Medical and surgical management of subperiosteal orbital abscess secondary to acute sinusitis in children

Objective: To evaluate the presentations and outcomes of pediatric subperiosteal orbital abscesses (SPOA) secondary to acute sinusitis. Study design: Case series. Setting: Tertiary children's hospital. Patients: Forty-three admissions diagnosed with SPOA by clinical presentation and contrast enhanced computed tomography (CECT) were retrospectively reviewed. Main outcome measures: Clinical presentations, CECT dimensions, treatment, outcomes, and microbiology. Results: Eighteen/43 (42%) patients resolved their infection with medical management only, including five children older than nine. Twenty-five/43 (58%) children underwent surgical drainage. Purulence was identified in 22 of 25 surgical patients, and the most common organism was Streptococcus milleri (7 patients). Compared to 22 patients with drained purulence, the 18 patients with abscesses managed medically had significant differences for: chemosis in 2/18 (11.1%) versus 14/22 (63.6%, p = 0.001), proptosis in 10/18 (55.6%) versus 20/22 (90.9%, p = 0.025), elevated intraocular pressure (IOP) in 0/18 (0%) versus 11/22 (50%, p < 0.001), severe restriction of extraocular movements in 1/18 (5.6%) versus 12/22 (54.5%, p = 0.002), and length of stay (4.3 versus 5.8 days, p = 0.038). The dimensions of medial SPOA managed medically were significantly smaller on CECT compared to surgically drained purulent SPOA: width (0.25 versus 1.46 cm, p < 0.001), height (0.73 versus 1.35 cm, p = 0.002), and length (1.1 versus 1.86 cm, p = 0.004). Persistent morbidities occurred in no patients managed medically and in 2/25 (8%) managed surgically. Conclusions: Children with small medial SPOA without significant ocular signs may be managed medically with favorable outcomes. Proposed criteria for medical management of medial SPOA include: (1) normal vision, pupil, and retina; (2) no ophthalmoplegia; (3) IOP < 20 mm Hg; (4) proptosis of 5 mm or less; and (5) abscess width of 4 mm or less. In contrast to prior series, older children with SPOA were managed successfully with medical therapy.