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Presentation
Case Findings: A 4 year old male child is brought to your office by his mother who notes that his right eyelids have seemed red and swollen for the past 24 hours. She says that the child was outside playing in the backyard yesterday and thinks he was stung by a bee over the right upper eyelid. The redness and swelling began soon after. Although the child is in some discomfort, he seems otherwise well and is afebrile. On examination there is mild-moderate edema of the upper and lower eyelids but no apparent proptosis. Visual acuity is 20/20 bilaterally with normal extraocular movements, pupillary responses, and IOPs.
What is the most likely diagnosis?
378% Orbital cellulitis
13% Necrotizing fasciitis
270% Preseptal cellulitis
62% Paranasal sinusitis
The Take-Home:
This little boy has preseptal cellulitis (also called periorbital cellulitis or anterior orbital cellulitis), an inflammation or infection of soft tissue anterior to the orbital septum. It occurs primarily in children, and although relatively benign it presents a challenge to clinicians in that it must be differentiated from the more sinister orbital cellulitis, an infection posterior to the orbital septum.
The Other Choices:
Orbital cellulitis should be in the differential diagnosis for a patient presenting with a red swollen eyelid. However, in this case, the absence of such features as proptosis, chemosis, ophthalmoplegia, decreased visual acuity, and systemic symptoms make preseptal cellulitis more likely.
Necrotizing fasciitis is a potentially devastating soft tissue infection that has the potential to spread rapidly and cause significant morbidity and mortality. It is commonly caused by Group A Streptococcus pyogenes. Occasionally, necrotizing fasciitis can affect the eyelids. Features suggestive of necrotizing fasciitis include rapidly advancing infection, pain of proportion to clinical exam, necrosis, and purulent discharge.
Paranasal sinusitis can be a cause of orbital cellulitis, however sinusitis alone cannot account for the case described.