What is the recommended management for orbital cellulitis?

Management of Orbital Cellulitis

Orbital cellulitis requires immediate hospitalization with intravenous broad-spectrum antibiotics, urgent contrast-enhanced CT imaging, and emergent ophthalmology consultation to prevent vision-threatening and life-threatening complications. 1, 2

Immediate Diagnostic Workup

Obtain CT orbits and paranasal sinuses with IV contrast immediately as the initial imaging modality of choice in the emergent setting. 3, 1, 2 This effectively evaluates:

• Bone erosion and sinus involvement 1
• Subperiosteal or orbital abscess formation 1, 2
• Intracranial extension 1, 2
• Frontal bone osteomyelitis (Pott's puffy tumor) 1
• Superior ophthalmic vein thrombosis or cavernous sinus thrombosis 2, 4

Add MRI of the brain and orbits with and without contrast if intracranial complications are suspected, as MRI provides superior soft-tissue resolution for detecting epidural abscess, subdural abscess, brain abscess, venous thrombosis, or meningitis. 3, 1, 2

Critical pitfall: Never obtain plain radiographs—they are insufficient to detect orbital pathology and have been supplanted by CT. 3, 1

Immediate Antibiotic Therapy

Start IV vancomycin immediately to cover methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant Staphylococcus pneumoniae. 1, 2

Combine vancomycin with a third-generation cephalosporin (ceftriaxone or cefotaxime) for comprehensive coverage of typical pathogens including Streptococcus pneumoniae, Haemophilus influenzae, Streptococcus pyogenes, Moraxella species, and anaerobic bacteria. 1, 2

Tailor antibiotics once culture and sensitivity results become available. 1

Critical pitfall: Never use oral antibiotics alone for orbital cellulitis—IV therapy is mandatory. 1

Essential Specialist Consultations

Obtain ophthalmology consultation immediately to assess visual acuity, extraocular movements, pupillary response, and monitor for vision-threatening complications. 1, 2

Consult otolaryngology urgently for guidance regarding surgical intervention, particularly if subperiosteal or orbital abscess is identified on imaging. 1, 2

Request infectious disease consultation for antimicrobial selection and management. 1

Obtain neurosurgical consultation urgently if there is frontal bone tenderness (concern for Pott's puffy tumor), altered mental status, severe headache, or imaging evidence of intracranial extension. 1, 5

Surgical Intervention Criteria

Surgical drainage is indicated if:

• Imaging reveals subperiosteal abscess or orbital abscess 1, 6
• Patient fails to improve within 24-48 hours on IV antibiotics 1, 2
• Loss of vision, unresponsive pupil, or densely packed orbit are present—these require immediate surgical drainage 6
• Frontal bone osteomyelitis is confirmed and may require surgical debridement 1

The decision for surgical drainage should be based on clinical findings rather than classification systems alone. 6

Monitoring Protocol

Perform daily assessment of:

• Visual acuity and visual fields 2
• Extraocular movements and ophthalmoplegia 2
• Pupillary response 6
• Proptosis progression 7, 8
• Signs of intracranial extension including altered mental status, severe headache, or neurologic deficits 1, 5

Reassess response to therapy within 24-48 hours—lack of improvement warrants repeat imaging and consideration for surgical intervention. 1, 2

Critical Pitfalls to Avoid

Never attempt outpatient management when proptosis, impaired extraocular movements, or severe periorbital pain and swelling are present. 1

Do not delay imaging while waiting for specialist consultation when intracranial complications are suspected. 1

Do not assume bilateral periorbital swelling is always cellulitis—consider venous congestion from cavernous sinus thrombosis, which requires immediate vascular imaging. 4

Recognize that point-of-care ultrasound cannot exclude intracranial extension of infection, despite its utility in differentiating preseptal from orbital cellulitis. 7

Understanding the Etiology

Orbital cellulitis is most commonly a complication of ethmoid sinusitis (45% of cases in children), particularly in patients younger than 5 years. 2 Other causes include trauma, orbital foreign bodies, dental infections, and hematogenous spread. 9, 8 The infection spreads through the thin medial orbital wall, orbital foramina, and valveless veins connecting the sinuses to the orbit. 8

Potential Complications Without Aggressive Management

Complications can include permanent vision loss, meningitis, intracranial abscess, cavernous sinus thrombosis, optic neuritis, central retinal artery occlusion, exposure keratopathy, and death. 1, 9, 8, 5 Fatal cases with intracranial extension have been reported, emphasizing the critical nature of early recognition and aggressive treatment. 5