PANCE Blueprint EENT (9%)

Orbital cellulitis (ReelDx)

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Patient will present as →  a 2-year-old who arrives at the ED with a swollen and erythematous eyelid, proptosis, pain with movement of the eye, and an inability to adduct or abduct his eye.

Infection of the orbital muscles and fat behind the eye (differentiate from periorbital cellulitis which is only an infection of the skin)

  • Pt will present with decreased extraocular movement, pain with movement of the eye and proptosis.

History, clinical exam, and focused assessment of extraocular muscles

  • If concerned about orbital cellulitis: need CT Scan of orbits (confirmatory) 
  • CBC

If orbital cellulitis/abscess seen on CT: needs ophthalmology evaluation

  • CBC and blood culture may be standard in some settings
  • Antibiotics: IV vs oral based on clinical scenario
Involvement of muscles and fat behind the eye!

Involvement of muscles and fat behind the eye!

Question 1
Which of the following clinical findings differentiates periorbital from orbital cellulitis?
A
erythema
Hint:
See D for explanation
B
fever
Hint:
See D for explanation
C
lid edema
Hint:
See D for explanation
D
worsening pain with eye movements
E
development of a rash on the face
Hint:
See D for explanation
Question 1 Explanation: 
Periorbital cellulits is characterized by warmth, redness, swelling, and tenderness over the affected eye, along with conjunctival injection, eyelid swelling, chemosis, and fever. Orbital cellulitis includes all the symptoms of periorbital (preseptal) cellulitis with the addition of ocular pain and limitation of eye movement. Other physical examination findings may include lid edema, proptosis, marked tenderness to the globe, decreased visual acuity, and pupillary paralysis.
Question 2
The most common organism isolated in periorbital cellulitis in vaccinated children in the absence of trauma is
A
H. influenzae type B
Hint:
Before widespread immunization, Haemophilus influenzae type B was the most common cause secondary to bacteremia (about 80% of cases) and remains so in nonimmunized populations.
B
Streptococcus pneumoniae
C
Moraxella catarrhalis
Hint:
See B for explanation
D
Staphylococcus aureus
Hint:
The most common pathogens associated with external foci (trauma) are Staphylococcus aureus and Streptococcus pyogenes, but these are seldom isolated from the blood
E
Pseudomonas aeruginosa
Hint:
See B for explanation
Question 2 Explanation: 
Periorbital and orbital cellulitis may be caused by trauma (e.g., a wound, an insect bite), an associated infection (e.g., sinusitis), or seeding from bacteremia. Before widespread immunization, Haemophilus influenzae type B was the most common cause secondary to bacteremia (about 80% of cases) and remains so in nonimmunized populations. Streptococcus pneumoniae accounted for most of the remaining 20% of cases. S. pneumoniae is the most likely agent in Haemophilus influenzae type B-vaccinated patients when sinusitis is present. The most common pathogens associated with external foci (trauma) are Staphylococcus aureus and Streptococcus pyogenes, but these are seldom isolated from the blood. In general, a bacterial pathogen is isolated from the blood in < 33% of patients with periorbital cellulitis.
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