Journal of Pediatric Critical Care

P - ISSN : 2349-6592    |    E - ISSN : 2455-7099

Original Article
Year : 2019 | Volume : 6 | Issue : 3 | Page : 25 - 30

Orbital Cellulitis - Incidence, Management and Outcome from Coastal Hospitals

Bal Mukund1, Sanjay Chaudhary1, Vivek Bhat2, Vineet V3, KM Adhikari4

1Asst Prof, Dept. of Pediatrics and Intensive Care, 3Resident, 4Professor and Head, Department of Pediatrics Pediatrics, INHS Asvini, Mumbai, Maharashtra, India. 2Pediatrician and Neonatologist, INHS Kalyani, Visakhapatnam, Andhra Pradesh, India

Correspondence Address:

Dr.Sanjay Chaudhary,Asst Prof, Dept. of Pediatrics and Intensive Care
INHS Asvini, Mumbai, Maharashtra, India.
Phone: +91 9869458725, Email:drsanjay68@yahoo.co.uk
Received: 11-Mar-19/Accepted: 17-May-19/Published online:05-Jun-19

Source of Funding:None Conflict of Interest:None

DOI:10.21304/2019.0603.0500


ABSTRACT
Orbital cellulitis is a potentially life-threatening and an uncommon emergency condition in children. There are little published data from incidence and prevalence in the developing country. This study was done to identify incidence, etiology and management of orbital cellulitis in children from two service hospitals in east and west coast of India.

Methods :
The two multispecialty service hospitals cater tertiary level care to dependant population with 80700 children between ages 1 month to 12 years. This study was a 2 years retrospective observational study using hospital based electronic information system and electronic case records from Jan 2017 to Dec 2018 between ages of 1 month to 12 years.

Results :
A total of 15 children with orbital cellulitis were included in the study giving incidence of 9.29 per 100000 in children <12 years age in our dependant population. The gender ratio was 2;1. 60% children had a preceding upper respiratory tract infection, 20% had furunculosis on face and 13 % had previous trauma to the face. Only in 3(20%) children, organisms were isolated and all grew Methicillin sensitive staphylococcus aureus(MSSA). All children were started on intravenous antibiotics as per unit policy. 6(40%) children required admission to Pediatric Intensive Care Unit (PICU) and surgical treatment was required in 2 (13%). All patients recovered with good outcome.

Conclusion:
The annual incidence of orbital cellulitis in our dependant population was 9.29 per 100000 per year. In children, it commonly follows upper respiratory infection or furunculosis of the face. Intravenous antibiotics and surgical management yields optimum result.

Keywords:
Orbital Cellulitis, Methicillin sensitive staphylococcus aureus, Intevenous antibiotics

Introduction
Infective orbital cellulitis is an uncommon infection of involving ocular adnexal structure behind orbital septum.1 Orbital cellulitis in children presents with proptosis, limitation of movement of eye, edema of conjunctiva (chemosis) and infl ammatory edema of eyelids. This is potentially life threatening and blinding hence an aggressive treatment is advocated in children. The mean age of involvement in literature is 7 years with range of 10 month to 18 years. Children can also present with fever, decreased appetite, leukocyctosis or systemic spills and complications. There is paucity of data regarding incidence from developing country, however data from Scotland and California shows 1.6 and 3.51 per 100000 of the pediatric population.1
Orbital cellulitis generally antecedates upper respiratory tract infection but can also follow direct infection from wounds on face, metastatic spread of organism from bacteremia or direct extension from lids or paranasal sinuses like ethmoid or sphenoid sinuses which is also the commonest cause.2The preseptal cellulitis is defi ned in which infection is limited to anterior orbital septum limiting the spread of infection.When these crosses posterior to the septum is termed post-septal or orbital cellulitis.3The children have thin bony septa in the medial wall of orbit known as lamina papyracea which overlies the ethmoid sinuses.4 The medial wall may be often incomplete because of a small defect known as Zuckerkandel dehiscence (in ethmoid bone)alongwith small neurovascular bundle.5These bone also have large vascular foramina, open suture lines,more porous bones, relatively large ostia of sinuses and greater porosity of bones, all predisposes a child to orbital cellulitis. The paranasal sinuses primarily drain through orbital venous channel that are without valves allowing both anterograde and retrograde spread of infections.6 These factors also predisposes to intracranial extension of the infections. Most frequent causative organisms are staphylococcus aureus including methicillin resistant S. aureus (MRSA), streptococcus species, Hemophilus species or a polymicrobial cultures.7-9
Chandlers classifi cation of orbital complications of sinusitis (Table 1) have been described which depicts exact clinical signs and likely diagnosis was introduced in the early 1970’s.10 Recently this classifi cation has been challenged and new classifi cation based on location within orbit has been proposed.11 Ophthalmoplegia or proptosis at presentation depicts a postseptal disease and hence requires intravenous antibiotics and surgery in selected cases.4 The potential for complications of orbital cellulitis are great as permanent vision loss have been reported in 11-26% of cases. 12 The main causes may be panophthalmitis, compressive optic neuropathy, retinal or choroidal ischemia, toxic optic neuritis or due to exposure keratitis. Intracranial extension is rare but known to present with meningitis, brain abscess, epidural or subdural empyema and cavernous sinus thrombosis.5 Differential diagnosis includes idiopathic orbital infl ammation, acute leukemia, histiocytic disorders, rhabdomyosarcoma, orbital trauma, orbital foreign body and rarely sarcoidosis or granulomatous vasculitis. Orbital cellulitis must be diagnosed early and treated aggressively. Systemic antibiotic therapy and hospitalization is usual recommended therapy. It’s recommended to do contrast computerized tomography (CT) of orbits including central nervous system (CNS) to detect complications like subperiosteal abscess or intracranial extention. A combination of 3rd generations Cephalosporins with Vancomycin, with or without Metronidazole is initial recommended therapy.13 If there is no improvement with intravenous antibiotics or in any abscess collection requires surgical drainage by external ethmoidectomy, or by functional endoscopic sinus surgery.14 Generally, a child shows improvement within 48 hrs and becomes afebrile. Many clinicians recommend routine drainage of subperiosteal abscess if age > 9 years and trial of intravenous antibiotics in children with age < 9 years. Recently study from India and united states have shown advantages of adding oral corticosteroid. Theoretically, oral corticosteroid can reduce edema, cytokines effects, decrease fi broblast proliferation, scarring and long term sequelae in orbital cellulitis.15Routine use of anticoagulation is also not a standard recommendation.

Results
Incidence
Our hospital caters to a pediatric population of 80700 in the dependant pediatric population (< 12 years) of military station. A total of 7502 children required indoor admission in the hospitals from 01 Jan 2017 to 31 Dec 2018. A total 15 cases of orbital cellulitis were identifi ed who were admitted in our hospitals yielding to annual incidence of 9.29/100000 per year in our dependant pediatric population. A hospital admission rate of 0.2 % was due to orbital cellulitis. There were 10 male children and 5 females giving gender ration of male to female as 2:1. The median age was 24 months(18-48 months).

Presentation and Etiology
All children presented with swelling eyes with mean duration of presentation of 2 days. 6 children (40%) had fever at presentation and pain in eyes were presenting complaints in 5 children. 9 children (60%) had preceding upper respiratory tract infection, trauma in 2 child (13.3%) and history of furunculosis on face were present in 3 children (20%). 3 Children had previous documented history of sinusitis. 12 children (80%) had unilateral presentation and 3 had bilateral presentation (Figure 1) and 8 children (66.6%) had right side involvement among unilateral involvement and 4 had left sided involvement. All children had chemosis, lid edema and proptosis at presentation but 4 children had ophthalmoplegia and pus discharge at presentation (Table 2). The mean leucocyte count was 14270 ( ± 1170)/cumm with polymorphs of 55(±4)%. Our hospital has no quanititaive CRP, hence these data were not analysed. Only 3 children (20%) showed any organism on culture, blood culture was positive in 2 children and 1 child showed growth on local pus culture (Table 3). All 3 children showed growth of Methicillin sensitive staphylococcal aureus (MSSA). 3 children underwent CT scan, one additionally required MRI (Figure 2), revealing ethmoid sinus involvement in all and 2 showing orbital abscess and both also required surgical intervention.

Management and Outcome
All children were managed by a multidisciplinary team of Pediatrician, ENT specialists and Ophthalmologists. All children were started on injectible antibiotics on admission. A combination of 3rd generation cephalosporin and Teicoplanin with or without metronidazole were used in 9 children (60%) and in 3 children (20%) Piperacillin and rest 3 children were started on amoxicillin- clavulanate. All children were also given oral ibuprofen or paracetamol for pain relief. The mean duration of resolution of swelling was 72 hours and mean duration of injectible antibiotics was 6 days. Sinus surgery and abscess drainage was required in 2 children (13.3%) by ENT specialists as both these children responded poorly to parental antibiotics. All children were given antibiotics eye drop and lubricants during treatment. Mean duration for hospitalization was 11 days. We did not use any oral corticosteroid in the treatment as per unit policy and however all were given oral antibiotics at discharge. All children were followed up on 2, 6 and 12 weeks and none had any complication like ptosis, ocular movement restriction or proptosis at 6 or 12 weeks of follow-up.

Table 1:
Chandler’s classifi cation of sino-nasal related orbital infections

Table 2:
Presentation of orbital cellulitis

Table 3:
Microbiology of isolated pathogens


Figure 2:
MRI showing right intraorbital subperiosteal abscess with ethmoiditis

Discussion
Our data demonstrate the incidence of orbital cellulitis in children 9.29/100000 per year in our population. The incidence seems higher than previous published study from Scotland, Californian study or from Middle East. In the study by Murphy C et al from Scotland showed incidence of 1.6/100000 per year in children. The higher incidence in our country may be related to tropical climate, late presentation and high humidity in coastal areas. Like other studies, our studies documented, high vulnerability of orbital cellulitis in male children, M:F ratio of 2 although reason for same is obscure. Our median age was 24 months (18-48 month) lower than the previous study of 7 years. Our hospitals admit children only upto 12 years of age in the pediatric ward, hence our data may not be true representation of common pediatric population age.
Although we had relatively small number of patients from our dependant populations from two large bases, the study depicts the common occurrence of orbital cellulitis in children due to incomplete immunological development and anatomical considerations of paranasal sinuses and lamina papyrecea. In our study 60% of children had previous upper respiratory tract infection. In a study by Murphy C et al had 47% similar antecedent illness and 87% showed sinus disease. We did not do CT scan in all patients due to inherent radiation exposure and relatively good response to parental antibiotics. All 3 cases in which we did CT and/or MRI showed evidence of ethmoid sinusitis. We did not fi nd any history suggestive of recurrent orbital cellulitis or any history or pointer to primary immunodefi ciency syndrome. Various case series and reports suggest the inherent vulnerability of this infection in primary immunodefi ciency. We had history of trauma to face in 2 patients and history of furunculosis in face in 3 children as these predisposes to local spill of infection.
The common organisms in orbital cellulitis are staphylococcus, streptococcus and H. infl uenza. Prior to Hib vaccination, this was most common cause of orbital cellulitis in children and had propensity to spread to meninges and cause cavernous sinus thrombosis. Our dependant population receives this vaccine as a part of routine vaccination of station Health Organization.We had sent blood cultures and local swabs in all children however only 3 children (20%) grew organism, 2 on blood culture and 1 in local swab culture. All 3 had shown growth of MSSA. Our yield of pathogen in culture was low compared to other study. In a study in Scotland in 2014, the culture yield was 70% and common organisms were streptococcus and H. infl uenza. Polymicrobial culture was found in 53% cases.16 In another study from India, culture yield was also low to 23.8%.15 The cause of low yield in our study despite using BACTEC may be due to rampant misuse of antibiotics in the community or improper specimen collections.
Cannon P et al in their study from a tertiary care centre proved that orbital cellulitis can be successfully treated with oral ciprofl oxacin and clindamycin in children and adult. Both these oral antibiotics have good oral bioavailability comparable to intravenous preparations and also give broad spectrum cover to gram negative and gram positive organisms.17 Oral antibiotics decrease the cost of treatment, less disruption of treatment and prevention of complications due to intravenous therapy and cannulation. If methicllin resistance S aureus( MRSA) is suspected or culture proven, vancomycin or teicoplannin needs to be added. Surgical intervention is not usually required unless there is ophthalmoplegia with frank orbital abscess, frontal sinusitis (Pott Puffy tumor), intracranial complication, large sub-periosteal abscess, abscess volume > 5% of orbital volume or poor response to antibiotics in 48 hours. Garcia et al have shown that medical management alone may be suffi cient in age, 9 years old with subperiosteal abscess.18,19 Large abscess may require combined external and sinus drainage. Most can be managed with parental antibiotics therapy and followed by oral antibiotics like in our study as only 2 children required surgical intervention.
Corticosteroid use has been controversial, though encouraging results of its use are forthcoming in the treatment of orbital abscess. Pushkar N et al in a prospective study from India used adjuvant oral prednisolone at 1.5 mg/kg/day for 3 days , 1 mg/ kg/day for another 3 days followed by tapering over 1-2 weeks demonstrated early resolution of orbital edema, chemosis, early return of vision and movement and decrease in overall use of intravenous antibiotics and hospital stay.15 Davies BW et al used oral prednisolone as adjuvant when CRP≤ 4 mg/dl for 7 days at 1 mg/kg and showed early discharge from the hospital.16 These studies have not been able to clarify on dosage of corticosteroid, days of starting of steroid, exact use of biomarker to start steroid and total duration of steroid. More prospective trials are required before same can be recommended. We did not use steroid in our patients.
Our study is probably only study to depict the incidence of orbital cellulitis in pediatric population from India which is probably higher than reported from other western countries. Our study has several limitations. Since data were collected retrospectively from electronic records and case sheets hence accuracy is dependent on data acquisition. Incidence was calculated based on number of enrolled children in electronic data and health organization however since the dependant population is on movement may have some inaccuracy. Our dependant population has an early referral system hence the stages and overall outcome may not be representative of general population. Our hospital policy allows the admission of children up to 12 years in pediatric ward, hence the age data may be skewed. Method of culture collection is not specifi ed hence it’s possible that anaerobes and mixed infections might have been missed. We do not have acute phase reactants like quantitative C-reactive protein or procalcitonin as they are not routinely available in our hospital.

Conclusion
Our retrospective study highlighted increased incidence of orbital cellulitis in our population than published data from developed countries. Most can be managed effectively by parental antibiotics and if there is poor response with medical therapy, surgical treatment may be sought. Role of steroid is emerging is emerging however more prospective studies are required before same can be recommended routinely.

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