Starts as mild inflammatory edema
      1. URI history
      2. Low grade or absent fever
      3. Slowly progressive clinical course
      4. Swollen and discolored eyelid
    2. Progresses to orbital involvement
      1. Proptosis (Exophthalmos)
      2. Pain and limitation of eye movement
      3. Diplopia on side gaze due to inability to move eye
      4. Chemosis
      5. Retinal Exam
        1. Venous dilatation and tortuosity
      6. Papilledema
      7. Decreased Visual Acuity
  5. Radiology
    1. CT Sinuses and orbits or
    2. MRI sinuses and orbits
  6. Differential Diagnosis
    1. Preseptal Cellulitis
    2. Orbital pseudotumor
    3. Rhabdomyosarcoma
    4. Neuroblastoma
    5. Leukemia
    6. Lymphoma
    7. Other tumors
      1. Neurofibroma
      2. Glioma of the Optic Nerve
      3. Dermoid cyst
      4. Lymphangioma
      5. Hemangioma
      6. Wilms tumor
  7. Management
    1. General
      1. Observe in hospital
      2. Repeat CT sinuses/orbits if not improved in 48 hours
    2. Antibiotics (3 week course)
      1. First week: Parenteral antibiotics
        1. Ampicillin with sulbactam (Unasyn) or
        2. Third generation Cephalosporin (e.g. Cefotaxime)
      2. Next 2 weeks: Oral antibiotics (follows parenteral)
        1. Amoxicillin-Clavulanate (Augmentin) or
        2. Cefuroxime (Ceftin) or
        3. Cefprozil (Cefzil)
    3. Antibiotics: MRSA suspected (growing Incidence in outpatient community)
      1. Parenteral antibiotics
        1. Vancomycin or
        2. Linezolid or
        3. Daptomycin
      2. Oral antibiotics
        1. Clindamycin or
        2. Trimethoprim-sulfamethoxazole or
        3. Doxycycline
    4. Surgical drainage indications
      1. Large abscess
      2. Significant symptoms
      3. Insufficient improvement on antibiotics
  8. References
    1. Givner (2002) Pediatr Infect Dis 21:1157
    2. Micek (2007) Clin Infect Dis 45:S184
    3. Tovilla-Canales (2001) Curr Opin Ophthalmol 12:335

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