​Kembara Xtra - Medicine- Periorbital Cellulitis

​​​Kembara Xtra - Medicine- Periorbital Cellulitis 
An acute bacterial infection of the skin and subcutaneous tissue that is located anterior to the orbital septum and does not affect the orbital structures (globe, fat, and ocular muscles).


Caution 
It is crucial to differentiate between orbital cellulitis and periorbital cellulitis. A potentially fatal condition is orbital cellulitis. The posterior to the orbital septum, orbital cellulitis manifests as proptosis, restricted eye movement, pain with eye movement, and altered vision.

(Incidence and Prevalence) Epidemiology 
3 times more prevalent than orbital cellulitis; more frequently occurs in children, mean age 21 months.

Incidence
Wintertime incidence is higher (as a result of an increase in sinusitis cases) 

Pathophysiology and Etiology 

The anatomy of the eyelid separates orbital cellulitis from periorbital (preseptal) cellulitis: - The orbital septum, a layer of connective tissue that runs from the orbital bones to the edges of the upper and lower eyelids, serves as a defense against infection of the deeper orbital structures.
- Periorbital (preseptal) cellulitis is an infection of the tissues located anterior to the orbital septum.
Periorbital cellulitis often results from a concurrent infection of soft tissues of the face, while orbital (postseptal) cellulitis is an infection that extends deep to the orbital septum.
- Extension of sinusitis (through lamina papyracea)
- Localized injuries; animal or insect bites - Foreign bodies
- Extensive dental abscesses
Hematopoietic seeding
Staphylococcus aureus is a typical common organism (MRSA is on the rise). - Streptococcus pyogenes - Staphylococcus epidermidis
Since the introduction of the vaccine, the incidence of Haemophilus influenzae disease has decreased (should still be suspected in unimmunized or partially immunized patients). Atypical organisms include Acinetobacter sp., Nocardia brasiliensis, Bacillus anthracis, Pseudomonas aeruginosa, Pasteurella multocida, Mycobacterium tuberculosis, and Trichophyton sp.
Genetics
No inherited tendency is known


Acute sinusitis, conjunctivitis, blepharitis, dental infection, localized skin damage or puncture wounds, insect bites, and bacteremia are risk factors.


Prevention
Avoid injuries near the eyes, swim with abrasions on your face in fresh or salt water, and get routine vaccinations, especially for H. influenzae type B and Streptococcus pneumoniae. 

Presenting History Periorbital soft tissue indulation, erythema, warmth, and/or discomfort, typically accompanied by normal vision and eye movements 
Chemosis (conjunctival edema), proptosis, and pain with extraocular eye movements are signs of orbital cellulitis and should be taken seriously in severe cases of periorbital cellulitis.

Alert
Fever, conjunctival edema, and pain with eye movement all point to orbital cellulitis.

clinical assessment 

Vital signs and appearance in general (Patients with ocular cellulitis frequently present with systemic illness.) 
Examine the skin, conjunctiva, lashes, and structures around the eyes.
Erythema, swelling, and discomfort of the eyelids without congested orbits - Violaceous eyelid coloring is more frequently linked to H. influenzae.
Check for skin deterioration.
In order to rule out herpetic infection, look for vesicles.
Check the sinuses and the nasal vaults for symptoms of acute sinusitis.
Test ocular motility and visual acuity. Inspect the mouth cavity for dental abscesses.

Differential diagnosis: Orbital cellulitis. Orbital cellulitis may present with similar symptoms to periorbital cellulitis, including fever, proptosis, chemosis, ophthalmoplegia, impaired visual acuity, and pain with ocular movement.
Rapidly progressing malignancies, such as Rhabdomyosarcoma, Retinoblastoma, Lymphoma, and Leukemia, as well as allergic inflammation, orbital or periorbital trauma, dacryocystitis, hordeolum (stye), and orbital myositis

Diagnostic tests and laboratory results 

Initial examinations (lab, imaging)
With differential, CBC
Blood cultures (poor yield), purulent discharge from wounds (if present), and blood cultures 
If there is a suspicion of orbital cellulitis (marked eyelid swelling, fever, leukocytosis, or failure to improve after taking the recommended antibiotics within 24 to 48 hours), imaging is advised.
CT to assess the level of infection and look for abscess or inflammation in the orbit: narrow (2 mm) sections of CT with contrast; coronal and axial images with bone windows – Bulging of the medial rectus on a CT scan is the typical indication of orbital cellulitis.


Tests in the Future & Special Considerations

Children with orbital or periorbital cellulitis frequently have sinusitis as an underlying condition.
Admission for blood cultures, antibiotic medication, and consideration of lumbar puncture should be made if a kid is febrile, under 15 months old, and appears toxic.

Administration of Medicine 
Use oral antibiotics to treat periorbital cellulitis and make sure you get close monitoring.
The most likely pathogens (Staphylococcus and Streptococcus) should be treated with empiric antibiotics.
Observe the prevalence of MRSA in your area to decide whether you need coverage.
In the case of simple periorbital cellulitis, there is no proof that IV antibiotics are superior to PO antibiotics in speeding up recovery or preventing secondary problems.
Uncomplicated posttraumatic periorbital cellulitis: This condition is typically brought on by skin bacteria, particularly Staphylococcus and Streptococcus. - Clindamycin 300 mg PO TID, doxycycline 100 mg PO BID, or trimethoprim-sulfamethoxazole (TMP-SMX) - Cephalexin 500 mg PO q6h or dicloxacillin 500 mg PO q6h If MRSA is suspected, give 1 to 2 DS tablets orally every 12 hours. 
Dental abscesses can be treated with amoxicillin-clavulanate 875 mg PO BID or clindamycin 300 mg PO TID. Bacteremic cellulitis, which may be linked to meningitis, can be treated with ceftriaxone 1 g IV q24h plus vancomycin 15 mg/kg/dose IV q8-12h or clindamycin 600 to 900 mg IV q8h to treat MRSA. - Therapy sessions should last 10 to 14 days on average. Follow patients closely (daily follow-up until improvement occurs) when they are given oral antibiotics for suspected periorbital cellulitis to monitor antibiotic response and potential progression to orbital cellulitis. The need for IV antibiotic therapy should be reevaluated if symptoms do not subside within 24 hours.

Questions that need more consultation

If there is worry for orbital cellulitis or if individuals don't improve promptly after receiving first-line treatment, consult ENT and ophthalmology.

Surgery is typically not recommended in straightforward circumstances. Orbital surgery is recommended if there is an abscess or a probable impairment of vital structures. The strongest clinical indicator of need for surgery is diplopia.

Admission Requirement 
Mild cases in adults and children over the age of one year old can be safely addressed on an outpatient basis if the patient is stable and there are no systemic signs of toxicity.
Think about receiving IV antibiotics and hospitalization: - If the patient displays systemic illness
- Infants and toddlers (3),(4)[C]
If patients do not improve or deteriorate within 24 hours of oral antibiotics, they may not have received S. pneumoniae or H. influenzae vaccinations. No set rules specify when to transfer from parenteral to PO medication. - High suspicion for orbital cellulitis (eyelid edema with decreased vision, diplopia, aberrant light responses, or proptosis). Once eyelid edema and erythema have greatly diminished, switching from IV to PO antibiotics is generally acceptable.
An antibiotic regimen of 10 to 14 days is recommended.


patient observation

Keep an eye out for symptoms of orbital involvement, such as impaired vision or painful or restricted ocular movement.

Patient Education Observe proper skin care.
Avoid skin trauma, and if it returns after receiving treatment, report any early skin changes (swelling, redness, and pain).

Prognosis: Patients have good outcomes when given prompt care.
Recurrent periorbital cellulitis must be distinguished from treatment failure brought on by antibiotic resistance when it involves three or more periorbital infections in a 12-month period.


Complications include scarring, loss of vision, cavernous sinus thrombosis, orbital abscess formation, and osteomyelitis.

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