ORIGINAL STUDIES

Orbital Cellulitis in Children

Savithri Nageswaran, MD, MPH,* Charles R. Woods, MD, MS,*
Daniel K. Benjamin Jr, MD, MPH, PhD, Laurence B. Givner, MD,* and Avinash K. Shetty, MD*
Background: To review the epidemiology and management of
orbital cellulitis in children.
Methods: The medical records of children 18 years old and hospi-
talized from June 1, 1992, through May 31, 2002, at the Brenner
Childrens Hospital, with a discharge ICD-9 code indicating a diagnosis
of orbital cellulitis and conrmed by computed tomography scan were
reviewed. A literature search for additional studies for systematic
review was also conducted.
Results: Forty-one children with orbital cellulitis were identied.
The mean age was 7.5 years (range, 10 months to 16 years), and 30
(73%) were male (male:female ratio 2.7). All cases of orbital
cellulitis were associated with sinusitis; ethmoid sinusitis was
present in 40 (98%) patients. Proptosis and/or ophthalmoplegia was
documented in 30 (73%), and 34 (83%) had subperiosteal and/or
orbital abscesses. Twenty-nine (71%) had surgical drainage and 12
(29%) received antibiotic therapy only. The mean duration of
hospitalization was 5.8 days. The mean duration of antibiotic ther-
apy was 21 days.
Conclusions: Orbital cellulitis occurs throughout childhood and in
similar frequency among younger and older children. It is twice as
common among males as females. Selected cases of orbital celluli-
tis, including many with subperiosteal abscess, can be treated
successfully without surgical drainage.
Key Words: orbital cellulitis, subperiosteal abscess, sinusitis,
preseptal cellulitis, children
(Pediatr Infect Dis J 2006;25: 695699)
O
rbital cellulitis is a serious infection in children that can
result in signicant complications, including blindness,
cavernous sinus thrombosis, meningitis, subdural empyema,
and brain abscess.
1
These complications have become rare in
the antibiotic era, but the potential for sight- or life-threaten-
ing complications makes prompt diagnosis and early treat-
ment important.
2,3
The orbital septum divides the soft tissues of the eyelid
(preseptal space) from those of the orbit (postseptal space).
Periorbital (preseptal) cellulitis occurs anterior to the orbital
septum and results from trauma, contiguous infection or
primary bacteremia among young infants.
3
In orbital celluli-
tis, the infection is localized posterior to the orbital septum
and usually occurs as a complication of acute or chronic
sinusitis.
2,3
The last major review of orbital cellulitis in the pedi-
atric literature was published in 1987.
4
This review described
a case series from the Dallas area, with a mean of age of 12
years. In the mid-1990s, we treated several infants and
preschool-age children with orbital cellulitis, which raised the
question of whether a shift toward younger age among
children with orbital cellulitis was occurring. The one series
of orbital cellulitis in the pediatric literature since 1987
described good clinical outcomes with medical management
alone in 9 children 5 years old.
5
Recent case series in the
otolaryngology and ophthalmology literature also have doc-
umented substantial proportions of orbital cellulitis cases
among young children.
2,69
In an effort to explore potential epidemiologic changes
and management trends in children with orbital cellulitis, we
report our experience with 41 children in a 10-year period and
review other case series of orbital cellulitis in children pub-
lished since 1986.
MATERIALS AND METHODS
Local Study. Brenner Childrens Hospital (BCH) in Winston-
Salem, NC, part of the Wake Forest University Baptist
Medical Center, is a regional referral center for western North
Carolina, southern Virginia, eastern Tennessee and northern
South Carolina. BCH serves a total catchment area of ap-
proximately 2 million people, ranging from rural to small
urban areas. Annually, more than 4500 children receive
inpatient care, and there are more than 25,000 outpatient
visits to BCH. Medical records of children 18 years old
who were admitted to the BCH between June 1, 1992, and
May 31, 2002, were identied for review if any of the ICD-9
codes for orbital inammation were listed among the dis-
charge diagnoses (ie, 376.00, 376.01, 376.02, 376.03). Cases
were included if they had conrmation of orbital cellulitis by
computed tomography (CT). Children with orbital cellulitis
secondary to trauma or surgery and those with anatomic
abnormalities of the eye, malignancy, or other immunosup-
pressed states were excluded. Cases that had only preseptal
(periorbital) cellulitis without evidence of postseptal involve-
ment were also excluded.
Demographic characteristics, clinical features, microbi-
ologic and radiologic characteristics, and details of treatment,
complications, and follow-up were obtained. For determining
days of parenteral antibiotic therapy, days on which a child
Accepted for publication May 10, 2006.
From the *Department of Pediatrics, Wake Forest University Health Sci-
ences and Brenner Childrens Hospital, Winston-Salem, NC; and the
Department of Pediatrics and Duke Clinical Research Institute, Duke
University, Durham, NC.
Address for correspondence: Charles R. Woods, MD, MS, Wake Forest
University School of Medicine, Department of Pediatrics, Medical Cen-
ter Blvd, Winston-Salem, NC 27157. E-mail: cwoods@wfubmc.edu.
Copyright 2006 by Lippincott Williams & Wilkins
ISSN: 0891-3668/06/2508-0695
DOI: 10.1097/01.inf.0000227820.36036.f1
The Pediatric Infectious Disease Journal Volume 25, Number 8, August 2006 695
received an oral antibiotic along with a parenteral agent were
counted as parenteral days. Oral antibiotic duration was
dened as the number of days prescribed (intended); conr-
mation that all doses were taken after hospital discharge was
not available. This project was approved by the institutional
review board of the Wake Forest University School of Med-
icine.
Statistical Analysis. Student t tests were used for between-
groups comparisons for continuous variables with normal
distributions. Mann-Whitney U tests were used when distri-
butions of continuous variables were likely nonnormal.
2
methods, with continuity correction for 2- -2 tables, were
used for associations of categorical variables. Analyses were
conducted using SPSS 13.0 (SPSS, Inc., Chicago, IL).
Literature Review. To compare our results on age distribution
with previous studies, the PubMed database was searched for
studies that contained information on orbital cellulitis. The
search strategy used was orbital cellulitis or orbital abscess
or subperiosteal abscess limited to English literature, human
subjects, children 018 years, and the period 1985 through
2005. Studies were selected for review if they (1) described
series with more than 5 cases of orbital cellulitis in North
America; (2) were published subsequently to or were unavail-
able for inclusion in the 1987 publication by Israele and
Nelson
4
; and (3) clearly distinguished orbital cellulitis from
preseptal (periorbital) cellulitis on the bases of physical
ndings (ie, presence of proptosis, ophthalmoplegia) and/or
CT scan ndings demonstrating postseptal involvement. Ne-
TABLE 1. Characteristics of 41 Cases of Orbital Cellulitis at the Brenner Childrens Hospital, 1992 to 2002
Characteristic
Total Group
N 41
Age 7 yr,
N 19
Age 7 yr,
N 22
P Value
Age, years, mean SD (median)
range*
7.5 5.0 (8.8) 0.916.3 2.7 1.5 (2.6) 0.96.1 11.7 2.3 (11.2) 8.716.3
Male, No. (%) 30 (73) 16 (84) 14 (64) 0.26
White, No. (%) 32 (78) 15 (79) 17 (77) 0.99
Seasonality October-March,
No. (%)
23 (56) 11 (58) 12 (54) 0.99
Antibiotics before admission,
No. (%)
33 (80) 16 (84) 17 (77) 0.87
Days of antibiotics before
admission

3.1 2.4 3.0 2.2 3.2 2.6 0.86

Days of nasal congestion before
diagnosis, mean SD,
(median) range
6.4 8.6 (3) 030 8.7 9.9 (4) 030 4.4 6.9 (2.5) 030 0.12
Fever on or after presentation
(101F), No. (%)

27 (66) 11 (58) 16 (73) 0.50

Maximum temperature recorded,
F, mean SD
101.2 1.7 101.0 1.9 101.4 1.6 0.40
White blood cell count (WBC) on
admission, thousands, mean
SD (median) range
15.1 6.5 (14) 634 17.2 6.7 (16) 834 13.4 5.9 (12) 628 0.06
WBC 15,000, No. (%) 19 (46) 12 (63) 7 (32) 0.09
Ophthalmologic signs

None, No. (%) 11 (27) 9 (47) 2 (9) 0.016

Proptosis, No. (%) 25 (61) 8 (42) 17 (77) 0.048
Any ophthalmoplegia, No. (%) 19 (46) 3 (16) 16 (73) 0.001
Both, No. (%) 14 (34) 1 (5) 13 (59) 0.001
Left eye, No. (%) 23 (56) 12 (63) 11 (50) 0.60
Orbital cellulitis characteristics
Orbital cellulitis, no abscess or
phlegmon, No. (%)
7 (17) 5 (26) 2 (9) 0.24
Subperiosteal abscess (or
phlegmon), No. (%)
24 (59) 11 (58) 13 (59)
Orbital abscess subperiosteal
abscess,

No. (%)
10 (24) 3 (16) 7 (32)
Any surgical procedure, No. (%) 29 (71) 11 (58) 18 (82) 0.18
Drainage only, No. (%) 12 (29) 4 (21) 8 (36) 0.22

Drainage plus Ethmoidectomy,

No. (%)
17 (41) 7 (37) 10 (45)
Length of hospitalization, days,
mean SD
All patients 5.8 2.9 5.3 3.1 6.3 2.8 0.38
Medical treatment only (n 12) 4.2 1.9
#
3.6 1.7 5.2 2.1 0.23
Any surgical procedure (n 29) 6.5 3.0
#
6.4 3.4 6.5 2.9 0.97
SD standard deviation.
*Range given as minimum and maximum.

For those who had received antibiotics before admission.

Fever after presentation was not associated with receipt of antibiotics before admission.

Each analysis conducted as a 2- -2 table.

Includes 1 postseptal phlegmon that was not a frank abscess. Eight cases also had subperiosteal abscesses.

Analysis was with a 3- -2 table, with no surgery as the third category.

#
P 0.011 for difference between medical and surgical treatment groups in length of stay (Mann-Whitney U test).
Nageswaran et al The Pediatric Infectious Disease Journal Volume 25, Number 8, August 2006
2006 Lippincott Williams & Wilkins 696
onates were excluded. When necessary, mean ages for case
series were estimated using the midpoints of any age ranges
provided.
RESULTS
The ICD-9 codes identied 102 children during the
study period. Of the 102 children, 42 had only preseptal
cellulitis and 19 were excluded because of malignancy (6),
dacryocystitis (3), immunosuppression (3), trauma (3) post-
operative infection (2), and other (2). Thus, 41 children with
orbital cellulitis were included in this series.
The characteristics of orbital cellulitis are presented in
Table 1. The ages of the 41 children with orbital cellulitis
ranged from 10 months to 16 years, with a mean age of 7.5
years. There were few cases between the ages of 4 and 7
years, which could suggest a bimodal age distribution (Fig.
1). Thirty (73%) were male (male:female ratio of 2.7:1) and
32 (78%) were white (Table 1). Twenty-seven (66%) had
fever on or after presentation. Presence or absence of fever
was not associated with age or receipt of antibiotics (orally or
parenterally) before admission. Proptosis and/or ophthalmo-
plegia was present in 30 (73%). Ethmoid sinusitis was present
in 40 (98%), maxillary sinusitis in 29 (71%), frontal sinusitis
in 13 (32%) and sphenoid sinusitis in 9 (22%). Subperiosteal
or other orbital abscesses (or phlegmons) were present in 34
(83%). None had intracranial infection or any other serious
complication.
Clinical characteristics were compared between younger
(7 years) and older (7 years) children (Table 1). The younger
children had less documented proptosis and/or ophthalmoplegia
than did older children. The WBC count was higher among
younger children, but the difference was not statistically signif-
icant (P 0.06). Twelve of the 13 children with frontal sinusitis
were 9 years old (the youngest was 6 years old), an age
distribution expected developmentally. Other ndings were sim-
ilar for the 2 age groups.
Twenty-nine patients (71%) underwent surgical drainage,
and 17 (41%) had ethmoidectomy (Table 1). Twelve (29%)
were treated with antibiotics alone. During the initial study
period (19921997), 4/20 (20%) were treated with medical
management alone compared with 8/21 (38%) in more recent
years (19982002), P 0.35. The mean duration of hospital-
ization was 5.8 2.9 days overall. The length of stay was longer
for patients who underwent surgery than for those who did not
(6.5 days versus 4.2 days, P 0.011).
The most frequently used antibiotic regimen for initial
parenteral therapy was ampicillin-sulbactam (41%), followed by
nafcillin plus a third-generation cephalosporin (27%), usually
ceftizoxime. Amoxicillin-clavulanate was the most common
oral antibiotic used (68%). Clindamycin (intravenously and/or
orally) plus a third-generation cephalosporin (parenterally and/or
orally) as initial or subsequent therapy was used in 29% of
treatment courses.
The mean durations of total and parenteral antibiotic
therapy were 21.0 3.0 and 9.3 3.6 days, respectively.
Length of therapy was longer in those requiring surgery
versus those who did not: 22.1 2.1 day versus 18.2 3.4
days (P 0.003). There were no differences in any aspect of
antibiotic therapy between the younger and older age groups.
At discharge, no patients were expected to have any long-
term sequelae from their orbital infection.
Microbiologic Findings. Twenty-eight of the 29 children
who had surgical procedures had cultures sent from an
abscess (orbital or subperiosteal) and/or sinus. Most of the
children had received oral or parenteral antibiotics before
cultures were sent. At least 1 abscess or sinus culture from
18 of these children was positive, and 6 children had 2 or
more microbes isolated (Table 2). Two additional children
had positive blood cultures, one for Fusobacterium necro-
phorum plus Arcanobacterium hemolyticum and the other for
Streptococcus pyogenes. Overall, 7 (35%) of the 20 children
with positive culture(s) had evidence of polymicrobial infec-
tion. Coagulase-negative staphylococci, lactobacilli, and
Candida species were considered contaminants.
0
1
2
3
4
5
6
7
<1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Age in Years
N
u
m
b
e
r

o
f

C
a
s
e
s
FIGURE 1. Age distribution of 41 children with orbital celluli-
tis. There were few cases between the ages of 4 and 7 years,
which may imply a bimodal age distribution.
TABLE 2. The Microbiology Associated With Orbital
Cellulitis Among 20 Children With Positive Cultures
Organism
Total
Isolates
Abscess
Isolates
Aerobes
-or nonhemolytic streptococci* 7 3
Group A -hemolytic streptococci 3 2
Staphylococcus aureus* 3 3
Haemophilus influenzae

3 2
Group C -hemolytic streptococci* 2 2
Eikenella corrodens* 2 2
Arcanobacterium hemolyticum*

1
Moraxella catarrhalis* 1 1
Anaerobes
Peptostreptococcus* 4 3
Bacteroides species* 2 2
Fusobacterium necrophorum*

1
Anaerobic bacterium, unspecified* 1
*One or more isolates were from 1 or more of 7 children with polymicrobial culture results.

One was H. influenzae type b from a sinus culture (isolated in 1993 from a 16-mo-old).

Isolated in same blood culture in a child with a negative abscess culture.

The Pediatric Infectious Disease Journal Volume 25, Number 8, August 2006 Orbital Cellulitis in Children
2006 Lippincott Williams & Wilkins 697
DISCUSSION
Orbital cellulitis is an infrequent but serious complica-
tion of sinusitis in children.
1,2
Confusion has existed in both
the medical and surgical literatures about the denitions of
orbital versus preseptal (periorbital) cellulitides, entities that
differ greatly with regard to pathogenesis and management
strategies.
3
Ethmoid sinusitis is the most common origin of
orbital cellulitis at all ages and certainly predominates in
young children who have not yet formed their frontal sinus-
es.
2,3,6
In a retrospective study fromDallas published in 1987, the
mean age of children with orbital cellulitis was 12 years.
4
In the
1990s, we cared for several much younger children who devel-
oped orbital cellulitis, which led us to ask whether there was a
change in the epidemiology of orbital cellulitis. In our series of
41 children seen between 1992 and 2002, the mean age was 7.5
years. Table 3 (available online at www.pidj.com) summarizes
the epidemiologic and management information fromcase series
published since 1987 of children with orbital cellulitis
514
and
with orbital subperiosteal abscesses.
7,11,1523
Among the 594
cases of orbital cellulitis summarized between 1890 and the
mid-1970s (with a few extending into the 1980s), the estimated
mean age was 7.4 years, quite similar to our series.
4
The mean
ages of 11 series of orbital cellulitis with subperiosteal abscess
ranged from 5.5 to 9 years.
7,11,1523
The striking male preponderance that we observed with
orbital cellulitis (73%) and with subperiosteal abscess (75%)
has also been seen in most other cases series that provided
gender-specic data.
7,10,1318,2123
Overall, the male:female
ratios across these case series suggest that orbital cellulitis in
childhood is at least twice as common among males as
females. This is consistent with gender-related trends in other
serious infections in childhood.
Seasonal peaks of orbital cellulitis from late fall to early
spring have been reported in some studies
2,9,14
and may be
related in part to increased frequency of sinusitis complicat-
ing viral upper respiratory tract infections during cold
weather. No clear-cut seasonality was present in our study.
About one third of the children in our series did not have
fever after admission, and this was not attributable to receipt of
antibiotics before admission. Absent or low-grade fever in chil-
dren with orbital cellulitis has been noted in other recent series
as well.
14,23
Proptosis and limitation of ocular motility were
documented less frequently in younger versus older children in
our series. This also has been described by others.
23
The spectrum of bacteria isolated from our patients is
consistent with ndings in other series. The bacteria most
commonly causing orbital cellulitis include the typical patho-
gens associated with acute sinusitis, ie, S. pneumoniae, H.
inuenzae, M. catarrhalis, S. pyogenes, S. aureus, - and
nonhemolytic streptococci (including the S. milleri group)
and anaerobic bacteria of the upper respiratory tract (eg,
Bacteroides, Peptostreptococcus, Prevotella and Fusobacte-
rium).
3,4,9,13,14,1719,23
Polymicrobial infections also are com-
mon
14,19,23
and may be more frequent in older versus younger
children.
19,23
The diagnosis of orbital cellulitis is best conrmed by
CT scan with contrast infusion of the orbit.
1,3,5,24
Many of the
clinical signs of orbital cellulitis are distinctive (proptosis,
ophthalmoplegia),
7
but distinguishing between periorbital
(preseptal) and orbital cellulitis in young children based on
clinical observations alone can be difcult.
Historically, the presence of subperiosteal or intraor-
bital abscess was an indication for surgical drainage in
addition to antibiotic therapy.
2527
Medical management
alone now has been used selectively for 30 years, and is
successful in many cases.
2,5,15,16,20
Surgical drainage is indi-
cated for complete ophthalmoplegia and/or signicant visual
impairment (acute optic nerve or retinal compromise) or large
well-dened abscesses.
10,22,27,28
Other patients may receive
an initial trial of intravenous antibiotics for 2448 hours,
with close monitoring.
7,16,22,23
If there is no clinical improve-
ment, a repeated CT scan and/or surgical drainage should be
considered.
3,7
Children 7 years old may be more likely to
require drainage of orbital abscesses.
19,23,28
The variety of antibiotic selections in our series of
patients was similar to that in previous series.
57,14,16,17
Em-
piric antibiotic therapy at all ages should provide coverage for
pathogens associated with acute sinusitis (S. pneumoniae, H.
inuenzae, M. catarrhalis, S. pyogenes) as well as for S.
aureus and anaerobes. The recently favored choice of ampi-
cillin-sulbactam for initial empiric parenteral therapy seems
reasonable. This regimen may require reevaluation in this era
of signicant prevalence of community-acquired methicillin-
resistant S. aureus infections in many parts of the United
States.
29
Our local study is limited by its retrospective design
and relatively small number of cases, although it is one of the
larger series of orbital cellulitis reported to date. In the
literature review, a number of studies had to be excluded
because of confusion in terminology or the lack of clear
differentiation between orbital and periorbital cellulitis cases,
at least in terms of providing entity-specic demographic,
management, and outcomes data. For a number of included
studies, mean age estimates had to be derived from age-
interval data. Given the consistencies in age during the
various periods, it is unlikely that this introduced signicant
bias in mean age estimates. Finally, not all information of
interest was available in each of the studies reviewed.
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2006 Lippincott Williams & Wilkins 699