Drainage of Subperiosteal Orbital Abscess in Children
David E. Tunkel
INTRODUCTION
Acute sinusitis occurs in approximately 10% of the viral upper respiratory infections frequently seen in young children. Fortunately, complications of acute sinusitis are uncommon, but when they occur, serious morbidity may ensue. Orbital complications of sinusitis, when unrecognized or inadequately treated, can lead to ptosis, diplopia, and even blindness.
Orbital infections from sinusitis were classified by Chandler more than four decades ago, and this classification is used today to describe the progression in severity from preseptal cellulitis to orbital abscess to retro-orbital infection involving the cavernous sinus (Table 33.1). While preseptal orbital infection is more common, the subperiosteal orbital abscess (SPOA) (Chandler Stage III) is the most common orbital infection associated with sinusitis that is treated surgically. These abscesses occur from extension of infection in the ethmoid sinus most commonly into the medial subperiosteal orbital space, between the periorbita and the lamina papyracea (Fig. 33.1A and B). This extension can occur via retrograde thrombophlebitis, through preformed pathways such as the foramina of the ethmoid arteries, through congenital/posttraumatic dehiscences of the lamina papyracea, or from destruction of the thin bone by infection.
While a complete discussion of orbital complications of sinusitis is beyond the scope of this chapter, the key management issues for children with SPOA include (a) prompt diagnosis based on clinical suspicion and radiographic confirmation using computed tomography (CT), (b) appropriate selection of patients for either initial medical therapy or urgent surgical therapy, and (c) keen clinical follow-up to provide surgical drainage for medical failures or those with impending visual loss. The surgical challenges in SPOA treatment center on being able to drain these collections transnasally using modern endoscopic sinus surgical techniques, in the face of acute inflammation, within the small nasal and sinus cavities of small children other than through an external approach. Sinus surgeons who treat children with SPOA must understand the indications for the external approach to the orbit and have familiarity with open surgical techniques that have largely been supplanted by endoscopic sinus surgery.
HISTORY
The duration of orbital edema and the presence of any perceived visual changes such as decreased visual acuity or change in color perception should be documented. Such a history is usually unavailable for young children who may not self-report difficulties. The presence of prodromal symptoms of upper respiratory infection such as fever, cough, and nasal congestion suggests a sinonasal etiology of the orbital edema.
A documented history of prior episodes of sinusitis is usually lacking in children with SPOA. However, if chronic sinus disease is documented, or if nasal polyps have been identified, considerations for other extrasinus complications such as a mucocele should be entertained. Invasive sino-orbital fungal infection may be present in a child with orbital edema who is immunesuppressed, such as that caused by chemotherapy for hematologic
malignancy. Imaging and biopsy for culture/pathologic diagnosis should be performed quickly and aggressive medical and surgical interventions instituted immediately should fungal infection be found.
malignancy. Imaging and biopsy for culture/pathologic diagnosis should be performed quickly and aggressive medical and surgical interventions instituted immediately should fungal infection be found.
TABLE 33.1 Chandler Classification of Orbital Complications | |||||||||||||||||||||
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Infants and young children with orbital edema often have preseptal infection/edema from causes other than sinusitis, including insect bites, allergy, dacryocystitis, and hematogenous-spread bacterial infection. This by no means excludes sinusitis as a cause of orbital swelling in young children, as SPOA can be seen even in young infants. The age of a child is an important consideration, as older children with SPOA are more likely to require surgical drainage for successful treatment.
A history of recent antibiotic treatment can help with antibiotic selection and help assess the need for parenteral antibiotic therapy. While recurrent orbital infections from sinusitis are rare, the child who has such
recurrent disease should undergo immunologic workup as well as imaging to look for anatomic issues that may predispose to orbital infections (Fig. 33.2).
recurrent disease should undergo immunologic workup as well as imaging to look for anatomic issues that may predispose to orbital infections (Fig. 33.2).
 FIGURE 33.1 A: Edema and erythema of the left eyelid in a young child with a left SPOA. B: Axial CT image of left SPOA (arrow). |
 FIGURE 33.2 Coronal CT scan of the sinuses, taken during a disease-free period, of a child who has had three episodes of orbital cellulitis. Note the defect in the left lamina papyracea (arrows) adjacent to an opacified ethmoid cell. |
PHYSICAL EXAMINATION
The general physical examination of a child with edema and erythema of the eyelids who is suspected of having complications of acute sinusitis should start with evaluation of signs of systemic infection such as fever and lethargy. A focused examination of the nasal cavity and orbit(s), to assess the presence of acute rhinosinusitis and to measure the severity of orbital involvement, should follow. Edema and erythema of the nasal mucosa and purulent nasal secretions may be present. Nasal patency should be evaluated with anterior rhinoscopy in order to predict the ability to perform transnasal endoscopic drainage, if necessary.
The eyes and affected orbit must be evaluated, usually with the assistance and expertise of an ophthalmologist. The severity and nature of edema of the eyelid is evaluated, as ethmoiditis usually will produce edema and erythema more prominent in the upper lid (Fig. 33.3). Severe edema with loss of lid creases and/or skin color change (erythema) may indicate more advanced involvement of the orbit. Visual acuity measurement is
attempted although such assessment may be difficult in a sick young child. Pupil reactivity should be normal, and the presence of an afferent papillary defect is an ominous sign. The presence and severity of proptosis and/or restriction of gaze suggests postseptal orbital involvement and possible abscess formation. Eyelid fullness, position, and elevation should be assessed, as advanced orbital infections can be accompanied by infection in the lid spaces.
attempted although such assessment may be difficult in a sick young child. Pupil reactivity should be normal, and the presence of an afferent papillary defect is an ominous sign. The presence and severity of proptosis and/or restriction of gaze suggests postseptal orbital involvement and possible abscess formation. Eyelid fullness, position, and elevation should be assessed, as advanced orbital infections can be accompanied by infection in the lid spaces.
 FIGURE 33.3 A toddler with right ethmoid sinusitis and SPOA. Note upper>lower eyelid edema and erythema. |
Neurologic status should be assessed, as intracranial complications of acute sinusitis can occur in children with orbital complications. Any focal neurologic signs, or even generalized abnormalities such as extreme lethargy or severe headache, warrant intracranial imaging with contrast-enhanced CT or magnetic resonance imaging. Neurosurgical consultation must be obtained if an intracranial complication is suspected.
INDICATIONS
There is growing debate about the indications for surgery for children with radiographically proven SPOA. Over the last two decades, the role of initial medical management, without immediate surgery, has been emphasized and perhaps extended to children who may have previously been considered candidates for urgent surgery. Children with minimal orbital symptoms that are confined to edema of the eyelid and erythema without proptosis or gaze restriction can usually be treated and cured with systemic antibiotics, usually parenteral broad-spectrum antibiotics and topical nasal decongestants. My empiric antibiotic regimen usually includes clindamycin and ceftriaxone or ampicillin-sulbactam. If risk factors for methicillin-resistant Staphylococcus aureus or highly resistant Streptococcus pneumoniae are evident on history, I may use vancomycin as part of the empiric regimen.
Children with mild proptosis and/or slight gaze restriction create the most problematic surgical decisions. Often, the CT scan will demonstrate a small subperiosteal collection between the periorbita and the lamina papyracea. These children usually do well with medical therapy alone. They need close observation, serial visual checks, and aggressive follow-up by the otolaryngology and ophthalmology consultants. While visual loss is rare, it is a real possibility. Any sign of progression of symptoms/signs on antibiotics, and any reduction in visual acuity, warrant at least repeat imaging and more likely urgent surgical management. Additionally, surgery early in the progression of disease can usually be performed endoscopically through the nose, while the advanced inflammation seen later may mandate an open approach.
Older children (those >9 years of age), children with large SPOA collections, those with abscesses that are not medially located, those with visual compromise, and those who cannot be followed easily with clinical examinations should not be considered for medical therapy. Surgery should be performed in these patients to drain the abscess, decompress the orbit if needed, and provide cultures for directed medical therapy. Criteria for medical management of SPOA were advanced by Garcia and Harris in 2000 and are summarized in Table 33.2.
TABLE 33.2 Criteria for Medical Versus Surgical Management of Subperiosteal Orbital Abscesses | |||
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