PERIORBITAL AND ORBITAL INFECTIONS

CHAD KAUFFMAN DO

INDIANA OSTEOPATHIC ASSOCIATION

33RD ANNUAL WINTER UPDATE

12.6.14

LEARNING OBJECTIVES

1. UNDERSTAND THE MULTIPLE ROUTES OF INFECTION EXTENSION INVOLVING THE EYELIDS AND ORBIT

2. DESCRIBE THE KEY CLINICAL FEATURES THAT DIFFERENTIATE PRE-SEPTAL AND ORBITAL CELLULITIS

3. UNDERSTAND THE VARIED CONDITIONS PREDISPOSING TO PRE-ORBITAL AND ORBITAL CELLULITIS INCLUDING THEIR PRESENTATION AND TREATMENT

4. DISCUSS THE GENERAL TREATMENT DIFFERENCES BETWEEN PRE-SEPTAL AND ORBITAL CELLULITIS

ORBITAL ANATOMY

ORBITAL SEPTUM

FIBROUS MEMBRANE SEPARATING THE ORBITAL AND PRESEPTAL COMPARTMENT

UPPER EYELID

EXTENDS FROM THE PERIOSTEUM OF THE ORBITAL RIM TO THE LEVATOR APONEUROSIS

LOWER EYELID

EXTENDS FROM THE PERIOSTEUM OF THE ORBITAL RIM TO THE INFERIOR BORDER OF THE TARSAL PLATE

ROUTES OF INFECTION EXTENSION TO LIDS AND ORBIT

INDIRECT SPREAD VENOUS DRAINAGE SYSTEM SHARED BY CRANIAL AND

MIDFACE STRUCTURES

MULTIPLE ANASTOMOSES AND VALVELESS SYSTEM

ROUTES OF INFECTION EXTENSION TO LIDS AND ORBIT

DIRECT SPREAD ETHMOID SINUS THROUGH LAMINA PAPYRACEA - CONTAINED

SUBPEREOSTEAL ABSCESS OR PROGRESSIVE ORBITAL INVOLVEMENT

FRONTAL AND MAXILLARY SINUS

ORBITAL FLOOR

ODONTOGENIC – MAXILLARY SINUS - ORBIT

PRESEPTAL CELLULITIS AN INFECTION OR INFLAMMATORY PROCESS OF THE

EYELIDS AND PERIORBITAL STRUCTURES OCCURS ANTERIOR TO AND CONTAINED BY THE ORBITAL

SEPTUM

ORBITAL CELLULITIS OCCURS POSTERIOR TO THE ORBITAL SEPTUM INVOLVES THE SOFT TISSUE WITHIN THE BONY ORBIT

CELLULITIS - COMMON ETIOLOGIES

1. SPREAD FROM ADJACENT STRUCTURES – SKIN AND SINUSES

2. DIRECT INOCULATION FOLLOWING TRAUMA

3. BACTERIAL SPREAD UPPER RESPIRATORY OR MIDDLE EAR

PRESEPTAL – ASSOCIATED FACTORS

HORDEOLA AND CHALAZIA

IMPETIGO/ERYSIPELAS

BLEPHARITIS

CONJUNCTIVITIS

CANALICULITIS

DACRYOCYSTITIS

VIRAL DERMATITIS – HERPES SIMPLEX & HERPES ZOSTER

Eyelid swelling both causes and results from impeded venous flow and lymphatic drainage – leading to self-propagating process

CHALAZION

MOST COMMON INFLAMMATORY LESION OF EYELID

BLOCKED MEIBOMIAN GLAND

INFLAMMATORY NODULE/CYST

LIPOGRANULOMATOUS

NOT INFECTIOUS

TYPICALLY NOT PAINFUL

CHALAZION

MANAGED BY WARM COMPRESSES AND MASSAGE

EXCISION/ STEROID INJECTION

CHALAZION

PREVENTIONROUTINE USE OF WARM COMPRESSES

LID MARGIN CLEANSING

LOW DOSE ORAL DOXYCYCLINE

ERYSIPELAS

SUPERFICIAL CELLULITIS

USUALLY GROUP A STREP

INTENSELY ERYTHEMATOUS WITH SHARPLY DEMARCATED BORDER

HORDEOLUM

• BACTERIAL INFECTION

• MEBOMIAN GLAND OR CILIARY GLANDS (ZEISS OR MOLL)

• INTERNAL OR EXTERNAL

• TYPICALLY PAINFUL

• MAY LEAD TO PRESEPTAL CELLULITS

HORDEOLUM

• MANAGEMENT

• STAPHYLOCOCCAL - MOST COMMON ETIOLOGY

• SYSTEMIC ANTIBIOTICS

• LANCE/DRAIN AS ABLE

• CHRONIC INFLAMMATION ASSOCIATED WITH CHALAZION FORMATION

DACRYOCYSTITIS

• PAIN, REDNESS AND SWELLING BELOW THE MEDIAL CANTHAL TENDON

• TYPICALLY ASSOCIATED WITH BLOCKAGE OF THE NASOLACRIMAL SYSTEM

• TEAR STASIS AND RETENTION → SECONDARY BACTERIAL INFECTION

DACRYOCYSTITIS

• MANAGEMENT

• ANTIBIOTICS – SYSTEMIC

• WARM COMPRESSES

• DRAINAGE

DACRYOCYSTITIS

• MANAGEMENT• ORAL ANTIBIOTICS

• GRAM POSITIVE BACTERIA MOST COMMON

• CONSIDER GRAM NEG IN DIABETICS, IMMUNOCOMPROMISED, NH PATIENTS

• IV ANTIBIOTICS WHEN SEVERE/ASSOCIATED WITH ORBITAL CELLULITIS

• INCISION AND DRAINAGE OF ABSCESS

HERPES ZOSTER DERMATOBLEPHARITITS

• RECURRENCE OR REACTIVATION OF VARICELLA ZOSTER VIRUS

• BURNING, STABBING PAIN OF FOREHEAD/SCALP

• VESICULAR RASH IN V1 DISTRIBUTION

HERPES ZOSTER DERMATOBLEPHARITITS

• TREAT WITH ANTIVIRALS

• ACYCLOVIR IF IDENTIFIED WITHIN 72 HOURS OF SKIN LESION ONSET

• TREAT WITH ANTIVIRALS

• ACYCLOVIR IF IDENTIFIED WITHIN 72 HOURS OF SKIN LESION ONSET

PRESEPTAL CELLULITIS

• OTHER CAUSES OF EYELID SWELLING

• CONTACT DERMATITIS

• INSECT BITES

• THYROID EYE DISEASE

• DACRYOADENITIS

PRESEPTAL CELLULITIS

• OTHER CAUSES OF EYELID SWELLING

• CONTACT DERMATITIS

• THICKENED, ERYTHEMATOUS, SCALY SKIN

PRESEPTAL CELLULITIS

• OTHER CAUSES OF EYELID SWELLING

• INSECT BITES

PRESEPTAL CELLULITIS

• OTHER CAUSES OF EYELID SWELLING

• THYROID EYE DISEASE

• PERIORBITAL EDEMA

PRESEPTAL CELLULITIS• OTHER CAUSES OF EYELID

SWELLING

• DACRYOADENITIS• INFLAMMATION OF LACRIMAL

GLAND

• SUPEROTMEPORAL PAIN, SWELLING, ERYTHEMA

• “S” SHAPED LID DEFORMITY

• VARIOUS INFECTIOUS AND INFLAMMATORY CAUSES

PRESEPTAL MANAGEMENT

TYPICALLY OUTPATIENT ORAL ANTIBIOTICS

ALL CHILDREN < 1 YEAR OLD SHOULD BE HOSPITALIZED WITH IV ANTIBIOTICS

CULTURE WHEN ABLE – MORE LIKELY AFTER TRAUMATIC INSULT

MOST COMMON BACTERIA INVOLVED FOR ADULTS: STAPH AURUES AND STREP PYOGENES

MOST COMMON FOR CHILDREN: H INFLUENZA TYPE B AND STREP PNEUMONIA

IF ABSCESS DEVELOPS IT SHOULD BE INCISED AND DRAINED

PRESEPTAL MANAGEMENT

• TEENAGERS AND ADULTS• USUALLY ARISES FROM SUPERFICIAL SOURCE (TRAUMA, CHALAZION)

• TREATED WITH ORAL ANTIBIOTICS

• COMMONLY PENICILLINASE-RESISTANT PENICILLIN OR BACTRIM

• IMAGE IF:

• SOURCE OF INFECTION NOT DETERMINED

• NOT RESPONDING QUICKLY TO TREATMENT

• ORBITAL PROCESS SUSPECTED

PRESEPTAL MANAGEMENT

• CHILDREN• THE MOST COMMON CAUSE IS UNDERLYING SINUSITIS

• WORK UP WITH CT QUICKLY IF NO SOURCE OF DIRECT INOCULATION EASILY IDENTIFIED

• HOSPITALIZE AND IV ANTIBIOTICS

ORBITAL CELLULITIS

OPHTHALMIC SIGNS• PROPTOSIS

• MOTILITY DISTURBANCE

• PRONOUNCED EDEMA AND ERYTHEMA

• IMPAIRED VISION WITH AFFERENT PUPIL DEFECT

• CONJUNCTIVAL CHEMOSIS AND HYPEREMIA

• REDUCED CORNEAL SENSATION

ORBITAL CELLULITIS

• SOURCES OF INFECTION ARE SIMILAR TO PRESEPTAL• EXTENSION OF SINUS DISEASE

• PENETRATING TRAUMA

• INFECTED ADJACENT STRUCTURES

• OTHER UNCOMMON SOURCES• SCLERAL BUCKLES, AQUEOUS DRAINAGE DEVICES,

ENDOPHTHALMITIS

ORBITAL CELLULITIS

NONINFECTIOUS CAUSES OF ORBITAL INFLAMMATORY DISEASE

INFLAMMATORY AND AUTOIMMUNETHYROID OPHTHALMOPATHY

ORBITAL PSEUDOTUMOR

LYMPHOMA

DERMATOMYOSITIS-POLYMYOSITIS

WEGENER GRANULOMATOSIS

SJOGREN SYNDROME

ORBITAL CELLULITIS

NONINFECTIOUS CAUSES OF ORBITAL INFLAMMATORY DISEASE

VASCULAR

ORBITAL VENOUS MALFORMATION

CAVERNOUS SINUS THROMBOSIS

ARTERIOVENOUS FISTULA

SUPERIOR VENA CAVA SYNDROME

ORBITAL CELLULITIS

NONINFECTIOUS CAUSES OF ORBITAL INFLAMMATORY DISEASE

NEOPLASMS OF ORBIT AND LACRIMAL GLAND

PEDIATRIC: RHABDOMYOSARCOMA, LEUKEMIA, METASTATIC NEUROBLASTOMA, RETINOBLASTOMA

ADULT: LYMPHOMA

ORBITAL CELLULITIS

• > 90% OF ALL RELATED TO UNDERLYING SINUS DISEASE

• IN CHILDREN USUALLY SINGLE ORGANISM FROM SINUS (S AUREUS OR STREP PNEUMONIA)

• ADOLESCENTS AND ADULTS HAVE MORE COMPLEX BACTERIOLOGY (OFTEN 2-5 ORGANISMS)

• TRAUMA – GRAM - RODS

• DENTAL – MIXED, AGGRESSIVE AEROBES AND ANAEROBES

• IMMUNOCOMPROMISED/DIABETICS - FUNGI

ORBITAL CELLULITIS

• LABORATORY STUDIES• CBC

• NASAL SWAB IF PURULENT MATERIAL

• BLOOD CULTURES

• LUMBAR PUNCTURE IF MENINGEAL SIGNS PRESENT

ORBITAL CELLULITIS

• IMAGING STUDIES• ORBITAL CT

• THIN, AXIAL AND CORONAL, WITHOUT CONTRAST

• INCLUDE ORBITS, PARANASAL SINUSES, FRONTAL LOBES

• IF NEUROLOGIC INVOLVEMENT INCLUDE THE HEAD WHEN IMAGING

ORBITAL CELLULITIS

SIGNIFICANT MORBIDITY IF NOT APPROPRIATELY TREATED

ORBITAL APEX SYNDROME

BLINDNESS

CAVERNOUS SINUS THROMBOSIS

CRANIAL NERVE PALSIES

MENINGITIS

INTRACRANIAL ABSCESS

ORBITAL CELLULITIS

MEDICAL MANAGEMENT

ADMIT FOR IV ANTIBIOTICS

CEPHALOSPORIN – AMPICILLIN-SUL OR PIPERCILLIN - TAZO

VANCOMYCIN FOR MRSA

CLINDAMYCIN FOR ANAEROBIC COVERAGE

NASAL DECONGESTANTS

TRANSITION TO OUTPATIENT ORAL ANTIBIOTICS TREATMENT FOR 1-3 WEEKS

ORBITAL CELLULITIS

SURGICAL MANAGEMENTIF ORBITAL ABSCESS PRESENT

EARLY DRAINAGE OF INVOLVED SINUS

IF ORBITAL SIGNS PROGRESSING

Feature Preseptal Orbital

Proptosis Absent Present

Motility Normal - pain Decreased + pain and double vision

Vision Normal Reduced – check vision and color vision

Pupillary Reaction Normal +/- APD – check swinging flashlight test

Chemosis Rare Common

Corneal Sensation Normal May be reduced

Systemic Signs Absent/Mild Commonly severe (Fever/Leukocytosis)

DIFFERENTIATING FEATURES OF CELLULITIS