Differentiating Head, Neck, and Face Infections: Preceptal, Facial, and Orbital Cellulitis

Contributor: Meghan Hurley MD

Educational Pearls:

What is Cellulitis?

• A common and potentially serious bacterial skin infection.

• Caused by various types of bacteria, with Streptococcus and Staphylococcus species being the most common.

What is Preseptal Cellulitis and why is it more serious than facial cellulitis?

• Preseptal Cellulitis, also known as Periorbital Cellulitis, is a bacterial infection of the soft tissues in the eyelid and the surrounding area.

• This requires prompt and aggressive treatment to avoid progression into Orbital Cellulitis.

How is Preseptal Cellulitis treated?

• Oral antibiotics for five to seven days.

• In the setting of trauma (scratching bug bites) Clindamycin or TMP-SMX (for MRSA coverage) and Amoxicillin-clavulanic acid or Cefpodoxime or Cefdinir.

• If there is no trauma, monotherapy with amoxicillin-clavulanic acid is appropriate.

• Check immunization status against H.influenzae and adjust appropriately.

What is Orbital Cellulitis, how is it diagnosed, and why is it more serious than Preseptal Cellulitis?

• Orbital cellulitis involves the tissues behind the eyeball and within the eye socket itself.

• Key features include:

• Eye pain.

• Proptosis (Bulging of the eye out of its normal position).

• Impaired eye movement.

• Blurred or double vision.

• This can lead to three very serious complications:

• Orbital Compartment Syndrome. This can push eye forward, stretch optic nerve, and threaten vision.

• Meningitis given that the meninges of the brain are continuous with optic nerve.

• Endophthalmitis, which is inflammation of the inner coats of the eye. This can also threaten vision.

• If suspected, get a CT of the orbits and/or an MRI to look for an abscess behind the eyes.

How is Orbital Cellulitis treated?

• IV antibiotics. Cover for meningitis with Ceftriaxone and Vancomycin.

• Add Metronidazole until intracranial involvement has been ruled out.

• Drain the abscess surgically. Usually this is performed by an ophthalmologist or an otolaryngologist.

• Admit to the hospital.

References

1. Bae C, Bourget D. Periorbital Cellulitis. 2023 Jul 17. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 29261970.

2. Chaudhry IA, Shamsi FA, Elzaridi E, Al-Rashed W, Al-Amri A, Al-Anezi F, Arat YO, Holck DE. Outcome of treated orbital cellulitis in a tertiary eye care center in the middle East. Ophthalmology. 2007 Feb;114(2):345-54. doi: 10.1016/j.ophtha.2006.07.059. PMID: 17270683.

3. Seltz LB, Smith J, Durairaj VD, Enzenauer R, Todd J. Microbiology and antibiotic management of orbital cellulitis. Pediatrics. 2011 Mar;127(3):e566-72. doi: 10.1542/peds.2010-2117. Epub 2011 Feb 14. PMID: 21321025.

4. Wong SJ, Levi J. Management of pediatric orbital cellulitis: A systematic review. Int J Pediatr Otorhinolaryngol. 2018 Jul;110:123-129. doi: 10.1016/j.ijporl.2018.05.006. Epub 2018 May 8. PMID: 29859573.

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII