1

Introduction

Acute sinusitis is the predominant cause of orbital infection in children. An apparent redness or swelling of the orbital region can be a harbinger of a local orbital infection, a trauma, or more ominously, a spreading infection from the neighboring paranasal sinus. The clinician needs to be aware of the possibility of the paranasal sinus infection because the clinical symptoms may be subtle or even absent. Therefore, a high index of suspicion is often needed because a missed diagnosis or delayed treatment can result in potentially catastrophic complication, that is, loss of vision, intracranial extension of the infection, or disseminated sepsis.

2

Material and methods

The admission records of all the patients who were admitted to the Pediatric Surgical Ward (pediatric admission age criteria, up to 12 years old) in Sarawak General Hospital, Kuching, Sarawak, Malaysia, between January 2004 and May 2009 were retrospectively reviewed. Records of patients who presented with the Chandler et al classification of orbital complications—preseptal cellulitis, orbital cellulitis, subperiosteal abscess (extraconal), orbital abscess (intraconal), and cavernous sinus thrombosis—were closely studied. Ophthalmology consultations were obtained in all these cases. The results are detailed in Table 1 . Ultimately, 3 patients having subperiosteal orbital abscess (SPOA) were selected for this review. Their demographic data, clinical history, treatment, microbiology results, duration of hospital stay, complications, and outcome were reviewed.

2

Material and methods

The admission records of all the patients who were admitted to the Pediatric Surgical Ward (pediatric admission age criteria, up to 12 years old) in Sarawak General Hospital, Kuching, Sarawak, Malaysia, between January 2004 and May 2009 were retrospectively reviewed. Records of patients who presented with the Chandler et al classification of orbital complications—preseptal cellulitis, orbital cellulitis, subperiosteal abscess (extraconal), orbital abscess (intraconal), and cavernous sinus thrombosis—were closely studied. Ophthalmology consultations were obtained in all these cases. The results are detailed in Table 1 . Ultimately, 3 patients having subperiosteal orbital abscess (SPOA) were selected for this review. Their demographic data, clinical history, treatment, microbiology results, duration of hospital stay, complications, and outcome were reviewed.

3

Results

3.1

Case 1

A 38-day-old newborn, with a current weight of 4.34 kg, presented to the referring hospital with right periorbital swelling of 4 days’ duration, which was increasing in size, associated with fever and yellowish eye discharge ( Fig. 1 ). Ophthalmologic examination revealed absence of rapid pupillary afferent defect and limitation of eye movement on lateral gaze. There were no upper respiratory tract infection (URTI) symptoms. The mother was well antenatally, and the baby was born with a birth weight of 2.5 kg via full-term spontaneous vaginal delivery. However, it was complicated by birth asphyxia and presumed sepsis, requiring mechanical ventilation and 7 days of intravenous cefotaxime and crystalline penicillin. He was discharged well from the ward on the eighth day of life. On presentation to the referring hospital, the total white blood cell count (TWCC) was 17.4 × 10 ⁹ /L (reference range, 5.7–23.8 × 10 ⁹ /L) and the platelet count was 833 × 10 ⁹ /L (reference range, 150–400 × 10 ⁹ /L). He was also started on intravenous ceftazidime, cloxacillin, and metronidazole. On arrival on the third day, an urgent computed tomographic (CT) scan of the orbits and paranasal sinus was performed, demonstrating proptosis with a subperiosteal abscess collection measuring 3.1 × 1.9 cm on the medial wall of the right orbit displacing the medial rectus muscle and opacification of the ipsilateral ethmoid air cells. There was also dehiscence of the medial wall of the orbit ( Fig. 2 ). A diagnosis of right SPOA secondary to acute ethmoiditis was made. He also began to develop fever of 39°C. The blood culture grew methicillin-resistant coagulase-negative Staphylococcus (CNS), and direct eye smear for Gram stain taken earlier showed Acinetobacter sp (sensitive to amikacin, ampicillin sulbactam, amoxicillin clavulanate, piperacillin, and imepenem; resistant to netilmicin, gentamicin, ceftazidime, and meropenem). Subsequently, an emergency endoscopic drainage procedure of the abscess was performed the same day. Intraoperatively, the right medial meatus area was edematous; and thick pus was drained after an opening was made through the region of lamina papyracea (LP). The pus grew Staphylococcus aureus (sensitive to penicillin, oxaxillin, vancomycin, clindamycin, and fusidic acid) . Postoperatively, the newborn recovered uneventfully and was discharged on day 5 with broad-spectrum oral antibiotics.

A 38-day-old newborn presenting with high fever, right periorbital swelling, and proptosis associated with yellowish eye discharge. Note through the palpebral fissure that the eye was also pushed laterally.

Case 1. (A) Axial CECT scan showing a right SPOA (white arrow) causing proptosis and displacement of the medial rectus muscle. (B) Coronal CECT scan showing the medial collection (white arrow) with opacification of the maxillary sinus. However, the opacification of the ethmoid is less clear in this slice. Dehiscence is present in the medial wall of the orbit (black arrows) in both slices.

3.2

Case 2

A previously healthy 4-year-old boy presented with 3 days’ duration of progressively worsening left eye swelling and left ear purulent discharge with high fever of 38.5°C. There was no history of purulent rhinorrhea. On ophthalmologic examination, the left eye was proptosed, the upper eyelid was edematous, and the extraocular muscle movements were limited. Subconjuctival hemorrhage was also present on the medial aspect. Otoscopy revealed left otitis externa with inflamed dull tympanic membrane. His TWCC was 17.4 × 10 ⁹ /L and platelet count was 959 × 10 ⁹ /L. Paranasal sinus CT scans showed mucosal thickening in the left ethmoid air cells and bilateral maxillary antrum with a 2.2 × 0.5-cm subperiosteal collection in the left orbit displacing the medial rectus muscle with left mastoid effusion ( Fig. 3 ). He was started on intravenous ceftriaxone, cloxacillin, and metronidazole with framycetin and gramicidin (Sofradex; Sanofi-Aventis, Paris, France) ear drops. Subsequently, an emergency endoscopic decompression of the abscess with anterior ethmoidectomy was performed the same day. The pus, blood, and eye swab cultures were unremarkable. He recovered well and was discharged on day 3 with broad-spectrum oral antibiotics.

Case 2. (A) Coronal CECT scan showing left SPOA (black arrows) in the medial portion of the orbit with opacification of the ethmoidal air cells (white arrow). (B) Axial CECT scan of the bone window showing the opacification of the ipsilateral mastoid air cells (black arrow).