Medial Subperiosteal Abscess Research Articles

Orbital Subperiosteal Abscess: The Role of Nonsurgical Management Among Adolescents and Adults

ABSTRACT Purpose To investigate the role of nonsurgical management in the treatment of orbital cellulitis complicated by subperiosteal abscess (SPA) in adolescent and adult populations. Methods A retrospective cohort study to assess the demographic, clinical, and outcome profiles of adolescent and adult patients with orbital SPA treated nonsurgically versus those who received surgical intervention. Primary outcome measures included hospitalization length and best-corrected visual acuity (BCVA) in the final evaluation. Results The study comprised 76 patients diagnosed with SPA in the setting of orbital cellulitis. Twelve were stratified into the nonsurgical cohort, while 64 represented the surgical group. Sinusitis was the most prevalent risk factor among both populations, and the rate did not differ significantly. SPA was located medially at a significantly higher rate in the nonsurgical cohort compared with the surgical. No patients in the nonsurgical population had a relative afferent pupillary defect (RAPD) on presentation. The proportion of patients who received adjunctive systemic corticosteroid therapy was comparable in both groups. Hospitalization length was significantly higher in the surgery cohort. BCVA in the final evaluation was favourable in both groups. Sinusitis subgroup analysis including eight nonsurgical patients produced overall consistent results. Conclusions Findings from the largest study of orbital cellulitis complicated by SPA to date demonstrate a role for nonsurgical management in adolescent and adult patients who present with a medial SPA and/or ophthalmic examination without an RAPD. Among these populations, visual prognosis is favourable whether management includes surgical debridement or not, and surgical intervention may not predict a shorter duration of hospitalization.

Preseptal Versus Orbital Cellulitis in Children: An Observational Study.

Preseptal and orbital cellulitis are two types of infection surrounding the orbital septum with very different potential outcomes. Our aim was to describe key differential features of both conditions, laying special emphasis on diagnostic and therapeutic tools. A retrospective review of patients admitted to a tertiary hospital over a 15-year period (January 2004-October 2019) was conducted. We included 198 patients with preseptal and 45 with orbital cellulitis. Descriptive statistics were performed to examine the available information. Statistically significant differences were found between patients with preseptal and orbital cellulitis regarding age (3.9 ± 2.14 vs. 7.5 ± 4.24 years), presence of fever (51.5% vs. 82.2%), and preexisting sinusitis (2% vs. 77.8%) (all P < 0.001). Diplopia, ophthalmoplegia and proptosis were only present in orbital cellulitis (P < 0.001). Median values of C-reactive protein were significantly higher among children with orbital involvement [136.35 mg/L (IQR 74.08-168.98) vs. 17.85 (IQR 6.33-50.10), P < 0.0001]. A CRP>120 mg/L cut-off point for orbital cellulitis was obtained. Early CT scans were performed in 75.6% of suspected orbital cellulitis and helped detecting complications at an early stage. Abscesses were revealed in 70.6% of cases, especially medial subperiosteal abscesses (58.8%). All patients received intravenous antibiotics, whereas corticosteroids were preferred in patients with orbital implication (8.6% vs. 73.3%, P < 0.001). Only 26.7% of patients required additional surgery. Clinical presentation and CRP are extremely sensitive for differential diagnosis of preseptal and orbital cellulitis. Prompt initiation of intravenous antibiotics is mandatory and can prevent surgical procedures even in cases with incipient abscesses.

Our Experience in the Management of Orbital Complications in Acute Rhinosinusitis

Background and objectiveThe spread of an infection from the paranasal sinuses is rare but severe. Between 4% and 20% of all rhinosinusitis can become complicated, orbital involvement being the most frequent (60–75%). Orbital complications are more common in children but more severe in adults. We aim to analyse the epidemiological characteristics of these patients and to propose a management algorithm. Materials and methodsWe carried out a retrospective review of 21 patients with orbital complications of acute rhinosinusitis diagnosed in the same institution from 2005 to 2018. The diagnosis was based on clinical history, endoscopic examination and imaging tests. All patients received an intravenous antibiotic and were assessed by ophthalmology. An immediate surgical treatment was performed in the case of an abscess or poor response to medical management. ResultsThe average age was 24 years. Fifty-two percent were males and 48% females. According to Chandler's classification, 43% (9/21) had preseptal cellulitis (7 adults and 2 children), 10% (2/21) orbital cellulitis (one adult and one child), 43% (9/21) subperiosteal abscess (2 adults and 7 children), there was one case of orbital abscess in an adult and there were no cases of cavernous sinus thrombosis. A CT scan was performed in all patients and the cases of subperiosteal or orbital abscess were treated surgically, except 2 paediatric patients (<4 years) with a small and medial subperiosteal abscess (<4 mm) who responded well to medical treatment. The surgical approach is performed by endonasal endoscopy, perforating the lamina papyracea in cases of subperiosteal abscess and also opening the periorbita in orbital abscess. It was combined with an external palpebral approach in the 4 cases that presented a superior or lateral abscess. Two young adults (10%) presented an intracranial complication concomitantly. ConclusionOrbital complications of acute rhinosinusitis are rare but potentially severe. It is important to be aware of and suspect them in order to act quickly. It is essential to define the location and extension of the infection for correct management, as well as multidisciplinary treatment. The surgical approach is performed by endonasal endoscopy. It is limited by abscesses located on the roof of the orbit or on the lateral wall, when a combined external palpebral approach is required.

Nuestra experiencia en el manejo de las complicaciones orbitarias en la rinosinusitis aguda

Background and objectiveThe spread of an infection from the paranasal sinuses is rare but severe. Between 4% and 20% of all rhinosinusitis can become complicated, orbital involvement being the most frequent (60-75%). Orbital complications are more common in children but more severe in adults. We aim to analyse the epidemiological characteristics of these patients and to propose a management algorithm. Materials and methodsWe carried out a retrospective review of 21 patients with orbital complications of acute rhinosinusitis diagnosed in the same institution from 2005 to 2018. The diagnosis was based on clinical history, endoscopic examination and imaging tests. All patients received an intravenous antibiotic and were assessed by ophthalmology. An immediate surgical treatment was performed in the case of an abscess or poor response to medical management. ResultsThe average age was 24 years. Fifty-two percent were males and 48% females. According to Chandler's classification, 43% (9/21) had preseptal cellulitis (7 adults and 2 children), 10% (2/21) orbital cellulitis (one adult and one child), 43% (9/21) subperiosteal abscess (2 adults and 7 children), there was one case of orbital abscess in an adult and there were no cases of cavernous sinus thrombosis. A CT scan was performed in all patients and the cases of subperiosteal or orbital abscess were treated surgically, except 2 paediatric patients (<4 years) with a small and medial subperiosteal abscess (<4mm) who responded well to medical treatment. The surgical approach is performed by endonasal endoscopy, perforating the lamina papyracea in cases of subperiosteal abscess and also opening the periorbita in orbital abscess. It was combined with an external palpebral approach in the 4 cases that presented a superior or lateral abscess. Two young adults (10%) presented an intracranial complication concomitantly. ConclusionOrbital complications of acute rhinosinusitis are rare but potentially severe. It is important to be aware of and suspect them in order to act quickly. It is essential to define the location and extension of the infection for correct management, as well as multidisciplinary treatment. The surgical approach is performed by endonasal endoscopy. It is limited by abscesses located on the roof of the orbit or on the lateral wall, when a combined external palpebral approach is required.

The Use of Superomedial Conjunctival Approach in Drainage of Large Medial Subperiosteal Abscess Secondary to Ethmoiditis in Children: A Simple, Fast and Safe Technique

Purpose: To evaluate the superomedial conjunctival approach in management of large-sized medial subperiosteal abscess (MSPA) secondary to ethmoiditis in children. Methods: This prospective, non-randomized, clinical intervention case study was conducted at the Orbital Clinic of Assiut University Hospital, the referral center of Upper Egypt in the period between October, 2015 and March, 2018. The study included 9 children with MSPA secondary to ethmoiditis that met the criteria for surgical drainage. In all cases, the MSPA was large (more than 2 cm in its greatest dimension or more than 4 mm in width) and in 3 cases there was relative afferent papillary defect (RAPD). Children with small MSPA without any signs of compressive optic neuropathy that may improve with intravenous broad-spectrum antibiotics were excluded. Under general anesthesia and coverage of intravenous antibiotics, the conjunctiva between the superior and medial recti was incised 8 mm from the limbus with application of tractional sutures to both recti to pull the globe down and out. With malleable orbital retractor the superomedial conjunctiva was retracted medially and the abscess was easily opened with blunt scissors, suctioned and followed by repeated irrigation and suction with solution containing broad spectrum antibiotics. The tractional sutures were removed and followed by application of broad-spectrum antibiotic ointment and eye bandage for 6 h. Results: The age of the patients ranged from 1 to 10 y with an average of 6 y. 7 were males and 2 were females. The left side was involved in 6 cases while the right side was in 3 cases. On CT, the large MSPA was located posteriorly in 7 cases while it was anterior in 2 cases. In all cases and after drainage, the general symptoms were markedly improved within 48 h and the clinical signs were completely resolved in 1-2 weeks. The hospital stay was 2 d in 8 cases and 3 d in one case only. During the follow-up period of minimum 6 months (ranged from 6-30 m), no corneal complications or re-accumulation of MSPA with recurrence were reported. Conclusion: The excellent results we have achieved make the superomedial conjunctival approach highly recommended for drainage of large-sized MSPA secondary to ethmoiditis in children especially if it is located posteriorly where the external approach is far away from the lesion. The technique is a few minutes approach with no facial scar. Also, it carries no risk of medial rectus or optic nerve damages as reported with transnasal endoscopic approach with its long learning curve. However, extension of the study to involve more cases with longer follow-up is recommended.

Orbital cellulitis: early intervention saves vision

Orbital cellulitis describes an infection involving the soft tissues posterior to the orbital septum including the fat and muscle within the bony orbit. This condition is associated with severe sight and life-threatening complications. Distinguishing it from preseptal cellulitis is difficult, but important. Acute sinusitis is the commonest predisposing factor. Clinical findings alone are not specific enough to distinguish between preseptal and post septal orbital cellulitis. Early diagnosis using CT orbit is important to rule out complications such as orbital cellulitis, subperiosteal abscess. The most common location of subperiosteal abscess is the medial wall of the orbit. Transnasal endoscopic drainage of the abscess is a functional and minimally invasive technique and is the treatment of choice at present. Early diagnosis and intervention are mandatory to prevent the visual loss and life-threatening complication.Here, the authors describe a 2 months old infant with orbital cellulitis and medial subperiosteal abscess and treated with transnasal endoscopic drainage of the subperiosteal abscess.

Management of frontal sinusitis–associated subperiosteal abscess in children less than 9 years of age

To investigate practice patterns for cases of subperiosteal abscess (SPA) with concomitant frontal sinusitis to identify factors favorable to medical management in children <9years of age. The medical records of all pediatric cases of orbital and periorbital cellulitis admitted at a tertiary care center from 1999-2014 were reviewed retrospectively. Cases were included if radiography demonstrated sinusitis-associated SPA in children <9years of age. Cases of SPA with ipsilateral frontal sinusitis were compared to cases of SPA without ispilateral frontal sinus involvement. A total of 21 cases with ipsilateral frontal sinusitis and 76 without were included. Patients with frontal sinusitis had a higher incidence of nonmedial SPA compared to those without frontal sinus involvement (6/21 vs 5/76, P=0.01). Yet a majority of SPAs in the frontal sinusitis group were located medially (15/21 [71%]). All patients with superior or superomedial SPA underwent early surgical intervention. However, 14 of 15 patients (93%) in the frontal sinusitis cohort with medial SPAs were managed successfully with medical therapy alone. Medical management of frontal sinusitis-associated SPA appears safe for select children <9years of age with medial abscess. Although frontal sinusitis is cited as a criterion for surgical drainage of SPA, this criterion should be refined to frontal sinusitis with superiorly located abscesses.

Endoscopic drainage of orbital abscesses aided with intraoperative sonography

Background and purposeAccurate localization and adequate visualization of the superiorly or inferiorly located subperiosteal orbital abscesses or intraorbital abscess is difficult with transnasal endoscopic approach. Sonography is a well-known and effective tool for evaluation of orbital pathologies but no paper documenting intraoperative application of this method in orbital abscess surgery has been published to date. Material and methodsWe present a series of 12 patients in whom orbital abscesses were drained endoscopically with an aid of neuronavigation and intraoperative ultrasonography. The abscesses were localized subperiosteally in the medial (n=6), superior (n=2) or inferior (n=1) part of the orbit whereas in 3 patients the abscess was localized in the intraconal space. ResultsAccording to intraoperative sonographic imaging complete drainage of the abscess was achieved in 11 out of 12 patients and no complications occurred. Intraoperative sonography helped to limit opening of the orbital wall in the medial subperiosteal abscesses, enabled check-up for completeness of drainage of the far extending pouches in the superior and inferior subperiosteal abscesses and enabled visualization of the tip of surgical instrument when reaching deeply located intraorbital abscesses. ConclusionsIntraoperative ultrasonography facilitates the endoscopic management of orbital abscesses, especially those which are difficult to reach due to subperiosteal location in the superior and inferior parts of the orbit, or abscesses localized intraorbitally.

Managment of orbital complications of sinusitis

Purpose: We reported on the clinical approaches of ophthalmology and otorhinolaryngology departments in the treatment of the orbital complications of sinusitis. We also included an in-depth literature review. Methods: We retrospectively reviewed the medical files of 51 patients from January 2008 to January 2014. The records were evaluated for age, gender, type of orbital complications, symptoms, predisposing factors, imaging studies, medical and surgical management, culture results, and follow-up information. SPSS version 15.0 software (Statistical Analysis, The Statistical Package for Social Sciences Inc, Chicago, IL) was used for the statistical analysis. Results: Fifty-one patients met the criteria, with available medical records, for the study (29 male, 22 female). Thirty-two (62.7%) were diagnosed with preseptal cellulitis and 19 (37.3%) with postseptal cellulitis. After a detailed evaluation, 15 were diagnosed with a subperiosteal abscess (SPA), and 4 were diagnosed with orbital cellulitis. The age and gender was similar for the two groups. Five patients with medial SPA were treated with endoscopic sinus surgery, one patient with inferior SPA was treated with external surgery, and six patients with other localizations were treated with a combination of endoscopic sinus surgery and external surgery. All patients presented with periorbital erythema and edema. The length of hospitalization and duration of symptoms were similar in both groups. Visual acuity was between 1/10 to 10/10 (mean 7/10) and statistically significant for preseptal and postseptal cellulitis groups (p<0.001). All patients received intravenous antibiotics upon the first day of admission. Conclusion: Orbital complications of acute sinusitis required intensive follow-up and a multidisciplinary approach. A contrast-enhanced paranasal sinus computerized tomography (CT) scan can detect the extent of the infection. An initial trial of intravenosus (IV) antibiotics may be appropriate when close monitoring is possible. Surgery may be indicated when there has been no improvement within 48 hours of intravenous treatment, loss of visual acuity (under 8/10), and a non-medial abscess.

Management of pediatric orbital cellulitis and abscess

Orbital cellulitis and abscess formation in pediatric patients usually arises as a complication of acute sinusitis and if untreated may cause visual loss or life-threatening intracranial complications. This review describes the current evaluation and management of this condition. Computed tomography with contrast remains the optimal imaging study for orbital inflammation. Orbital inflammation is still classified by Chandler's original description as preseptal or postseptal and nearly all cases of preseptal cellulitis are managed with oral antibiotics. Most cases of postseptal cellulitis are managed with intravenous antibiotics, although surgical therapy is required for some abscesses, particularly large ones. Patients under 9 years respond to medical management more frequently than older patients but recent studies confirm that even children over 9 with small or moderate-sized abscesses and normal vision deserve a medical trial before surgical intervention. Medial subperiosteal abscesses that fail medical therapy are usually drained endoscopically, whereas lateral or intraconal abscesses require an open procedure. Periorbital complications of sinusitis in pediatric patients often respond to medical therapy but may require surgical intervention to prevent serious complications. Continuous in-house evaluation of patients is necessary to observe for progression of symptoms and to optimize outcome.

Extent of Resection of the Lamina Papyracea in Medial Subperiosteal Abscess

To compare the surgical outcomes of minimal and wide resections of the lamina papyracea in cases with medial subperiosteal abscess. University hospital. Case series and planned collection. Thirteen patients with medial subperiosteal abscess as a complication of sinusitis were included in this study. All patients had reduced visual acuity and ophthalmoplegia. Each patient underwent endoscopic sinus surgery to treat the abscess. Age, sex, extent of lamina resection, postoperative vision status, ophthalmoplegia, and the return of orbit to its normal position were recorded. Eight (62%) and 5 (38%) patients underwent minimal and wide endoscopic lamina papyracea resection, respectively. Proptosis, visual acuity, and ophthalmoplegia returned to normal within 24 to 48 hours. All patients received medical treatment in the form of intravenous antibiotics and steroids. Neither technique required revision surgery. Medial subperiosteal abscess is a serious medical condition that can lead to blindness. Endoscopic evacuation of the abscess is currently the treatment of choice. Minimal lamina papyracea resection may be sufficient to drain the abscess. It should be further evaluated as it may have the same result as wide lamina papyracea resection and wide exposure of the periorbit. The aim of the operation is to liberate the pus regardless of the extent of the resection. Revision surgery was not needed with either technique.

Orbital Complications of Acute Sinusitis in Children

Purpose. Acute sinusitis with orbital complications is an ambiguous disease. Without timely diagnosis and appropriate management, it may lead to ocular squela and even become a life-threatening disease. The purpose of this study was to evaluate the clinical presentation, diagnosis, management and outcome of orbital complications of acute sinusitis in children treated at our hospital over a 10-year period. Methods. We retrospectively reviewed 23 children with orbital complications of acute sinusitis who were admitted to our hospital from January 1995 to July 2004. The clinical presentation, laboratory examination, radiological examination, bacteriology, and treatment method were analyzed. Results. The mean age of the patients was 5.0 years, and 65% of patients were younger than 5 years. The mean hospitalization was 8.0 days. Computerized tomography confirmed medial subperiosteal abscess in six children and orbital abscess in three children. Six children underwent surgical intervention. One child had the same blood and pus results: Staphylococcus haemolyticus. Neither cavernous sinus thrombosis nor intracranial infection was noted. No sequela was found in these 23 patients during a follow-up period of 1 to 2 months. Conclusions. Orbital inflammation is the most common complication of acute sinusitis in children. Computerized tomography is very useful for staging orbital inflammation and guiding surgical intervention.

Management of medial subperiosteal abscess of the orbit in children—a 5 year experience

A medial subperiosteal abscess (SPA) of the orbit is the most common serious complication of sinusitis in children. The distinction between SPA and the more benign pre-septal disease is difficult to make especially in a young child in whom an ophthalmological evaluation is often difficult. Computerised tomography (CT) is the investigation of choice in making this distinction. Subperiosteal inflammatory disease of the orbit is initially treated with intravenous antibiotic therapy with surgery reserved for those patients who do not respond to medical treatment and in whom a medial SPA is confirmed by CT. Conventionally, the abscess is drained via an external incision and an ethmoidectomy is performed at the same time. More recently, successful drainage of SPA's has been accomplished endoscopically via a intranasal approach with less morbidity and superior cosmesis. We present a 5 year experience of 24 patients with CT scans suggestive of medial SPA who underwent endoscopic exploration of the medial subperiosteal orbital space. We discuss the current management of medial subperiosteal disease of the orbit in children and include a review of the literature. Also included is a clinical staging system which aids the management of orbital complications of sinusitis.

Subperiosteal Abscess of the Orbit: Computed Tomography and the Clinical Course

In an earlier study, a trial of i.v. antibiotics, with surgical drainage reserved for failure to respond, was recommended for children aged < 9 years with medial subperiosteal abscesses (SPAs) of modest size and without compromised vision. Careful monitoring is mandatory in these cases, and comparison of serial computed tomography (CT) scans frequently guides therapy. The present study examines how the CT findings actually relate to the clinical course of SPA. Initial and subsequent CT scans in 37 cases were analyzed with respect to the subperiosteal material encountered at surgery and the response to treatment. The subperiosteal material could not be predicted from the size or relative radiodensity of the collections in CT scans. Initial scans were not predictive of the clinical course. Serial scans showed enlargement of abscesses during the first few days of i.v. antibiotic therapy, regardless of the ultimate response to treatment. It is concluded that expansion of an SPA in serial CT scans during the first few days of treatment should not be equated to failure of the infection to respond to antibiotics alone. In interpreting serial scans, the time-dependent pharmacokinetics of antibiotic therapy should be considered.

Orbital wall thickness and the spread of infection from the paranasal sinuses.

Ninety-three human skulls (80 adults and 13 children) have been examined and the extent of thin bone in the party walls between the orbit and the frontal, ethmoidal and maxillary sinuses has been assessed. Translucent bone is most often present in the lateral wall of the ethmoidal labyrinth and least often in the floor of the frontal sinus. In children such bone is present significantly less often in the roof of the maxillary sinus (P less than 0.001) than in adults. Computerized tomography scans and clinical data from 6 patients with orbital cellulitis were reviewed. In one of these an inferolateral subperiosteal abscess of the orbit was associated with a defect in the roof of the maxillary sinus. Two patients had a medial subperiosteal abscess associated with ethmoiditis and in one there was direct continuity between the abscess and the adjacent ethmoidal cells. In another case a superolateral abscess was demonstrated in continuity with a surgical defect in the floor of the frontal sinus. We conclude that the ethmoidal, frontal or maxillary sinuses may be sources of orbital infection and that spread occurs either by direct extension through the sinus wall or by local thrombophlebitis.