An evidence based review of Periorbital Cellulitis

Baring, D.E.C. & Hilmi, O.J.

ENT Department, 16 Alexandra Parade, Glasgow Royal inrmary, Glasgow Royal Inrmary, Glasgow, UK
Accepted for publication 7 January 2011 Clin. Otolaryngol. 2011, 36, 5764

EMERGENCY ORL: CONTROVERSIES IN MANAGEMENT

Dear Editor, Sepsis in and around the eye is a common problem which can lead to devastating morbidity or mortality from uncontrolled disease, with blindness or intracranial infection being well documented.1,2 The purpose of this paper is to review the literature surrounding this problem, establish current UK practice and discuss the areas of controversy and their related evidence. There is some difculty reviewing the literature relating to eye sepsis due to the wide variety of interchangeable terminology used. The basic pathology of eye sepsis can be divided by its relation to the orbital septum. Disease anterior of the septum is pre-septal whilst disease posterior is post-septal. The main distinction between these is that, while pre-septal disease can expand in an unrestricted manner anteriorly, post-septal disease is conned to a rigid box made up of the bony orbit and the orbital septum. Uncontrolled swelling within this box leads to a rise in pressure, effectively an orbital compartment syndrome, causing stretch and ischaemia of the optic nerve which if not rapidly relieved leads to blindness. Other mechanisms of visual insult are described including, corneal exposure by proptosis, raised intraocular pressure and vascular events.3 All these events can occur over a few hours leading to blindness.1 The commonest cause of post-septal infection is from sinusitis with infection spreading into the orbit from the adjacent sinus (usually the ethmoids via the lamina papyracea). Pre-septal disease is generally caused by non-sinus problems such as trauma, insect bites and dacrocystitis. Pre-septal disease rarely extends into the orbit, with only a minority of dacrocystitis cases reported to do this.4 The venous drainage pathway of the orbit is into the cavernous sinus and propagation of infection from orbital sepsis can cause cavernous sinus thrombosis.

Inspection of the Scottish admission data 19972005 for orbital sepsis (including both pre- and post-septal disease) show that the largest group of patients is formed by children aged <10 years (Fig. 1). Chandler classied orbital disease into ve categories (not representing progressive stages):5 (Fig. 2) 1 Pre-septal disease = eyelid swelling without proptosis, ophthalmoplegia or loss of vision. 2 Orbital cellulitis = inammation of the orbital fat. 3 Subperiosteal abscess = pus collection elevating the periosteum off the bony orbit. 4 Orbital abscess = pus collection within the orbit. 5 Cavernous sinus thrombosis. The clinical distinction between Type 1 (pre-septal) and the rest (post-septal) is the presence of proptosis, ophthalmoplegia and loss of vision (Type 5 can have bilateral problems). It should be borne in mind that this can be very difcult to dene on clinical grounds alone. A variety of protocols suggesting management strategies for peri-orbital infections have been published. Howe and Jones describe the current standard practice in UK.6 While Sobol et al.7 discuss their approach in Canada.
Methods

Correspondence: David Baring, ENT Department, 16 Alexandra Parade, Glasgow Royal inrmary, Glasgow G31 2ER, UK. Fax: 01412111671; e-mail:davidbaring@hotmail.com 2011 Blackwell Publishing Ltd Clinical Otolaryngology 36, 5764

A literature review was conducted in April 2010 using Medline and the search terms Orbital cellulitis, Periorbital cellulitis, Subperiosteal abscess limited to English language and 1990-present day as a starting point. Further papers were identied on reading the initial results of the search. Abstracts of 413 papers were initially identied and 52 selected as relevant to the subject. These comprised of case series, review articles and case reports. There were no prospective randomised controlled trials identied and the case series comparing management were all retrospective. Our proposed care pathway based on these works is presented in Fig. 3 with areas of controversy highlighted and a standard checklist for ensuring appropriate management is not missed. These areas will be discussed in detail in the remainder of the article.
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cultures had a low yield throughout.9,1115 The results of cultures in these series are summarised in Table 1.
Keypoints on baseline investigations

Base line investigations are just that and do not alter the initial management of the condition.

II Medical management
Fig. 1. Age of admissions with orbital sepsis (Scotland 1997 2005).

All patients should commence medical management on the suspicion of peri-orbital cellulitis without delaying treatment whilst investigations are being organised.
Antibiotics

Pre-septal

Type 1

Type 2

Type 3

Type 4

Post-septal

Key

Globe Cellulitis (no Pus) Pus

Fig. 2. Chandler classication.

Areas of Controversy I Baseline investigations

Blood tests. Full blood count, erythrocyte sedimentation rate (ESR), C reactive protein (CRP) are routinely taken for a baseline analysis. Orbital cellulitis in children tends to have a higher WCC than preseptal disease.8 It should be noted 50% of adult patients in one series had no elevation of their white cell count.9 Cultures. Blood cultures are reported in many series. The results are positive 33% of the time at best (in children under 5 years),10 however most series have very low results for positive blood cultures overall 2.76%.11,12 Swabs can be taken from the eyes (pre-septal) and nose (sinugenic). However some reports do not advocate this due to the risk of misleading results with culture of commensal organisms.6 Review of case series who took samples from a variety of routes in a mixed population (adult, paediatric, pre and post-septal) shows surgical specimens to be the most likely to be positive, while swabbing mucosa was positive in half cases (however this is not subdivided into pre-septal post-septal) and blood

Whilst the role of antibiotics is not controversial there is discussion about the route of administration, type and duration. The potential complications of orbital infection are such that an aggressive approach is taken to the treatment of infection, intravenous broad spectrum antibiotics covering both Staphylococci and Streptococci are recommended for all but the mildest of pre-septal disease.16 Haemophilus inuenza is no longer represented to the same degree in the United Kingdom since the introduction of HiB vaccine but should be considered in susceptible individuals.14 Anaerobes form a signicant minority of cultures (24% orbital collections and 45% intracranial collections12) and consideration should be given to ensuring cover from outset.6 One study was identied which advocated the use of oral clindamycin and ciprooxacin reporting satisfactory outcomes in a retrospective comparison with a similar cohort previously treated with intra-venous antibiotics.17 It is worth noting this study was an Ophthalmology study and had hourly eye observations as part of their protocol and as such may not be widely applicable. Studies from North America have advocated prolonged courses of antibiotic with 3 weeks being suggested for orbital complications of sinusitis.16,18 However, most series have no didactic limit on length of treatment with clinical judgement being the decisive factor.
Keypoints on Medical Management

Route of administration Intravenous. Type Based on local infection prole and sensitivity (Seek Microbiology advice). Duration At least 7 days depending upon clinical improvement.

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Patient identified with peri-orbital infection

I. Baseline investigations: Admission for in-patient treatment and assessment Bloods FBC, CRP Culture eye, nose, blood (>38.0 C) Assessment by ENT and opthalmology Nasal examination Visual examination Visual acuity Colour vision Pupil reactions Eye movements Visual/neurological disturbance Unable to assess patient No visual disturbance No neurological disturbance Stable, co-operative patient Fundoscopy

III. Imaging: contrast enhanced CT scan sinus + brain

II. Medical management: IV antibiotics as per local protocal Consider steroids

Sustained progressive improvement

No collection

Nasal decongestant 4 hourly neuro obs Daily ophthalmology review

Discharge once swelling resolved + pyrexia settled

Collection

IV. Surgical management: Collection drained via Endoscopic if purely medial orbit and feasible External/combined approach in all other cases
Consider medical management of small medial SPA in the young if regular assessment possible

Failure to improve despite optimal management (2448 h)

Complete course of antibiotics + follow up 46 weeks

Consider further medical treatment versus surgical decompression/sinus washout if not settling/visual comprimise

Intracranial complication on scand/w neurosurgery

Checklist for notes:

Assessed by ENT Assessed by ophthalmology Start on IV antibiotics as per microbiology advice Start on topical decongestants Consider need for CT scan (with contrast sinuses + brain) Admit to ward Instructions given for observations + fasting (IVI)

Key
Discussed further in text Progressive disease Improving disease

Fig. 3. Care pathway for orbital sepsis.

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Table 1. Summary of the culture results of case series of orbital sepsis Surgical specimen (abscess sinus aspirate) 22 35 22 58 18 25 34 36 81 106 (76%)

Author McKinley
13

Number 38 101 27 13 52 104 335

Blood culture 2 27 2 88 0 13 NA 4 67 8 195 (4%)

Nasal swab 56 4 10 6 10 3 13 17 29 NA 35 68 (51%)

Eye swab 22 26 44 4 13 18 52 NA 50 111 (45%)

Bacteria Staph sp 22, Strep sp 13, Haemoph sp 3 Staph sp, strep sp, E. coli Staph sp = Strep sp Strep 4, Hi 2, Staph 1 Staph 18, Strep 15, nil 21, others 18 Strep 23, Staph 12, other 14

Uzcategui11 Robinson9 Aabideen14 Ferguson15 Oxford12 Total (%)

Steroids

Only one retrospective study was identied looking at the use of corticosteroids for orbital cellulitis with subperiosteal abscess in addition to the usual treatments. No signicant difference was identied between two small goups (n = 23) and no adverse outcomes were reported with the use of adjuvant corticosteroids.19
Keypoints

immediate scanning if post-septal disease cannot be excluded by bedside examination and a further interval scan (2436 h) in the event of failure to improve.20 The paediatric population can be non-compliant with formal vision assessment and as such require a lower threshold for scanning which might need to be done under general anaesthetic. In this situation there should be the ability to operatively intervene, if necessary, under the same anaesthetic. MRI. The main role for MRI is the evaluation of intracranial complications (e.g. cerebritis, cavernous sinus thrombosis).21 Its excellent soft tissue detail will distinguish pre-septal disease from post-septal disease but will not give the bony detail that CT provides. Because it is rarely available out of hours and takes signicantly longer than a CT to perform, its role in the acute management of orbital cellulitis is limited. Recently diffusion-weighted imaging has been described but its role is primarily in helping distinguish between the nonacute inammatory conditions of the orbit.22 USS. Kaplan et al.23 describe the use of a standardised orbital ultrasound technique that is well tolerated in children in sinugenic post-septal infection. CT scanning was inconclusive as to whether there was a collection in 4 7 in their series and ultrasound was diagnostic. Limitations of ultrasound include availability and operator-dependent expertise plus the inability to visualise the posterior 1 3 of the orbit. It may have a role in the equivocal case of post-septal disease in clarifying if there is a collection, however this may not alter subsequent management in the presence of normal vision where medical management is to be tried.

There is no evidence supporting the routine use of steroids in patients with orbital sepsis.

III Imaging
Choice of scan

CT. Contrast enhanced CT scanning of the brain and sinuses is the investigation of choice described in the current literature. It is best to be explicit with this and avoid generic terms such as CT head as this can lead to the wrong type and resolution of scanning missing subtle disease. The areas of controversy are when to perform the scan and should it be repeated. There are advocates of other imaging modalities and these will be discussed. In patients with a normal visual assessment it has been advocated that scanning should only be performed after a period of adequate medical treatment and failure to improve, whilst not delaying surgery waiting for a scan in the event of visual deterioration.6 Others would advocate

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Keypoints on imaging

CT scanning with contrast of the brain and sinuses is the gold standard investigation. If a general anaesthetic is needed for CT scanning arrangements should be made for surgical intervention under the same anaesthetic if required.

IV Management of subperiosteal abscess

Subperiosteal abscess represents type 3 disease as per the Chandler classication. There is extensive debate in the literature whether these should be managed medically or surgically.2427
Medical management

Proponents of medical management state that limited medially placed disease in the young population is likely to resolve with intravenous antibiotics and that early surgical intervention is unwarranted, can be cosmetically disguring and does not improve outcome. However more extensive disease involving the superior or lateral orbit, failure to improve on medical therapy in medial disease, or any deterioration in visual signs (acuity, colour vision, proptosis or ophthalmoplegia) should dictate surgical drainage. There are now a large number of reported series with medical management being used as the primary modality for post-septal disease.

Table 2 contains a heterogeneous mix of papers with differing age groups and selections of post-septal disease. Despite this limitation there is a case for medical management of some intra-orbital collections. Any deterioration of vision or of eye signs suggestive of progressive disease mandate prompt surgical intervention to drain any collection and decompress the orbit. Various situations are described suggesting a lower likelihood of success for medical treatment of intra-orbital collections: 1 Larger abscess (>10 mm)32 2 Non-medial subperiosteal abscess26 3 Intracranial disease also present34 4 Increasing age (>9 years),26 (>6 years)29,32 5 Proptosis >2 mm31 6 Gas in orbit17 7 Dental infection.17 If an attempt is made to treat disease with medical management it is vital resources are in place with ready access to ophthalmology review (2 hourly to once daily observations being suggested)6,24 and to surgical intervention in the event of visual compromise.
Keypoints on Management of Subperiosteal Abscess

There is evidence to support the medical management of Subperiosteal abscesses but only where facilities exist for close observations and rapid conversion to surgical management if required.

Table 2. Medical management of subperiosteal abscess of the orbit Name Botting et al.28 Cannon et al.17 Garcia and Harris26 Greenberg and Pollard29 Nargeswaran et al.18 Noel et al.30 Oxford and McClay12 Rahbar et al.31 Number post-septal 35 36 40 25 41 23 44 14 Conversion to surgery 8 35 14 36 13 40 12 25 29 41 3 23 24 44 9 14 Indications Visual disturbance not Visual disturbance not Visual disturbance not <9 years Visual disturbance not Visual disturbance not Visual disturbance not Visual disturbance not Visual disturbance not responding responding responding, responding responding responding responding responding Complications Nil at 3 12 Nil Nil 1 repeat drainage 1 12 Nil NA 1 ptosis post drainage 2 required repeat surgery for residual abscess NA Nil Nil Nil

Ryan et al.32 Sobol et al.7 Souliere et al.24 Yang et al.33 Total

70 12 10 20 370

23 70 8 12 5 10 13 20 161 370 (43%)

Visual Visual Visual Visual

disturbance not disturbance not disturbance not disturbance not

responding responding responding responding

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V Surgical management of orbital disease

Areas of controversy in the surgical management of subperiosteal abscess management are in the surgical approach and the use or not of drains.
External approach

The traditional approach to drainage of orbital collections is via a Lynch-Howarth incision with elevation of the orbital periosteum to expose the medial orbit and abscess cavity. The incision can be broken to help prevent webbing.6 A drainage passage from the medial orbit can be created by fracturing the lamina papyracea medially. Superior extension and elevation can be achieved by extending the incision and permits access to the superior orbit in the event of frontal sinus involvement. The main concern with this approach is that it necessitates a scar on the face, which although usually heals well with minimal cosmetic decit, can be complicated by disguring webbing.
Endoscopic approach

lachrymal apparatus and dissection onto the medial orbital wall in order to elevate the periosteum and access the abscess cavity.17,41 Exposure can be extended inferiorly by including an inferior fornix incision permitting access from the fronto-zygomatic suture laterally to the frontoethmoid suture.41 A similar approach can be taken to extend superiorly. The rationale behind this approach is to avoid a scar whilst ensuring adequate exposure of the abscess. Technical problems relate to prolapse of intraorbital fat obscuring the eld of view. One concern with approaching a subperiosteal abscess in this manner is that you need to breach the periorbitum with the potential for spread of infection into the orbital fat. The pterional approach involves removal of the lateral and superiolateral orbital walls to provide decompression of the orbital contents.42 This approach is not common practice for orbital sepsis.
Drains

Since the advent of endoscopic sinus surgery an alternative approach for the drainage of orbital collections, especially medial ones, has been advocated.3538 The extent of ethmoid dissection is debated with full dissection being suggested by some39 and more limited dissection by others.36 However all involve a medial to lateral approach through the ethmoid sinus system to a greater or lesser extent, breaching the lamina papyracea and hence accessing the collection. Technically this can be challenging due to bleeding from the inamed tissues obscuring the operative eld and in paediatric cases access can be restricted. Therefore the bale-out option of the external approach should be available.6,35 The major risk of the endoscopic approach alone is inadequate drainage of the collection and in those with superior-lateral extension at least a combined approach should be considered. Tanna et al.40 describe their use of functional endoscopic sinus surgery (FESS) and 5 13 patients were successfully treated via an endscopic approach, the other 8 13 underwent an external approach (however 6 8 had previously undergone an endoscopic approach with residual recurrent collection thereafter).
Periorbital approaches

We found nothing in the literature about the role of drains. By denition the endoscopic approach does not require a formal drain as the abscess cavity has been exteriorised into the nasal cavity. With the open approaches drains are the Gold Standard but increasingly with combined approaches there need is being questioned.
Complications

Two other approaches are described, the transcuruncular and pterional. The transcuruncular approach involves incision of the conjunctiva lateral and posterior to the

These are present in all modalities of treatment. However without treatment the outcome is poor with visual loss and intracranial sepsis highly likely. In all groups the following are real possibilities: Immediate Surgical damage to orbital structures bleeding blindness Early Diplopia (commonly resolves) o Progressive swelling is normal 24 h post op o Residual recurrent disease o Intracranial sepsis Late Residual visual defect (diplopia, decreased acuity) o Scarring o Enophthalmos There is no evidence to suggest that one mode is more effective than another. Often it will depend on local resources, expertise and experience. It should also be borne in mind that in the presence of orbital sepsis and acute rhinosinusitis without an intra-orbital collection surgical intervention in the form of FESS or washout can help to decrease bacterial load and provide samples for culture.
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Keypoints on Surgical Management of Orbital Disease

The standard external approach with drain remains the current standard approach in the UK for the management of subperiosteal abscess of the orbit. Endoscopic approaches are becoming increasingly used in expert hands.

Conclusion

Management of this disease needs to be via a multidisciplinary approach with adequate resources to provide ongoing assessment and prompt intervention when required. When conducted appropriately the disastrous outcomes of visual loss or neurological decit can be minimised.
Conict of interest

None to declare.
References
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