8/27/2015

Preseptalcellulitis

OfficialreprintfromUpToDate
www.uptodate.com2015UpToDate

Preseptalcellulitis
Authors
ChristopherGappy,MD
StevenMArcher,MD
MichaelBarza,MD

SectionEditors
StephenBCalderwood,MD
JonathanTrobe,MD
MorvenSEdwards,MD

DeputyEditor
AllysonBloom,MD

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Jul2015.|Thistopiclastupdated:Jun24,2015.
INTRODUCTIONPreseptalcellulitis(sometimescalledperiorbitalcellulitis)isaninfectionoftheanterior
portionoftheeyelid,notinvolvingtheorbitorotherocularstructures.Incontrast,orbitalcellulitisisaninfection
involvingthecontentsoftheorbit(fatandocularmuscles)butnottheglobe.Althoughpreseptalandorbital
cellulitismaybeconfusedwithoneanotherbecausebothcancauseocularpainandeyelidswellinganderythema,
theyhaveverydifferentclinicalimplications.Preseptalcellulitisisgenerallyamildconditionthatrarelyleadsto
seriouscomplications,whereasorbitalcellulitismaycauselossofvisionandevenlossoflife.Orbitalcellulitiscan
usuallybedistinguishedfrompreseptalcellulitisbyitsclinicalfeatures(ophthalmoplegia,painwitheye
movements,andproptosis)andbyimagingstudies.Incasesinwhichthedistinctionisnotclear,cliniciansshould
treatpatientsasthoughtheyhaveorbitalcellulitis.Bothconditionsaremorecommoninchildrenthaninadults,
andpreseptalcellulitisismuchmorecommonthanorbitalcellulitis.
Thepathogenesis,microbiology,clinicalmanifestations,diagnosis,andtreatmentofpreseptalcellulitiswillbe
reviewedhere.Orbitalcellulitisanditscomplications,suchassubperiostealabscessandorbitalabscess,are
discussedseparately.Orbitalinfectionscausedbyfungi,mainlytheMucorales(whichcausemucormycosis)and
Aspergillussppand,muchmorerarely,Mycobacteriumtuberculosis,arealsopresentedelsewhere.(See"Orbital
cellulitis"and"Mucormycosis(zygomycosis)"and"Epidemiologyandclinicalmanifestationsofinvasive
aspergillosis"and"Tuberculosisandtheeye".)
TERMINOLOGYPreseptalcellulitisandorbitalcellulitisinvolvedifferentanatomicsites,withpreseptalcellulitis
referringtoinfectionsofthesofttissuesanteriortotheorbitalseptumandorbitalcellulitisreferringtoinfections
posteriortoit(figure1).Neitherinfectioninvolvestheglobe.(See'Anatomy'below.)
Thereissomedebateregardingtheappropriateterminologyfortheseinfections.Somecliniciansusetheterm
"periorbitalcellulitis"ratherthan"preseptalcellulitis"orusethetermsinterchangeably.Weprefertheterm
"preseptalcellulitis"tomakeacleardistinctionbetweenthisinfectionandthemoreseriousinfection,"orbital
cellulitis."Orbitalcellulitisissometimesreferredtoas"postseptalcellulitis"wefavortheterm"orbitalcellulitis,"
andwilluseitthroughoutthistopic.
ANATOMYBasicfamiliaritywiththeanatomyoftheeyeisfundamentaltounderstandingthepathogenesis,
clinicalmanifestations,andcomplicationsofpreseptalandorbitalcellulitis.Theorbitisaconeshapedstructure,
lyinghorizontally,withitsapexintheskull.Itissurroundedbyparanasalsinuses,namely,thefrontal(lying
superior),ethmoid(medial)andmaxillary(inferior)sinuses(figure2).Theorbitislinedbyperiosteum.Theethmoid
sinusesareseparatedfromtheorbitbyapaperthinlayercalledthelaminapapyracea,whichcontainsmany
perforationsfornervesandbloodvesselsaswellassomenaturalfenestrationstermedZuckerkandls
dehiscences.Themostcommonrouteofinfectionoftheorbitisbyextensionfromtheethmoidsinuses,
presumablythroughtheseperforations.
Theorbitalseptumisamembranoussheetthatextendsfromtheperiosteumoftheorbittothetarsalplateand
formstheanteriorboundaryoftheorbitalcompartment(figure1).Asnotedabove,preseptalcellulitisinvolvesthe
softtissuesanteriortotheorbitalseptum.Thesuperiorandinferiorophthalmicveinsdrainblooddirectlyintothe
cavernoussinus(figure3).Becauseofthiscommunicationandbecausetheinferiororbitalveinsarevalveless,
infectioncanpassreadilyfromtheorbittointracranialstructures[1].
http://www.uptodate.com/contents/preseptalcellulitis?topicKey=ID%2F16650&elapsedTimeMs=15&source=machineLearning&searchTerm=cellulitis&select

1/16

8/27/2015

Preseptalcellulitis

EPIDEMIOLOGYPreseptalcellulitisismuchmorecommonthanorbitalcellulitis.Intwopediatriccaseseries,
94percentand87percentofcases,respectively,werediagnosedaspreseptalcellulitis[2,3]theremainderof
caseswerediagnosedasorbitalcellulitis.Bothinfectionsaremuchmorecommoninchildrenthaninadults
accordingly,mostofthedataregardingtheseinfectionscomesfromstudiesinchildren.
Itisimportanttodistinguishbetweenpreseptalandorbitalcellulitisbecausethecomplications,treatments,and
outcomesofthetwoentitiesareverydifferent.(See'Clinicalmanifestations'below.)
PATHOGENESISWhereastheparanasalsinusesarethemainsourceofinfectioninorbitalcellulitis,many
casesofpreseptalcellulitis(theproportionvaryingfromstudytostudy)arisefromexternalsources.Inone
retrospectiveseriesof315childrenadmittedtothehospitalwithpreseptalororbitalcellulitis,sinusitiswasthe
underlyingconditioninall18childrenwithorbitalcellulitisbutinonly15percentofthosewithpreseptalcellulitis
[2].However,otherstudieshavefoundsinusitistobethemostcommoncauseofpreseptalcellulitis[4,5].
Othersitesfromwhichpreseptalcellulitismayarisearethesurroundingtissuesofthefaceandeyelidsfollowing
localtrauma[6,7],insectbites[7],animalbites[8],orforeignbodies.Inoneretrospectiveseriesof104patients
withpreseptalcellulitisadmittedtoatertiarycarecenter,roughly30percentwerethoughttooriginatefromeachof
thefollowingcauses:acutedacryocystitis,sinusitisorupperrespiratorytractinfection,ortrauma(includingrecent
eyelidorstrabismussurgery)[9].Inanotherretrospectivestudythatincluded262childrenwithpreseptalororbital
cellulitis,trauma(includinginsectbites)wasmuchmorecommoninpatientswithpreseptalcellulitisthaninthose
withorbitalcellulitis(40versus11percent)[3].Bacteremicseedingofthepreseptalspaceisrare.Itis
occasionallyseenininfantswithbacteremiaduetoStreptococcuspneumoniae,Streptococcuspyogenes,or
Haemophilusinfluenzae.
MICROBIOLOGYDataconcerningthecausesofpreseptalcellulitisarelimited.Bloodculturesarealmost
alwaysnegative,anditisusuallydifficulttoobtainculturesfromtheinfectedsite.Basedontheavailabledata,the
mostcommoncausesofpreseptalcellulitisareStaphylococcusaureus,Streptococcuspneumoniae,other
streptococci,andanaerobes(table1)[3,9],presumablydependingonthesiteoforiginoftheinfection.
OfS.aureusstrains,communityacquiredmethicillinresistantS.aureus(CAMRSA)isthoughttobean
increasinglycommoncauseofinfection.AlthoughmostcasesofpreseptalcellulitiscausedbyCAMRSAhave
beenpublishedonlyascasereportsorretrospectiveseries[10,11],theproportionofotherskinandsofttissue
infectionscausedbyCAMRSAhasincreaseddramatically.Inareportof422adultspresentingtoemergency
departmentsin11UnitedStatescitiesin2004withskinandsofttissueinfections,59percentwerecausedby
MRSAand97percentofcasesofMRSAwerecausedbyCAMRSA[12].(See"Methicillinresistant
Staphylococcusaureusinfectioninadults:Epidemiology",sectionon'Communityassociatedmethicillinresistant
Staphylococcusaureus'.)
AlthoughHaemophilusinfluenzaewaspreviouslyacommoncauseofpreseptalcellulitis,routineimmunizationof
childrenwiththeH.influenzaetypebvaccinehascausedasharpdeclineintheincidenceofthisspeciesasa
causeofpreseptalcellulitis[2].(See"Microbiology,epidemiologyandtreatmentofHaemophilusinfluenzae".)
InfrequentcausesofpreseptalcellulitisincludeAcinetobacterspecies[13,14],Nocardiabrasiliensis[15],Bacillus
anthracis[16],Pseudomonasaeruginosa[17],Neisseriagonorrhoeae[18],Proteusspp[19],Pasteurellamultocida
[8],Mycobacteriumtuberculosis[20],andTrichophytonspp(thecauseof"ringworm")[21].Thesepathogenscan
usuallybelinkedtospecificexposures.
CLINICALMANIFESTATIONSPatientswithpreseptalcellulitistypicallypresentwithocularpain,eyelid
swelling,anderythema(picture1)importantly,preseptalandorbitalcellulitismaybeconfusedwithoneanother
becausebothinfectionscancausethesemanifestations,buttheyhaveverydifferentclinicalimplications[3,22
25].Incontrasttopreseptalcellulitis,orbitalcellulitiscausesswellingandinflammationoftheextraocularmuscles
andfattytissueswithintheorbit,leadingtopainwitheyemovements,proptosis,andophthalmoplegiawith
diplopia.Chemosis(conjunctivalswelling)mayoccasionallyoccurinseverecasesofpreseptalcellulitisbutis
morecommonwithorbitalcellulitis.Orbitalcellulitis,butnotpreseptalcellulitis,maycausevisualimpairment.Ina
http://www.uptodate.com/contents/preseptalcellulitis?topicKey=ID%2F16650&elapsedTimeMs=15&source=machineLearning&searchTerm=cellulitis&select

2/16

8/27/2015

Preseptalcellulitis

retrospectivestudythatincluded262children,feveroccurredmorecommonlyinthosewithorbitalcellulitisthanin
thosewithpreseptalcellulitis(94versus47percent)[3].Leukocytosismaybepresentinpatientswithpreseptal
cellulitisbutisnotasensitiveindicatorofthisinfection.Theclinicalmanifestationsoforbitalcellulitisare
discussedingreaterdetailseparately.(See"Orbitalcellulitis",sectionon'Clinicalmanifestations'.)
Seriouscomplicationsareveryrareinpreseptalcellulitis.Itisrareforuntreatedpreseptalcellulitistogiveriseto
orbitalcellulitisandveryrareforeitherinfectiontoinvadetheglobe(toproduceendophthalmitis).However,some
casesthatareinitiallydiagnosedaspreseptalcellulitismay,infact,beorbitalcellulitis.Therefore,cliniciansmust
bevigilantforfeaturessuggestingpossiblemisdiagnosis.(See'Diagnosis'belowand"Orbitalcellulitis",sectionon
'Diagnosis'.)
Thetablesindicatetheclinicalsignsandsymptomsassociatedwiththetwoconditions(table2andtable3).
Combinedwithimagingstudies,whenindicated,thesefeaturesusuallyallowforareasonabledegreeof
confidenceindistinguishingbetweenthetwoentities.However,theclinicalevaluationcanbechallenginginyoung
children,whomaynotbeabletocooperatewithafullexamination.
DIFFERENTIALDIAGNOSISThedifferentialdiagnosisofpreseptalcellulitisincludes:
Orbitalcellulitis(see"Orbitalcellulitis")
Insectbite
Allergicresponse
Hordeolum(stye)
Conjunctivitis
Itiscriticaltodistinguishpreseptalcellulitisfromthemoreseriousorbitalcellulitis.(See"Orbitalcellulitis",section
on'Diagnosis'.)
DIAGNOSISThediagnosisofpreseptalcellulitisisbaseduponthehistory(eg,insectbite,localfaceand/or
eyelidtrauma)andphysicalexamination,but,incasesinwhichthereisdoubt,computedtomography(CT)
scanningoftheorbitsandsinusesisusedtodistinguishpreseptalcellulitisfromorbitalcellulitis.Theapproachto
diagnosiswhenacaseofpreseptalcellulitisisdifficulttodistinguishfromorbitalcellulitisisdiscussedseparately.
(See"Orbitalcellulitis",sectionon'Diagnosis'.)
Despitethelowyield,werecommendobtainingbloodculturesfrompatientswithsuspectedpreseptalcellulitis
beforetheadministrationofantibiotics.
ImagingstudiesContrastenhancedCTscanningoftheorbitsandsinusesishelpfulfordistinguishing
betweenpreseptalandorbitalcellulitis.Inpreseptalcellulitis,thereisswellingoftheeyelid(s)butnoproptosis,no
fatstrandingoftheorbitalcontents,andnoedemaoftheextraocularmuscles.Sinusitismaybepresentin
preseptalcellulitisbutisalmostalwayspresentinorbitalcellulitis.Itisimportanttonotethatinsomecasesof
orbitalcellulitis,theCTscanabnormalitiesmaybesubtle.
Imagingstudiesareindicatedifanyoftheclinicalsignsorsymptomspointtoorbitalcellulitisratherthanpreseptal
cellulitis.Theyarealsoindicatedinpatientswithpresumedpreseptalcellulitiswhoexhibitmarkedeyelidswelling,
fever,andleukocytosis,orwhoseinfectionfailstoshowimprovementafter24to48hoursofappropriate
antibiotics.Imagingstudiesinpatientswithsuspectedorbitalcellulitisarediscussedindetailseparately.(See
"Orbitalcellulitis",sectionon'Imagingstudies'.)
TREATMENTTherearenorandomizedtrialsofantibioticregimensforthetreatmentofpreseptalcellulitis.
Bloodculturesarerarelypositiveandculturesfromthesiteofinfectionaredifficulttoobtain.Therefore,treatment
isalmostalwaysempiricandbaseduponknowledgeofthecommoninfectingorganisms(Staphylococcusaureus,
Streptococcuspneumoniae,otherstreptococciandanaerobes)andtheirusualsusceptibilitypatterns.
http://www.uptodate.com/contents/preseptalcellulitis?topicKey=ID%2F16650&elapsedTimeMs=15&source=machineLearning&searchTerm=cellulitis&select

3/16

8/27/2015

Preseptalcellulitis

Adultsandchildrenolderthanoneyearofagewithmildpreseptalcellulitisandnosignsofsystemictoxicitycan
generallybetreatedasoutpatientswithoralantibioticsprovidedthatclosefollowupcanbeensured.Children
youngerthanoneyearofage,childrenwhocannotcooperatefullyforanexamination,andpatientswhoare
severelyillshouldgenerallybeadmittedtothehospitalandmanagedaccordingtotherecommendationsfororbital
cellulitis.Thisisdiscussedingreaterdetailseparately.(See"Orbitalcellulitis",sectionon'Treatment'.)
Itisimportanttonotethatpatientswithsubtleclinicaland/orradiographicfindingssuggestingthattheorbitis
involvedshouldbetreatedasthoughtheyhaveorbitalcellulitisgiventheseriouscomplicationsofthisentity.
Youngchildrenwhoarenotabletocooperateforathoroughexaminationshouldalsobetreatedasthoughthey
haveorbitalcellulitis.(See"Orbitalcellulitis",sectionon'Treatment'.)
AntibioticregimensThechoiceofantibioticsforempirictreatmenthasbeenmademuchmoredifficultbythe
emergenceofcommunityacquiredmethicillinresistantS.aureus(CAMRSA),whichnowconstituteasubstantial
proportionofcommunityacquiredstrainsofS.aureus.Previously,amoxicillinclavulanicacid,cefpodoxime,and
cefdinirwereexcellentchoices.However,theseagentsdonothaveactivityagainstCAMRSA.Orally
administereddrugsthathavegoodactivityagainstmoststrainsofCAMRSAincludetrimethoprim
sulfamethoxazole,clindamycin,andtetracyclines(eg,doxycycline).However,trimethoprimsulfamethoxazoleand
doxycyclinearenotreliablyeffectiveforgroupAstreptococcalinfections,anddoxycyclineisnotapprovedforuse
inchildrenundertheageofeightyears,andshouldbeusedwithcautioninsuchpatients.
Therefore,wesuggestoneofthefollowingregimensforempiricoraltreatmentofpreseptalcellulitis:
Clindamycin:
Inchildren:30to40mg/kgperdayinthreetofourequallydivideddoses,nottoexceed1.8gramsper
day[26]
Inadults:300mgeveryeighthours)monotherapyor
Trimethoprimsulfamethoxazole(TMPSMXinchildren:8to12mg/kgperdayofthetrimethoprimcomponent
dividedevery12hoursinadults:8mg/kgperdayofthetrimethoprimcomponentdividedevery8or12hours
[onedoublestrengthtabletcontains160mgoftrimethoprimasexamples,TMPSMXcanbegivenasone
doublestrengthtabletevery8hoursortwodoublestrengthtabletsevery12hoursdependingonthepatient's
weight])plusoneofthefollowing:
Amoxicillin
Inchildren:usualdosingis45mg/kgperdaydividedevery12hoursdosingforsevereinfections
orwhenpenicillinresistantStreptococcuspneumoniaeisaconcernis80to100mg/kgperdayin
divideddoseseveryeighthours
Inadults:875mgorallyevery12hoursor
Amoxicillinclavulanicacid
Inchildren:usualdosingis45mg/kgperdaydividedevery12hoursdosingforsevereinfections
orwhenpenicillinresistantS.pneumoniaeisaconcern(usingthe600mg/5mLsuspension)is90
mg/kgperdaydividedevery12hours
Inadults:875mgevery12hoursor
Cefpodoxime
Inchildren<12yearsofage:10mg/kgperdaydividedevery12hours,usualmaximumdose200
mginchildren12yearsandadolescents:400mgevery12hours
Inadults:400mgevery12hoursor
http://www.uptodate.com/contents/preseptalcellulitis?topicKey=ID%2F16650&elapsedTimeMs=15&source=machineLearning&searchTerm=cellulitis&select

4/16

8/27/2015

Preseptalcellulitis

Cefdinir
Inchildren:7mg/kgtwicedaily,maximumdailydose600mg
Inadults:300mgtwicedaily
Therecommendationtouseclindamycinaloneisbasedprimarilyonpublishedsusceptibilitydataratherthanon
clinicalefficacydataforpatientswithpreseptalcellulitis.However,thedrughasshowngoodefficacyforskinand
softtissueinfectionscausedbystaphylococciandstreptococci[26].(See"Treatmentofskinandsofttissue
infectionsduetomethicillinresistantStaphylococcusaureusinadults",sectionon'Clindamycin'and"Evaluation
andmanagementofsuspectedmethicillinresistantStaphylococcusaureusskinandsofttissueinfectionsin
children".)
IfthepatienthasnotbeenimmunizedagainstHaemophilusinfluenzae,oneofthecombinationregimensshouldbe
usedinordertoinsurecoverageforthisorganism.
Topicalantibioticshavenoroleinthetreatmentofthisinfection.
ResponsetotherapyPreseptalcellulitistypicallyrespondsrapidlyandcompletelytoappropriateantibiotics.
Outpatientswhoseinfectionsfailtoshowsignsofimprovementin24hoursshouldgenerallybehospitalized,
treatedwithbroadspectrumintravenousantibiotics,andundergoacomputedtomography(CT)scantoevaluate
fororbitalcellulitisanditscomplications.(See"Orbitalcellulitis",sectionon'Treatment'.)
DurationTherearenocontrolledtrialsevaluatingthedurationofantimicrobialtherapyinpreseptalcellulitis.
Treatmentrecommendationsarebasedonsmallcaseseries.Wegenerallyrecommendadurationof7to10days
[27,28],butifsignsofcellulitispersistattheendofthisperiod,treatmentshouldbecontinueduntiltheeyelid
erythemaandswellinghaveresolvedornearlyresolved.
RecurrentpreseptalcellulitisPreseptalcellulitisrarelyrecurs.Whenitdoes,itisusuallyduetoanunderlying
causethathasnotbeendiagnosed[29,30].Acaseseriesofsixpatientswithrecurrentpreseptalcellulitis,defined
asthreeormoreepisodeswithinaoneyearperiodwithcompleteresolutionbetweenepisodes,identifiedthe
underlyingcauseintwopatientsasenvironmentalallergies,andinonepatienteachasrecurrentsinusitis,herpes
simplexinfection,contactdermatitistocosmetics,andMunchausenssyndrome[29].Ananatomicabnormalityof
thesinusesmayalsopredisposetorecurrentpreseptalcellulitis[30].
SUMMARYANDRECOMMENDATIONSPreseptalcellulitisandorbitalcellulitisinvolvedifferentanatomic
sites,withpreseptalcellulitisreferringtoinfectionsofthesofttissuesanteriortotheorbitalseptumandorbital
cellulitisreferringtoinfectionsposteriortoit(figure1).Orbitalcellulitisinvolvesthemusclesandfatlocatedwithin
theorbit.Althoughpreseptalandorbitalcellulitismaybeconfusedwithoneanotherbecausebothcancause
ocularpainandeyelidswellinganderythema,theyhaveverydifferentclinicalimplications.Preseptalcellulitisis
generallyamildconditionthatrarelyleadstoseriouscomplications,whereasorbitalcellulitismaycauselossof
visionandevenlossoflife.Orbitalcellulitiscanusuallybedistinguishedfrompreseptalcellulitisbyitsclinical
features(ophthalmoplegia,painwitheyemovements,andproptosis)andbyimagingstudiesincasesinwhichthe
distinctionisnotclear,cliniciansshouldtreatpatientsasthoughtheyhaveorbitalcellulitis.Bothconditionsare
morecommoninchildrenthaninadults.(See'Introduction'aboveand'Terminology'above.)
Preseptalcellulitisarisesmostcommonlyfromsinusitisoracontiguousinfectionofthesofttissuesofthe
faceandeyelidssecondarytolocaltrauma,insectoranimalbites,orforeignbodies.(See'Pathogenesis'
above.)
ThemostcommoncausesofpreseptalcellulitisareStreptococcuspneumoniaeandotherstreptococci,
Staphylococcusaureus(includingcommunityacquiredmethicillinresistantS.aureus[CAMRSA]),and
anaerobes(table1).(See'Microbiology'above.)
Thediagnosisofpreseptalcellulitisisbaseduponthehistory(eg,insectbite,localfaceand/oreyelidtrauma)
andphysicalexamination.However,incasesinwhichthereisdoubt,computedtomography(CT)scanning
http://www.uptodate.com/contents/preseptalcellulitis?topicKey=ID%2F16650&elapsedTimeMs=15&source=machineLearning&searchTerm=cellulitis&select

5/16

8/27/2015

Preseptalcellulitis

oftheorbitsandsinusescanusuallydistinguishpreseptalcellulitisfromorbitalcellulitis.(See'Diagnosis'
above.)
Duringtheinitialevaluation,itiscriticaltodistinguishpreseptalcellulitisfromthemoreseriousorbital
cellulitis(table2andtable3).Althoughbothpreseptalcellulitisandorbitalcellulitistypicallycauseeyelid
swellinganderythema,thepresenceofophthalmoplegia,painwitheyemovements,chemosis,and/or
proptosisoccuronlywithorbitalcellulitis.(See'Clinicalmanifestations'above.)
Adultsandchildrenolderthanoneyearofagewithmildpreseptalcellulitiscanbemanagedonanoutpatient
basis,providedthatthepatienthasnosignsofsystemictoxicityandclosefollowupisensured.Inthese
cases,werecommendtreatmentwithoralantibioticswithactivityagainstS.aureus(includingMRSA)and
streptococci,suchasclindamycinmonotherapyorcombinationtherapywithtrimethoprimsulfamethoxazole
plusoneofthefollowingagents:amoxicillin,amoxicillinclavulanicacid,cefpodoxime,orcefdinir(Grade
2B).IfthepatienthasnotbeenimmunizedagainstHaemophilusinfluenzae,oneofthecombinationregimens
shouldbeused.(See'Antibioticregimens'above.)
Wegenerallyrecommendatreatmentdurationof7to10days,butifsignsofcellulitispersistattheendof
thisperiod,treatmentshouldbecontinueduntiltheerythemaandswellinghaveresolvedornearlyresolved.
(See'Duration'above.)
Patientsyoungerthanoneyearofageandthosewhoareseverelyillshouldbeadmittedtothehospitaland
managedaccordingtotherecommendationsfororbitalcellulitis.Patientswithsubtleclinicaland/or
radiographicfindingssuggestingthattheorbitisinvolved,aswellasyoungchildrenwhoarenotableto
cooperateforathoroughexamination,shouldalsobetreatedasthoughtheyhaveorbitalcellulitisgiventhe
seriouscomplicationsofthisentity.(See"Orbitalcellulitis",sectionon'Treatment'.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
Topic16650Version13.0

http://www.uptodate.com/contents/preseptalcellulitis?topicKey=ID%2F16650&elapsedTimeMs=15&source=machineLearning&searchTerm=cellulitis&select

6/16

8/27/2015

Preseptalcellulitis

GRAPHICS
Theorbitalseptum

Diagramshowingtheproximityoftheperiosteuminrelationtotheorbital
septum.Orbitalcellulitisarisesposteriortotheorbitalseptum.
Graphic68971Version4.0

http://www.uptodate.com/contents/preseptalcellulitis?topicKey=ID%2F16650&elapsedTimeMs=15&source=machineLearning&searchTerm=cellulitis&select

7/16

8/27/2015

Preseptalcellulitis

Medialwalloftheleftorbit(lateralwallremoved)

Notetheproximityofthefrontal,ethmoidal,andmaxillarysinusestothe
orbitalspace.Thelaminapapyraceaisthethinbonewallonthesurfaceof
theethmoidaircells.
Graphic71411Version5.0

http://www.uptodate.com/contents/preseptalcellulitis?topicKey=ID%2F16650&elapsedTimeMs=15&source=machineLearning&searchTerm=cellulitis&select

8/16

8/27/2015

Preseptalcellulitis

Venousdrainageoftheorbit

Thediagramdemonstratesthecommunicationbetweenethmoidalsinuses,theorbit,
andthecavernoussinus.
Graphic61214Version2.0

http://www.uptodate.com/contents/preseptalcellulitis?topicKey=ID%2F16650&elapsedTimeMs=15&source=machineLearning&searchTerm=cellulitis&select

9/16

8/27/2015

Preseptalcellulitis

Microbiologyofpreseptalandorbitalcellulitis*
Preseptal
cellulitis

Orbitalcellulitis

Chaudhry,
etal [1]

Botting,
etal [2]

McKinley,
etal [3]

Numberof
patients

104

227

38

Numberof

36

53

MSSA
MRSA

Seltz,et
al [4]

Nageswaran,
etal [5]

Botting,
etal [2]

Goytia,et
al [6]

94

41

35

85

24

29

20

11

29

32

11

14

NR

NR

NR

NR

NR

NR

NR

NR

15

13

10

14

Rothia
mucilaginosa

Haemophilus
influenzae

Haemophilus

Klebsiella
pneumoniae

Moraxella
catarrhalis

Arcanobacterium

patientswitha
positiveculture
(except )

Staphylococcus
aureus

Alphahemolytic
streptococci
(includingS.
pneumoniae)or
nonhemolytic
streptococci
Betahemolytic
streptococci
(includingS.
pyogenes)
Streptococcus
anginosus
(formerlyS.
milleri)

parainfluenzae

spp
Eikenella

http://www.uptodate.com/contents/preseptalcellulitis?topicKey=ID%2F16650&elapsedTimeMs=15&source=machineLearning&searchTerm=cellulitis&selec

10/16

8/27/2015

Preseptalcellulitis

corrodens
Anaerobes

Skin

11

12

Possible
pathogen

10

Sitesofculture

Blood,
wound,

NR

Blood,
orbital

Blood,
sinus/orbit,

Orbital
abscess,

NR

Blood,
endoscopic

abscess,
eye,sinus,
epidural

subdural
space

subperiostial
abscess,sinus

flora/contaminant

abscess

sinus,
subperiostea
intraorbital

abscess,
nose
MSSA:methicillinsusceptibleStaphylococcusaureusMRSA:methicillinresistantStaphylococcusaureus
NR:notreported.
*Resultsarereportedasthenumberofculturesthatgrewagivenorganism.Someculturesgrew>1
organismandsomepatientshad>1positiveculture.
Resultsarereportedasnumberofpositivecultures(ratherthannumberofpatientswithapositive
culture)somepatientsmayhavehad>1positiveculture.
StaphylococcussppandStreptococcussppwererecoveredfrom26(72percent)ofcultures,butthe
authorsdidnotreportthenumberofpositiveculturesforindividualspecies.
InMcKinley,etal [3] ,coagulasenegativeStaphylococcussppwasreportedasarecoveredorganism,
butinSeltz,etal [4] ,thisorganismwasclassifiedasacontaminant.Wehaveclassifieditasa
contaminantforbothstudies.
Theauthorsofthisstudyclassifedsome(butnotall)sinus/orbitculturesaspossiblepathogensrather
thantruepathogens.
References:
1. ChaudhryIA,ShamsiFA,ElzaridiE,etal.Inpatientpreseptalcellulitis:experiencefromatertiary
eyecarecentre.BrJOphthalmol200892:1337.
2. BottingAM,McIntoshD,MahadevanM.Paediatricpreandpostseptalperiorbitalinfectionsare
differentdiseases.Aretrospectivereviewof262cases.IntJPediatrOtorhinolaryngol2008
72:377.
3. McKinleySH,YenMT,MillerAM,YenKG.Microbiologyofpediatricorbitalcellulitis.AmJOphthalmol
2007144:497.
4. SeltzLB,SmithJ,DurairajVD,etal.Microbiologyandantibioticmanagementoforbitalcellulitis.
Pediatrics2011127:e566.
5. NageswaranS,WoodsCR,BenjaminDKJr,etal.Orbitalcellulitisinchildren.PediatrInfectDisJ
200625:695.
6. GoytiaVK,GiannoniCM,EdwardsMS.Intraorbitalandintracranialextensionofsinusitis:
comparativemorbidity.JPediatr2011158:486.
Graphic77104Version3.0

http://www.uptodate.com/contents/preseptalcellulitis?topicKey=ID%2F16650&elapsedTimeMs=15&source=machineLearning&searchTerm=cellulitis&selec

11/16

8/27/2015

Preseptalcellulitis

Orbitalcellulitis

Thisyounggirlhaserythemaandedemainthepreseptalarea,whichcouldbe
causedbyeitherorbitalorpreseptalinfection.
Reproducedwithpermissionfrom:FleisherGR,LudwigW,BaskinMN.AtlasofPediatric
EmergencyMedicine.Philadelphia:LippincottWilliams&Wilkins,2004.Copyright
2004LippincottWilliams&Wilkins.
Graphic57604Version2.0

http://www.uptodate.com/contents/preseptalcellulitis?topicKey=ID%2F16650&elapsedTimeMs=15&source=machineLearning&searchTerm=cellulitis&selec

12/16

8/27/2015

Preseptalcellulitis

Clinicalfeaturesofpreseptalandorbitalcellulitis
Clinicalfeature

Preseptalcellulitis

Orbitalcellulitis

Eyelidswellingwithorwithout
erythema

Yes

Yes

Eyepain/tenderness

Maybepresent

Yesmaycausedeepeye
pain

Painwitheyemovements

No

Yes

Proptosis

No

Usually,butmaybe
subtle

Ophthalmoplegia+/diplopia

No

Yes

Visionimpairment

No

Maybepresent*

Chemosis

Rarelypresent

Maybepresent

Fever

Maybepresent

Usuallypresent

Leukocytosis

Maybepresent

Maybepresent

*Anafferentpupillarydefectmaysignalimpendingvisualloss.
References:
1. SeltzLB,SmithJ,DurairajVD,etal.Microbiologyandantibioticmanagementoforbitalcellulitis.
Pediatrics2011127:e566.
2. DurandML.Periocularinfections.In:PrinciplesandPracticeofInfectiousDiseases,7thed,Mandell
GL,Bennett,etal.(Eds),ChurchillLivingstoneElsevier,Philadelphia2010.p.1569.
3. ChaudhryIA,ShamsiFA,ElzaridiE,etal.Inpatientpreseptalcellulitis:experiencefromatertiary
eyecarecentre.BrJOphthalmol200892:1337.
4. BottingAM,McIntoshD,MahadevanM.Paediatricpreandpostseptalperiorbitalinfectionsare
differentdiseases.Aretrospectivereviewof262cases.IntJPediatrOtorhinolaryngol2008
72:377.
5. NageswaranS,WoodsCR,BenjaminDKJr,etal.Orbitalcellulitisinchildren.PediatrInfectDisJ
200625:695.
6. SobolSE,MarchandJ,TewfikTL,etal.Orbitalcomplicationsofsinusitisinchildren.JOtolaryngol
200231:131.
7. GivnerLB.Periorbitalversusorbitalcellulitis.PediatrInfectDisJ200221:1157.
Graphic55123Version3.0

http://www.uptodate.com/contents/preseptalcellulitis?topicKey=ID%2F16650&elapsedTimeMs=15&source=machineLearning&searchTerm=cellulitis&selec

13/16

8/27/2015

Preseptalcellulitis

Clinicalmanifestationsofpreseptalandorbitalcellulitisstudieson
admission
Study:Studydesign,patientpopulation
Nageswaran,et

Chaudhry,et

al [1]:
Retrospective,
children

Botting,et

al [2]:
Retrospective,
children

al [3]:
Retrospective ,
childrenand
adults

Sobol,etal [4]:
Retrospective,
children

Typeofcellulitis

Typeofcellulitis

Typeofcellulitis

Typeofcellulitis

Preseptal

Orbital
(n=41)

Preseptal
(n=
227)

Orbital
(n=
35)

Preseptal
(n=
104)

Orbital

Preseptal
(n=
101)

Orbital
(n=
26)

Presept

Age(yrs)

7.5
(range
016)

3.9

7.5

19
(range
075)

3.8
(range
016)

6.4
(range
013)

Historyof

Excluded

89(39)

4(11)

28

Eyepainand/or
tenderness

64(62)

Eyelidswelling
+/erythema

104
(100)

Proptosis

25(61)

2(0.9)

33

1(1)

20

trauma*

(94)

(77)

Ophthalmoplegia

19(46)

1(0.4)

4(11)

1(1)

20
(77)

Diplopia

2(0.9)

19
(54)

Visionimpaired

1(3)

3(3)

3(11)

No
ophthalmologic
signs(proptosis,
ophthalmoplegia,

11(27)

Chemosis

Fever

27(66)

106(47)

33
(94)

Children
52
percent
adults
10

59(59)

18
(69)

visualloss)

percent
Whitebloodcell
count>15,000

19(46)

http://www.uptodate.com/contents/preseptalcellulitis?topicKey=ID%2F16650&elapsedTimeMs=15&source=machineLearning&searchTerm=cellulitis&selec

14/16

8/27/2015

Preseptalcellulitis

Sinusitis
Ethmoid

21(9)

32
(91)

40(98)

30

22

sinusitis

(86)

(86)

Maxillary
sinusitis

29(71)

21
(60)

22
(86)

Subperiosteal
abscess

24(59)

12
(34)

Orbitalabscess

10(24)

2(6)

>Surgical
procedure

29(71)

11(5)

8(23)

52
(50)

6
(23)

Resultsarereportedasnumberofpatientswithagivenfinding(percent).
*Eg,insectbites,scratches.
ThisstudyinvolvedpatientsreferredtoatertiarycarehospitalinSaudiArabia.38.5percentofpatients
were>16yearsofage.Manyhadacutedacryocystitis,trauma,orrecentsurgery,whichisprobablywhy
suchalargeproportionofpatientsunderwentsurgicalprocedures.
Inthisstudy,12casesofchildrenwithsubperiostealabscesswereevaluatedseparatelythesecases
arenotshowninthetable,butthefindingsweresimilartothosewithsimpleorbitalcellulitis.Ofpatients
withorbitalcellulitisorsubperiostealabscess,12of38(32percent)hadasubperiostealabscess66
percentofpatientswithsubperiostealabscessunderwentsurgery.
ThemeanageisreportedforallstudiesexceptforSeltzetal [5] thisstudyreportedthemedianage.
Theethmoidandmaxillarysinuseswereinvolvedmostcommonly,butsomepatientshadfrontal
sinusitisand/orsphenoidsinusitismanypatientshadinvolvementofmultiplesinuses.
References:
1. NageswaranS,WoodsCR,BenjaminDKJr,etal.Orbitalcellulitisinchildren.PediatrInfectDisJ
200625:695.
2. BottingAM,McIntoshD,MahadevanM.Paediatricpreandpostseptalperiorbitalinfectionsare
differentdiseasesAretrospectivereviewof262cases.IntJPediatrOtorhinolaryngol2008
72:377.
3. ChaudhryIA,ShamsiFA,ElzaridiE,etal.Inpatientpreseptalcellulitis:experiencefromatertiary
eyecarecentre.BrJOphthalmol200892:1337.
4. SobolSE,MarchandJ,TewfikTL,etal.Orbitalcomplicationsofsinusitisinchildren.JOtolaryngol
200231:131.
5. SeltzLB,SmithJ,DurairajVD,etal.Microbiologyandantibioticmanagementoforbitalcellulitis.
Pediatrics2011127:e566.
Graphic62818Version3.0

http://www.uptodate.com/contents/preseptalcellulitis?topicKey=ID%2F16650&elapsedTimeMs=15&source=machineLearning&searchTerm=cellulitis&selec

15/16

8/27/2015

Preseptalcellulitis

http://www.uptodate.com/contents/preseptalcellulitis?topicKey=ID%2F16650&elapsedTimeMs=15&source=machineLearning&searchTerm=cellulitis&selec

16/16