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Suspected orbital cellulitis — MRCEM SBA MCQ

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EasyInfection and sepsisSuspected orbital cellulitisMRCEM SBA

A 35-year-old woman attends the emergency department with fever and worsening swelling around her left eye after four days of nasal congestion and facial pain. Her temperature is 38.6°C and blood pressure is 122/74 mmHg. The left eye is mildly proptosed, and abduction is restricted and painful. Visual acuity is 6/6 in each eye, with no relative afferent pupillary defect. Blood cultures have been taken and intravenous access established. She has no antibiotic allergy. Which initial management plan is most appropriate?

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Correct answer: A — Start intravenous antibiotics; arrange urgent contrast-enhanced CT of the head and orbits; admit for ophthalmology assessment.

The preceding sinus symptoms suggest a possible source of infection, while **proptosis and painful, restricted eye movement** indicate orbital involvement rather than uncomplicated preseptal cellulitis. Suspected orbital cellulitis is a sight-threatening emergency. Start intravenous antibiotics promptly, arrange urgent contrast-enhanced imaging to assess orbital disease, and admit for specialist assessment. Preserved visual acuity does not make the orbital signs safe to manage as an outpatient. NICE recommends hospital referral when orbital cellulitis is suspected; UK emergency department guidance supports contrast-enhanced CT, intravenous antibiotics and admission. ([nice.org.uk](https://www.nice.org.uk/guidance/ng141/chapter/Recommendations)) **B** could suit mild preseptal cellulitis without proptosis or impaired eye movements, but not this presentation. **C** provides appropriate treatment and admission but delays imaging despite signs of orbital involvement. **D** obtains the appropriate scan but unnecessarily delays antibiotics while awaiting confirmation. **E** assumes an abscess requiring drainage before imaging has established one; her examination does not itself establish a need for immediate orbital surgery. Specialist review and imaging should guide any drainage decision. ([gloshospitals.nhs.uk](https://www.gloshospitals.nhs.uk/media/documents/ED_ADULT_GUIDELINES__ORBITALFACIAL_CELLULITIS_June_20.pdf))

Reference: NICE NG141: Cellulitis and erysipelas: antimicrobial prescribing — Recommendations (2019) — https://www.nice.org.uk/guidance/ng141/chapter/Recommendations Gloucestershire Hospitals NHS Foundation Trust: ED Adult Guidelines – Facial Cellulitis (June 2020) — https://www.gloshospitals.nhs.uk/media/documents/ED_ADULT_GUIDELINES__ORBITALFACIAL_CELLULITIS_June_20.pdf