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14.9 Orbital Cellulitis

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Orbital cellulitis is an infection of the soft tissues of the orbit posterior to the orbital septum. It may be a continuum of preseptal cellulitis, which is an infection of the soft tissue of the eyelids and periocular region anterior to the orbital septum. Orbital cellulitis may result from an extension of an infection from the paranasal sinuses or other periorbital structures such as the face, globe, or lacrimal sac, direct inoculation of the orbit from trauma or surgery or as a haematogenous spread from bacteremia

Diagnostic Criteria

  • Fever, malaise, and a history of recent sinusitis or upper respiratory tract infection
  • Proptosis and ophthalmoplegia are the cardinal signs of orbital cellulitis.
  • Conjunctival chemosis, dyschromatopsia, and relative afferent pupillary defect
  • Decreased vision
  • Elevated intraocular pressure
  • Pain on eye movement
  • Orbital pain and tenderness: are present early
  • Swollen eyelids, chemosis, hyperemia of the conjunctiva, and resistance to retropulsion of the globe may be present
  • Purulent nasal discharge may be present
  • For very ill children, vision may difficult to evaluate in very ill children with marked edema

Investigations

  • Full Blood Count and ESR
  • Blood culture
  • Assessment of purulent nasal discharge or from the abscess (Swab for Gram Stain)
  • CT Scan with Contrast and MRI will help differentiating it with other diseases but also identifying the source or extension of the disease

Non-Pharmacological Treatment

  • Patients must be hospitalised
  • Adequate hydration
  • Lower the temperature
  • Daily evaluation and monitor the vital signs
  • Management of orbital cellulitis is done with consultation from other medical team (Neurosurgical (if brain extension is seen), ENT (for involvement of sinuses), Paediatrician (for paediatric patients) and Physicians

Pharmacological Treatment

The antibiotic will be tailored when the laboratory results are out

Adults, give:

B: Ampiclox 1 gm IV stat then 500 mg 6 hourly for 2 weeks

AND

A: Gentamicin 160 mg IV once a day for 7 days

AND

B: Metronidazole 500 mg IV 8 hourly for 7 days

OR

D: Cefutaxime 1–2 gm IV once a day for 7–10 days

AND

D: Vancomycin 15–20 mg/kg IV 8–12 hourly

 

Children more than one month old give:

B: Ampiclox 50 mg /kg IV 8 hourly for 7–14 days

AND

A: Gentamicin 7.5 mg/kg IV, once a day for 5 -7 days

AND

B: Metronidazole 7.5–15 mg/kg IV 6hourly for 7–10 days

OR

D: Cefotaxime 50 mg/kg IV once a day for 7–10 days

AND

D: Vancomycin 10 mg/kg IV 6 hourly for 7–10 day

Note: Individual dose not to exceed 1 gm

 

Children less or equal to one month old give:

B: Ampiclox 25–50 mg/kg IV 8hourly for 7–14 days

AND

A: Gentamicin 5 mg/kg IV once a day for 5–7 days

 

Steroidal anti – inflammatory medicines

To be given after 48 hours of antibiotic therapy. Give:

B: Prednisolone 1–2 mg /kg (PO) once a day to be tapered slowly.

 

Analgesics/non-steroidal anti-inflammatory medicines

Adults:

A: Ibuprofen tablets 400–800 mg (PO) 6–8hourly; not to exceed 3.2 g/day

OR

A: Paracetamol 1 gm 4–6 hourly (PO) to a maximum of 4 doses per 24 hours, for 3 days

Children:

A: Ibuprofen tablets 30–40mg/kg per day (PO) in 3–4 doses

OR

A: Paracetamol 10–14 mg/kg for 3 days

Note: Do not use Ibuprofen in patients with bleeding disorders or peptic ulcers

Surgical Treatment

Surgical drainage is only indicated when there is:

  • A decrease in vision
  • Development of an afferent pupillary defect
  • Progression of Proptosis despite appropriate antibiotic therapy
  • The size of the abscess does not reduce on CT scan within 48–72 hours after appropriate antibiotics have been administered
  • If brain abscesses develop and do not respond to antibiotic therapy, then craniotomy is indicated
  • Presence of a drainable fluid collection is evident on CT scan in patients older than 16 years

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