Aims: Paediatric orbital cellulitis (OC) is commonly sinugenic in origin. Severe ocular and intracranial complications can ensue. Areas of controversy are the timing of imaging; timing of surgery; and the role of upfront medical management in small medially placed subperiosteal abscesses. This study compares upfront medical against surgical management of OC, and examines institutional adherence to imaging protocols to clarify the role of imaging in assisting surgical intervention. Methodology: Retrospective cohort study of five years (2018-2022) of all children presenting to Royal Children’s Hospital with sinugenic OC. Data collection was performed for patient and demographic data, radiologic features, and treatment modalities. Primary outcome of interest was time to resolution. Secondary outcomes were inpatient length of stay, return to theatre, and morbidity. A decision tree was created to visualise care trajectory. Results: 101 patients met inclusion criteria (48 medical management, 53 surgical. Relevant comorbidities were immunocompromise (0.07%), and sinusitis (41.6%). There were statistically significant differences in Chandler classification, upfront radiology, and delayed radiology for medically and surgically managed patients. Measurements for Chandler 3 pus volume is currently ongoing. Time to resolution was 14 days and 19 days respectively (p=0.05). Rate of conversion to surgery of medically managed patients was 32.4% (n=23/71). Resource rationalization of CT was poor, and 40.6% (n=41/101) had scans that did not change management. 67.4% (n=62/92) patients with upfront scans were initially managed medically. Three patients with delayed imaging had changes in clinical management- one had delayed surgery, and two avoided surgery. Inpatient complication rate was 3.96% (n=4/101), and readmission rate was 3.96% (n=4/101). Conclusions: Medical management of early OC without upfront imaging is an appropriate treatment pathway, and will improve imaging rationalisation.