1. health and fitness
2. disease

WAHT-PAE-069
This guideline has been printed from the Worcestershire Acute Hospitals NHS Trust intranet on
24/09/2012,13:34
It is the responsibility of every individual to check that this is the latest version/copy of this document.
GUIDELINE FOR MANAGEMENT OF PRESEPTAL AND
ORBITAL CELLULITIS IN CHILDREN
This guidance does not override the individual responsibility of health professionals
to make appropriate decision according to the circumstances of the individual
patient in consultation with the patient and /or carer. Health care professionals
must be prepared to justify any deviation from this guidance.
INTRODUCTION
The management of preseptal and orbital cellulitis depends on accurate diagnosis
and prompt treatment to minimise potentially life-threatening complications. This
guideline covers all paediatric patients admitted to any Children’s ward within the
Worcestershire Acute Hospitals NHS Trust
THIS GUIDELINE IS FOR USE BY THE FOLLOWING STAFF GROUPS :
This guideline is for use by paediatric medical staff.
Lead Clinician(s)
Dr D Castling
Consultant Paediatrician
Approved by Clinical Director on behalf of Paediatric
Clinical Improvement Group on :
14 July 2008
Approved by Dr Andrew Short on behalf of Paediatric
Clinical Governance Committee:
21 September 2012
This guideline should not be used after end of:
September 2014
Key amendments to this guideline
Date
Amendment
Approved by:
(name of committee or
accountable director)
July 2010 No further amendment made
D Castling
06.07.2012 Extended 3 months to allow for review
D Castling/A Short
21.09.2012 Minor changes to the wording in the audit section only D Castling/A Short
Guideline for Management of Preseptal and Orbital Cellulitis in Children
WAHT-PAE-069
Version 2.2
Page 1 of 8
WAHT-PAE-069
This guideline has been printed from the Worcestershire Acute Hospitals NHS Trust intranet on
24/09/2012,13:34
It is the responsibility of every individual to check that this is the latest version/copy of this document.
GUIDELINE FOR MANAGEMENT OF PRESEPTAL AND
ORBITAL CELLULITIS IN CHILDREN
INTRODUCTION
N.B. Please see flow chart on page 4 of this guideline
The orbital septum is a nearly impervious barrier to spread of infection from the preseptal to
orbital area. Infection and inflammation confined to the eyelids and structures anterior to the
orbital septum is referred to as preseptal (or periorbital) cellulitis. Whereas, infection of the
orbital soft tissue posterior to the orbital septum is known as orbital cellulitis and most
commonly occurs as a complication of sinusitis. Orbital cellulitis is potentially life threatening
as there is a risk of direct extension to the brain. Other complications associated with orbital
cellulitis include orbital abscess, subperiosteal abscess, brain abscess, meningitis, optic
neuritis, cavernous sinus thrombosis and blindness.
The most likely organisms include Strep pyogenes, Strep pneumoniae & Staph aureus. Over
5 years of age Staph aureus is most common. Anaerobes are unusual. Haemophilus
influenza type b is a very uncommon cause of orbital cellulites since HiB immunisation.
PRESEPTAL CELLULITIS
More common in younger children. Usually caused by Strep pyogenes, Strep pneumoniae or
Staph aureus.
Secondary to: Infection affecting the skin or adjacent structure e.g. hordoelum (stye) or
conjunctivitis, trauma, insect bite or upper respiratory tract infection (may lead to
bacteraemic periorbital cellulitis).
Associated findings: Swelling, erythema, oedema, warmth, and tenderness. (Globe
unaffected therefore no other ocular signs or symptoms.)
ORBITAL CELLULITIS
Is an OCULAR EMERGENCY and more common in older children. It can be caused by
Streptococcus spp (including Strep Milleri, pneumococcus and group A beta haemolytic
streptococcus), Staph aureus and more rarely Haemophilus influenzae, anaerobes or
Neisseria meningitidis.
Secondary to: Spread of infection from surrounding structures –sinusitis (particularly
ethmoid sinus), trauma, surgery and blood-borne spread
Associated findings: Pain, conjunctival oedema, erythema, warm lid, flu-like symptoms,
pyrexia, meningism, proptosis, restricted ocular motility, reduced visual acuity, and abnormal
pupil reflexes.
Guideline for Management of Preseptal and Orbital Cellulitis in Children
WAHT-PAE-069
Version 2.2
Page 2 of 8
WAHT-PAE-069
This guideline has been printed from the Worcestershire Acute Hospitals NHS Trust intranet on
24/09/2012,13:34
It is the responsibility of every individual to check that this is the latest version/copy of this document.
INDICATIONS FOR ADMISSION
Most patients with periorbital swelling will require admission. The only safe patient to send
home is one with minimal upper lid oedema, a normal eye examination and none of the
features below.
Proptosis
Diplopia
Restricted ocular motility
Reduced visual acuity
Abnormal pupil reflexes
Full eye examination not possible
Toxic or systemically unwell
Central nervous system signs or symptoms (drowsiness, vomiting, headache, seizure
or cranial nerve lesion).
CT scanning should be used as an adjunct to clinical findings. Indications for CT:
Central signs
Unable to accurately assess vision
Proptosis
Restricted ocular motility
Deteriorating visual acuity
Bilateral oedema
No improvement/deterioration at 24 hours
Swinging pyrexia not resolving at 36 hours
Lumbar puncture should be considered in some high risk cases (see flow chart). Not if
focal neurology present. Lumbar puncture should be deferred until after the CT scan.
Consider particularly in children <12 months old as often difficult to appreciate meningeal
signs.
Antibiotics – see flow chart for protocol. (Doses as per latest BNF for Children.)
For preseptal cellulitis, if penicillin allergy, use oral clarithromycin.
For orbital cellulitis, or IV therapy for preseptal cellulitis and penicillin allergy, discuss
with Microbiologist.
IV Ceftriaxone could be used as an alternative to IV Cefotaxime to allow once daily
treatment, or for home IV therapy if considered appropriate.
Any patient with meningeal involvement will need an extended course of IV
antibiotic and should be discussed with microbiology.
Surgical drainage is recommended if:
CT shows evidence of an abscess.
Visual acuity worse than 20/60 on initial evaluation.
Severe orbital complications e.g. blindness or afferent papillary defect.
Progression of orbital signs and symptoms despite therapy.
Lack of improvement within 48 hours despite medical therapy.
Guideline for Management of Preseptal and Orbital Cellulitis in Children
WAHT-PAE-069
Version 2.2
Page 3 of 8
WAHT-PAE-069
This guideline has been printed from the Worcestershire Acute Hospitals NHS Trust intranet on
24/09/2012,13:34
It is the responsibility of every individual to check that this is the latest version/copy of this document.
FLOWCHART FOR MANAGEMENT OF PRESEPTAL AND ORBITAL CELLULITIS IN
CHILDREN
Patient presents with eyelid swelling
Painful eye movements
+/- chemosis
+/- proptosis
+/- restricted eye movements
+/- visual loss
No chemosis
No proptosis
No ophthalmoplegia
No visual loss
PRESEPTAL
Oral co-amoxiclav if only mild
swelling (registrar review)
Complete 7 days Abx
Home with open access
Eye swab for MC+S
Nasal swab for MC+S
(if discharge)
FBC, CRP, U&E
Blood cultures
Consider LP (after
CT, particularly in high
risk group –after
excluded ICP)
No improvement
or deterioration after 24 hrs
IV Cefotaxime
Add in IV Metronidazole if no
improvement in 12-18 hours
Abx FULL/HIGH dose
Analgesia
ENT & Ophthalmology opinion
IV Abx until joint decision fit for
home – complete 10 days of Abx.
Abx will depend on culture and
sensitivities, d/w microbiology
High risk cases of orbital cellulitis
<2 years
Meningeal or focal neurological
symptoms
Eye malformation or operation in
the vicinity
Clinically toxic child
Visual loss or limitation of eye
movements
ORBITAL
IV Cefotaxime
Add in IV Metronidazole if no
improvement in 12-18 hours
Abx FULL/HIGH dose – (see
BNF) depending on culture and
sensitivities
Analgesia
Nasal decongestant (ephedrine
0.5% nose drops TDS)
Immediate referral to ENT &
Ophthalmology
CT scan – coronal & axial views
of orbits & sinuses (to visualise
optic nerve)
Check visual acuity,
pupil response, eye
motility, daily.
If clinical deterioration
check more frequently
IV antibiotics for 24-48 hours,
followed by oral antibiotics for 7-14
days if satisfactory response
Consider repeat CT scan or
immediate operation if:
o Failure of medical management
o Decrease in visual acuity
Abscess
Severe ophthalmoplegia
Visual acuity
Endoscopic or open surgical drainage
(send material for M, C+S)
Guideline for Management of Preseptal and Orbital Cellulitis in Children
WAHT-PAE-069
Version 2.2
Page 4 of 8
WAHT-PAE-069
This guideline has been printed from the Worcestershire Acute Hospitals NHS Trust intranet on
24/09/2012,13:34
It is the responsibility of every individual to check that this is the latest version/copy of this document.
MONITORING TOOL
How will monitoring be carried out?
Clinical Audit/Round Table discussion
Who will monitor compliance with the guideline?
Paediatric Clinical Governance Group
STANDARDS
Audit all cases of preseptal/orbital cellulitis that
proceed to surgery
For all cases that result in loss of sight, report
incident on Datix and hold a round table
discussions
%
100%
CLINICAL EXCEPTIONS
100%
REFERENCES
Dudin A & Othman A. Acute periorbital swelling: Evaluation of management protocol.
Paediatric Emergency Care. 1996:12, 16-20
Goldberg F, Berne A & Oski F. Differentiation of Orbital Cellulitis From Preseptal Cellulitis by
Computerised Tomography. Paediatrics. 1978:62, 1000-1005
Rhys-Williams S & Carruth J. Orbital infection secondary to sinusitis in children: diagnosis
and management. Clinical Otolaryngol. 1992:17, 550-557
Howe L & Jones N. Guidelines for the management of periorbital cellulitis/abscess.
Clinical Otolaryngol. 2004:29, 725-728
Schwartz G & Wright S. Changing Bacteriology of Periorbital Cellulitis. Annals of Emergency
Medicine. 1996:28(6), 617-620
Laurence B & Givner M. Periorbital versus Orbital Cellulitis. Concise Reviews of Paediatric
Infectious Diseases. 2002 (Dec), 1157-1158
Ellen R & Wald M. Periorbital and Orbital Infections. Paediatrics in Review. 2004: 25(9), 312319
Guideline for Management of Preseptal and Orbital Cellulitis in Children
WAHT-PAE-069
Version 2.2
Page 5 of 8
WAHT-PAE-069
This guideline has been printed from the Worcestershire Acute Hospitals NHS Trust intranet on
24/09/2012,13:34
It is the responsibility of every individual to check that this is the latest version/copy of this document.
CONTRIBUTION LIST
Key individuals involved in developing the document
Name
Dr D Castling
Dr K Furneaux
Dr J Brent
Designation
Consultant Paediatrician
Senior House Officer
ST2 Trainee in Paediatrics
Circulated to the following individuals for comments
Name
Designation
Mr M Porter
Consultant ENT Surgeon
Miss G Thurairajan
Consultant Ophthalmologist
Dr N Ahmad
Consultant Paediatrician
Dr M Ahmed
Consultant Paediatrician
Dr T Bindal
Consultant Paediatrician
Dr D Castling
Consultant Paediatrician
Dr T C Dawson
Consultant Paediatrician
Dr T El-Azzabi
Consultant Paediatrician
Dr G Frost
Consultant Paediatrician
Dr A Gallagher
Consultant Paediatrician
Dr M Hanlon
Consultant Paediatrician
Dr L Harry
Consultant Paediatrician
Dr B Kamalarajan
Consultant Paediatrician
Dr K Nathavitharana
Consultant Paediatrician
Dr C Onyon
Consultant Paediatrician
Dr J E Scanlon
Consultant Paediatrician
Dr A Short
Clinical Director/Consultant Paediatrician
Dr V Weckemann
Consultant Paediatrician
Dr F Childs
Consultant Paediatrician - Community
Dr J Crane
Consultant Paediatrician - Community
Dr D Lewis
Consultant Paediatrician - Community
Dr A Mills
Consultant Paediatrician - Community
A Borg
Directorate Manager
D Picken
Matron, Paediatrics
N Pegg
Ward Manager, Riverbank
L Greenway
Ward Manager, Ward 1
S Courts
Orchard Services Manager
M Chippendale
Advanced Nurse Practitioner
Matt Kaye/Sarah Scott
Lead Pharmacist for Paediatrics and Neonatal
Circulated to the following CD’s/Heads of dept for comments from their directorates /
departments
Name
Directorate / Department
V Bullock
Manager, Neonatal Unit
Dr C Catchpole
Consultant Microbiologist
Circulated to the chair of the following committee’s / groups for comments
Name
A Smith
Committee / group
Medical Safety Committee
Guideline for Management of Preseptal and Orbital Cellulitis in Children
WAHT-PAE-069
Version 2.2
Page 6 of 8
WAHT-PAE-069
This guideline has been printed from the Worcestershire Acute Hospitals NHS Trust intranet on
24/09/2012,13:34
It is the responsibility of every individual to check that this is the latest version/copy of this document.
Supporting Document 1 – Checklist for review and approval of key documents
This checklist is designed to be completed whilst a key document is being developed / reviewed.
A completed checklist will need to be returned with the document before it can be published on the
intranet.
For documents that are being reviewed and reissued without change, this checklist will still need to be
completed, to ensure that the document is in the correct format, has any new documentation included.
1
Type of document
Clinical guideline
2
Title of document
Guideline for Management of Preseptal or Orbital
Cellulitis in Children
3
Is this a new document?
Yes
No
If no, what is the reference number WAHT-PAE069
4
For existing documents, have
you included and completed the
key amendments box?
Yes
No
5
Owning department
Paediatrics
6
Clinical lead/s
Dr Douglas Castling
7
Pharmacist name (required if
medication is involved)
Sarah Scott/Matt Kaye
8
Has all mandatory content been
included (see relevant document
template)
Yes
No
9
If this is a new document have
properly completed Equality
Impact and Financial
Assessments been included?
Yes
No
10
Please describe the consultation
that has been carried out for this
document
Reviewed by clinical lead and agreed for extension
by Clinical Director. Extension to be documented
at Paediatric Clinical Governance meeting on
26.10.12
11
Please state how you want the
title of this document to appear
on the intranet, for search
purposes and which specialty
this document relates to.
Management of preseptal or orbital cellulitis in
children
N/A
Once the document has been developed and is ready for approval, send to the Clinical
Governance Department, along with this partially completed checklist, for them to check
format, mandatory content etc. Once checked, the document and checklist will be submitted
to relevant committee for approval.
Guideline for Management of Preseptal and Orbital Cellulitis in Children
WAHT-PAE-069
Version 2.2
Page 7 of 8
WAHT-PAE-069
This guideline has been printed from the Worcestershire Acute Hospitals NHS Trust intranet on
24/09/2012,13:34
It is the responsibility of every individual to check that this is the latest version/copy of this document.
Implementation
Briefly describe the steps that will be taken to ensure that this key document is implemented
Action
Person responsible Timescale
No change to practice. Members of the Paediatric
Dr A Short
October 2012
Clinical Governance Committee to be informed of
extension of guideline at meeting on 26.10.12
Plan for dissemination
Disseminated to
Members of the Paediatric Clinical Governance Committee to be
informed of the extension of this guideline.
1
Step 1 To be completed by
Clinical Governance
Department
Is the document in the correct
format?
Has all mandatory content been
included?
2
3
4
Yes
No
Yes
No
Date
26 October 2012
Date form returned
21/09/2012
Name of the approving body
Paediatric Clinical Governance Committee
(person or committee/s)
Step 2 To be completed by Committee Chair/ Accountable Director
Approved by (Name of Chair/
Dr Andrew Short
Accountable Director):
Approval date
21 September 2012 - extension to be confirmed
and documented at the meeting on 26 October
2012
Please return an electronic version of the approved document and completed checklist to the
Clinical Governance Department, and ensure that a copy of the committee minutes is also
provided (or approval email from accountable director in the case of minor amendments).
Office use only
Reference
Number
WAHT-PAE-069
Date form received
21/09/2012
Date document
published
24/09/2012
Version No.
2.2
Guideline for Management of Preseptal and Orbital Cellulitis in Children
WAHT-PAE-069
Version 2.2
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