Paeds · ophthalmology
Preseptal and orbital cellulitis
Also known as Preseptal cellulitis · Periorbital cellulitis · Orbital cellulitis · Postseptal cellulitis · Subperiosteal abscess of the orbit · Chandler classification of orbital complications
Fellowship topic on preseptal and orbital cellulitis in children: the orbital septum as the dividing line between a mild preseptal infection and a sight-threatening postseptal one; the Chandler five-stage classification of orbital complications of sinusitis from inflammatory oedema through orbital cellulitis, subperiosteal abscess and orbital abscess to cavernous sinus thrombosis; the sinogenic pathophysiology through the thin lamina papyracea and the valveless venous drainage; the Staphylococcus aureus, Streptococcus pyogenes, S. pneumoniae and Streptococcus anginosus microbiology; the clinical signs that separate the well child with preseptal swelling from the sick child with proptosis, ophthalmoplegia and visual loss; the role of contrast CT and the medical-versus-surgical decision for subperiosteal abscess including the age-based Garcia-Harris criteria; stepwise oral and intravenous antibiotic management; the intracranial and visual complications; and ANZ, UK and North American guidance.
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Target exams
Red flags
- Proptosis, limitation of eye movements, pain on eye movement, decreased visual acuity or a relative afferent pupillary defect in a child with periorbital swelling — orbital cellulitis; admit for intravenous antibiotics and urgent ophthalmology and ENT review
- A child who is systemically unwell, febrile and toxic with rapidly worsening orbital signs — risk of optic nerve compromise, orbital abscess or intracranial extension
- Bilateral eye signs, cranial nerve palsies, severe headache, neck stiffness or deteriorating conscious state — cavernous sinus thrombosis, meningitis or intracranial abscess
- No improvement or deterioration after 24 to 48 hours of intravenous antibiotics — search for a subperiosteal or orbital abscess needing surgical drainage
- A very young child or an unvaccinated child with periorbital cellulitis and systemic upset — consider Haemophilus influenzae type b and invasive disease
Life stages
Care settings
Clinical exam formats
Board mappings
- General Paediatrics and Ophthalmology: preseptal versus orbital cellulitis — recognition, the septum, the red-flag orbital signs and stepwise antibiotic treatment
- Infectious diseases: sinusitis complications, Staphylococcus aureus and streptococcal orbital infection, intracranial extension
- Renewed curriculum — Infectious diseases and emergency care: orbital cellulitis as a sight- and life-threatening emergency, contrast CT and the medical-versus-surgical decision
- Ophthalmology: subperiosteal abscess, the Garcia-Harris criteria and optic nerve compromise
- General Paediatrics: distinguishing preseptal from orbital cellulitis, when to image, when to refer and the intravenous antibiotic regimen
- Emergency care: resuscitation of the child with orbital cellulitis and sepsis, and escalation to ophthalmology and ENT
- Long Case / Structured discussion: a child with orbital cellulitis and subperiosteal abscess — diagnosis, imaging, medical versus surgical management and complications
- Communication station: explaining the difference between preseptal and orbital cellulitis to a family and the plan for admission
- Level 2 / 3 — Infection and Ophthalmology: periorbital and orbital cellulitis, sinusitis complications and antibiotic stewardship
- Emergency and acute care: the child with a red swollen eye — recognition of the postseptal emergency
- Foundation of Practice (FOP): the Chandler classification, the orbital signs and the causative organisms
- Applied Knowledge in Practice (AKP): CT indications, intravenous antibiotic choice and surgical criteria for subperiosteal abscess
- History-taking and management: the child with periorbital swelling and the recognition of orbital cellulitis
- Communication: explaining admission, intravenous antibiotics and the surgical decision to a family
- General Pediatrics Content Outline — preseptal and orbital cellulitis: diagnosis, treatment and complications
- Infectious Diseases: sinusitis orbital complications, S. aureus and streptococcal infection, intracranial extension
- Ophthalmology: subperiosteal abscess, optic neuropathy and the medical-versus-surgical approach
- Patient Care: recognition and stepwise management of preseptal and orbital cellulitis across severity, with timely imaging and referral
- Systems-Based Practice: multidisciplinary care with ophthalmology and ENT, and safe disposition and follow-up
- Medical Knowledge: orbital septum anatomy, Chandler classification, microbiology and antibiotic selection
- Medical Expert: preseptal and orbital cellulitis diagnosis, imaging, treatment and complications
- Collaborator: multidisciplinary management with ophthalmology, ENT and infectious diseases
- Communicator: explaining the difference in severity and the admission plan to a family
The septum is the line — preseptal versus orbital
Preseptal (periorbital) cellulitis
Orbital (postseptal) cellulitis
Overview & Definition
Picture a four-year-old brought to the emergency department with a swollen, red eye. Yesterday it was a mildly puffy lid after a small scratch; today the whole lid is tense and erythematous, but the eye itself looks normal, the child can move it in every direction without pain, the vision is fine, and the child is playful and afebrile. This is the common, benign end of the spectrum — preseptal cellulitis — and it will settle with oral antibiotics and safety-net advice. Now picture a different four-year-old, brought in the same evening with a swollen, red eye that protrudes, cannot look to the side, hurts when it tries, and is accompanied by fever and a listless child. This is the dangerous end — orbital cellulitis — and it will not settle without a hospital, an intravenous line and a scan. Recognising which child is which, and acting fast on the second, is the whole skill. [1] [3]
Periorbital infection is divided by the orbital septum, a fibrous sheet continuous with the periosteum of the orbital rim that forms the anterior boundary of the orbit. Preseptal (periorbital) cellulitis is infection of the eyelid and periorbital soft tissues anterior to this septum; it is common, usually mild, and most often follows a local skin breach, conjunctivitis or trauma. Orbital (postseptal) cellulitis is infection posterior to the septum, involving the orbital fat, extraocular muscles and neurovascular structures; it is uncommon but sight- and life-threatening, and it most often spreads from adjacent paranasal sinusitis. [2] [4]
The clinician's task is layered. The first layer is triage — separating the well child with anterior lid swelling from the sick child whose infection has crossed the septum, using the orbital signs that examiners test every time. The second layer is investigation — deciding when contrast CT is needed and reading it for a subperiosteal or orbital collection. The third layer is treatment — oral antibiotics for uncomplicated preseptal disease, intravenous antibiotics for orbital disease, and a surgical decision for the abscess that will not resolve or that threatens vision. [5] [11]
References11ShowHide
- [1]Nageswaran S; Woods CR; Benjamin DK Jr; Givner LB; et al Orbital cellulitis in children. Pediatr Infect Dis J, 2006.PMID 16874168
- [2]Sobol SE; Marchand J; Tewfik TL; Manoukian JJ; et al Orbital complications of sinusitis in children. J Otolaryngol, 2002.PMID 12121013
- [3]Botting AM; McIntosh D; Mahadevan M Paediatric pre- and post-septal peri-orbital infections are different diseases. A retrospective review of 262 cases. Int J Pediatr Otorhinolaryngol, 2008.PMID 18191234
- [4]Chaudhry IA; Al-Rashed W; Arat YO The hot orbit: orbital cellulitis. Middle East Afr J Ophthalmol, 2012.PMID 22346113
- [5]Georgakopoulos CD; Eliopoulou MI; Stasinos S; Exarchou A; et al Periorbital and orbital cellulitis: a 10-year review of hospitalized children. Eur J Ophthalmol, 2010.PMID 20544674
- [6]Gutowski WM; Mulbury PE; Hengerer AS; Kido DK The role of C.T. scans in managing the orbital complications of ethmoiditis. Int J Pediatr Otorhinolaryngol, 1988.PMID 3397230
- [7]Greenberg MF; Pollard ZF Medical treatment of pediatric subperiosteal orbital abscess secondary to sinusitis. J AAPOS, 1998.PMID 10532723
- [8]Yang M; Quah BL; Seah LL; Looi A Orbital cellulitis in children—medical treatment versus surgical management. Orbit, 2009.PMID 19839897
- [9]Chaudhry IA; Shamsi FA; Elzaridi E; Al-Rashed W; et al Inpatient preseptal cellulitis: experience from a tertiary eye care centre. Br J Ophthalmol, 2008.PMID 18697809
- [10]Quintanilla-Dieck L; Chinnadurai S; Goudy SL; Virgin FW Characteristics of superior orbital subperiosteal abscesses in children. Laryngoscope, 2017.PMID 27291943
- [11]McDermott SM; Onwuka A; Elmaraghy C; Walz PC Management patterns in pediatric complicated sinusitis. Otolaryngol Head Neck Surg, 2020.PMID 32396416