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Management of Orbital Subperiosteal Abscess in Children
Reza Rahbar, DMD, MD;
Caroline D. Robson, MD;
Robert A. Petersen, MD;
James DiCanzio, MS;
Kristina W. Rosbe, MD;
Trevor J. McGill, MD;
Gerald B. Healy, MD
Arch Otolaryngol Head Neck Surg. 2001;127:281-286.
ABSTRACT
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Objectives To present guidelines for the management of an orbital subperiosteal
abscess (SPA) in children and to assess the efficacy and safety of transnasal
endoscopic drainage of an orbital SPA.
Setting Tertiary care children's hospital.
Patients Nineteen patients treated for an SPA between July 1997 and December
1999. The age of the patients ranged from 17 months to 14 years (mean, 6 years).
The male-female ratio was 10:9. Treatment modalities included transnasal endoscopic
drainage (n = 11), external drainage (n = 3), and intravenous antibiotics
alone (n = 5).
Results Bilateral pansinusitis was the most common cause. All patients received
an initial trial of intravenous antibiotics. Based on the Fisher exact test,
no statistically significant differences were detected for age, sex, presence
of gaze restriction, and radiographic findings. Based on multiple logistic
regression, degree of proptosis was the only significant multivariate predictor
of surgery (P = .003). The estimated probability
of surgery was 6% when there was no proptosis, and 92% for 2 mm of proptosis.
The location of the SPA determined the route of surgical drainage. Eleven
patients with a medially based SPA underwent drainage via the transnasal endoscopic
approach, and 3 with a superior SPA underwent drainage externally. The external
approach was associated with a longer hospital stay (median, 7 days) than
either the endoscopic or the intravenous antibiotic approach (median, 5 days).
INTRODUCTION
ACUTE SINUSITIS of the ethmoid and maxillary complex is the most frequent
cause of a subperiosteal abscess (SPA). The incidence of an SPA in orbital
infections is about 15% in children. The close anatomic relation of the orbit
to the paranasal sinuses predisposes to the contiguous spread of infection
through the ophthalmic venous system, which anastomoses freely with the facial,
pterygoid, and cranial venous system. Retrograde spread of infection can lead
to complications such as endophthalmitis, cavernous sinus thrombosis, meningitis,
cerebritis, brain abscess, or death.1, 2, 3
In the preantibiotic era, 20% of patients with periorbital cellulitis had
permanent loss of vision, and 17% died from central nervous system complications.4 Today, despite antimicrobial and surgical management,
15% to 30% of patients with an SPA develop various visual sequelae.5
Treatment of an SPA remains controversial. The role of an initial therapeutic
trial of intravenous (IV) antibiotics and the timing and methods of surgical
drainage are not well established. This report presents some guidelines for
the diagnosis and treatment of an SPA based on clinical, ophthalmologic, and
radiographic findings, and evaluates the efficacy and safety of endoscopic
drainage of an orbital SPA.
PATIENTS AND METHODS
Nineteen patients with clinical and radiographic evidence of an orbital
SPA secondary to sinusitis were treated at The Children's Hospital, Boston,
Mass, between July 1997 and December 1999. All patients underwent a complete
head and neck examination by the otolaryngology and ophthalmology services.
The results of a computed tomographic (CT) scan were reviewed for all patients.
All patients received an initial trial of IV antibiotics. Five patients were
treated with IV antibiotics alone. Fourteen patients underwent surgical drainage:
3 via an external approach and 11 via transnasal endoscopic drainage of the
SPA.
Endoscopic drainage was performed under general anesthesia. The nasal
cavity was packed with oxymetazoline hydrochloride–soaked cotton for
several minutes, and 0.5% lidocaine with 1:200 000 epinephrine was used
for local anesthesia. The middle turbinate was medialized, and the uncinate
process was removed. A middle meatus maxillary antrostomy and complete ethmoidectomy
were performed. The lamina papyracea was identified, and a Freer elevator
was used to make an opening in the inferior aspect of the bone. The opening
was enlarged to permit drainage of the SPA, and appropriate cultures were
obtained. The nasal cavity was irrigated with copious amounts of isotonic
sodium chloride solution and then coated with a water-soluble antibiotic ointment.
No packing was used.
The variables analyzed included age, sex, clinical presentation, ophthalmologic
manifestation, imaging findings, treatment modality, length of the hospital
stay, complications, and microbiological specimens collected.
Patients requiring surgical intervention (by either procedure) were
compared with those whose abscesses resolved with IV antibiotics based on
sex, age, and clinical manifestations. Because of the small number of patients
studied, we used nonparametric statistical methods for all comparisons. The
Fisher exact test was used to evaluate differences in the distribution of
sex, presence or absence of gaze restriction, and radiographic findings of
(1) orbital fat involvement, (2) degree of rim enhancement (RE) of the SPA,
and (3) number of ocular muscles enhanced. Patients' age, abscess volume,
and degree of proptosis were compared with the Wilcoxon rank sum test. Length
of the hospital stay associated with each type of intervention was compared
using the Kruskal-Wallis test.6 A multiple
stepwise logistic regression analysis7 was
performed to identify the variables independently predictive of surgical intervention
and to generate theoretical probability curves. For all statistical tests,
results were considered significant if P<.05 (2-tailed).
Data analysis was performed using SAS statistical software, version 6.12 (SAS
Institute Inc, Cary, NC).
RESULTS
PATIENTS
Nineteen patients were included in this study. The age range was 3 to
11 years (mean, 7.3 years) for the external drainage group, 2 to 11 years
(mean, 5.4 years) for the IV antibiotics group, and 17 months to 14 years
(mean, 5.8 years) for the endoscopic drainage group. The male-female ratio
was 10:9 (Table 1). The most common
clinical presentations were upper respiratory tract infection, fever, and
eye swelling. There was no significant medical history in any patient, and
immunizations were up-to-date in all.
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Table 1. Characteristics of the Patients Studied*
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OPHTHALMOLOGIC EXAMINATION
All patients were examined by the ophthalmology service for (1) degree
of periorbital or eyelid edema and erythema, (2) gaze restriction, (3) degree
of proptosis, (4) visual acuity, and (5) fundoscopic examination. All data
were reviewed and interpreted by a single ophthalmologist (R.A.P.). All patients
presented with marked eyelid edema and erythema, and were divided into those
with complete eye closure and those with partial eye closure. Gaze restriction
was noted in 10 of 11 patients in the endoscopic drainage group, 2 of 3 in
the external drainage group, and 2 of 5 in the IV antibiotics group. All patients
who underwent surgical drainage had proptosis, ranging from 2 to 5 mm (mean,
2.7 mm) for the endoscopic drainage group and 1 to 4 mm (mean, 2.3 mm) for
the external drainage group. Only 1 patient from the IV antibiotics group
had proptosis (2 mm). Visual acuity was normal in all patients. The fundoscopic
examination revealed mildly dilated retinal vessels in only 2 patients from
the endoscopic drainage group.
IMAGING FINDINGS
The CT images were reviewed by a single neuroradiologist (C.D.R.) blinded
to the treatment modality. The CT scan was reviewed for (1) number and location
of sinuses involved; (2) location, size, and RE of the SPA; (3) radiographic
evidence of orbital fat and muscle changes; and (4) anatomical abnormality
of the sinuses and adjacent structures (Figure
1).
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Figure 1. A, Coronal view of a medial SPA.
B, Axial view of a medial SPA. C, Coronal view of a superior SPA. D, Coronal
view of an inferior-medial SPA. E and F, Orbital fat and muscle enhancement.
SPA indicates subperiosteal abscess.
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Bilateral pansinusitis was the most common presentation. It was noted
in 8 of 11 patients in the endoscopic drainage group, 2 of 3 in the external
drainage group, and 4 of 5 in the IV antibiotics group. All other patients
had involvement of more than 2 sinuses ipsilateral to the SPA. Maxillary and
ethmoid sinuses were involved in all patients (Table 1).
The location of the SPA was described based on the medial axis of the
orbit on coronal and axial images. Medial SPA was the most common location,
noted in 10 of 11 patients in the endoscopic drainage group and in all 5 patients
in the IV antibiotics group. One patient from the endoscopic drainage group
presented with an inferior-medial SPA. Three patients presented with a superiorly
based SPA. An estimated volume of the SPA (superior-inferior x transverse
x anterior-posterior dimension) was recorded based on the largest superior-inferior,
transverse, and anterior-posterior dimension on the axial and coronal CT images
(Table 2).
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Table 2. Measurement of SPAs*
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The contralateral medial rectus muscle was used as a point of reference
for describing the degree of radiographic RE of the SPA (1 indicates less;
2, equal; and 3, more). All patients showed RE equal to or greater than that
of the medial rectus muscle, except for 3 from the IV antibiotics group, 1
from the external drainage group, and 2 from the endoscopic drainage group,
who showed RE less than that of the medial rectus muscle. All patients showed
orbital fat enhancement on CT, except 2 from the IV antibiotics group and
1 from the external drainage group.
Swelling and enhancement of at least 2 extraocular muscles were noted
in all patients. Medial rectus, superior oblique, and superior rectus muscles
were most commonly involved (Table 1).
No specific anatomical abnormalities predisposing the patients to an SPA were
noted.
TREATMENT
All patients received IV antibiotics and oxymetazoline nasal drops as
the initial treatment. Visual examinations were performed twice daily by the
ophthalmology service. Five patients responded well to IV antibiotics alone
within the first 24 to 36 hours: 4 received a combination of ampicillin sodium
and sulbactam sodium (Unasyn), and 1 received a combination of oxacillin sodium
and cefotaxime sodium. The length of the hospital stay ranged from 2 to 6
days (mean, 5 days) for this group. All 5 patients were discharged home from
the hospital with a prescription to take a combination of amoxicillin and
clavulanate potassium (Augmentin) for an average of 14 days. The other 14
patients received IV antibiotics (ampicillin sodium–sulbactam sodium
or clindamycin) for 1 to 5 days (mean, 2 days) before surgical drainage. The
principle indication for surgery was worsening of ophthalmologic examination
results. Three patients with a superior SPA underwent external incision and
drainage. The length of the hospital stay ranged from 7 to 14 days (mean,
9 days) for the external drainage group. One patient was discharged home from
the hospital with a 1-week prescription of oral clindamycin, and 2 were discharged
with a 10-day prescription of amoxicillin–clavulanate potassium. Eleven
patients underwent transnasal endoscopic drainage for a medially based SPA.
Two of these patients required a second endoscopic procedure because of worsening
of ophthalmologic examination results; this examination was performed 24 to
48 hours after the initial surgery. One patient had persistence of a purulent
collection within the posterior ethmoid and orbital subperiosteal area. A
second patient had a collection of antibiotic ointment, with an organized
clot obstructing the surgical opening of lamina papyracea and the ethmoid
cavity. Both patients showed improvement within 24 hours after the second
procedure. The length of the hospital stay ranged from 3 to 7 days (mean,
5 days) for the endoscopic drainage group. All patients were discharged home
from the hospital with a prescription to take amoxicillin–clavulanate
potassium for an average of 10 days.
Purulent drainage was noted in 9 of 11 patients in the endoscopic drainage
group and in all 3 patients in the external drainage group. Two patients in
the endoscopic drainage group had serosanguineous drainage. Cultures grew
combinations of streptococcus, staphylococcus, and Haemophilus
influenzae. No anaerobic organisms were detected.
STATISTICAL RESULTS
The demographic and clinical characteristics of the surgical and nonsurgical
patients are summarized in Table 3.
No statistically significant differences were detected for sex, age, presence
of gaze restriction, radiographic evidence of orbital fat involvement, degree
of RE, or number of ocular muscles affected (P .08
for all). Patients requiring surgical intervention tended to have a higher
degree of proptosis and larger abscess volumes than did those whose abscesses
resolved with IV antibiotics alone. However, results from the stepwise multiple
logistic regression indicated that proptosis was the only significant multivariate
predictor of surgical intervention (odds ratio, 12.9; P = .003). Since patients with larger abscesses also tended to have
a higher degree of proptosis, the addition of abscess volume did not improve
the predictive value of the model. Using the logistic regression equation,
we can estimate the probability of surgery given the degree of proptosis.
As illustrated in Figure 2, the
estimated probability of surgery is approximately 6% when there is no proptosis
(0 mm) and increases to 92% for a proptosis of 2 mm. Of the 2 types of surgical
intervention, external excision was associated with a longer hospital stay
(median, 7 days; range, 7-14 days) than either transnasal endoscopy (median,
5 days; range, 3-7 days) or IV antibiotics (median, 5 days; range, 2-6 days)
(P = .03).
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Table 3. Demographic and Clinical Characteristics of Patients Successfully
Treated With IV Antibiotics and Those Requiring Surgical Intervention*
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Figure 2. Frequency distribution (left axis)
with respect to proptosis for patients successfully treated with intravenous
(IV) antibiotics alone and those requiring surgical intervention. The theoretical
curve showing the relation between the probability of surgery (right axis)
and the degree of proptosis was derived from the logistic regression equation
(slope, 2.55; intercept, -2.67; P= .003).
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COMMENT
Orbital infection encompasses a wide range of causative factors: bacterial
septicemia, penetrating injury, or secondary to skin infection. Sinusitis
remains the most common cause of an acute orbital infection. Chandler et al4 proposed a classification system based on the extension
of the disease process ranging from periseptal cellulitis to cavernous sinus
thrombosis. Orbital involvement is due to direct extension of infection through
a natural bony dehiscence, local thrombophlebitis, or thromboemboli along
the valveless venous system. This condition can affect all age groups, but
is generally more frequent in the pediatric population.8
The management of an "acute orbit" depends on the cause and severity
of infection. The typical presentation for preseptal cellulitis is inflammation
of the eyelid, without proptosis or restriction of gaze. Orbital involvement
could present as chemosis, proptosis, restriction of gaze, and visual changes.
The distinction between preseptal cellulitis and orbital involvement is important,
and cannot be made with clinical examination alone. Delay in treatment can
result in blindness in up to 10% of patients with an SPA.9
The advent and evolution of orbital imaging techniques in the past 2
decades have enhanced the diagnosis of an SPA. The CT scan depicts a localized
and homogeneous elevation of the periorbit adjacent to opacified sinuses.
The classic CT appearance of an SPA is a convex low-density lesion with an
enhancing rim next to the medial orbital wall. The presence of low density
or air within the area is suggestive of abscess formation. There is no consensus
as to the use of a CT scan as part of the initial workup. Some authors10 believe that imaging is not necessary for preseptal
inflammation when there is no proptosis or gaze restriction. Some11 also advocate an initial trial of IV antibiotics
in cases suggestive of an SPA before obtaining a CT scan.
The most common presentation of an SPA in our series was periorbital
swelling and erythema, which in isolation are physical findings that represent
nonspecific inflammation common to preseptal and postseptal causes. We have
presented 3 cases of an SPA manifesting with periorbital cellulitis, without
any proptosis, restriction of gaze, or vision changes. Because of the aggressive
nature of an SPA and the need for close monitoring of vision, we believe it
is prudent to obtain a CT scan even if the only presentation is preseptal
cellulitis, to further evaluate the status of the orbit. However, the role
of a serial CT scan for evaluation of an SPA is controversial. There is evidence
that the size of the SPA may increase during the first few days of IV antibiotic
treatment regardless of the ultimate response to treatment.12
The treatment of an orbital SPA is controversial. Some authors13, 14, 15 advocate an initial
trial of IV antibiotics despite radiographic evidence of an SPA. Others16, 17, 18 believe the presence
of an SPA to be an absolute indication for immediate surgical drainage of
the abscess and the infected sinuses. Even with appropriate treatment, there
is a significant complication rate of 20% and a visual loss of 14% to 33%.19, 20, 21 The mechanism of
visual loss is thought to be secondary to elevation of intraorbital pressure
caused by the mass effect of the abscess, resulting in retinal ischemia due
to central artery occlusion or thrombophlebitis along the valveless orbital
veins. Visual loss may also occur because of optic neuritis caused by extension
of infection.
We have described 19 patients with an SPA. Five patients responded well
to conservative management. Only patients with a superiorly based SPA underwent
drainage externally. Eleven patients with a medial or a medial-inferior SPA
underwent drainage through a transnasal endoscopic approach. Two patients
from the endoscopic drainage group required a second endoscopic procedure.
Patients were followed up for an average of 20 months, and no other complications
were noted. There were no statistically significant differences between groups
for sex, age, presence or absence of gaze restriction, and radiographic findings.
The only significant multivariate predictor of surgical intervention was the
degree of proptosis.
In patients with normal vision, a trial of IV antibiotics is reasonable
only when careful monitoring of vision is possible. There is no consensus
as to the proper frequency of visual examinations during initial medical management.
Assessment of visual acuity ranging from every 2 hours to twice daily is recommended
during the initial medical management of an SPA.22
Based on our data, the possibility of the need for surgical drainage based
on the degree of proptosis should also be considered. According to our logistic
model, patients presenting with proptosis of 2 and 3 mm had an estimated 92%
and 99% chance of requiring surgical drainage, respectively. Therefore, it
appears that in patients with proptosis greater than 2 mm, delay in surgical
drainage would prolong the hospital stay and recovery periods.
Because of the potential for loss of vision and the devastating morbidity
associated with an SPA, we recommend immediate surgical drainage when there
is (1) impairment of vision, (2) worsening of the visual examination results
(periorbital erythema or edema, proptosis, and restriction of gaze), (3) any
sign of systemic manifestation or complication, (4) an inability to perform
a reliable and serial ophthalmologic examination, (5) an immunocompromised
patient, and (6) a lack of response to an initial trial of appropriate IV
antibiotics. In our series, no patient required immediate surgical drainage.
The duration of the initial IV antibiotic treatment should be individualized
based on the serial ophthalmologic examination results. External drainage
of an SPA and ethmoidectomy through a Lynch incision has been the traditional
approach. With advances in sinonasal surgery, transnasal endoscopic drainage
of SPAs has been popularized, as it reduces the necessity for an external
incision and facilitates drainage of sinuses.23, 24
CONCLUSIONS
Prompt diagnosis and appropriate management of an SPA are essential
to avoid serious and life-threatening complications. An individualized therapeutic
approach should be based on a team decision involving the pediatrician, ophthalmologist,
radiologist, and otolaryngologist. An initial trial of IV antibiotics is only
appropriate when the visual acuity is normal and close monitoring is possible.
Based on our experience, an orbital SPA can be successfully and safely managed
by a transnasal endoscopic approach in selected patients. Methods of surgical
drainage should be based on the location of the abscess and, most important,
the experience of the otolaryngologist.
AUTHOR INFORMATION
Accepted for publication August 11, 2000.
Presented at the American Society of Pediatric Otolaryngology, Orlando,
Fla, May 17-19, 2000.
From the Departments of Otolaryngology and Communication Disorders
(Drs Rahbar, Rosbe, McGill, and Healy), Radiology (Dr Robson), Ophthalmology
(Dr Petersen), and Clinical Research (Mr DiCanzio), The Children's Hospital,
Boston, Mass; and the Departments of Otology and Laryngology (Drs Rahbar,
Rosbe, McGill, and Healy), Radiology (Dr Robson), and Ophthalmology (Dr Petersen),
Harvard Medical School, Boston.
Corresponding author and reprints: Reza Rahbar, DMD, MD, Department
of Otolaryngology and Communication Disorders, The Children's Hospital, 300
Longwood Ave, Boston, MA 02115 (e-mail: rahbar{at}a1.tch.harvard.edu).
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