Orbital cellulitis physical examination

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Tarek Nafee, M.D. [2]

Orbital cellulitis Microchapters
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Overview

Patients with orbital cellulitis usually appear ill. Physical examination of patients with orbital cellulitis is usually remarkable for fever, proptosis, ophthalmoplegia, and impaired visual acuity. Patients should undergo a complete physical examination, paying particular attention to general appearance, vital signs, visual acuity, visual field, orbital positioning, ocular movmements, oropharynx, and nasopharynx examinations.

Physical Examination

Patients with orbital cellulitis usually appear ill. Physical examination of patients with orbital cellulitis is usually remarkable for fever, proptosis, ophthalmoplegia, and impaired visual acuity.The physical examination should assess:

• Vital signs
• Best-corrected visual acuity(BCVA)
• Color vision assessment
• Proptosis measurements using Hertel exophthalmometry
• Visual field assessment
• Assessment of pupillary function with particular attention paid to the presence of a relative afferent pupillary defect (rAPD)
• Ocular motility and presence of pain with eye movements; additionally, there may be involvement of the III, IV, and VI cranial nerves in cases of cavernous sinus involvement.
• Orbit exam should include documentation of direction of displacement of the globe
• Measurement of intraocular pressure (IOP)
• Slit lamp test in cases of severe proptosis
• Dilated fundus exam to exclude optic neuropathy or retinal vascular occlusion
• Nasal sinus examination
• Otoscopy for presence of otitis media
• Oral examination for oropharyngeal infection and dentition

Signs

Patients with orbital cellulitis may present with some or all of the following signs:

General Appearance

Patients with orbital cellulitis usually appear ill and have marked inflammation and edema of the periorbital area.

Vital Signs

Patients with orbital cellulitis may have the following vital signs, which are suggestive of infection:

• Fever
• Hypotension
• Tachycardia
• Tachypnea

Skin

Patients with orbital cellulitis may present with the following skin findings:

• Erythema of the periorbital skin and eyelid
• Edema of the periorbital skin and eyelid

HEENT

Patients with orbital cellulitis may have the following HEENT findings on physical examination:

Head

Patients with orbital cellulitis may present with the following signs:

• Evidence of recent orbital or head trauma, or surgery (e.g., scars, injuries, etc.)
• Evidence of recent insect bites

Eyes

Patients with orbital cellulitis may present with some or all the following signs:

• Periorbital edema and erythema
• Proptosis
• Chemosis
• Ophthalmoplegia
• Restricted or painful ocular movements
• Reduced visual acuity
• Increased intraocular pressure (IOP)
• Displacement of the globe
• Diminished visual field
• Signs of orbital trauma, or periorbital surgery (scars, injuries)
• Signs of periorbital insect bites

Ear

Patients with orbital cellulitis may present with signs which are suggestive of inner or middle ear infection:

• Erythema, edema and discharge present on otoscopy
• Reduced hearing
• Children may show signs of "tugging" on the affected ear

Nose

Patients with orbital cellulitis may present with signs which are suggestive of sinusitis:

• Nasal purulent discharge
• Erythema and edema of the nares, nasopharynx, and sinuses
• Painful sinuses upon applying pressure

Throat/Oral

Patients with orbital cellulitis may present with signs which are suggestive of oral, pharyngeal, or upper respiratory tract infections:

• Erythematous oropharynx
• Exudative tonsils
• Dental caries
• Tooth abscess

Neck

Patients with orbital cellulitis may present with tender cervical lymph nodes, which are suggestive of regional infection.

Lung

Patients with orbital cellulitis may present with wheezing or coughing, which are suggestive of upper respiratory tract infection.