Paediatric Clinical Guidelines
Infectious 8.1
February 2002
GUIDELINES FOR THE MANAGEMENT OF PERIORBITAL
CELLULITIS/ABCESS
Indications for Admission
-
The majority of patients with periobital swelling
Diplopia
CNS signs or symptoms
Reduced visual acuity
Reduced light reflexes or swinging light test
Patients who are toxic or systemically unwell
Proptosis
Ophthalmoplegia
Patients in whom it is not possible to examine the eye
The only patient suitable for discharge is: someone with minimal upper lid oedema,
normal eye examination and with none of the above.
Augmentin has a suitable spectrum of activity for these patients.
Treatment Plan
1.
2.
3.
4.
Arrange an ophthalmological opinion
Arrange an ENT opinion
IV access – blood cultures
Intravenous Cefuroxime (100 mgs/kg/day in 3 doses) and Metronidazole (7.5 mgs/kg tds,
max 400 mgs) with nasal Ephedrine 0.5% nose drops three times a day in the head back,
nostril up position
5. Don’t forget to give adequate analgesia to allow a proper assessment
6. The following should be done twice daily following ophthalmology advice:
a. Assess colour vision and acuity. This must be done with the eye open and on the
eye in question on its own. If the patient has glasses and these are not available
then test acuity through a pinhole.
b. Test for eye movement to see if there is any ophthalmoplegia
c. Test the pupil reflexes
If there is gross proptosis, ophthalmoplegia or concern these observations should be done on an
hourly basis.
Indications for CT
1. Central symptoms or signs, eg drowsy, had a fit, cranial nerve lesion, headache and
vomiting
2. Gross proptosis
3. Ophthalmoplegia
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4.
5.
6.
7.
Deteriorating acuity or colour vision or unable to evaluate vision
Bilateral periorbital oedema (? Cavernous sinus thrombosis)
No improvement or deterioration at 24-36 hours
Swinging pyrexia not resolving within 36 hours
N.B. If vision is deteriorating rapidly the orbit must be decompressed. This should be
done within an hour and if imaging cannot be done within this time then do not wait for it.
References
1. Wald E R, Pang D, Milmore G J, Schramm V L, (1981) Sinusitis and its Complications
in a Paediatric Patient. Paediatric Clinics of North America. 28 (4) 777-796
2. Brook I, Friedman E M, Rodriquez W J, Controni G, (1980) Complications of Sinusitis
in Children. Paediatrics. 66, 568-572
3. Wagenmann M, Naclerio R, (1992) Complications of Sinusitis. J Allergy Clin Immunol.
90, 552-4
4. Uzcategui N, Warman R, Simth A, Howard C W, (1998) Clinical Practice Guidelines for
the Management of Orbital Cellulitis. L Pediatr Ophthlamol Strabismus. 35, 73-79
5. Rubin S E, Rubin L G, Zito J, Goldstein M N, Eng C, (1989) Medical Management of
Subperiosteal Abscess in Children, J Pediatr Ophthalmol Strabismus. 26, 21-26
6. Schramm Jr V L, Curtin H D, (1982) Evaluation of Orbital Cellulitis and Results of
Treatment. Laryngoscope. 92, 732-738
7. Davis J P, Stearns M P, (1994) Orbital Complications of Sinusitis: Avoid Delays in
Diagnosis. Postgraduate Med J. 70, 108-110
8. Chandler J R, Langenbrunner D J, Stevens E R, (1970) The Pathogenesis of Orbital
Complications in Acute Sinusitis. Laryngoscope. 80, 1414-1428
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Parent Information Sheet
 Your child has been diagnosed as having peri – orbital cellulitis (an
infection in front of the eye).
 Most of these infections can be safely treated at home with antibiotics
given by mouth.
 If antibiotics by mouth do not start to improve the swelling within
24 hours, your child will need to come into hospital so that
antibiotics can be given directly into a vein.
 It is important that he / she completes the course of antibiotics
provided by the doctor.
 If he / she becomes more unwell with headache, vomiting, increased
drowsiness then he / she will need to be seen quickly to make sure
more serious infection isn’t present.
 Arrangements need to be made for your GP to review your child in
the next 24 hours to ensure that the infection is getting better. You
may be the best judge that the eye swelling has reduced.
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PAEDIATRIC CLINICAL GUIDELINES
ISSUE:
VERSION: FINAL
Title: Management of Periorbital Cellulitis/Abscess
Author:
Job Title:
Professor N S Jones
Professor in Otorhinolaryngology
First Issued:
Date Revised:
Review Date:
Document Derivation:
i.e. References:
Consultation Process:
Dr Maria Atkinson – Paediatric Specialist
Registrar
Dr Stephanie Smith – Consultant Emergency
Paediatrician
Clive Newman – Paediatric Pharmacist
Included in document
February 2002
February 2005
Ratified By:
Paediatric Clinical Guidelines Committee
Chaired By:
Consultant with Responsibility: Dr Stephanie Smith
Distribution:
All wards QMC and CHN
Training issues:
Included in Induction Programme
Audit:
This guideline has been registered with Nottingham City Hospital NHS Trust and QMC
Clinical Guidelines Committee. However, clinical guidelines are ’guidelines’ only. The
interpretation and application of clinical guidelines will remain the responsibility of the
individual clinician. If in doubt contact a senior colleague or expert. Caution is advised
when using guidelines after the review date.
MANUAL AMENDMENTS RECORD
(please complete when making any hand-written changes/ amendments to guideline and not processed
through guideline committee)
Date
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Author
Description