II. Epidemiology
- Mean age: 12 years old
III. Pathophysiology
-
Bacterial Ethmoid Sinusitis extension to involve orbit (60-80% of cases)
- Extends via thin medial bony wall into orbit
- Extends via retrobulbar veins (no valves) into lids
- Typical Organisms
- Streptococcus Pneumoniae
- Group A Streptococcus
- Staphylococcus aureus
- Moraxella catarrhalis
- HaemophilusInfluenzae (under age 3 years, decreasing due to Immunization)
- Mixed Bacterial Infection including Anaerobes
- Organisms in Immunocompromised patients (e.g. HIV Infection or AIDS)
- Pseudomonas aeruginosa
- Opportunistic fungal infections
IV. Course: Stages
V. Signs
- Starts as mild inflammatory edema
- URI history
- Low grade or absent fever
- Slowly progressive clinical course
- Swollen and discolored Eyelid
- Progresses to orbital involvement
- Fever
- Proptosis (Exophthalmos)
- Pain and limitation of eye Extraocular Movement
- Key distinguishing feature from Preseptal Cellulitis
- Diplopia on side gaze due to inability to move eye
- Marcus Gun Pupil (relative afferent pupilary defect)
- Swinging Flashlight Test abnormal (affected pupil constricts less in response to light)
- Chemosis
- Retinal Exam
- Venous dilatation and tortuosity
- Papilledema
- Decreased Visual Acuity
VI. Imaging
- Modalities
- CT Sinuses and orbits with IV Contrast (preferred in most cases) or
- MRI sinuses and orbits
- Indications: Distinguish preseptal from Orbital Cellulitis (and evaluate sinus involvement)
- Change in Visual Acuity
- Proptosis
- Decreased Extraocular Movements
- Diplopia
- Eye not able to be examined (e.g. due to local Eyelid Edema)
VII. Differential Diagnosis
- Preseptal Cellulitis
- Orbital pseudotumor
- Rhabdomyosarcoma
- Neuroblastoma
- Leukemia
- Lymphoma
- Other tumors
- Neurofibroma
- Glioma of the Optic Nerve
- Dermoid cyst
- Lymphangioma
- Hemangioma
- Wilms tumor
VIII. Management
-
General
- Observe in hospital with at least daily Visual Acuity and Pupillary Light Reflex
- Repeat CT Sinuses/orbits if not improved in 48 hours
- Antibiotics course: 7-14 days
-
Parenteral antibiotics (initial 2-3 drug regimen)
- Antibiotic 1 (choose 1)
- Vancomycin 15-30 mg/kg IV every 8-12 hours (preferred) OR
- Daptomycin 6 mg/kg IV every 24 hours OR
- Linezolid 600 mg IV every 12 hours
- Antibiotic 2 (choose 1 )
- Piperacillin-Tazobactam 4.5 g IV every 8 hours OR
- Ceftriaxone 2 g IV every 24 hours AND Metronidazole 1 g IV every 12 hours OR
- Moxifloxicin 400 mg IV every 24 hours (if Penicillin allergic)
- Antibiotic 1 (choose 1)
- Oral antibiotics (once infection controlled and based on microbiology)
- See Preseptal Cellulitis management
- Consider additional MRSA coverage (e.g. Septra, doxycyline)
- Amoxicillin-Clavulanate (Augmentin)
- Cefuroxime (Ceftin) or
- Cefpodoxime
- Cefprozil (Cefzil)
- Surgical drainage indications
- Large abscess
- Significant symptoms
- Insufficient improvement on antibiotics
- References
- (2017) Sanford Guide, accessed on IOS 2/2/2017
- Carlisle (2015) Am Fam Physician 92(2): 106-12 [PubMed]
IX. Complications
- Endophthalmitis (risk of permanent Vision Loss)
- Epidural Abscess or Subdural Abscess
- Meningitis
-
Cavernous Sinus Thrombosis or Dural sinus thrombosis
- May present first with Cranial Nerve 6 Palsy (Abducens Nerve Palsy), unable to gaze laterally
X. Prognosis
- Advanced AIDS
- Associated with poor outcomes related to Pseudomonas and opportunistic fungal infections
- Johnson (1999) Arch Ophthalmol 117(1): 57-64 [PubMed]
XI. References
- Williams (2017) Crit Dec Emerg Med 31(2): 3-12
- Givner (2002) Pediatr Infect Dis 21:1157-8 [PubMed]
- Micek (2007) Clin Infect Dis 45:S184-90 [PubMed]
- Tovilla-Canales (2001) Curr Opin Ophthalmol 12:335-41 [PubMed]