Nonsurgical management of subperiosteal abscess of the orbit.

Abstract

In their study of pediatric subperiosteal abscess (SPA),1Garcia GH, Harris GJ. Criteria for nonsurgical management of subperiosteal abscess of the orbit: analysis of outcomes 1988–1998. Ophthalmology 2000;107:1454–6; discussion 1457–8.Google Scholar Drs. Garcia and Harris present recent data that support a shift in the current standard of care in treating these infections. However, we do believe a few comments are in order. First, among the multiple criteria for their nonsurgical management protocol, the authors are careful to exclude any cases of SPA in children that may be secondary to dental infection, because these cases are more likely to harbor resistant anaerobic infections. We would suggest that the authors’ data on pediatric SPA, as well as our own2Greenberg M.F. Pollard Z.F. Medical treatment of pediatric subperiosteal orbital abscess secondary to sinusitis.J AAPOS. 1998; 2: 351-355Abstract Full Text PDF PubMed Scopus (56) Google Scholar and others,3Rubin S.E. Rubin L.G. Zito J. et al.Medical management of orbital sub-periosteal abscess in children.J Pediatr Ophthalmol Strabismus. 1989; 26: 21-27PubMed Google Scholar limits any management generalizations to those cases specifically secondary to sinusitis. A pediatric orbital infection secondary to any other cause should be managed cautiously, because current data are not available to support any specific management protocol. Second, the authors recommend surgical drainage of pediatric SPA in cases that fail to “defervesce in 36 hours” of medical management. We urge caution with the term “defervesce,” because our experience has shown that several clinical signs are useful, whereas other old standbys may prove unreliable. In particular, the return of appetite after 1 or more days of pretreatment anorexia almost always portends eventual recovery under medical management. In addition, improvement in the range of any pretreatment ocular motility restriction will also predict eventual success. Any improvement, even 5° or 10°, is significant, and we recommend careful repeated measurements by the same ophthalmologist each time, because only this individual can note such improvement with certainty. On the other hand, periorbital edema and eyelid swelling often will fail to improve or will even increase the day after successful treatment. This is presumably because of the large volume of intravenous fluids given along with antibiotics to these uniformly dehydrated children. The typical recumbent position of the hospitalized patient adds to the periorbital fluid collection. Likewise, radiologic findings are affected, and repeat computed tomography scans may show failure to resolve, worsening, or even emergence of a new subperiosteal fluid collection, despite effective infection control. Several authors have documented such “sterile abscesses” when drained.3Rubin S.E. Rubin L.G. Zito J. et al.Medical management of orbital sub-periosteal abscess in children.J Pediatr Ophthalmol Strabismus. 1989; 26: 21-27PubMed Google Scholar, 4Harris G.J. Subperiosteal abscess of the orbit. Age as a factor in the bacteriology and response to treatment.Ophthalmology. 1994; 101: 585-595Abstract Full Text PDF PubMed Scopus (137) Google Scholar Increased eye swelling with SPA enlargement despite antibiotics is a traditional criterion for surgical drainage. However, we have observed such patients eating breakfast for the first time in 2 days, with improved eye motions revealed once the eyelids were pried open. These were successfully managed medically. Last, as the authors point out, children older than 9 years of age with SPA may, indeed, be managed medically, although with more caution than those in the younger age group. The authors exclude those who show no “clinical improvement in 72 hours” from further medical management. In our experience, such older children often require longer courses of treatment, and “defervesce” more slowly, sometimes requiring well over a week of treatment before fever and swelling are significantly resolved. One teenager we treated resumed eating well 2 days after intravenous antibiotics began and “felt fine” despite prominent proptosis and pain to globe retropulsion, which took over a month to resolve. Currently, the bulk of data supports surgical drainage of SPA, because few have documented medical management in the pediatric age group. Some believe pediatric SPA may be more dangerous because vision cannot accurately be followed in young children. Dr. Harris’ elegant study of age-dependent bacteriologic differences within SPAs explains why pediatric cases respond differently than adult cases.4Harris G.J. Subperiosteal abscess of the orbit. Age as a factor in the bacteriology and response to treatment.Ophthalmology. 1994; 101: 585-595Abstract Full Text PDF PubMed Scopus (137) Google Scholar We congratulate the authors on this new, excellent prospective study and applaud their efforts to develop guidelines in which medical management is safest. However, their data should not be interpreted to suggest that surgery is indicated for those outside the guidelines, because many of these may also be managed medically. Nonsurgical management of subperiosteal abscess of the orbit: Author’s replyOphthalmologyVol. 108Issue 7Preview Full-Text PDF