Orbital Cellulitis Differential Diagnoses

Updated: May 29, 2019
  • Author: John N Harrington, MD, FACS; Chief Editor: Edsel B Ing, MD, MPH, FRCSC, PhD, MA  more...
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Diagnostic Considerations

Orbital cellulitis should be suspected in any patient with adnexal, facial, or dental infection when orbital pain, proptosis, limitation of ocular motility, lid edema, or orbital congestion develops. A computed tomography (CT) scan should be obtained, and the patient should be hospitalized and placed on broad-spectrum, intravenous (IV) antibiotic therapy as deemed appropriate.

Conditions to consider in the differential diagnosis of orbital cellulitis include the following:

  • Endocrine dysfunction - Thyroid-associated orbitopathy

  • Idiopathic inflammation - Orbital myositis, orbital pseudotumor, Wegener granulomatosis

  • Carotid cavernous fistula

  • Neoplasm with inflammation - Burkitt lymphoma, histiocytosis X (Letterer-Siwe), leukemia, metastatic carcinoma, retinoblastoma, rhabdomyosarcoma, sarcoidosis

  • Cavernous sinus thrombosis

Orbital cellulitis resulting from sinusitis usually can be distinguished easily from other causes of acute inflammatory proptosis by clinical signs, computed tomography (CT) scanning, and the assessment of risk factors.

Thyroid-associated orbitopathy usually has a more subacute course than orbital cellulitis, with characteristic features such as lid retraction and preferential involvement of the inferior recti and medial recti, typically with tendon sparing.

Orbital inflammatory syndrome may cause rapidly developing orbital congestion, proptosis, and limitation of motility. Patients are usually afebrile and typically do not have sinus opacification. Orbital myositis may involve the tendon of the muscle and can involve the lateral rectus.

Carotid cavernous fistula should show episcleral venous congestion and bounding mires on tonometry. There may be a subjective bruit.

Careful history and review of orbital imaging should be performed to exclude occult orbital foreign body.

Bleeding from lymphangioma, rhabdomyosarcoma, and necrotic retinoblastoma may imitate the appearance of pediatric orbital cellulitis. Orbital lymphoma and metastatic orbital tumor are neoplastic mimics of orbital cellulitis in adults.

Cavernous sinus thrombosis, a serious complication of paranasal sinusitis that most commonly results from the anterograde spread of infection involving the mid-third of the face (eg, orbit, mouth, paranasal sinuses), may be difficult to distinguish from simple orbital cellulitis. (Cavernous sinus thrombosis and superior ophthalmic vein thrombosis [16] may also occur with and may be caused by orbital cellulitis.)

A patient with cavernous sinus thrombosis without orbital cellulitis will show ophthalmoplegia but little proptosis, normal retropulsion of the globe, hypesthesia in the distribution of the first and second divisions of the trigeminal nerve, dilated retinal veins, orbital congestion, and, possibly, neurologic defects (eg, altered sensorium). MRI with magnetic resonance venography (MRV) can help to confirm the diagnosis of cavernous sinus thrombosis.

In children, rhabdomyosarcoma, Langerhans cell histiocytosis, and extraocular spread of retinoblastoma may mimic the appearance of orbital cellulitis.

Differential Diagnoses