Preseptal and Orbital in Children Clinical Guideline

V4.0

June 2021

Summary

CHILD PRESENTING WITH /PERIORBITAL SWELLING/ 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 :

 No proptosis  No Proptosis  Proptosis  No ophthalmoplegia  No opththalmoplegia  Pain with eye  No pain on eye  No pain on eye movements movements movements   No  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  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 .  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 vision satisfactory but significant bilateral visual Afferent defect or significant proptosis & proptosis/no globe and/or neurological visual acuity failing or chemosis or displacement? symptoms & signs? gone and/or fixed ophthalmoplegia? globe?

CT Sinuses Consider CT Sinuses Concern is: Cavernous within 2 hours within 24 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 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

[email protected]

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

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 . 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 (especially ethmoid and maxillary sinusitis) trauma including orbital fracture hordeolum () 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 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

erythema of skin (can extend beyond orbital rim) proptosis

lid oedema, warmth, tenderness restriction of extraocular motility

Signs ptosis pain with

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) Acute Viral with eyelid swelling Dysthyroid Acute with eyelid swelling Neoplasia with 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 No (Name and Job 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 [email protected]

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