e xtends from the periosteum of the orbital rim to the levator aponeurosis
TRANSCRIPT
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PERIORBITAL AND ORBITAL INFECTIONS
CHAD KAUFFMAN DO
INDIANA OSTEOPATHIC ASSOCIATION
33RD ANNUAL WINTER UPDATE
12.6.14
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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
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ORBITAL ANATOMY
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ORBITAL SEPTUM
FIBROUS MEMBRANE SEPARATING THE ORBITAL AND PRESEPTAL COMPARTMENT
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UPPER EYELID
EXTENDS FROM THE PERIOSTEUM OF THE ORBITAL RIM TO THE LEVATOR APONEUROSIS
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LOWER EYELID
EXTENDS FROM THE PERIOSTEUM OF THE ORBITAL RIM TO THE INFERIOR BORDER OF THE TARSAL PLATE
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ROUTES OF INFECTION EXTENSION TO LIDS AND ORBIT
INDIRECT SPREAD VENOUS DRAINAGE SYSTEM SHARED BY CRANIAL AND
MIDFACE STRUCTURES
MULTIPLE ANASTOMOSES AND VALVELESS SYSTEM
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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
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PRESEPTAL CELLULITIS AN INFECTION OR INFLAMMATORY PROCESS OF THE
EYELIDS AND PERIORBITAL STRUCTURES OCCURS ANTERIOR TO AND CONTAINED BY THE ORBITAL
SEPTUM
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ORBITAL CELLULITIS OCCURS POSTERIOR TO THE ORBITAL SEPTUM INVOLVES THE SOFT TISSUE WITHIN THE BONY ORBIT
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CELLULITIS - COMMON ETIOLOGIES
1. SPREAD FROM ADJACENT STRUCTURES – SKIN AND SINUSES
2. DIRECT INOCULATION FOLLOWING TRAUMA
3. BACTERIAL SPREAD UPPER RESPIRATORY OR MIDDLE EAR
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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
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CHALAZION
MOST COMMON INFLAMMATORY LESION OF EYELID
BLOCKED MEIBOMIAN GLAND
INFLAMMATORY NODULE/CYST
LIPOGRANULOMATOUS
NOT INFECTIOUS
TYPICALLY NOT PAINFUL
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CHALAZION
MANAGED BY WARM COMPRESSES AND MASSAGE
EXCISION/ STEROID INJECTION
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CHALAZION
PREVENTIONROUTINE USE OF WARM COMPRESSES
LID MARGIN CLEANSING
LOW DOSE ORAL DOXYCYCLINE
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ERYSIPELAS
SUPERFICIAL CELLULITIS
USUALLY GROUP A STREP
INTENSELY ERYTHEMATOUS WITH SHARPLY DEMARCATED BORDER
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HORDEOLUM
• BACTERIAL INFECTION
• MEBOMIAN GLAND OR CILIARY GLANDS (ZEISS OR MOLL)
• INTERNAL OR EXTERNAL
• TYPICALLY PAINFUL
• MAY LEAD TO PRESEPTAL CELLULITS
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HORDEOLUM
• MANAGEMENT
• STAPHYLOCOCCAL - MOST COMMON ETIOLOGY
• SYSTEMIC ANTIBIOTICS
• LANCE/DRAIN AS ABLE
• CHRONIC INFLAMMATION ASSOCIATED WITH CHALAZION FORMATION
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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
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DACRYOCYSTITIS
• MANAGEMENT
• ANTIBIOTICS – SYSTEMIC
• WARM COMPRESSES
• DRAINAGE
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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
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HERPES ZOSTER DERMATOBLEPHARITITS
• RECURRENCE OR REACTIVATION OF VARICELLA ZOSTER VIRUS
• BURNING, STABBING PAIN OF FOREHEAD/SCALP
• VESICULAR RASH IN V1 DISTRIBUTION
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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
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PRESEPTAL CELLULITIS
• OTHER CAUSES OF EYELID SWELLING
• CONTACT DERMATITIS
• INSECT BITES
• THYROID EYE DISEASE
• DACRYOADENITIS
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PRESEPTAL CELLULITIS
• OTHER CAUSES OF EYELID SWELLING
• CONTACT DERMATITIS
• THICKENED, ERYTHEMATOUS, SCALY SKIN
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PRESEPTAL CELLULITIS
• OTHER CAUSES OF EYELID SWELLING
• INSECT BITES
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PRESEPTAL CELLULITIS
• OTHER CAUSES OF EYELID SWELLING
• THYROID EYE DISEASE
• PERIORBITAL EDEMA
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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
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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
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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
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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
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ORBITAL CELLULITIS
OPHTHALMIC SIGNS• PROPTOSIS
• MOTILITY DISTURBANCE
• PRONOUNCED EDEMA AND ERYTHEMA
• IMPAIRED VISION WITH AFFERENT PUPIL DEFECT
• CONJUNCTIVAL CHEMOSIS AND HYPEREMIA
• REDUCED CORNEAL SENSATION
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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
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ORBITAL CELLULITIS
NONINFECTIOUS CAUSES OF ORBITAL INFLAMMATORY DISEASE
INFLAMMATORY AND AUTOIMMUNETHYROID OPHTHALMOPATHY
ORBITAL PSEUDOTUMOR
LYMPHOMA
DERMATOMYOSITIS-POLYMYOSITIS
WEGENER GRANULOMATOSIS
SJOGREN SYNDROME
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ORBITAL CELLULITIS
NONINFECTIOUS CAUSES OF ORBITAL INFLAMMATORY DISEASE
VASCULAR
ORBITAL VENOUS MALFORMATION
CAVERNOUS SINUS THROMBOSIS
ARTERIOVENOUS FISTULA
SUPERIOR VENA CAVA SYNDROME
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ORBITAL CELLULITIS
NONINFECTIOUS CAUSES OF ORBITAL INFLAMMATORY DISEASE
NEOPLASMS OF ORBIT AND LACRIMAL GLAND
PEDIATRIC: RHABDOMYOSARCOMA, LEUKEMIA, METASTATIC NEUROBLASTOMA, RETINOBLASTOMA
ADULT: LYMPHOMA
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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
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ORBITAL CELLULITIS
• LABORATORY STUDIES• CBC
• NASAL SWAB IF PURULENT MATERIAL
• BLOOD CULTURES
• LUMBAR PUNCTURE IF MENINGEAL SIGNS PRESENT
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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
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ORBITAL CELLULITIS
SIGNIFICANT MORBIDITY IF NOT APPROPRIATELY TREATED
ORBITAL APEX SYNDROME
BLINDNESS
CAVERNOUS SINUS THROMBOSIS
CRANIAL NERVE PALSIES
MENINGITIS
INTRACRANIAL ABSCESS
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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
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ORBITAL CELLULITIS
SURGICAL MANAGEMENTIF ORBITAL ABSCESS PRESENT
EARLY DRAINAGE OF INVOLVED SINUS
IF ORBITAL SIGNS PROGRESSING
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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