There are disagreements in the definition of "inflammation of the periorbital tissue" (periorbital cellulitis) and "inflammation of the orbital cellulite" (orbital cellulitis) associated with the treatment of diseases in this area, complicating the management of these patients. A clear understanding of the pathogenesis of these different conditions allows us to understand other characteristics associated with their diagnosis and treatment.

The pathogenesis of the development of inflammation of periorbital tissue (periorbital cellulitis) and orbital tissue is completely different. Periorbital cellulitis can be characterized as preseptal inflammation, as the infection is localized in front of the connective tissue of the eyelids, which is a continuation of the periosteum of the bones of the skull. This membrane acts as an effective barrier to the spread of infection in the orbit and, therefore, contrary to popular belief, periorbital cellulitis never enters into inflammation of the orbit. There are two reasons for the development of periorbital cellulite. The first is trauma (including an insect bite), which is more common in young children. The second is primary bacteremia, which is most characteristic for children in the first 3 years of life who are at high risk of developing pneumococcal bacteremia.

With the inflammation of the orbital fiber, the orbit (postseptal inflammation) is directly involved in the process. With the exception of cases of penetrating sores of the orbit, this condition is almost always a complication of sinusitis due to the spread of infection to the tissues of the orbit. The walls of the orbit are simultaneously the walls of the paranasal sinuses: the upper lower of the frontal sinus, the inner lateral wall of the cells of the ethmoid labyrinth and the lower upper wall of the maxillary sinus. The most common source of infection is the cells of the ethmoid labyrinth, as they are separated from the orbit by the thinner "paper" plate of the ethmoid bone. In such cases, a subperiosteal abscess may first form, then phlegmon of the orbit may develop. In adolescents, in addition to the cells of the ethmoid labyrinth, the frontal sinus can be a source of infection. Since inflammation of the orbit is almost always a complication of sinusitis, it is more common in schoolchildren. Thus, according to the results of a retrospective analysis of 178 patients carried out in Dallas, the average age of patients with periorbital cellulitis was 21 months, and with inflammation of the orbit - 12 years. In some cases, sinusitis / inflammation of the orbit can cause bacteremia.

The clinical manifestations of periorbital cellulitis are hyperemia, infiltration, pain, local hyperthermia of periorbital tissue. If injured, the skin may exhibit abrasion / injury or insect bite. Symptoms are usually limited by local manifestations, but sometimes there may be general reactions (fever, leukocytosis, in some cases bacteremia). If the cause was pneumococcal bacteremia, general manifestations are usually present.

Inflammation of the orbit also reveals infiltration and hyperemia of the periorbital tissue, but in addition, exophthalmos, restriction of mobility of the eyeball and a decrease in visual acuity, which does not occur with cellulite periorbital, may appear. Often a full exam is difficult due to swelling of the eyelids and marked narrowing of the eyelid fissure. If inflammation of the orbit fiber cannot be completely ruled out (or if there is a suspicion of phlegmon in the orbit), the patient has been shown to undergo a CT scan. In this case, changes such as exophthalmos, an inflammatory reaction of the oculomotor muscles, a subperiosteal abscess, an orbiting phlegmon can be detected. In addition, there are signs of unilateral or bilateral sinusitis. Again, it should be emphasized that sinusitis is important in the pathogenesis of inflammation of the orbit, but not periobital cellulitis. Although there may be swelling of the eyelids with uncomplicated sinusitis, but in this case, unlike periorbital cellulitis, there is no infiltration and pain. It should also be remembered that changes in the sinuses with CT can be even with simple SARS.

In post-traumatic periorbital cellulitis, the most common pathogens are Staphylococcus aureus and Streptococcus pyogenes. If the cause was bacteremia, the most likely causative agent will be Streptococcus pneumoniae, especially in children the first 3 years of life. Previously, the cause of bacteremia was often Haemophilus influenzae type b, but after the introduction of hemophilus influenzae vaccination into the vaccination schedule, this pathogen is rare. In addition, the incidence of bacteremia caused by S. pneumoniae is currently being reduced. Since inflammation of the orbit fiber develops as a complication of acute or chronic sinusitis, the causative agents here may be bacteria that cause sinusitis, in addition, mixed microflora may occur.

In uncomplicated post-traumatic periorbital cellulitis, treatment is usually performed with oral antibiotics active against gram-positive bacteria. In children without previous trauma and with systemic manifestations, pneumococcal bacteremia cannot be excluded. Since these patients are at risk of developing meningitis, and in children, a physical examination may not always reveal meningitis, a spinal tap is indicated. Whatever its results (many researchers note minimal differences or no change in the cerebrospinal fluid with subsequent excretion of the pathogen), hospitalization is recommended for parenteral treatment of children with periorbital cellulitis, a history of trauma and manifestations systemic. Identification of changes in cerebrospinal fluid provides the basis for the appointment of vancomycin or ceftriaxone (in this case, a study of the sensitivity of the pathogen is desirable). Ceftriaxone alone can be prescribed to patients if there are no changes in the cerebrospinal fluid. In the context of therapy, when there are no symptoms of meningitis, there is usually a rapid positive dynamic of periorbital pneumococcal cellulitis, even if it is accompanied by bacteremia. But in all cases, despite a significant improvement and the absence of fever, it is necessary to endure a 10-day course of treatment. In some cases, it is recommended to use step-by-step antibacterial therapy.

The treatment of patients with orbital inflammation must be carried out under the supervision of several specialists: pediatrician, otolaryngologist, ophthalmologist. The drugs of choice may be aminopenicillins protected by an inhibitor. In the past, surgery was recommended in patients with this complication. Currently, antibiotic therapy is preferred. Surgery, including drainage of the affected abscess and sinuses, is only indicated for patients with precisely diagnosed abscess, complete immobility of the eyeball, and / or severe visual impairment. In other cases, conservative therapy can be performed under the supervision of various specialists. If there is no improvement within 24 to 36 hours, a computed tomography and / or repeat surgery is indicated. Parenteral antibiotic therapy should be done for at least 1 week, then, when the condition improves, you can switch to oral medications. The total duration of treatment should be at least 3 weeks.