Preseptal and Orbital Cellulitis in Children

Clinical Guideline

V4.0

June 2021
Summary

CHILD PRESENTING WITH EYELID/PERIORBITAL SWELLING/ERYTHEMA

Assess clinical indicators:

Mild Moderate Severe

Systemically well and no Evidence of systemic Systemically unwell and/or
concerning features on illness and or moderate swelling such that unable
examination: swelling of eyelid and to examine eye properly or
periorbital tissues but eye features suggest Orbital
visible and no other cellulitis or infection
concerning features: posterior to orbital
septum:

 No proptosis  No Proptosis  Proptosis

 No ophthalmoplegia  No opththalmoplegia  Pain with eye
 No pain on eye  No pain on eye movements
movements movements  Diplopia
 No chemosis  No chemosis  Ophthalmoplegia
 No Headache  No headache  Reduced visual acuity
 Normal visual acuity  Normal visual acuity  Abnormal light reflexes
 Normal light reflexes  Normal light reflexes  Chemosis of globe
 Systemically well  No CNS signs or  Severe or persistent
 No CNS signs or symptoms headache
symptoms  Toxic or systemically
unwell
 CNS signs or symptoms
ACTION
 If no fever consider  ADMIT
differentials: allergic  Take bloods including FBC
reaction or nephrotic and blood cultures
syndrome  Start IV antibiotics
 If working diagnosis (Check Antimicrobial
remains preseptal cellulitis prescribing guideline)
treat with oral antibiotics:  If symptoms progress, seek
(Check Antimicrobial urgent ophthalmological
prescribing guideline) and ENT review. THIS IS AN EMERGENCY
 Discharge home with  Consider CT imaging
advice to return/seek  Consider oral switch and Proceed to Orbital Cellulitis
medical attention if discharge when all table below
worsening or any green/mild features,
concerning features swelling resolving and
develop (describe in safety child well with no clinical
netting advice in discharge concern – if in doubt check
summary) with ophthalmology.
 Consider need for follow  Safety net advice regarding
up review GP or PAU concerning features to be
written in discharge
summary

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 ORBITAL CELLULITIS
All children need admission, prompt investigation and treatment

 IV ANTIBIOTICS TO BE STARTED WITHIN 1 HOUR (see antimicrobial prescribing policy)

 SENIOR ENT/OPHTHALMOLOGY ASSESSMENT WITHIN 6 HOURS OF ADMISSION
Prescribe Analgesia
Prescribe decongestant nose drops
Make NBM until management plan decided – may need IV fluids
If patient is MRSA carrier then discuss with Microbiology

CRITICAL ASSESSMENTS:

Visual acuity & colour No visual loss no

Does the patient have Is there a Relative significant
vision satisfactory but
bilateral visual Afferent Pupil defect or proptosis/no globe
significant proptosis &
and/or neurological visual acuity failing or displacement?
chemosis or
symptoms & signs? gone and/or fixed
ophthalmoplegia?
globe?
CT Sinuses Consider CT Sinuses
Concern is: Cavernous within 24 hours –
within 2 hours
sinus thrombosis discuss with
ophthalmology/ENT

Clinical improvement on IV antibiotics?

 Emergency CT +/- EMERGENCY
MRI 100 MINS TO SAVE EYE Switch to oral antibiotics once sustained
 Liaise with tertiary improvement - discuss with ophthalmology/ENT
Neurology/ Needs surgical drainage
Neurosurgery (external sinus approach)

 Review antibiotics No clinical improvement on IV antibiotics or

with microbiology localised abscess on imaging?

Consider surgical drainage

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1. Aim/Purpose of this Guideline
1.1. This guideline applies to medical and nursing staff caring for a child with
Preseptal and Orbital Cellulitis.

1.2. This version supersedes any previous versions of this document.

Data Protection Act 2018 (General Data Protection Regulation – GDPR)

Legislation
The Trust has a duty under the DPA18 to ensure that there is a valid legal basis to
process personal and sensitive data. The legal basis for processing must be identified
and documented before the processing begins. In many cases we may need consent;
this must be explicit, informed and documented. We cannot rely on opt out, it must be
opt in.
DPA18 is applicable to all staff; this includes those working as contractors and providers
of services.
For more information about your obligations under the DPA18 please see the
Information Use Framework Policy or contact the Information Governance Team
rch-tr.infogov@nhs.net

2. The Guidance
2.1. Preorbital and orbital cellulitis are both infections that may present with swelling
and erythema of the eyelid and periorbital tissues. The terms preseptal and
septal may be used instead of periorbital and orbital respectively.

Infections of the preseptal and septal tissues range in severity, from relatively
minor to potentially life-threatening. These infections occur most commonly in
children under the age of 10 years (incidence 1.6 per 100,000 and 0.10 per
100,000 in children and adults respectively)

2.1.1. Preseptal cellulitis

 bacterial infection of tissues lying anterior to the orbital septum

(therefore not an orbital condition)

 in young children, high risk of extension into the orbit

2.1.2. Septal cellulitis

 bacterial infection of tissues lying posterior to the orbital septum

(within the orbit)

 severe sight and life-threatening emergency

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2.2. Preseptal cellulitis
Preseptal cellulitis is most common in the under 5 years age group. There is
often a site of initial infection such as a minor injury to the skin or insect bite to
the periorbital tissues. Infection can sometimes arise secondary to an URTI.
There is tenderness, swelling, warmth and redness of tissues. Fever may be
present. Swelling may be sufficient to obscure the eye, in such cases an
ophthalmological examination is essential to exclude orbital cellulitis. The most
common organisms are Strep pyogenes, Strep pneumoniae and Staph aureus.
Haemophilus influenza may be a cause in unimmunised children and may be
associated with concurrent meningitis. Atypical organisms including fungi may
be responsible in immunocompromised and diabetics. Mixed aerobes and
anaerobes are more common in the over 15 years.

2.3. Septal cellulitis

Septal cellulitis usually arises secondary to spread from the ethmoid sinus and
bone, which progresses to subperiosteal abscess then orbital abscess or
cellulitis. It can then extend more posteriorly to cause cavernous sinus
thrombosis and meningitis. There may be a co-existent URTI or history of recent
infection. Risk factors for intracranial infection include those >7years;
subperiosteal abscess; headache and fever persisting despite IV antibiotics;
immunocompromised and diabetics. Bilateral periorbital oedema may indicate
cavernous sinus thrombosis. In cases where meningitis is suspected LP may be
required but should only be undertaken after imaging as intracranial extension
may be silent.

Preseptal vs Septal cellulitis:

See table on next page

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 Preseptal vs Septal cellulitis:

Pre septal Septal

insect bite
acute sinusitis (especially ethmoid and
maxillary sinusitis)
dacryocystitis
trauma including orbital fracture
hordeolum (stye)
Predisposing factors dacryocystitis
impetigo (skin infection)
preseptal cellulitis
trauma, sharp or blunt, around eye
dental abscess
recent surgery around eye

sudden onset of unilateral swelling of

conjunctiva and lids that may be painful
acute onset of swelling, redness
and tenderness of lids pain on ocular movement

fever blurred vision and reduced visual acuity

Symptoms
malaise diplopia

irritability in children fever

severe malaise

severe eyelid redness and oedema

ptosis
erythema of skin (can extend
beyond orbital rim) proptosis

lid oedema, warmth, tenderness restriction of extraocular motility

Signs ptosis pain with eye movement

pyrexia (fever greater than 38°C, visual acuity may be reduced

normal temperature ranges from
36-37.5°C impaired colour vision

pupil reactions may be abnormal (RAPD)

pyrexia

Feature Preseptal cellulitis Orbital cellulitis

Proptosis Absent Present

Ocular Motility Normal Painful, restricted
Visual acuity Normal Reduced in severe cases
Colour vision Normal Reduced in severe cases
RAPD (relative
afferent pupillary Normal Reduced in severe cases
defect)

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2.4. Differential diagnosis

Preseptal cellulitis Septal cellulitis

Orbital cellulitis Cavernous sinus thrombosis
Horeolum (stye) Mucormycosis
Acute blepharitis Sarcoidosis
Viral conjunctivitis with eyelid swelling Dysthyroid exophthalmos
Acute allergic conjunctivitis with eyelid swelling Neoplasia with inflammation
Angioneurotic oedema

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3. Monitoring compliance and effectiveness
Element to be Compliance with guideline and process outlined in summary
monitored
Lead Paediatric Consultant Audit Lead
Tool Individual case by case review of medical notes or specific audit tool
Frequency As required or indicated
Reporting Paediatric consultant Directorate audit and guidelines meeting
arrangements
Acting on Paediatric consultant
recommendations
and Lead(s)
Change in Directorate audit and guidelines meeting Required actions will be
practice and identified and completed in3-6 months
lessons to be
shared

4. Equality and Diversity

4.1. This document complies with the Royal Cornwall Hospitals NHS Trust
service Equality and Diversity statement which can be found in the 'Equality,
Inclusion & Human Rights Policy' or the Equality and Diversity website.

4.2. Equality Impact Assessment

The Initial Equality Impact Assessment Screening Form is at Appendix 2.

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Appendix 1. Governance Information
Preseptal and Orbital Cellulitis in Children
Document Title
Clinical Guideline V4.0
This document replaces (exact PRESEPTAL AND ORBITAL CELLULITIS IN
title of previous version): CHILDREN- CLINICAL GUIDELINE V3.0
Date Issued/Approved: June 2021

Date Valid From: June 2021

Date Valid To: June 2024

Dr. Tom Fontaine; Paediatric Consultant and
Directorate / Department
Lucy Williams; Advance Paediatric Nurse
responsible (author/owner):
Practitioner
Contact details: 01872 253041

Clear guidance on management of preseptal and

Brief summary of contents
orbital cellulitis in children.

Suggested Keywords: Cellulitis Preseptal Orbital children

RCHT CFT KCCG
Target Audience

Executive Director responsible
Medical Director
for Policy:
Paediatric consultants
Approval route for consultation Directorate audit and guidelines meeting ENT
and ratification: consultant
Microbiology consultant
General Manager confirming
Mary Baulch
approval processes
Name of Governance Lead
confirming approval by specialty
Caroline Amukusana
and care group management
meetings
Links to key external standards None required
Related Documents: None required
Training Need Identified? No
Publication Location (refer to
Policy on Policies – Approvals Internet & Intranet  Intranet Only
and Ratification):
Document Library Folder/Sub
Clinical/ Paediatrics
Folder

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Version Control Table

Version Changes Made by

Date Summary of Changes (Name and Job
No
Title)
July 13 V1.0 Initial Issue Dr.S.Harris, Paediatric
Consultant

Dr.S.Harris, Paediatric
January V2.0 Review of content. Reformat into template for Consultant
15 documents library.

Dr.S.Harris, Paediatric
Nov V3.0 No changes Consultant
2017

Dr. Tom Fontaine;

Updated to new Trust format Paediatric Consultant
May 2021 V4.0 Flowcharts moved from appendixes to summary and Lucy Williams;
section and replaced by tables for clarity Advance Paediatric
Nurse Practitioner

All or part of this document can be released under the Freedom of Information
Act 2000

This document is to be retained for 10 years from the date of expiry.

This document is only valid on the day of printing

Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy for the Development and Management of Knowledge, Procedural and Web
Documents (The Policy on Policies). It should not be altered in any way without the
express permission of the author or their Line Manager.

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 Appendix 2. Equality Impact Assessment

Section 1: Equality Impact Assessment Form

Name of the strategy / policy /proposal / service function to be assessed
Preseptal and Orbital Cellulitis in Children Clinical Guideline V4.0
Directorate and service area: Is this a new or existing Policy?
Child Health Existing
Name of individual/group completing EIA Contact details:
Child Health Audit and Guidelines Group 01872 252 800
1. Policy Aim Clear guidance on the management of preseptal and orbital cellulitis
Who is the
strategy / policy /
proposal / service
function aimed at?

2. Policy Objectives Clear guidance on the management of preseptal and orbital cellulitis
3. Policy Intended Evidenced based and standardised practice
Outcomes

4. How will Audit and review

you measure
the outcome?

5. Who is intended Children and families

to benefit from the
policy?
6a). Who did you Local External
Workforce Patients Other
consult with? groups organisations
X

b). Please list any Please record specific names of groups:

groups who have
been consulted Child Health Audit and Guidelines meeting.
about this procedure.
c). What was the
outcome of the
consultation?

Approved 23/06/2021

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7. The Impact
Please complete the following table. If you are unsure/don’t know if there is a negative impact
you need to repeat the consultation step.
Are there concerns that the policy could have a positive/negative impact on:
Protected
Yes No Unsure Rationale for Assessment / Existing Evidence
Characteristic
Age
X
Sex (male, female
non-binary, asexual X
etc.)

Gender
reassignment X

Race/ethnic Any information provided should be in an accessible

communities format for the parent/carer/patient’s needs – i.e.
X
/groups available in different languages if required/access to
an interpreter if required
Disability
Those parent/carer/patients with any identified
(learning disability,
additional needs will be referred for additional support
physical disability,
as appropriate - i.e to the Liaison team or for
sensory impairment,
X specialised equipment.
mental health
Written information will be provided in a format to
problems and some
meet the family’s needs e.g. easy read, audio etc
long term health
conditions)
Religion/ All staff should be aware of any beliefs that may
other beliefs X impact on the decision to treat and respond
accordingly
Marriage and civil
partnership X

Pregnancy and
maternity X

Sexual orientation
(bisexual, gay, X
heterosexual, lesbian)
If all characteristics are ticked ‘no’, and this is not a major working or service
change, you can end the assessment here as long as you have a robust rationale
in place.
I am confident that section 2 of this EIA does not need completing as there are no highlighted
risks of negative impact occurring because of this policy.

Name of person confirming result of initial

Child Health Audit and Guidelines group
impact assessment:
If you have ticked ‘yes’ to any characteristic above OR this is a major working or
service change, you will need to complete section 2 of the EIA form available here:
Section 2. Full Equality Analysis

For guidance please refer to the Equality Impact Assessments Policy (available
from the document library) or contact the Human Rights, Equality and Inclusion
Lead india.bundock@nhs.net

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