Orbital cellulitis physical examination: Difference between revisions
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{{Orbital cellulitis}} | {{Orbital cellulitis}} | ||
==Overview== | ==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 | 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.<ref name=Eyewikiorbitalcellulitis>American Academy of Ophthalmology EyeWiki (2015)http://eyewiki.aao.org/Orbital_Cellulitis</ref><ref name=orbitalcellulitiisstanford>Stanford Orbital Cellulitis Summary (2011)http://peds.stanford.edu/Rotations/blue_team/documents/Periorbital_and_Orbital_Cellulitis_Summary.pdf</ref><ref name="pmid22224014">{{cite journal| author=Lam Choi VB, Yuen HK, Biswas J, Yanoff M| title=Update in pathological diagnosis of orbital infections and inflammations. | journal=Middle East Afr J Ophthalmol | year= 2011 | volume= 18 | issue= 4 | pages= 268-76 | pmid=22224014 | doi=10.4103/0974-9233.90127 | pmc=3249811 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22224014 }} </ref><ref name="pmid22346113">{{cite journal| author=Chaudhry IA, Al-Rashed W, Arat YO| title=The hot orbit: orbital cellulitis. | journal=Middle East Afr J Ophthalmol | year= 2012 | volume= 19 | issue= 1 | pages= 34-42 | pmid=22346113 | doi=10.4103/0974-9233.92114 | pmc=3277022 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22346113 }} </ref><ref name="pmid15318671">{{cite journal| author=Hasanee K, Sharma S| title=Ophthaproblem. Orbital cellulitis. | journal=Can Fam Physician | year= 2004 | volume= 50 | issue= | pages= 359, 365, 367 | pmid=15318671 | doi= | pmc=2214559 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15318671 }} </ref><ref name=merckmanualorbitalcellulitis> Merck Manual Professional Version (2016)https://www.merckmanuals.com/professional/eye-disorders/orbital-diseases/preseptal-and-orbital-cellulitis</ref> | ||
==Physical Examination== | ==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:<ref name=Eyewikiorbitalcellulitis>American Academy of Ophthalmology EyeWiki (2015)http://eyewiki.aao.org/Orbital_Cellulitis</ref> | 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:<ref name=Eyewikiorbitalcellulitis>American Academy of Ophthalmology EyeWiki (2015)http://eyewiki.aao.org/Orbital_Cellulitis</ref> | ||
*[[Vital signs]] | *[[Vital signs]] | ||
*Best-corrected | *[[visual acuity|Best-corrected visual acuity]](BCVA) | ||
*Color vision assessment | *Color vision assessment | ||
*[[Proptosis]] measurements using Hertel exophthalmometry | *[[Proptosis]] measurements using Hertel exophthalmometry | ||
*[[Visual field]] assessment | *[[Visual field]] assessment | ||
*Assessment of [[pupillary]] function with particular attention paid to the presence of a relative afferent [[pupillary]] defect (rAPD) | *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. | *[[Eye movement|Ocular motility]] and presence of pain with eye movements; additionally, there may be involvement of the [[Oculomotor nerve|III]], [[Trochlear nerve|IV]], and [[Abducent nerve|VI]] [[cranial nerves]] in cases of [[cavernous sinus]] involvement. | ||
*[[Orbit]] exam should include documentation of direction of displacement of the globe | *[[Orbit]] exam should include documentation of direction of displacement of the globe | ||
*Measurement of [[intraocular pressure]] (IOP) | *Measurement of [[intraocular pressure]] (IOP) | ||
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*Nasal [[sinus]] examination | *Nasal [[sinus]] examination | ||
*[[Otoscopy]] for presence of [[otitis media]] | *[[Otoscopy]] for presence of [[otitis media]] | ||
*Oral examination for oropharyngeal [[infection]] and dentition | *Oral examination for [[oropharyngeal]] [[infection]] and dentition | ||
==Signs== | ==Signs== | ||
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===Skin=== | ===Skin=== | ||
Patients with orbital cellulitis may present with the following skin findings: | Patients with orbital cellulitis may present with the following skin findings: | ||
*[[Erythema]] of the periorbital skin and eyelid | *[[Erythema]] of the periorbital skin and [[eyelid]] | ||
*[[Edema]] of the periorbital skin and eyelid | *[[Edema]] of the periorbital skin and [[eyelid]] | ||
===HEENT=== | ===HEENT=== | ||
Patients with orbital cellulitis may have the following HEENT findings on physical examination: | Patients with orbital cellulitis may have the following HEENT findings on physical examination: | ||
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Patients with orbital cellulitis may present with the following signs: | 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 orbital or head [[trauma]], or surgery (e.g., scars, injuries, etc.) | ||
*Evidence of recent insect bites | *Evidence of recent [[insect bites]] | ||
====Eyes==== | ====Eyes==== | ||
Patients with orbital cellulitis may present with some or all the following signs: | Patients with orbital cellulitis may present with some or all the following signs: | ||
| Line 54: | Line 54: | ||
*Diminished [[visual field]] | *Diminished [[visual field]] | ||
*Signs of orbital trauma, or periorbital surgery (scars, injuries) | *Signs of orbital trauma, or periorbital surgery (scars, injuries) | ||
*Signs of periorbital insect bites | *Signs of periorbital [[insect bites]] | ||
====Ear==== | ====Ear==== | ||
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====Nose==== | ====Nose==== | ||
Patients with orbital cellulitis may present with signs which are suggestive of [[sinusitis]]: | Patients with orbital cellulitis may present with signs which are suggestive of [[sinusitis]]: | ||
*Nasal | *Nasal [[discharge|purulent discharge]] | ||
*[[Erythema]] and [[edema]] of the [[nares]], [[nasopharynx]], and [[sinuses]] | *[[Erythema]] and [[edema]] of the [[nares]], [[nasopharynx]], and [[sinuses]] | ||
*Painful [[sinuses]] upon applying pressure | *Painful [[sinuses]] upon applying pressure | ||
| Line 71: | Line 71: | ||
Patients with orbital cellulitis may present with signs which are suggestive of [[oral]], [[pharyngeal]], or [[upper respiratory tract infection|upper respiratory tract]] infections: | Patients with orbital cellulitis may present with signs which are suggestive of [[oral]], [[pharyngeal]], or [[upper respiratory tract infection|upper respiratory tract]] infections: | ||
*[[Erythematous]] [[oropharynx]] | *[[Erythematous]] [[oropharynx]] | ||
*Exudative tonsils | *Exudative [[Tonsil|tonsils]] | ||
*[[Dental caries]] | *[[Dental caries]] | ||
*[[Tooth abscess]] | *[[Tooth abscess]] | ||
Revision as of 16:10, 30 March 2017
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Tarek Nafee, M.D. [2]
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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.[1][2][3][4][5][6]
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:[1]
- 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:[1][2][3][4][5][6]
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:
Skin
Patients with orbital cellulitis may present with the following skin findings:
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.
References
- ↑ 1.0 1.1 1.2 American Academy of Ophthalmology EyeWiki (2015)http://eyewiki.aao.org/Orbital_Cellulitis
- ↑ 2.0 2.1 Stanford Orbital Cellulitis Summary (2011)http://peds.stanford.edu/Rotations/blue_team/documents/Periorbital_and_Orbital_Cellulitis_Summary.pdf
- ↑ 3.0 3.1 Lam Choi VB, Yuen HK, Biswas J, Yanoff M (2011). "Update in pathological diagnosis of orbital infections and inflammations". Middle East Afr J Ophthalmol. 18 (4): 268–76. doi:10.4103/0974-9233.90127. PMC 3249811. PMID 22224014.
- ↑ 4.0 4.1 Chaudhry IA, Al-Rashed W, Arat YO (2012). "The hot orbit: orbital cellulitis". Middle East Afr J Ophthalmol. 19 (1): 34–42. doi:10.4103/0974-9233.92114. PMC 3277022. PMID 22346113.
- ↑ 5.0 5.1 Hasanee K, Sharma S (2004). "Ophthaproblem. Orbital cellulitis". Can Fam Physician. 50: 359, 365, 367. PMC 2214559. PMID 15318671.
- ↑ 6.0 6.1 Merck Manual Professional Version (2016)https://www.merckmanuals.com/professional/eye-disorders/orbital-diseases/preseptal-and-orbital-cellulitis