Orbital cellulitis is caused by an infection of the orbital structures posterior to the orbital septum.1 Patients may develop significant ophthalmic and systemic morbidity with rare, life-threatening sequelae such as cavernous sinus thrombosis and septicemia.1,2 In the literature, the mean age at presentation for pediatric orbital cellulitis and subperiosteal abscess is approximately 7 years.2,3
Etiopathologically, pediatric orbital cellulitis occurs by either the contiguous spread of infection from the adjacent structures (ie, paranasal sinuses, eyelid, lacrimal sac [dacryocystitis], and teeth) or distant exogenous or endogenous sources.1–7 Pediatric orbital cellulitis has been reported to occur in 3% to 4% of children with acute rhinosinusitis.2 More than 90% of patients with pediatric orbital cellulitis have radiologically confirmed paranasal sinusitis, with ethmoidal and maxillary being most common.1–8 The medial orbital wall is thin (lamina papyracea) and porous, which may explain the spread of infection from the ethmoid sinuses to the orbit or subperiosteal space.1,3,4 Furthermore, a valveless venous system of Breschet may also help in this mode of spread.4,7
Computed tomography (CT) is considered the investigative procedure of choice to diagnose an orbital or subperiosteal abscess, mucosal hypertrophy of the paranasal sinuses, or intracranial involvement. CT scan results influence and direct the treatment and surgical intervention plans.1,3,4,9 Systemic broad-spectrum antibiotics with or without steroids have been recently promoted as the medical management of choice, after obtaining adequate blood cultures. The culture positivity rate ranges from 61.5% to 68.8%, whereas similar organisms were detected from other culture sites in 46% of patients.2–6 Garcia and Harris10 used intravenous broad-spectrum antibiotics in 29 children diagnosed as having orbital subperiosteal abscess, with resolution in 27 (93.1%) patients.
Overall, the management of pediatric orbital cellulitis requires a multidisciplinary approach involving ophthalmologists, otolaryngologists, pediatricians, microbiologists, and, on occasion, neurologists. The surgical management of pediatric orbital cellulitis is influenced by various local and systemic factors, including visual status, size and location of the orbital abscess, subperiosteal abscess, sinuses involved, presumed pathogens, anticipated bacterial response, and intracranial complications.3,4,7,9,11 Thus, worsening of visual acuity, deterioration of pupillary changes, poor response to antibiotics, and evidence of a large abscess (> 10 mm diameter) are considered important indications for surgery.12,13 Ryan et al.9 found that older patients (> 8 years) and larger (> 10 mm) abscesses required frequent surgical interventions.
Nasal endoscopic drainage of an orbital abscess has been shown to provide an early and more effective treatment along with the management of paranasal sinusitis.11–15 Functional endoscopic sinus surgery is more effective for the treatment of subperiosteal abscess and orbital abscess secondary to paranasal sinusitis.11–14 The advantages of functional endoscopic sinus surgery are the avoidance of external ethmoidectomy and associated external facial scar, benefit of early drainage, and quicker recovery for the patient. In the current study, we discuss the clinical profile and the multidisciplinary management outcomes in children treated for pediatric orbital cellulitis.
Patients and Methods
This prospective study was conducted after obtaining permission from the institute's ethics committee, and the study followed the tenets of the Declaration of Helsinki. We enrolled children diagnosed as having orbital cellulitis who presented to the Post Graduate Institute of Medical Education and Research, Chandigarh, India, between July 2016 and September 2017 (ie, 15 months). The departments of ophthalmology, otolaryngology, pediatrics, radiology, and microbiology were involved in our study.
A detailed history and thorough clinical examination of all enrolled children was performed. Patient demographics, the onset of symptoms, duration of complaints, constitutional symptoms, history of upper respiratory tract infection, impetigo, dental infections, and trauma and ocular surgery in addition to past treatments were specifically noted. The detailed ophthalmic examination included best corrected visual acuity (BCVA), pupillary reactions (direct, consensual, and relative afferent pupillary defect), eyelid edema, conjunctival chemosis, proptosis, extraocular movements, detailed anterior segment examination (corneal ulcer, exposure keratopathy), and posterior segment examination with an indirect ophthalmoscope.
All patients were classified according to Chandler's classification of orbital cellulitis.16 Patients with orbital cellulitis grade 2 (orbital inflammation), grade 3 (subperiosteal abscess), grade 4 (orbital abscess), and grade 5 (cavernous sinus thrombosis) were included in our study. Children presenting with other urgent orbital conditions (orbital tumors or other orbital inflammatory diseases), previous surgeries for the same complaints, and children who were not cooperative for the visual assessment were excluded from the study. Extraocular movements were evaluated with an ocular motility grading system: grade 0 (no restriction of ocular movements), grade 1 (mild restriction, 25% deficit), grade 2 (moderate restriction, 50% deficit), and grade 3 (severe restriction, ≥ 75% deficit).17 The blood investigations (hemoglobin, total leukocyte count, differential leukocyte count, erythrocyte sedimentation rate, and blood culture) and conjunctival swabs were sent for microbial culture and sensitivity. Pus and inflammatory exudates were examined by Gram staining and KOH test, and were cultured on blood agar, chocolate agar, and Sabouraud's dextrose agar.
CT scans of the orbits and paranasal sinuses were requested for all patients. All children underwent otolaryngologic and pediatric consultations. CT or other orbital imaging (magnetic resonance imaging) findings were also noted. All patients were admitted to our hospital and were treated with intravenous broad-spectrum antibiotics, covering both Gram-positive and Gram-negative bacteria. Intravenous ceftriaxone (50 to 75 mg/kg/day in two divided doses), amikacin (15 to 22.5 mg/kg/day in two to three divided doses), and metronidazole (30 mg/kg/day in three divided doses) were administered for a minimum of 7 days. The antibiotics were modified according to the microbiological culture and sensitivity reports.
When an orbital abscess or subperiosteal abscess was detected on radiology (CT), surgical intervention (in the form of abscess drainage via an external or nasal endoscopic route with or without functional endoscopic sinus surgery) was performed, depending on the location of the abscess. The drained discharge was sent for culture and sensitivity, and the treatment was modified accordingly. Broad-spectrum intravenous antibiotics were continued until complete clinical resolution of the disease. The constitutional signs and ophthalmic features were observed every 6 to 8 hours during admission. The visual acuity, inflammatory signs, conjunctival chemosis, extraocular movements, pupillary reactions, and proptosis were assessed on a daily basis from days 1 to 7, followed by days 14, 21, and 30 after starting the treatment.
A minimum follow-up of 12 months was noted in all patients. The main outcome features observed were visual acuity, pupillary reaction, extraocular movements, and proptosis. We defined “complete success” if a complete recovery was shown for all four criteria without any functional (visual acuity, pupillary reactions, and extraocular movements) or anatomical (proptosis) sequelae or dysfunction. “Partial success” was defined as a final visual acuity of better than 0.6 logarithm of the minimum angle of resolution (logMAR), no proptosis, and/or mild persistent limitation of extraocular movements. “Failure” was defined as a final visual acuity of worse than 1.0 logMAR, relative afferent pupillary defect, severe limitation of extraocular movements, significant proptosis, or any permanent sequelae or complication.
A total of 40 children with a mean age of 7.5 years (range: 4 to 12 years) were included in the study (Figures 1–3). All of the children had unilateral involvement, with a mean duration of symptoms of 3 days (range: 2 to 7 days). A distinctive male preponderance (n = 28, 70%) was noted. The patients' presenting features are listed in Table 1. The BCVA was better than 0.8 logMAR in 22 (55%) and 1.0 logMAR or worse in 18 (45%) children. Twelve (30%) children received oral antibiotics before presenting to our institute.
(A) A 5-year-old boy with complete blepharoptosis, eyelid erythema and edema, and fullness of orbital sulci with proptosis. (B) On lifting the eyelid, the conjunctiva showed congestion and chemosis with restricted elevation and inferior dystopia. (C) The computed tomography scan (coronal sections) showed florid ethmoid sinusitis and superior subperiosteal abscess. (D) Intraoperative endoscopic view of functional endoscopic sinus surgery with subperiosteal abscess drainage. (E) At 6 months of follow-up, the orbital cellulitis appeared resolved with restriction of elevation (anatomical failure).
(A) A 3-year-old boy with right eyelid edema, erythema, blepharoptosis, conjunctival congestion and chemosis, restricted ocular movements, inferior dystopia, and proptosis. The left upper eyelid showed mild spillover edema. (B) The coronal section of the computed tomography scan showed ethmoid sinusitis with right superomedial subperiosteal abscess. (C) At the 4-month follow-up after functional endoscopic sinus surgery, the patient showed complete recovery.
(A) A 3-year-old boy recovering from left orbital cellulitis with medical treatment, and left adduction. (B) Computed tomography scans of the orbits (coronal sections) showed left pan-sinusitis (black arrow) with orbital inflammation and soft-tissue stranding. (C) A 7-year-old boy recovering from right orbital cellulitis with mild extraocular movement limitation. (D) Computed tomography scans of orbits (coronal sections) showed right ethmoid sinusitis with medial subperiosteal abscess (black arrow) managed with endoscopic drainage and functional endoscopic sinus surgery.
Presenting Clinical Features of 40 Children With Orbital Cellulitis
The laboratory work-up showed an elevated total leukocyte count and erythrocyte sedimentation rate in 36 (90%) and 32 (80%) patients, respectively. The conjunctival swabs showed growth (n = 5) of Staphylococcus aureus, whereas the blood culture was positive (n = 6) for Streptococcus pneumoniae in 4 (10%) and Staphylococcus aureus in 2 (5%) children.
CT scans of the orbits and paranasal sinuses were requested for all children and 6 children underwent additional magnetic resonance imaging, as indicated by the pediatricians to analyze the posterior spread of infection. On imaging, preseptal soft tissue inflammation was observed in all 40 (100%) children, orbital fat stranding in 38 (95%) children, orbital abscess in 15 (37.5%) children, and subperiosteal abscess in 8 (20%) (Figures 1C, 2B, 3B, and 3D). None had features suggestive of cavernous sinus thrombosis at presentation. Paranasal sinusitis (n = 30, 75%) was the most common predisposing factor, followed by eyelid furuncle (n = 6, 15%), ophthalmic trauma (n = 2, 5%), and dental infection (n = 2, 5%). Additional orbital imaging findings are listed in Table 2.
Radiological Features of Study Patients
All children were admitted and conjunctival swabs and blood cultures were requested. All patients received intravenous ceftriaxone, amikacin, and metronidazole as per the doses mentioned above. Oral steroids (1mg/kg/day) were added on the third day of intravenous antibiotics in all patients. The average duration of the hospital stay was 9 days. The children who showed worsening visual acuity, pupillary reactions, restriction of extraocular movements, and/or increasing proptosis after 48 hours of intravenous antibiotics were considered for surgical intervention. The final decision to operate on a patient was made by combined consultation between pediatricians, ophthalmologists, radiologists, and otolaryngology surgeons. None of the children required surgical intervention for deterioration.
Of 40 children, 23 required surgical drainage of orbital abscesses and 17 were treated with medication (Figures 3A–3B). The oculoplastics surgeons drained the orbital (n = 12) and subperiosteal (n = 5) abscesses via an external transcutaneous route. The corrugated rubber drain was used in all procedures. The otolaryngology surgeons used the nasal endoscopic route for draining the orbital and subperiosteal abscess in 3 patients. A combined or additional functional endoscopic sinus surgery was performed to clear the causative obstructive sinusitis in 10 children (Figure 1). We did not find a significant difference in recovery time or overall ophthalmic outcome between external and endonasal drainage. The drained pus (exudates) from the external or endoscopic drainage yielded a positive culture for Streptococcus pyogenes (n = 4), Staphylococcus aureus (n = 3), and methicillin-resistant Staphylococcus aureus (n = 2).
At a mean follow-up of 15 months, 32 (80%) patients showed complete anatomical (proptosis) and functional (visual acuity, pupillary reactions, and extraocular movements) recovery, whereas 4 (10%) patients had partial improvement. The remaining 4 patients developed optic atrophy, relative afferent pupillary defect, restrictive strabismus, and exposure keratopathy. Accordingly, the BCVA improved in 32 patients, remained stable in 4 patients, and deteriorated in 4 patients. The “delayed response to treatment” (ie, more bacterial load and virulence of the organism) can be attributed to causing deterioration of vision. The relative afferent pupillary defect persisted in 2 (5%) patients. Patients who responded to the medical or surgical treatment showed maximal recovery in the first 4 weeks. There was no statistical difference in the outcomes of the 12 children who received oral antibiotics before admission to our hospital.
Our prospective analysis of the disease profile and long-term ophthalmic outcomes in patients with pediatric orbital cellulitis after multidisciplinary management provides evidence based on the anatomical and functional ophthalmic parameters. We found paranasal sinusitis to be a causative factor in 75% of children, which is also supported in the published literature as the most common (80%) predisposing factor for bacterial pediatric orbital cellulitis.11,17,18 Additionally, we found eyelid furuncle and ophthalmic injury as etiologies in 15% and 5% of patients, respectively.
In the current study, the Gram-positive cocci (Staphylococcus aureus [n = 5] and Streptococcus pyogenes [n = 4]) were the most commonly isolated organisms, which is in agreement with the published reports.6,7,17,18 Moreover, in the literature, patients older than 15 years have complex infections caused by multiple aerobic and anaerobic organisms that are slow to clear despite medical and surgical interventions.6,19 An Indian population study by Suneetha et al.20 showed a culture positivity rate of 68.8% in patients with orbital cellulitis. The organism-yield in our study was comparatively less (39%), which can be attributed to the administration of oral antibiotics by the previous treating physicians before referring the patients to our tertiary care institute.21
Ferguson and McNab22 reported the orbital CT imaging findings in pediatric orbital cellulitis as inflammatory changes in 29% of patients, subperiosteal abscesses in 62% of patients, and orbital abscesses in 9% of patients. In our study, the majority of patients (39 of 40) had inflammatory fat stranding of orbital tissues, whereas 19 patients (14 orbital, 5 subperiosteal abscesses) had localized orbital abscesses that were surgically drained. In the literature, radiologically confirmed sinusitis (ethmoidal and maxillary) was noted in more than 90% of patients with pediatric orbital cellulitis.10,11 We found paranasal sinus involvement in 75% of the children.
All patients were treated with planned intravenous antibiotics, and vancomycin or other antibiotics were administered based on the sensitivity pattern. Surgical intervention was required in 57.5% of our patients, which is in concurrence with the reports of McKinley et al.5 (60%) and Ferguson and McNab22 (69%). The need for surgical intervention and its appropriate timing is one of the difficult assessments in the management of pediatric orbital cellulitis. In our evidence-based opinion, a progressive diminution of visual acuity, new or deteriorating relative afferent pupillary defect, limitation of extraocular movements, and worsening of proptosis are clinical indicators of the need for early surgical intervention.
Approximately 74% to 85% of orbital complications arise from acute sinusitis more often in the pediatric population, which may result in devastating consequences.15,16 In the current study, 4 (10%) children developed complications or sequelae of pediatric orbital cellulitis in the form of optic atrophy, corneal opacity, and restrictive strabismus. Thus, a prompt diagnosis, multidisciplinary consultation, and appropriate treatment remain crucial in overall management. The strength of our study is its prospective design, single-institute, multispecialty approach, and holistic management of pediatric orbital cellulitis. A small sample size and lack of control group are the main limitations of our study.
Pediatric orbital cellulitis is a potential sight-threatening infection requiring careful examination, appropriate radiology, and multidisciplinary management. The clinical features at presentation, hospital admission, and broad-spectrum intravenous antibiotics are essential for better ophthalmic outcomes. Any clinical deterioration during treatment and radiological evidence of orbital or subperiosteal abscess warrants surgical intervention. Therefore, the ophthalmology, pediatric, otolaryngology, radiology, and microbiology departments play crucial roles in the proper treatment of the child.
- Jain A, Rubin PA. Orbital cellulitis in children. Int Ophthalmol Clin. 2001;41:71–86. doi:10.1097/00004397-200110000-00009 [CrossRef]11698739
- Torretta S, Guastella C, Marchisio P, et al. Sinonasal-related orbital infections in children: a clinical and therapeutic overview. J Clin Med. 2019;8:E101. doi:10.3390/jcm8010101 [CrossRef]30654566
- Crosbie RA, Nairn J, Kubba H. Management of paediatric periorbital cellulitis: our experience of 243 children managed according to a standardised protocol 2012–2015. Int J Pediatr Otorhinolaryngol. 2016;87:134–138. doi:10.1016/j.ijporl.2016.06.025 [CrossRef]27368460
- Wong SJ, Levi J. Management of pediatric orbital cellulitis: a systematic review. Int J Pediatr Otorhinolaryngol. 2018;110:123–129. doi:10.1016/j.ijporl.2018.05.006 [CrossRef]29859573
- McKinley SH, Yen MT, Miller AM, Yen KG. Microbiology of pediatric orbital cellulitis. Am J Ophthalmol. 2007;144:497–501. doi:10.1016/j.ajo.2007.04.049 [CrossRef]17698020
- Seltz LB, Smith J, Durairaj VD, Enzenauer R, Todd J. Microbiology and antibiotic management of orbital cellulitis. Pediatrics. 2011;127:e566–e572. doi:10.1542/peds.2010-2117 [CrossRef]21321025
- Tunkel DE. Drainage of subperiosteal orbital abscess in children. In: Kennedy D, ed. Master Techniques in Otolaryngology Head and Neck Surgery: Rhinology. Philadelphia: Wolters Kluwer; 2015:287–298.
- Gonçalves R, Menezes C, Machado R, Ribeiro I, Lemos JA. Periorbital cellulitis in children: analysis of outcome of intravenous antibiotic therapy. Orbit. 2016;35:175–180. doi:10.1080/01676830.2016.1176205 [CrossRef]27192038
- Ryan JT, Preciado DA, Bauman N, et al. Management of pediatric orbital cellulitis in patients with radiographic findings of subperiosteal abscess. Otolaryngol Head Neck Surg. 2009;140:907–911. doi:10.1016/j.otohns.2009.02.014 [CrossRef]19467413
- Garcia GH, Harris GJ. Criteria for nonsurgical management of subperiosteal abscess of the orbit: analysis of outcomes 1988–1998. Ophthalmology. 2000;107:1454–1456. doi:10.1016/S0161-6420(00)00242-6 [CrossRef]
- Todman MS, Enzer YR. Medical management versus surgical intervention of pediatric orbital cellulitis: the importance of subperiosteal abscess volume as a new criterion. Ophthalmic Plast Reconstr Surg. 2011;27:255–259. doi:10.1097/IOP.0b013e3182082b17 [CrossRef]21415801
- Starkey CR, Steele RW. Medical management of orbital cellulitis. Pediatr Infect Dis J. 2001;20:1002–1005. doi:10.1097/00006454-200110000-00017 [CrossRef]11642617
- Le TD, Liu ES, Adatia FA, Buncic JR, Blaser S. The effect of adding orbital computed tomography findings to the Chandler criteria for classifying pediatric orbital cellulitis in predicting which patients will require surgical intervention. J AAPOS. 2014;18:271–277. doi:10.1016/j.jaapos.2014.01.015 [CrossRef]24924283
- Rahbar R, Robson CD, Petersen RA, et al. Management of orbital subperiosteal abscess in children. Arch Otolaryngol Head Neck Surg. 2001;127:281–286. doi:10.1001/archotol.127.3.281 [CrossRef]11255472
- Huang SF, Lee TJ, Lee YS, et al. Acute rhinosinusitis related orbital infection in pediatric patients: a retrospective analysis. Ann Otol Rhinol Laryngol. 2011;120:185–190. doi:10.1177/000348941112000307 [CrossRef]21510144
- Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of orbital complications in acute sinusitis. Laryngoscope. 1970;80:1414–1428. doi:10.1288/00005537-197009000-00007 [CrossRef]5470225
- O'Flynn EA. Strabismus documentation: an alternative approach. Ophthalmic Literature. 1995;48:132.
- Meara DJ. Sinonasal disease and orbital cellulitis in children. Oral Maxillofac Surg Clin North Am. 2012;24:487–496. doi:10.1016/j.coms.2012.05.002 [CrossRef]22857719
- Weiss A, Friendly D, Eglin K, Chang M, Gold B. Bacterial periorbital and orbital cellulitis in childhood. Ophthalmology. 1983;90:195–203. doi:10.1016/S0161-6420(83)34573-5 [CrossRef]6866441
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- Pandian DG, Babu RK, Chaitra A, et al. Nine years' review on preseptal and orbital cellulitis and emergence of community acquired methicillin-resistant Staphylococcus aureus in a tertiary hospital in India. Indian J Ophthalmol. 2011;59:431–435. doi:10.4103/0301-4738.86309 [CrossRef]22011486
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Presenting Clinical Features of 40 Children With Orbital Cellulitis
|Feature||No. of Patients||Percentage|
|Eyelid edema, diminution of vision, conjunctival congestion, conjunctival chemosis||40||100%|
|Restriction of extraocular movements, pain||36||90%|
|Relative afferent pupillary defect||16||40%|
|Exposure keratopathy, optic disc edema||6||15%|
Radiological Features of Study Patients
|Feature||No. of Patients||Percentage|
| Ethmoid sinus||10||25%|
| Ethmoid and sphenoid||4||10%|
| Ethmoid and maxillary||4||10%|