Symptoms and Treatment of Periorbital Cellulitis
Periorbital cellulitis presents with eyelid erythema, swelling, tenderness, and warmth, and must be distinguished from the more serious orbital cellulitis which involves the contents of the orbit and can threaten both vision and life. 1
Clinical Presentation
Key Symptoms
- Rapidly spreading erythema, swelling, tenderness, and warmth of the eyelid and periorbital tissues 2
- Eyelid edema that may be severe enough to cause the eye to be swollen shut 3
- Usually unilateral presentation 3
- Skin surface may appear dimpled like an orange peel (peau d'orange) due to superficial cutaneous edema 2
- Vesicles, bullae, and cutaneous hemorrhage (petechiae or ecchymoses) may develop in some cases 2
Systemic Manifestations
- Fever is common, especially in children 3
- Mild systemic symptoms including malaise 2
- In severe cases, tachycardia, confusion, and leukocytosis may be present 2
Important Distinguishing Features from Orbital Cellulitis
- Periorbital cellulitis is limited to tissues anterior to the orbital septum 1
- Absence of proptosis (bulging of the eye) 2
- No limitation of extraocular movements 2
- No visual impairment 2
- No pain with eye movement 4
Risk Factors and Etiology
- Upper respiratory tract infections (68% of periorbital cellulitis cases in children) 3
- Trauma to the eyelids (20% of cases) 3
- Sinusitis (particularly ethmoid sinusitis) is more commonly associated with orbital cellulitis (79%) but can lead to periorbital cellulitis 3, 2
- Age: periorbital cellulitis is more common in children under 5 years of age 3
- Skin conditions that disrupt the skin barrier 5
Diagnosis
Clinical Evaluation
- Careful assessment of visual acuity (if possible) 2
- Evaluation of extraocular movements 2
- Assessment for proptosis 2
- Examination of conjunctiva for injection and chemosis 2
- Testing of corneal sensation when appropriate 2
Laboratory Studies
- Complete blood count with differential (elevated white blood cell count may indicate more severe infection) 4
- Blood cultures (though often negative) 3
Imaging
- CT scan with contrast is the most useful imaging modality when orbital involvement is suspected 2
- Helps differentiate between preseptal (periorbital) and postseptal (orbital) cellulitis 2
- Can identify underlying sinusitis and potential complications 2
- MRI may be considered if intracranial complications are suspected 2
Treatment
Antibiotic Therapy
- For mild periorbital cellulitis, oral antibiotics with coverage for streptococci and staphylococci may be sufficient 6
- Suitable oral options include amoxicillin-clavulanate, dicloxacillin, cephalexin, or clindamycin 2
- For moderate to severe cases, intravenous antibiotics are recommended 3
- Common IV regimens include ceftriaxone plus clindamycin to provide coverage against Streptococcus pneumoniae, Haemophilus influenzae, Streptococcus pyogenes, and anaerobes 6, 3
- Consider adding vancomycin if MRSA is suspected 6
Duration of Therapy
- Continue intravenous antibiotics until significant clinical improvement is observed 6
- Complete a total of 10-14 days of antibiotic therapy (IV followed by oral) 6
Supportive Measures
Surgical Intervention
- Rarely needed for uncomplicated periorbital cellulitis (only about 3-6% of cases) 3, 7
- May be necessary if there is progression despite antibiotic therapy or if abscess formation occurs 3
Monitoring and Follow-up
- Daily assessment of clinical status including visual function and eye movements 6
- Multidisciplinary approach involving pediatricians, ophthalmologists, and otorhinolaryngologists as needed 7
- Close follow-up to ensure complete resolution and detect potential recurrences 6
Potential Complications
- Progression to orbital cellulitis 1
- Visual impairment if infection extends into the orbit 6
- Intracranial complications including cavernous sinus thrombosis, meningitis, or brain abscess in untreated or inadequately treated cases 6