Inflammation of the fatty tissue of the orbit - orbital cellulitis. Cellulitis of the orbit - orbital cellulitis

Preseptal cellulitis is an inflammation of the eyelids and surrounding skin anterior to the orbital fascia; Orbital cellulitis is an inflammation of the orbital tissue behind the orbital fascia. They may be caused exogenous infection(in case of injury), infection that spreads from the paranasal sinuses or teeth, as well as metastatic spread from an infectious focus of any location. Symptoms include eyelid pain, discoloration, and swelling;

Orbital cellulitis also causes increased body temperature, malaise, exophthalmos, and impaired eye movement and vision. The diagnosis is based on medical history, examination and neuroimaging. Treatment consists of antibiotics and sometimes surgical drainage.

Preseptal and orbital cellulitis are two various diseases, which are characterized by similar symptoms. Preseptal cellulitis usually begins anterior to the orbital fascia; orbital cellulitis usually begins behind the orbital fascia. Both are more common in children; Preseptal cellulitis occurs more often than orbital cellulitis.

Etiology and pathophysiology

Preseptal cellulitis develops as a result of the spread of infection due to local trauma in the face or eyelid, insect bites, infections of the upper respiratory tract, conjunctivitis or chalazion.

Orbital cellulitis is most often caused by the spread of infection from adjacent sinuses, especially from ethmoid sinus(from 75 to 90%); less commonly, it is caused by infection after injury (eg, insect or animal bite, penetrating eye injury) or spread of infection from the facial area.

Pathogens vary in etiology and depending on age. The most common pathogen that is associated with infection paranasal sinuses nose is Streptococcus pneumoniae, while Staphylococcus pyogenes predominates in infection after local trauma. Nowadays, cases of Haemophilus influenzae type B are less common after vaccination. Fungi are rare pathogens that cause orbital cellulitis in diabetic and immunosuppressed patients. In children under 9 years of age, one aerobic pathogen is detected; Patients over 15 years of age usually have mixed aerobic and anaerobic infections.

Since orbital cellulitis arises from adjacent areas with a violent infection (sinusitis), separated by a thin bone wall, orbital infection can be severe and severe. Subperiosteal collections of fluid may develop, sometimes in large quantities, called subperiosteal abscesses, but many are initially sterile.

Complications include vision loss (3% to 11%) from ischemic retinopathy and optic neuropathy; disturbances in eye movement (ophthalmoplegia) caused by inflammation of soft tissues; intracranial consequences central spread of infection, including cavernous sinus thrombosis, meningitis and cerebral abscess.

Symptoms and signs

Preseptal cellulitis is characterized by tension, swelling and redness or discoloration of the eyelids (violet in the case of H. influenzae). Patients are sometimes unable to open their eyes, but visual acuity may remain normal.

Symptoms and signs of orbital cellulitis include swelling and redness of the eyelids and surrounding soft tissue, hyperemia and swelling of the conjunctiva, limited eye movement, pain with eye movement, decreased visual acuity, and exophthalmos caused by orbital swelling. Symptoms are often present primary infection(eg, nasal discharge and bleeding from sinusitis, periodontal pain and swelling from an abscess). Suspected meningitis may be caused by fever, malaise and headache. All these signs may be absent in early period diseases.

If subperiosteal abscesses are large enough, they can cause swelling and redness of the eyelids, impaired ocular motility, exophthalmos, and decreased visual function.

Diagnostics

The diagnosis is made clinically. An ophthalmologist is involved if preseptal or orbital cellulitis is suspected, as visual acuity must be monitored. If the eyelids are swollen, eyelid retractors may be needed to examine the eyeball, primary signs complicated infections may be difficult to detect. Preseptal and orbital cellulitis can be identified clinically. The diagnosis of preseptal cellulitis is likely if the eye is normal except for swelling of the eyelids, there is a localized focus of infection in the skin, and there are no symptoms systemic disease. If the findings are equivocal, examination is difficult (in young children), or there is nasal discharge (sinusitis), a CT scan should be done to confirm orbital cellulitis and diagnose sinusitis. If thrombosis of cavernous sinusitis is suspected, an MRI is necessary.

The direction of exophthalmos may be a clue to localizing the infection; for example, spread from the frontal sinus causes the eye to shift downward and outward, from the ethmoidal sinus - laterally and outward.

Blood cultures are often tested in patients with cellulitis (preferably before antibiotics are used), but a positive response is detected in less than 33% of patients. If meningitis is suspected, it is performed lumbar puncture. Other laboratory tests are of little value.

Differential diagnosis is carried out with non-infectious inflammation after injury, insect bites without cellulite; foreign body, allergic reaction, tumor or other inflammatory diseases (for example, dacryocystitis, dacryoadenitis, inflammatory pseudotumor of the orbit). Inflammatory diseases can usually be diagnosed by location and external manifestations.

Treatment

Both forms of cellulite are treated with antibiotics.

In patients with preseptal cellulitis, treatment should be directed against the causative agents of sinusitis. Contaminated wounds may have a gram-negative infection. For treatment, amoxicillin with clavulanic acid is used at a dose of 30 mg/kg every 8 hours (for children under 12 years of age) or 500 mg 3 times a day or 875 mg 2 times a day (for adults) for 10 days for the treatment of outpatient patients; for patients undergoing treatment in a hospital, ampicillin or sulbactam is prescribed at a dose of 50 mg/kg intravenously every 6 hours (for children) or from 1.5 to 3.0 (for adults) intravenously every 6 hours (maximum 8 g of ampicillin per day) within 7 days. Ambulatory treatment is an option for patients in whom orbital cellulitis has been definitely excluded, or in children without signs of systemic infection who have responsible parents or guardians.

Patients with orbital cellulitis should be hospitalized and treated with antibiotics in the dose required to treat meningitis. Second- and third-generation cephalosphorins are used, such as cefatoxime at a dose of 50 mg/kg intravenously every 6 hours (for children under 12 years of age) or 1-2 g intravenously every 6 hours (for adults) for 14 days if cellulite is present; Imipenem, ceftriaxone and piperacillin/tazobactam are other drugs of choice. If cellulitis is associated with trauma or a foreign body, choose antibiotics active against gram-positive (vancomycin 1 g IV every 12 hours) and gram-negative pathogens (eg, ertapenem 100 mg IV once daily) for 7 to 10 days or until clinical improvement.

Surgical treatment to decompress the orbit and open the infected sinuses is indicated if vision is impaired and the presence of foreign body. CT scan reveals orbital or subperiosteal abscesses or orbital infection that does not respond to antibiotics.

Or orbital cellulitis - acute diffuse inflammation of the fiber of the orbit of the eye. Diagnosed in less than 1% of patients. Usually detected in children under 5 years of age, rarely occurs in other age groups.

Phlegmon of the orbit is differentiated from phlegmon of the eyelid, Quincke's edema, neurocutaneous disease, acute dacryocystitis and other diseases with similar symptoms.

Clinical picture

The disease is manifested by rapidly swelling tissues of the eye. May occur after diseases of the paranasal sinuses or acute respiratory viral infections.

On early stages Possible chemosis of the conjunctiva, exophthalmos, deterioration in the mobility of the eyeball. When the eye becomes infected, vision deteriorates.

Causes

The development of orbital phlegmon is associated with injuries to the facial bones, skin cuts, infectious diseases teeth, sinuses and eyes. It can also be provoked

• sinusitis;
• acute dacryocystitis;
• oral infections;
• boils and styes on the face;
• complications of typhus, scarlet fever and influenza;
• breakthrough of pus into the orbit.

The main causative agents of the disease are staphylococci (white and golden), Lactobacteriaceae bacteria or Escherichia coli.

Classification

Orbital tissue becomes infected, passing through stages

• preseptal cellulite;
• orbital cellulite;
• subperiosteal abscess;
• abscess and phlegmon of the orbit.

Diagnosis of the disease

An ophthalmologist examines and palpates the patient's eye. Upon examination Special attention addresses swelling of the eyelid and purulent discharge from the eye.

Examinations by a dentist and otolaryngologist are also necessary.

Main research:

• general blood analysis;
• radiography of the orbit;
• examination of the paranasal sinuses (x-ray, ultrasound);
• transillumination;
• examination of the eye using a slit lamp;
• measuring the degree of protrusion of the eyeball.

Treatment of orbital phlegmon

The patient is hospitalized in the hospital. Stenosis is being treated nasolacrimal duct, chronic dacryocystitis, etc. At the first stage of treatment, strong antibiotics, detoxification drugs and injections.

Additionally, functional endoscopic ethmoidotomy, micromaxylotomy, puncture and drainage of the paranasal sinus are prescribed. During fluctuation, the tissues of the orbit are dissected, the retrobulbar space is opened, and the wound canal is drained.

Forecast

When treating phlegmon at an early stage, the prognosis is favorable. Complications are likely later.

Prevention

Prevention of orbital phlegmon consists of treatment chronic processes in the eye and the use of sulfonamides and antibiotics for eye injuries.

Orbital (postseptal) cellulitis is an infection of the soft tissues of the orbit posterior to the orbital septum. In both cases, the cause of the disease may be an external source of infection (for example, a wound), spread of infection from the sinuses or teeth, or metastatic spread of infection from a distant site. Clinical manifestations include pain and darkening of the skin in the eyelid area, as well as swelling of adjacent tissues. In the case of orbital cellulitis, the following are possible: exophthalmos of the eyeball, impaired eye movement and decreased vision. The diagnosis is made based on complaints, examination and CT or MRI data. Treatment is with antibiotics and, in some cases, by draining the phlegmon.

Preseptal and orbital cellulitis are two different diseases that have a number of similarities clinical manifestations. Preseptal cellulitis usually occurs anterior to the orbital septum. Orbital cellulitis develops deeper, posterior to the orbital septum. Both conditions are common among children, but preseptal cellulitis is more common.

Preseptal (periorbital) cellulite. Causes

The most common causes of preseptal cellulitis are spread of infection from a wound to the face or eyelids, an insect or animal bite, conjunctivitis, chalazion, or sinusitis.

The most common causes of orbital sinusitis are the spread of infection from the adjacent paranasal sinuses, most often from the ethmoidal labyrinth (75-90%). Less commonly, the cause is direct infection as a result of injury or hematogenous spread of infection from a focus located in the face or teeth.

The causative agents of the infection depend on its source, as well as on the age of the patients. In the case of concomitant sinusitis, the causative agent is most often Streptococcus pneumoniae, while in the presence of previous trauma, the main causative agents are considered Staphylococcus aureus and S. pyogenes. Previously, Haemophilus influenzae type B was a common pathogen, but the incidence has now decreased due to active vaccination. Fungal infections found mainly among patients with diabetes mellitus or immunosuppression. The cause of the disease among children under 9 years of age is most often a single aerobic pathogen. Among older patients, especially those over 15 years of age, mixed infections predominate, including both aerobic and anaerobic (Bacteroides, Peptostreptococcus) pathogens.

Preseptal (periorbital) cellulite. Pathophysiology

The cause of the development of orbital cellulite may be big number sources active infection, which are separated only by a thin bone septum. Due to this infectious process in the orbit may spread to adjacent structures. Against this background, under the periosteum can accumulate a large number of liquids. Such lesions are called subperiosteal abscesses, although many of them are initially sterile.

Increased intraorbital pressure causes ischemic retinopathy and optic neuropathy, which can lead to vision loss (3-11%).

Preseptal (periorbital) cellulite. Symptoms and signs

Clinical manifestations of preseptal cellulitis are tenderness and swelling of the surrounding tissues, a feeling of heat, redness or darkening of the eyelid (with an infection caused by H. influenzae, a purple hue is possible) and, in some cases, fever. Sometimes the swelling of the eyelids is so severe that patients cannot open their eyes. Swelling and painful sensations may interfere with the examination, but it reveals that vision and eye movement are not impaired, and there is no protrusion of the eyeball.

Clinical manifestations of orbital cellulitis are swelling and redness of the eyelid and surrounding tissues, swelling and hyperemia of the conjunctiva, decreased eye mobility, pain when moving the eyes, decreased vigilance and exophthalmos caused by swelling of the orbital tissues. In addition, all signs of previous infection remain (for example, nasal discharge and bleeding from sinusitis, toothache, swelling of the gums).

Fever is also present in most cases. If the patient has headache and drowsiness, the development of meningitis should be suspected. In the early stages of the disease, the described symptoms may be absent.

Large subperiosteal abscesses can aggravate the severity of the condition.

Preseptal (periorbital) cellulite. Diagnostics

The assessment is mainly based on the clinical picture.

If orbital cellulitis is suspected, CT or MRI.

A preliminary diagnosis is established based on clinical picture. Differential diagnosis is carried out with injuries, insect or animal bites without the development of cellulite, foreign body, allergic reactions, tumors and inflammatory pseudotumor of the orbit.

Swelling of the eyelids may result in the need for a retractor to examine the eyeball. The initial manifestations of a complicated infection may be minor. If orbital cellulitis is suspected, consultation with an ophthalmologist is necessary.

Preseptal and orbital cellulitis can be differentiated based on their clinical presentation. In the case of preseptal cellulitis, the only manifestation is swelling of the eyelids. The presence of a source of infection located nearby also indicates high probability preseptal cellulite.

If the clinical picture is ambiguous, difficulty examining the eyeball (for example, in small children), or the presence of nasal discharge (indicating sinusitis), CT or MRI should be performed to exclude orbital cellulitis, tumor or pseudotumor.

The localization of the source of infection can be determined by the direction of exophthalmos of the eyeball. For example, pressure from the frontal sinus leads to bulging of the eyeball downwards and outwards, and from the side of the ethmoidal labyrinth - laterally and outwards.

Blood cultures are performed in many cases (ideally before antibiotic therapy is started), but blood culture growth is observed in less than a third of cases. If meningitis is suspected, a lumbar puncture is recommended. If preexisting sinusitis is suspected, culture of sinus discharge may be helpful. Others laboratory research do not play a significant role in the diagnostic search.

Preseptal (periorbital) cellulite. Treatment

Preseptal cellulitis. Basic antibiotic therapy should be directed against sinusitis pathogens (S. pneumoniae, non-typeable H. influenzae, S. aureus, Moraxella catarrhalis). If there is a risk of infection with methicillin-resistant S. aureus, it is necessary to use antibiotics that are effective against it (for example, clindamycin, trimethoprim/sulfamethoxazole, or doxycycline when taken orally in an outpatient setting or vancomycin when treated in a hospital setting). If the patient has contaminated wounds, the risk of anaerobic infection should be considered.

Treatment on an outpatient basis is allowed if orbital cellulitis has been completely excluded. In this case, children should be under constant supervision of their parents or guardians, and they should not show signs of generalization of the infection. All patients receiving treatment on an outpatient basis should be observed by an ophthalmologist. For outpatient use, the following treatment regimen is recommended: amoxicillin + clavulanic acid.

At inpatient treatment ampicillin/sulbactam is used for 7 days.

Orbital cellulitis. If orbital cellulitis is detected, the patient must be hospitalized for antibiotic therapy in a dosage similar to that for the treatment of meningitis. Recommended if you have sinusitis intravenous use 2nd and 3rd generation cephalosporins such as cefotaxime. Imipenem, ceftriaxone and piperacillin/tazobactam may also be used. If the cause of cellulite is injury or a foreign body, it is necessary to use combination antibiotic therapy directed against both gram-positive and gram-negative flora. The course of treatment is either 7-10 days or continues until the condition improves.

Indications for surgical decompression of the orbit, drainage of an abscess, opening of infected sinuses, or a combination of these procedures are:

• decreased vigilance,
• suspicion of the presence of an abscess or foreign body,
• instrumentally detected orbital or large subperiosteal abscess,
• ineffectiveness of antibiotic therapy.

Key Points

Preseptal and orbital cellulitis are differentiated depending on where the source of infection is localized - anterior or posterior to the orbital septum.

• The cause of orbital cellulitis is most often the spread of infection from the frontal sinus or ethmoidal labyrinth, while the cause of preseptal sinusitis is infected wounds face and eyelids, insect or animal bites, or chalazion.
• Clinical manifestations of both diseases may include pain and swelling of the tissues, redness or darkening of the eyelid, and fever.
• Orbital cellulitis should be suspected if the patient has decreased ocular motility, exophthalmos, or decreased vision.

Treatment is with antibiotics. In case of complicated orbital cellulitis (eg, abscess, foreign body, visual disturbances, ineffectiveness of antibiotics), surgical treatment is indicated.

What is cellulitis (phlegmon) of the orbit?

What causes cellulitis (phlegmon) of the orbit

The causes of the disease are purulent processes in the facial area ( erysipelas, boils, styes, purulent dacryocystitis, eyelid abscess, purulent sinusitis). Orbital phlegmon can be caused by injuries to the orbit with tissue infection by pyogenic microbes, as well as the introduction of infected foreign bodies into the orbit. Rarely, this pathology occurs in infectious diseases(scarlet fever, flu, typhus). Phlegmon of the orbit also occurs as a result of the spread of a purulent process from a neighboring lesion to the retrobulbar tissue (ruptured subperiosteal abscesses).

Symptoms Cellulitis (phlegmon) of the orbit

The process is usually one-sided, develops suddenly and quickly (within several hours or 1-2 days).

Pain in the eyelids and eye sockets and headache appear. The pain intensifies with palpation and eye movements. The eyelids are hyperemic, swollen and tense, it is almost impossible to open them. General state the patient is seriously ill (high body temperature, weakness).

Restriction of eyeball mobility and exophthalmos quickly occur. In cases where the development of phlegmon was preceded by periostitis or osteitis of the orbital walls, displacement of the eyeball is possible. As inflammation develops, chemosis of the conjunctiva of the eyeball appears, the edematous mucous membrane does not fit into the conjunctival sac and is pinched by the edematous eyelids, exophthalmos increases, eyeball becomes almost motionless, vision decreases sharply. Between the protruding eye and the edge of the orbit, the swollen contents of the orbit are felt.

When involved in the inflammatory process optic nerve neuritis develops with a predominance stagnation and retinal vein thrombosis. As a result of trophic disorders caused by compression of the nerves, keratitis and purulent corneal ulcers are sometimes observed. Inflammation often progresses to choroid eyes, retina and causes purulent choroiditis and panophthalmitis with subsequent atrophy of the eye. When the process is limited, an abscess forms in the orbit, which sometimes spontaneously opens through the skin or conjunctiva.

The inflammatory process can progress to meninges and venous sinuses (cavernous sinus). Sepsis may develop. Stormy beginning, fast progressive and severe course differentiate orbital phlegmon from tenonitis.

Diagnosis Cellulitis (phlegmon) of the orbit

Radiography of the paranasal sinuses and orbit is necessary, which is important for differential diagnosis phlegmon of the orbit from periostitis of the orbital wall, as well as to prevent a foreign body from entering the orbit during injury.

Treatment of cellulitis (phlegmon) of the orbit

The use of antibiotics orally, intramuscularly and intramuscularly is indicated. severe cases intravenously. Intramuscularly - benzylpenicillin sodium salt 500,000 units 4 times a day, methicillin sodium salt 1-2 g every 6 hours (before administration, the drug is dissolved in bidistilled water or 0.5% novocaine solution), oxacillin sodium salt 0.25 -0.5 g every 4-6 hours (then after a few days they switch to oral administration of 1 g every 4-6 hours); 4% solution of gentamicin 40 mg, kanamycin sulfate 0.5 g every 8-12 hours. Gentamicin and kanamycin, despite high efficiency in the treatment of staphylococcal purulent infection, due to nephrotoxic and ototoxic effects, is used to a limited extent and only in cases where other drugs do not have an effect.

For intravenous administration benzylpenicillin sodium salt is dissolved in 10 ml of water for injection or sterile isotonic solution sodium chloride, administered 1-2 times a day in combination with intramuscular injections. Daily dose benzylpenicillin sodium salt for intravenous administration 2,000,000-3,000,000 units. Ristomycin sulfate is administered intravenously by drip, dissolving in a sterile isotonic sodium chloride solution. Infuse 500,000 units of ristomycin sulfate (250 ml of solution) for 30-60 minutes 1-2 times a day. At the end of the infusion, without removing the needle, it is recommended to inject 10-20 ml of isotonic sodium chloride solution (to prevent phlebitis). If there are contraindications to copious fluid administration required amount The drug is dissolved in 20-40 ml of 5% glucose solution or isotonic sodium chloride solution and administered (very slowly!) intravenously. The dose for the first administration of ristomycin sulfate should not exceed 250,000 units. The daily dose of ristomycin sulfate for adults is 1,000,000-1,500,000 units: this dose is administered in 2 doses (with an interval of 12 hours). The duration of treatment depends on the course of the disease. Erythromycin, oleandomycin phosphate, lincomycin hydrochloride, ampiox, ampicillin are given orally. A 40% solution of hexamethylenetetramine, 10 ml (5-10 infusions), a 40% glucose solution, 20 ml, is administered intravenously. ascorbic acid(10-15 infusions). If there are areas of fluctuation, wide tissue incisions with penetration into the orbital cavity, insertion of turundas for drainage of the wound cavity, bandages with hypertonic (10%) sodium chloride solution are indicated.

When the cause of orbital phlegmon is identified, the underlying disease is treated ( inflammatory processes paranasal sinuses, etc.). Urgent use antibiotics in the required doses significantly improves the prognosis of the disease.

Which doctors should you contact if you have cellulitis (phlegmon) of the orbit?

Ophthalmologist

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