Cellulitis, abscess and necrotising soft-tissue infection: Case

This toddler presents with eyelid swelling, erythema, and fever complicated by proptosis and painful eye movement, which together shift the working diagnosis from simple periorbital cellulitis to orbital cellulitis. The preceding upper respiratory symptoms point to ethmoid sinusitis as the source, because the thin lamina papyracea allows infection to spread from the ethmoid sinus into the orbit. This is the critical distinction that determines imaging, admission, and the threshold for surgery. [1]

Clinical findings

The key findings are the proptosis and the reluctance to move the eye, which signal extension of infection posterior to the orbital septum. The candidate should distinguish periorbital cellulitis, which involves the eyelid and superficial tissues anterior to the septum and in which the child is well with no proptosis or visual change, from orbital cellulitis, which lies posterior to the septum and threatens vision and intracranial spread. The presence of proptosis, painful eye movement, and systemic fever in this child makes orbital cellulitis the working diagnosis. [1]

The examination should assess visual acuity, eye movements, pupillary responses, and the degree of proptosis, and should look for signs of intracranial spread such as meningism or a reduced conscious level. The differential includes periorbital cellulitis, orbital cellulitis with or without a subperiosteal or orbital abscess, dacryocystitis, and allergic eyelid swelling, but the proptosis and painful eye movement make a preseptal cause unlikely. [1]

Management

The child needs urgent contrast-enhanced computed tomography of the orbits and sinuses to confirm orbital cellulitis and to detect a subperiosteal or orbital abscess. Intravenous antibiotics should be started immediately, directed at the sinus pathogens that cause orbital cellulitis, namely Streptococcus pneumoniae, other streptococci, Staphylococcus aureus including MRSA where prevalent, and anaerobes from the sinuses. A typical regimen is a third-generation cephalosporin such as ceftriaxone with metronidazole added for anaerobic cover, with clindamycin or vancomycin added if MRSA is suspected. [2]

Urgent otolaryngology and ophthalmology review is essential. A subperiosteal or orbital abscess, a deteriorating clinical picture, or a failure to improve on intravenous antibiotics within 24 to 48 hours are indications for surgical drainage of the abscess and the involved sinus. The decision to operate balances the risk of optic nerve compromise and intracranial spread against the morbidity of surgery, and is made jointly between the paediatrician, the otolaryngologist, and the ophthalmologist. [2]

Complications and follow-up

Orbital cellulitis carries a risk of permanent visual loss from optic nerve compression or stretch, intracranial spread causing meningitis, subdural empyema, or cavernous sinus thrombosis, and the formation of a persistent orbital abscess. Children managed promptly with intravenous antibiotics and timely surgical drainage generally recover fully, but delayed presentation or a missed orbital abscess can leave permanent sequelae. [2]

This child needs close observation for visual change, intracranial signs, and response to antibiotics, with a clear plan for repeat imaging if she deteriorates. After recovery, follow-up should address the underlying sinus disease and reinforce the safety-net for any recurrence of eyelid swelling with systemic illness, because a second episode of orbital cellulitis can occur and shares the same red flags. [3]