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10 Management of Periorbital Cellulitis in the 21st Century |
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Summary for the Clinician |
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■ Intravenous antibiotics e ective against orbital |
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pathogens in vitro may be ine ective in the clini- |
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10 |
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cal treatment of advanced orbital cellulitis. |
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■ Harris confirmed the tendency toward culture- |
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negative or single-isolate infections in children |
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younger than 9 years that responded to antibi- |
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otic therapy alone. |
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■ Experience gleaned from these studies has clas- |
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sified the need for surgical intervention into |
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emergent, urgent, and expectant groups. |
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■ Emergency drainage was deemed appropriate |
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for cases of optic nerve or retinal compromise |
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secondary to induced mass e ect. |
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■ Virtually all patients older than 14 years will |
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have a complex, polymicrobial infection, which |
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should be drained more urgently as antibiotics |
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are less likely to be e ective. |
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■ Patients younger than 9 years can usually be |
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observed given the predilection to simple infec- |
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tions in this population and the typical response |
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to antibiotics alone. |
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■ For observation, the following need to be absent: |
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age of 9 years or older, frontal sinusitis, nonme- |
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dial or large subperiosteal abscess, gas within |
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abscess on CT or other suspicion of anaerobic |
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infection, recurrence after prior surgical inter- |
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vention, radiologic evidence of chronic sinusitis, |
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acute optic nerve or retinal compromise, or den- |
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tal etiology of infection predisposing to anaero- |
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bic infiltration. |
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■ The only universal rule in the current literature |
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is that the decision to intervene surgically must |
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rest on the physician’s opinion, clinical judg- |
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ment, and knowledge of the potential course of |
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orbital cellulitis. |
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10.9Prevention of Orbital Cellulitis After Orbital Fracture
Orbital cellulitis is a rare side e ect of an orbital fracture [2]. When cellulitis does result from orbital blowout fracture, one mechanism is thought to be the formation of anatomical communications between the fractured sinuses and orbit [19]. However, the sinus is a sterile space. These new anatomical communications between the orbit and sinus exist for the life of the patient. As a
result, cellulitis may arise from several days to over 20 years after initial orbital injury. In addition, orbital decompression is a common procedure, representing a controlled fracture of the sinus, and has a very low incidence of postoperative orbital infection. Further, sinuses are protected by lymphocytes, interferons, and alkaline mucus that circulates every 10 min. Logically, sinusitis in these fracture patients has been associated with the development of subsequent orbital cellulitis, albeit rarely, especially in the early healing phases weeks to months after the injury. The role for prophylactic antibiotics has never been established. The potential orbital cellulitis following fracture should hold no clinical importance in patients not su ering from sinusitis.
Given the very low incidence of cellulitis attributable to blowout fractures, the prolonged healing of sinus mucosa compared to the short nature of antibiotic treatment, the possibility of a long lag period between injury and orbital cellulitis, and previous case reports showing no obvious benefit from the prophylaxis of orbital cellulitis following blowout fracture, physicians should consider not prescribing antibiotics for orbital fractures. The practice thereof may be unnecessarily costly, time consuming, and potentially harmful to the patients in this era of antibiotic resistance. Patients with active sinus disease at the time of their fracture should still be treated with oral antibiotics, even though studies show they do not always prevent infection.
Summary for the Clinician
■It is important to consider MRSA as a cause of infection when choosing appropriate antibiotic therapy.
■CT scan of the orbit and sinus is a very helpful tool when determining the best course of treatment.
■Antibiotics are most e ective as single therapy in young children, whereas antibiotics and surgery are more often needed in teenagers and adults.
■MRSA infections of the orbit require aggressive management with appropriate antibiotics and early surgery when indicated.
■Atypical infections like orbital cellulitis not arising from the sinus or infections that potentially may spread to adjacent areas (like frontal sinusitis with orbital involvement and possible intracranial spread) should be treated surgically in a more urgent matter.
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