Orbital cellulitis in this child might have been induced by trauma and sinusitis. However, this case was characterized by certain specific features: the child had no history of sinusitis, whereas a history of orbital trauma one year earlier was present. This condition is not consistent with previous reports indicating that trauma-induced orbital cellulitis usually occurs within a few days post-trauma [4]. We, therefore, speculated that the damage of the local orbital structures caused by the trauma could easily induce orbital cellulitis in a later period of life. Moreover, no orbital abscess was detected by the repeated CT examinations in this patient, which is consistent with the existing literature evidence. Notably, MRI can improve the diagnosis rate of patients with orbital abscess [5]. In this patient, broad-spectrum antibiotics were first used as empirical treatment after suspected orbital cellulitis. Additionally, close contact was maintained with ophthalmology and otolaryngology departments. During the conservative treatment, the visual acuity and imaging conditions were dynamically evaluated. Due to the absence of considerable improvement, surgical treatment was considered and applied, followed by hormone anti-inflammatory agent administration until the child was finally cured.
In this study, we also conducted a literature review on PubMed using the terms "orbital cellulitis" and collected data associated with children reported in the past five years. We then analyzed and summarized its clinical features, treatment, and differential diagnosis. Interestingly, we found that most of the studied children had unilateral eye disease. The most common predisposing etiologies were infection of the adjacent area (such as sinusitis, dental disease, upper respiratory tract infection, and facial skin infection), recent trauma/surgery, foreign body, and insect bites. Staphylococcus aureus and non-hemolytic streptococci were the major pathogens [6]. Fungal infections should be considered as part of the initial workup in each patient diagnosed with preseptal/septal cellulitis unresponsive to empirical broad-spectrum antibiotic therapy, high CRP levels, and severe proptosis [7]. A high index of suspicion for fungal infection should also be taken into consideration after surgical intervention with insertion of prosthetic materials [5]. In our case, the child was diagnosed with sinusitis and trauma-induced orbital cellulitis (Table S1).
Acute sinusitis is infectious or non-infectious inflammation of the nasal cavity and sinus mucosa. However, due to the thinner sinus bone walls and weaker immune system in children than those in adults, this disease leads to a higher incidence of nasal orbital complications and more extensive progression of the disease into the adjacent tissues. Acute sinusitis complications can be divided into peripheral soft tissue infections, osteitis, and intraorbital and intracranial complications. Intraorbital complications are most common, accounting for approximately 80% of all complications. Importantly, these complications have a rapid onset and progression, and, if not timely treated, they can cause optic neuritis, cavernous sinus thrombophlebitis, and can even lead to life-endangering intracranial infection [1, 2].
The clinical manifestations of the orbital complications of acute sinusitis include acute sinusitis, fever, headache, red and swollen eyelids, bulging eyeballs, restricted movement, eyeball tenderness, bulbar conjunctival edema, ptosis (in severe cases), and even loss of vision. The blood test in our case showed an increase in the white blood cell count (mainly that of neutrophils). Our patient initially had a fever, headache, eyelid swelling, but then gradually developed bulging eyes, restricted movement, and vision decline. It is noteworthy that in the literature review we performed, the main symptoms reported were eyelid redness and swelling.
CT examination is of considerable value in the diagnosis and treatment of orbital cellulitis. It can not only facilitate the diagnosis, but can also clarify the extent of the lesion, the involvement of adjacent bone walls and extraocular muscles, the degree of sinusitis and its relationship with orbital infection, showing the formation of abscesses and their locations. Therefore, timely incision and drainage should be implemented. MRI should be routinely applied for examinations in patients with suspected intracranial complications. Additionally, DWI (diffusion-weighted imaging) can improve the diagnosis rate in almost all patients with orbital abscess by the concurrent use of enhanced scan images [22]. In the present case, the orbital abscess was found only through MRI. Most patients with orbital cellulitis are cured by active treatment. However, acute periorbital swelling in some children can be misdiagnosed as orbital cellulitis. Hence, disease diagnosis is to be performed based on the assessment of infection indicators, clinical presentation, imaging features, the feedback on the effect of antibiotic treatment, and even of histopathology results. A history of sinusitis, high temperature, leukocytosis, and a normal pupil and fundus are usually present in children with true orbital cellulitis [20]. Importantly, timely diagnosis and treatment are essential for the prevention of potential irreversible visual loss [9], which highlights the importance of differential diagnosis of acute periorbital swelling in children. Nevertheless, most cases in which correct treatment has been implemented will be resolved without adverse residual effects (Table 1).
Table 1
List of diseases that are easily misdiagnosed as orbital cellulitis.
Patient Information | Ocular Symptoms | Risk Factors | Diagnosis | CT or MRI | Treatment | Reference |
7 years, female | painful, swelling and ptosis | upper respiratory tract infection | Idiopathic Orbital Inflammation | MRI | corticosteroid | [8] |
7 years, male | periorbital swelling and arm pain | no | Acute Sickle Cell Orbitopathy | CT | antibiotics | [9] |
3 years, No mention of gender | swelling, purulent discharge | no | retinoblastoma | CT | Enucleation and chemotherapy | [10] |
9 years, female | swelling | no | Langerhans cell histiocytosis | CT and MRI | chemotherapy | [11] |
14 years, male | proptosis, eyelid edema and low vision | no | Sickle Cell Disease | MRI | ampicilin-sulbactam and methylprednisolone | [12] |
10 years, female | swelling | no | Langerhans cell histiocytosis | CT | surgically debulked and corticosteroids | [13] |
10 days, male | swelling, mucopurulent discharge and an incomplete fistulous tract | live in poor hygiene area | External ophthalmomyiasis | no | remove the larval with forceps and antibiotics | [14] |
5 years, male | swelling and restriction of movements of right eye | no | Intra-ocular medulloepithelioma | MRI | Enucleation and chemotherapy | [15] |
1 years, No mention of gender | swelling | no | Langerhans cell histiocytosis | MRI | chemotherapy | [16] |
12 years, female | Reduced vision, diplopia, and swollen | insect bites | ophthalmomyiasis | no | Nd:YAG laser photodisruption and corticosteroids | [17] |
9 years, male | swelling | no | leukemia | MRI | radiotherapy | [18] |
12 years, male | swelling and ptosis | global developmental delay | Granulomatosis with polyangiitis | MRI | steroid and methotrexate | [19] |
Mean age: 8 months female (80%) | swelling | retinoblastoma family history (40%) | Retinoblastoma | MRI | Enucleation and chemotherapy | [20] |
8 years, male | swelling | no | venous lymphatic malformation | CT and MRI | surgery | [21] |
No consensus guideline for the treatment of children with orbital cellulitis exists. The main empirical treatment for periorbital infection is the application of broad-spectrum antibiotics. Early diagnosis and appropriate antibiotic treatment are essential for the prevention of life-threatening complications. An empirical treatment is generally recommended that is directed against at least 90% of the possible pathogen microorganisms. It is critical that all patients should be treated against Streptococcus pneumoniae, Streptococcus pyogenes, Streptococcus viridans, Staphylococcus aureus, Haemophilus representatives, and anaerobes. In areas with a low incidence of MRSA, the administration of ampicillin/sulbactam, followed by amoxicillin/clavulanic acid, is the best monotherapy. In case of concerns regarding cerebrospinal fluid penetration or suspected or confirmed allergy to penicillin, ceftriaxone can be considered as part of an empirical treatment plan. However, the therapy in patients with severe illness is usually combined with the implementation of metronidazole and vancomycin. Additionally, in patients with mild illness or in areas with high rates of clindamycin susceptibility, it can be considered for use. signs of clinical and laboratory improvement are present, a transition from initial intravenous treatment to oral treatment can be considered. The total treatment duration of these infections has decreased considerably in recent years to approximately two weeks, even in cases of orbital or subperiosteal infections [23–26]. After CT examination for diagnosis confirmation, children with orbital honeycomb inflammation combined with sinusitis are usually treated with systemic antibiotics, nasal glucocorticoids, nasal cavity washing, agents promoting mucosal dissolution, negative pressure to attract nasal secretions, etc. After the exclusion of tumors and systemic immune system diseases, 3–5-day corticosteroid therapy can be applied systemically, with a dexamethasone dosage of 0.1–0.2 mg/kg. This treatment is to be terminated after the symptoms have significantly improved. The use of systemic steroids as an adjunct to the systemic antibiotic treatment of orbital cellulitis can reduce orbital inflammation while diminishing the risk of infection aggravation [27, 28]. Due to the present lack of guidelines for corticosteroid dosage in children with orbital cellulitis, CRP levels can be used as an effective indicator for determination of the need for corticosteroid application in orbital cellulitis [29]. In an earlier study, IV dexamethasone was administered on admission concurrently with broad spectrum IV antibiotics. The dosing regimen selected was based on the standard pediatric IV dosing of dexamethasone for the treatment of inflammation (0.3 mg/kg/d divided every 6 hours) [30]. Antibiotics with high sensitivity can be replaced depending on the specific drug sensitivity results. Importantly, surgical incision and pus drainage are to be performed in cases of incorrect or missed orbital cellulitis diagnosis, as well as when the applied antibiotics therapy has been ineffective, the imaging has shown abscess formation, or after vision loss + persistent high fever despite intravenous antibiotics administration for 24–48 hours and worsening clinical symptoms. The rates of surgery in most studies are within the range of 0–11% [31]. Importantly, subperiosteal abscess is not an absolute indication for immediate surgery (Figure 3) [32].
Here, we present our analysis and summary of the initial treatment process features in a case of an orbital mass detected in children. The following information was collected: a history of trauma or eye surgery, presence of eyelid edema, extraocular movement, abnormal changes in visual acuity, exophthalmos, diplopia, fever, headache, and other clinical manifestations. Routine blood test + CRP + blood culture + CT examination results were also required. CT scans were necessary for the following conditions in patients with orbital cellulitis: inability to perform a complete eye evaluation, exophthalmos, ophthalmoplegia, and pain in external eye movements, decreased vision, or central symptoms (seizures, focal neurological deficits, or a change in the mental state). In clinical cases of intracranial complications or cavernous sinus thrombosis or such suspected on the basis of CT findings, such as changes in the mental status, persistent fever after appropriate treatment, or CT findings suggesting intracranial expansion, MRI should be considered [25, 31]. When the clinical manifestations support orbital cellulitis, but the CT examination results are normal, MRI examination is recommended to be performed to facilitate the diagnosis [33]. In case of intracranial symptoms, MRI examination is to be performed. If orbital cellulitis is diagnosed, conservative treatment can be initially administered, including the application of topical quinolone-containing eye drops on the eyelids, levofloxacin eye drops, and gatifloxacin eye ointment in combination with systemic broad-spectrum antibiotic therapy (Figure 3).
Briefly, in cases of orbital swelling, we recommend that multidisciplinary consultation should be performed, considering all infectious and non-infectious causative factors. Ineffective three-day conservative treatment should be followed by CT/MRI examination for diagnosis and treatment facilitation. However, surgery is to be considered in cases of persistent or progressive symptoms.