Endgames Picture Quiz

A swollen right eye in a child

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h554 (Published 05 February 2015) Cite this as: BMJ 2015;350:h554
  1. Mark S Harris, foundation year 2 doctor, ear, nose, and throat surgery1,
  2. Gaurav Chawdhary, specialist trainee, ear, nose, and throat surgery2
  1. 1Northampton General Hospital, Northampton NN1 5BD, UK
  2. 2Royal Berkshire Hospital, Reading, UK
  1. Correspondence to: M S Harris mh8481{at}my.bristol.ac.uk

A 9 year old boy presented to the emergency department with a one day history of generalised swelling of the right eye, conjunctival oedema, and difficulty opening the eye (fig 1). In the preceding two weeks he had experienced coryzal symptoms.


Fig 1 Periorbital swelling of the right eye


  • 1. What is the diagnosis?

  • 2. What is the likely infective source?

  • 3. Why is urgent assessment essential?

  • 4. How would you assess this patient?

  • 5. How would you treat this patient?


1. What is the diagnosis?

Short answer

Periorbital (preseptal) or orbital (post-septal) cellulitis.

Long answer

The terminology used in the literature is often ambiguous, with the terms “periorbital” and “preseptal” cellulitis used interchangeably. Similarly, the terms “orbital” cellulitis and “post-septal” cellulitis are also used interchangeably.

The orbital septum is a tough fibrous membrane that forms the scaffold for the eyelids. It also provides a barrier to infection between the superficial tissues of the face and the deep tissues within the orbits.1 2 Infection superficial to this layer (preseptal) is termed periorbital cellulitis, whereas infection deep to the orbital septum (post-septal) is termed orbital cellulitis.

2. What is the likely infective source?

Short answer

Infection of the paranasal sinuses (most commonly ethmoid sinusitis). Causative organisms tend to reflect the underlying involvement of sinus disease, with Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus, and Haemophilus species most commonly being cultured.3

Long answer

Periorbital and orbital cellulitis can have a sinugenic or non-sinugenic cause. Given the history of coryzal symptoms, this patient’s infection probably originated from the paranasal sinuses (maxillary, ethmoid, frontal, or sphenoid sinusitis).

Anatomically, the ethmoid sinuses lie directly medial to the orbits and are separated from the orbital cavities by a ‘paper thin’ layer of bone called the lamina papyracea. This makes the orbital cavities vulnerable to direct spread of infection from the nose.1 2

Non-sinugenic causes of infection are less common but include facial cellulitis that spreads to the periorbital soft tissues, local trauma that causes periorbital infection, and haematogenous spread from a distant focus.4

3. Why is urgent assessment essential?

Short answer

This is a potentially sight threatening or life threatening infection. Sight is threatened if the infection compresses the optic nerve and life is threatened if the infection spreads intracranially (posteriorly into the cavernous sinuses).

Long answer

It can be difficult to differentiate periorbital (preseptal) infection from the more serious orbital (post-septal) infection on the basis of clinical examination alone. Given the potentially catastrophic outcomes (blindness and intracranial infection) in suboptimally treated orbital infection, guidelines advocate that almost all cases require admission to hospital for formal assessment and management.5 Only mild upper lid swelling with a normal eye examination is considered safe to manage on an outpatient basis, and then with regular review to assess for any signs of progression.

The seriousness of infection must be rapidly established: it needs to be ascertained whether this is periorbital (preseptal) cellulitis or the more worrying orbital (post-septal) cellulitis. Periorbital (preseptal) cellulitis does not directly threaten sight or life. Alternatively, orbital cellulitis (post-septal) is characterised by infection deep into the orbital septum within the orbital cavity. It is thus more dangerous because it can damage the optic nerve and cause blindness through direct compression and toxic infective metabolites. It may also spread posteriorly through venous drainage channels to cause cavernous sinus infection or thrombosis, which is life threatening. Other intracranial complications have been reported and include extradural, subdural, and intracerebral abscess; meningitis; and encephalitis.4 5 6

Chandler’s classification describes the progressively more serious stages of infection:

  • Group I: Preseptal cellulitis (periorbital)

  • Group II: Orbital cellulitis

  • Group III: Subperiosteal abscess

  • Group IV: Orbital abscess

  • Group V: Cavernous sinus thrombosis.4

An alternative system described by Jain and Rubin in 2001 provides a simpler classification of periorbital infections:

  • Preseptal cellulitis

  • Orbital cellulitis (with or without intracranial complications)

  • Orbital abscess (with or without intracranial complications)

    • -Intraorbital abscess, which may arise from a collection of purulent material in an orbital cellulitis

    • - Subperiosteal abscess, which may lead to true infection of orbital soft tissues.4

4. How would you assess this patient?

Short answer

Look for adverse signs of orbital involvement (proptosis, red eye, painful or reduced eye movements, diplopia, impaired red colour vision, reduced visual acuity, or relative afferent pupillary defect) or intracranial involvement (altered Glasgow coma score and signs of sepsis or meningitis). If present, request urgent contrast computed tomography of the head, including coronal and axial views of the sinuses and orbits.

Long answer

Adverse signs suggestive of orbital involvement include: proptosis, red eye, painful or reduced eye movements, diplopia, impaired red colour vision, reduced visual acuity, and relative afferent pupillary defect. A relative afferent pupillary defect is a clinical sign that can be elicited using the swinging light test, and it indicates a potential lesion of the optic nerve.

Signs of intracranial spread include severe bilateral eyelid oedema (cavernous sinus thrombosis), other cranial nerve involvement, altered Glasgow coma score, and signs of systemic sepsis or meningitis. Sepsis is defined by the Royal College of Physicians as any two of the following criteria in the presence of an infection:

  • Heart rate greater than 90 beats/min

  • Temperature greater than 38.3°C or less than 36°C

  • Respiratory rate greater than 20 breaths/min or arterial carbon dioxide pressure less than 32 mm Hg (4.3 kPa)

  • Total white cell count less than 4×109/L or more than 12×109/L.7

Important signs that might indicate meningitis include drowsiness, vomiting, seizures, cranial nerve disturbance, and meningism (characterised by the triad of headache, photophobia, and neck stiffness).5

Urgent radiological imaging is needed to confirm or exclude orbital or intracranial involvement in patients with adverse signs. The gold standard test is contrast enhanced computed tomography of the head, including coronal and axial views of the sinuses and orbits.4 6 This allows accurate identification of the suspected pathology and informs subsequent treatment, whether medical or surgical. If surgery is needed, imaging directs the likely approach and extent, depending on where the abscess is and whether neurosurgical input is required. Magnetic resonance imaging of the head may also be considered, in addition to computed tomography, to better define any intracranial complications; discussion with a radiologist will help to determine the optimum imaging in each case.6

Other baseline investigations should be conducted, including full blood count, urea and electrolytes, and C reactive protein, to monitor the patient’s infective markers and renal function. Blood cultures should be considered before starting antibiotics. Furthermore, any localised ocular, skin, or nasal discharge should be swabbed and sent for microbiological culture and sensitivity analysis.6

5. How would you treat this patient?

Short answer

Integrated care from ophthalmology (for visual assessment), otolaryngology (for potential surgical management), and paediatrics (if the patient is systemically unwell and requires admission) is recommended for comprehensive assessment and management. The patient will require systemic antibiotics, topical nasal steroids and nasal decongestants, and in the case of orbital abscess, surgical drainage.

Long answer

An integrated approach to care from multiple specialties, including ophthalmology, otolaryngology, and paediatrics, may be needed to manage this condition.5 6 Indeed, such patients can initially present to any of these disciplines. A detailed ophthalmological assessment is crucial; formal documentation of visual acuity is needed to monitor vision over time. It is also important for medicolegal reasons in the event of a poor visual outcome. Patients are usually admitted under joint care with the paediatrics department, which often coordinates care between specialties and may manage paediatric aspects of care, such as treatment of systemic sepsis and fluid balance requirements. Finally operative intervention, if needed, is usually carried out by otolaryngologists, who also treat the sinugenic infective cause. If the infection has spread intracranially, neurological or neurosurgical input may be required.6

Regarding specific treatment, in periorbital (preseptal) cellulitis with no adverse signs oral or intravenous antibiotics should be given as dictated by clinical severity. In orbital (post-septal) cellulitis without abscess formation, intravenous broad spectrum antibiotics should be used to cover for staphylococci and streptococci.8 Abscess formation necessitates further anaerobic cover. The specific antibiotic protocol varies from one hospital to another, but a standard empirical regimen is cefuroxime and metronidazole.5 This may change as sample sensitivities become available. In addition, the patient should receive topical nasal decongestants and topical nasal steroids to treat the acute sinusitis. Patients require close monitoring for deterioration, with red-green colour vision and visual acuity initially measured hourly.6

If the patient does not improve with antibiotics or serious complications are identified on examination or investigation, surgical intervention may be needed to decompress the orbit and drain the abscess and sinuses. The surgical approach can be either endoscopic or external.

The endoscopic approach uses functional endoscopic sinus surgery to elevate the lamina papyracea and reach the orbital abscess from inside the nose. The external approach involves a curvilinear (Lynch-Howarth) incision over the superomedial aspect of the eye and subperiosteal dissection into the orbit until pus is encountered.

Patient outcome

The patient was initially treated with intravenous antibiotics. However, he did not respond to conservative management, with worsening visual acuity and reduced superomedial movement in his right eye (fig 2). Computed tomography showed worsening orbital cellulitis and he therefore underwent open surgical intervention with placement of a drain. His orbital infection greatly improved after surgical drainage, with reduced periorbital swelling and improved visual function and eye movements. He underwent a further course of antibiotics, initially as an inpatient and then as an outpatient. He had complete resolution of his symptoms at six weeks’ follow-up.


Fig 2 Reduced superomedial eye movement associated with orbital cellulitis. (A) Reduced medial eye movement; (B) reduced superior eye movement


Cite this as: BMJ 2015;350:h554


  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: none.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

  • Parental consent obtained.


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