Approach

Imaging should be considered and requested urgently if orbital cellulitis is suspected. If there is evidence of sinusitis, an ear, nose and throat consult should be obtained for sinus drainage. Sub-periosteal orbital abscess, an orbital complication of sinusitis, often requires surgical drainage for resolution. Initial medical management may be attempted if there is no visual compromise and the abscess is 'small' (less than 1 cm in length by 0.4 cm in width).[28][29] Although some authors have recommended urgent drainage in patients over the age of 9 years, regardless of abscess size, medical management has also been reported to be successful in older patients.[30][31]​​ Initial management is usually with intravenous antibiotics (for 24-48 hours), prior to making a decision about surgical intervention, unless there is visual compromise.[28][29]​​

Urgent intervention is also favoured if there is frontal sinusitis because of the greater risk of intracranial infectious complications. If there are multiple infected sinuses, a large abscess (greater than 1 cm by 0.4 cm), or visual compromise, early drainage is warranted, even in young children. Older patients are more likely to have polymicrobial infections and underlying chronic sinusitis, which may be less amenable to medical management alone.

The mainstay of treatment for both peri-orbital and orbital cellulitis is broad-spectrum antibiotics.[15]​ Treatment is always empirical initially, with therapy targeted according to cultures, once known. Although peri-orbital cellulitis appears and behaves far less ominously than orbital cellulitis, it should never be left untreated, as it can extend to cause orbital cellulitis.

Sepsis should be suspected if there is acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection. Senior colleagues should be involved as indicated, and local sepsis protocols followed. See Sepsis in adults and Sepsis in children for more information.

Evidence supporting the use of corticosteroids for treating peri-orbital and orbital cellulitis is limited and conflicting, but they may be considered for selected patients.[19][26][32][33]​​​​​

Peri-orbital cellulitis

The majority of paediatric patients require immediate empirical intravenous antibiotic therapy for 2-5 days because of the risk of occult orbital cellulitis or, rarely, worsening to orbital cellulitis and its complications. Alternatively, empirical oral therapy may be initiated in children with reliable daily follow-up.[34]​ In adults who are adherent with therapy and clinically stable, oral antibiotics should be administered with careful follow-up.[19]

Orbital cellulitis

All patients with orbital cellulitis should be admitted for empirical intravenous antibiotic therapy. Early consultant involvement is recommended, particularly for children, including ophthalmology and ear, nose and throat, with input from other specialties as needed (e.g., paediatrics, infectious diseases).[15][19][20]​​[35]​​​​​[36]​​​​​​ Prompt orbital imaging to identify underlying sinusitis is mandatory. An orbital abscess is a common complication of patients with orbital cellulitis. Although intravenous antibiotic therapy and use of nasal decongestants may suffice in clearing small abscesses associated with isolated ethmoid sinusitis, surgical drainage of the affected sinus and abscess is usually required in larger abscesses.[14]​ Lateral canthotomy and cantholysis may be required to reduce intra-ocular pressure before orbitotomy can be performed if there is visual loss at presentation. It should be noted that, following initiation of appropriate treatment, it may take several days for orbital cellulitis to clinically improve. Systemic corticosteroids may reduce swelling of the sinus ostia and improve drainage in some patients.[19][32][33]​​

Antibiotic therapy

Antibiotics should cover sinus pathogens that exhibit beta-lactamase resistance and should penetrate cerebrospinal fluid.[1][9][10][11]​​[12][13][16]​ There are no standard rules on the type of treatment in adults or children because of the great decline in culture-positive isolates. Therefore, empirical antibiotic treatment should be targeted against the typical pathogens, including Staphylococcus aureus, the Streptococcusspecies (Streptococcus milleri,Streptococcus pyogenes, and Streptococcus pneumoniae), and anaerobic bacteria.[37] In immunised adults and children, Haemophilus influenzae is less of a concern. Polymicrobial infection is possible, and includes infection with aerobic and anaerobic bacteria, fungal species and mycobacteria, especially in the setting of chronic sinusitis.[38]

Empirical antimicrobial regimens

Positive culture rates are between 0% and 33%.[22] Therefore, because cultures are likely to be negative,​ empirical antibiotic therapy should be started immediately after cultures are obtained, and the patient switched to targeted antibiotic therapy only if cultures are positive.[21][23]

Because S pyogenes remains very sensitive to penicillin, treatment and duration depends on the likelihood of MRSA. In communities with low antibiotic resistance, empirical regimens include beta-lactamase-resistant penicillins, a third-generation cephalosporin, or clindamycin, or alternatively, metronidazole plus cefuroxime.[1][9][11]​​[13][39]​​​​​​​​ If there are concerns about antibiotic resistance, treat with vancomycin plus cefotaxime and clindamycin, or alternatively, vancomycin plus piperacillin/tazobactam. Daptomycin, linezolid, and telavancin are potential alternatives for patients who are allergic to vancomycin. However, there is little experience using these agents for orbital or intracranial infections, and they should be given under the guidance of an infectious disease consultant.

When cultures are known, ongoing antibiotic therapy will depend on local policy and sensitivities. It is recommended that regimens are checked with an infectious disease consultant.

Although not usually indicated, empirical antifungal therapy with amphotericin-B should be considered for immunosuppressed patients or ketoacidotic patients. Targeted therapy should be considered in patients with positive fungal cultures. Patients with suspicious (viscid, dark brown-black) nasal discharge should also be considered for antifungal therapy.

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