What are the symptoms and treatment options for periorbital cellulitis?

Symptoms and Treatment of Periorbital Cellulitis

Periorbital cellulitis is characterized by eyelid swelling, redness, warmth, and tenderness, typically arising from localized trauma or bacteremia most often caused by Staphylococcus aureus, Streptococcus pyogenes, or Streptococcus pneumoniae. 1

Clinical Presentation

Key Symptoms

• Eyelid swelling (most common presenting sign)
• Eyelid erythema (redness)
• Warmth and tenderness of the affected area
• Conjunctival hyperemia (78% of cases) 2
• Fever (may be present, especially in children)
• Pain with eye movement (less common than in orbital cellulitis)

Important Distinguishing Features

• No proptosis (distinguishes from orbital cellulitis)
• No ophthalmoplegia (normal eye movement)
• No visual changes (vision typically preserved)
• No chemosis (conjunctival swelling)

Risk Factors and Predisposing Conditions

• Upper respiratory tract infections (68% of cases) 3
• Trauma to the eyelids (20% of cases) 3
• Age < 5 years (85% of periorbital cellulitis cases occur in this age group) 3
• Previous skin infections
• Insect bites

Diagnostic Approach

Physical Examination

• Assess for eyelid swelling, redness, and tenderness
• Evaluate eye movements (normal in periorbital cellulitis)
• Check visual acuity (should be normal)
• Assess for proptosis (absent in periorbital cellulitis)

Imaging

• CT scan with contrast is the initial imaging modality of choice in suspected cases to:
  • Differentiate periorbital from orbital cellulitis
  • Identify potential complications
  • Evaluate for sinusitis as a source 1

Laboratory Tests

• Blood cultures (often negative in periorbital cellulitis) 3
• Skin/wound cultures when drainage is present

Treatment

Antibiotic Therapy

• First-line treatment: Intravenous antibiotics 3, 2

  • Amoxicillin-clavulanate is commonly used 2
  • Ceftriaxone with metronidazole has shown the shortest hospital stay (3.8 days) and reduced need for surgical intervention 4

• Alternative regimens:

  • Cephalexin (500 mg 3-4 times daily for 5-6 days)
  • Clindamycin (300-450 mg orally three times daily for 5-6 days)
  • Doxycycline (100 mg twice daily for 5-6 days) - avoid in children under 8 years 5

Adjunctive Therapy

• Intranasal decongestants and corticosteroids may reduce the need for surgical intervention 4
• Warm compresses to the affected area
• Pain management as needed

Duration of Treatment

• Typical inpatient stay: 3-4 days for uncomplicated periorbital cellulitis 2
• Complete antibiotic course: 5-7 days total 5

Surgical Intervention

• Rarely needed for uncomplicated periorbital cellulitis (only 6-7% of cases) 3, 2
• Reserved for cases with abscess formation or failure to respond to antibiotics

Monitoring and Follow-up

• Reassess within 48-72 hours to ensure clinical improvement 5
• If no improvement is observed:
  • Consider broadening antibiotic coverage
  • Reevaluate for possible orbital involvement
  • Consider imaging to rule out abscess formation

Complications and Warning Signs

• Progression to orbital cellulitis (watch for proptosis, ophthalmoplegia, or vision changes)
• Meningitis (rare but serious complication, especially in children with bacteremia) 6
• Cavernous sinus thrombosis (severe headache, altered mental status)

Special Considerations

• Children under 5 years require close monitoring due to higher risk of complications
• Patients with prior MRSA infection may need targeted antibiotic coverage
• Immunocompromised patients may require broader antimicrobial coverage and longer treatment

Remember that periorbital cellulitis is distinct from the more serious orbital cellulitis, which involves the contents of the orbit and can threaten both vision and life 7.