Clinical Determinants for the Surgical versus Conservative Medical Management of Subperiosteal Abscesses in the Pediatric Population: Our Experience Compared to the Literature

Background: Orbital complications of bacterial sinusitis are rare but potentially devastating. Early recognition and appropriate management are imperative, especially because a delay in diagnosis can cause rapid clinical deterioration. Recognizing the risk factors contributing to the disease and identifying disease trends can help identify at-risk children and hopefully result in earlier diagnosis, improved management, and potential reduction in morbidity. Subperiosteal abscesses (SPA) are classified as Group III according to the Chandler system for orbital complications. There is a lack of consensus management guidelines, and a review of the literature reveals several distinct protocols currently in practice at other institutions.

Objective: To present the clinical factors that were the most influential in guiding our management decisions and compare them with those at other institutions.

Methods: Over the past 5 years, twelve patients with subperiosteal abscesses underwent functional endoscopic sinus surgery. In two patients, medical management was attempted prior to proceeding with surgery. In the remaining patients, concerning ophthalmologic findings were seen on exam, warranting immediate surgery to avid lasting sequelae.

Results: Ages of surgical patients varied from 3 to 17 years, with a mean age of 8.9. Average hospital length of stay for surgical patients was 4.1 days, comparable to the 4- to 6-day average stay for nonsurgical patients. Surgical candidates had features of visual changes, proptosis, evidence of SPA on CT scan, or lack of improvement after at least 24 hours of antibiotic treatment. 4 of our 12 patients had initially presented to an outside hospital and had CT scans confirming SPA prior to arrival. The remaining 8 had CT scans ordered as part of their workup; imaging confirmed SPA in all 8. The dimensions of the SPA varied from 0.2 × 0.2 × 0.6 cm (AP × RL × SI, at maximum planar length) up to 2.7 × 3.8 × 2.1 cm. Bacteriologic analysis of SPA cultures demonstrated the predominance of relatively simple, monomicrobial infections in our younger patients. Consistent with the literature, the older patients in our series had cultures demonstrating a polymicrobial infection with both aerobes and anaerobes. The postoperative course for all 12 of our patients was uneventful, with resolution of orbital symptoms and no new complaints.

Conclusion: Key factors impacting the decision of surgical versus conservative management of subperiosteal abscess are visual deterioration and lack of improvement after 24 hours of antibiotics. There is no algorithm for treatment of SPA, but there are cautionary ophthalmologic findings that warrant immediate surgical drainage. No age driven cut-offs exist for surgical or medical management. Clinical judgement is crucial and patient presentation, along with laboratory and radiological findings should guide physician decision making.