PANCE Blueprint EENT (7%)

Periorbital (Preseptal) Cellulitis

Patient will present as → a 5-year-old child presents with unilateral eye swelling, redness, and pain. The child had a recent upper respiratory infection. On examination, the eyelid is erythematous and swollen, but the eye itself is not protruding, and the child can move the eye without pain. There are no signs of proptosis, ophthalmoplegia, or visual impairment, which would suggest orbital cellulitis. The child is treated with oral antibiotics, and close follow-up is ensured to monitor for any progression to orbital cellulitis.

Preseptal (periorbital) cellulitis is an infection of the anterior portion of the eyelid and DOES NOT involve the orbit or other ocular structures

  • Common causes include trauma to the eyelid, insect bites, local skin infections, and sinusitis
  • Symptoms include unilateral ocular pain, eyelid swelling, and erythema. It may be associated with fever and systemic symptoms
    • NO proptosis, ophthalmoplegia, or pain with eye movements (distinguishes from orbital cellulitis)
  • The most common causative organisms are Staphylococcus aureus (including MRSA), Streptococcus pyogenes are the most common pathogens related to infection of the skin and skin structures
  • Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis are the most common pathogens related to sinusitis

Blueprint comparisons you need to know!

Periorbital Cellulitis vs. Orbital Cellulitis

  • Periorbital cellulitis involves tissues anterior to the orbital septum, while orbital cellulitis involves tissues posterior to the septum
  • Periorbital cellulitis typically presents with eyelid swelling and erythema, while orbital cellulitis also includes ophthalmoplegia, pain with eye movements, proptosis, and impaired visual acuity
  • Periorbital cellulitis is generally a mild condition, while orbital cellulitis can lead to vision loss and life-threatening complications
Feature Orbital Cellulitis Preorbital (Periorbital) Cellulitis
  Orbital cellulitis - no watermark Celulitis Periorbitaria (Preseptal)
Definition Infection involving the eye tissues posterior to the orbital septum Infection involving the tissues anterior to the orbital septum
Etiology Often secondary to sinusitis, trauma, or surgery Commonly follows local trauma, insect bites, or conjunctivitis
Common Pathogens Staphylococcus aureus, Streptococcus species, Haemophilus influenzae Staphylococcus aureus, Streptococcus species
Age Group More common in children and young adults More common in children
Clinical Features Painful eye movement, proptosis, ophthalmoplegia, decreased vision, fever Eyelid swelling and erythema, fever may be present
Eye Movement Painful and restricted Normal and painless
Vision May be impaired Usually normal
Proptosis Present (eye bulging) Absent
Systemic Symptoms Fever, malaise, potentially severe illness Fever may be present but systemic symptoms are less severe
Diagnosis Clinical examination, CT or MRI to assess extent and complications Clinical examination, CT scan to rule out orbital cellulitis if severe
Complications Abscess formation, vision loss, cavernous sinus thrombosis, intracranial spread Rare, but can progress to orbital cellulitis if untreated
Management Hospitalization, intravenous antibiotics, possible surgical drainage Oral antibiotics, outpatient management unless severe or unresponsive
Prognosis Requires prompt treatment to prevent serious complications Good with appropriate antibiotic therapy, fewer complications

Primarily clinical, based on the presence of eyelid swelling and erythema without signs of orbital involvement

  • CT imaging of the orbits and sinuses is indicated if signs or symptoms suggest orbital cellulitis or if the patient fails to improve after 24-48 hours of appropriate antibiotic therapy
    • In periorbital cellulitis, CT may show eyelid swelling WITHOUT involvement of orbital structures. Sinusitis may be present
  • Blood cultures are not routinely necessary but may be considered in very young, toxic-appearing, or unimmunized patients
Celulitis Periorbitaria (Preseptal)

Periorbital cellulitis in 20 years old man

Most patients older than one year with mild periorbital cellulitis can be treated as outpatients with oral antibiotics - Treatment duration is typically 5-7 days, but should be continued until clinical improvement

  • For patients without periorbital skin trauma, empiric therapy with amoxicillin-clavulanic acid is recommended. Alternatives include cefpodoxime, cefuroxime, cefdinir, or levofloxacin for penicillin-allergic patients
  • For patients with periorbital skin trauma, empiric therapy should include coverage for S. aureus (including MRSA) and streptococci, such as linezolid alone or trimethoprim-sulfamethoxazole plus amoxicillin-clavulanic acid, cefpodoxime, cefuroxime, or cefdinir.
  • Hospitalization is recommended for children under one year, severely ill patients, or those who fail to improve with outpatient therapy
  • Follow-up is critical to ensure resolution and to monitor for progression to orbital cellulitis

**If the distinction between periorbital and orbital cellulitis is unclear, management should proceed as for orbital cellulitis.

Question 1
A 5-year-old boy presents with swelling and erythema of his left upper and lower eyelids. His mother reports that he had a mild upper respiratory infection last week. He has been vigorously rubbing his eyelids. What is the most likely underlying cause of his current condition?
Trauma to the periorbital area
Though the child has been vigorously rubbing his eyelids this is more likely a consequence (rather than a cause) of the patients periorbital infection
Insect bite
Insect bites can cause periorbital cellulitis, but there is no mention of an insect bite in the given history.
Extension from sinusitis
Bacteremia can occasionally lead to periorbital cellulitis, but it is less common than local extension from sinusitis, especially in the post-Haemophilus influenzae type b (Hib) vaccine era.
Orbital foreign body
An orbital foreign body can cause orbital cellulitis, but periorbital cellulitis is more commonly caused by extension from sinusitis or local skin infections.
Question 1 Explanation: 
Extension from sinusitis, particularly ethmoid sinusitis, is one of the most common causes of periorbital cellulitis in children. The thin lamina papyracea separating the ethmoid sinuses from the orbit, along with the valveless venous connections, allows for the easy spread of infection from the sinuses to the periorbital tissues. In this case, the patient's recent history of an upper respiratory infection suggests a possible preceding sinusitis. While other factors such as trauma, insect bites, and bacteremia can also lead to periorbital cellulitis, sinusitis remains the most likely cause in this clinical scenario.
Question 2
A 7-year-old girl presents to the emergency department with swelling, redness, and warmth of the left upper eyelid. She denies pain with eye movement and has no visual disturbances. Her temperature is 37.8°C (100°F). She reports a recent insect bite near the affected area. What is the most appropriate next step in the diagnosis of this patient's condition?
Orbital CT scan
CT scan is indicated if there are signs of orbital cellulitis, such as proptosis, ophthalmoplegia, or decreased vision, none of which are present in this case.
MRI of the orbit
MRI is similar to CT in its indication and is used less frequently in the initial evaluation due to longer acquisition times.
Clinical examination and observation
Blood cultures
Blood cultures are not routinely indicated unless there is a high suspicion of systemic involvement or the patient appears septic.
Lumbar puncture
Lumbar puncture is unnecessary in the evaluation of periorbital cellulitis and is more relevant in cases of suspected meningitis or central nervous system infections.
Question 2 Explanation: 
The most appropriate next step in the diagnosis of periorbital cellulitis is a thorough clinical examination and observation. Given the lack of signs suggestive of orbital involvement (no pain with eye movement or visual disturbances) and the presence of a clear etiology (recent insect bite), clinical diagnosis is usually sufficient. Imaging studies like CT or MRI are reserved for cases with concerning symptoms suggestive of orbital cellulitis.
Question 3
A 6-year-old boy presents with swelling, erythema, and warmth around his right eye for the past 24 hours. He was bitten by an insect three days ago. On examination, there is no proptosis, and extraocular movements are normal. He has a mild fever of 38°C (100.4°F). What is the most appropriate initial treatment for this patient?
Oral amoxicillin-clavulanate
Intravenous vancomycin
IV vancomycin is reserved for more severe cases or if there is a suspicion of MRSA infection, which is not indicated in this uncomplicated periorbital cellulitis case.
Topical antibiotic ointment
Topical antibiotics are not sufficient for treating periorbital cellulitis, as the infection requires systemic therapy.
Oral trimethoprim-sulfamethoxazole
While this can cover MRSA, it is not the first-line treatment for uncomplicated periorbital cellulitis where broad coverage of common skin flora is needed.
Intravenous ceftriaxone
IV ceftriaxone is used for more severe or complicated cases requiring hospitalization. This patient can be managed with oral antibiotics.
Question 3 Explanation: 
Oral amoxicillin-clavulanate is the most appropriate initial treatment for uncomplicated periorbital cellulitis. It covers the common pathogens (Staphylococcus aureus and Streptococcus species) and is suitable for outpatient management. Given the absence of severe symptoms such as proptosis or ophthalmoplegia, oral antibiotics are appropriate.
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References: Merck Manual · UpToDate

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