Review Article
Comparison of Surgical Approaches of Subperiosteal Abscess in Children
Huang SF1,2*, Lee TJ1, Young CK3 and Wang CN4
1Department of Otolaryngology, Chang Gung Memorial Hospital, Taiwan
2Department of Public Health, Chang Gung University, Taiwan
3Department of Otolaryngology, Chang Gung Memorial Hospital, Taiwan
4Universal eye center, Taiwan
*Corresponding author: Shiang-Fu Huang, Department of Otolaryngology, Chang Gung Memorial Hospital. 5 Fu-Shin Street, KweiShan, Taoyuan 333, Taiwan
Published: 01 Sep, 2016
Cite this article as: Huang SF, Lee TJ, Young CK, Wang CN. Comparison of Surgical Approaches of Subperiosteal Abscess in Children. Clin Surg. 2016; 1: 1095.
Abstract
Background: Orbital subperiosteal abscesses (SPOAs) in children requires timely treatment for potential complications. The best surgical approaches for SPOAs were non-conclusive. In this study,
we analyzed the treatment outcomes comparing different surgical approaches.
Methodology: The medical records of children less than18 years old hospitalized from 1996 through
2007, at the Chang Gung Memorial Hospital, with a diagnosis of SPOAs confirmed by computed
tomography scan were reviewed. Surgical intervention was indicated only with failed medical
therapy, progression of symptoms, or onset of complications. For SPOAs located in the medial
aspect of orbit, we use transnasal endoscopic (TNE) approach; SPOAs in the superior aspect of
orbit, we use external (EXT) approach; and SPOAs in both the medial and superior aspects of orbit,
we use combined approach.
Results: Twenty-two patients, 14 boys and 8 girls, were identified (mean age, 5.45 years [range,
12 days to 18 years). Ten patients were treated with a TNE approach, 8 patients required an EXT
approach and 4 patients received combined approach. The age of patients receiving EXT approach
is significantly younger than other groups (ANOVA: P=0.023). The most frequent symptoms
were fever (100%) and the most involved sinus was maxillary sinus. The most frequently isolated
organisms were Staphylococcus aureus, Streptococcus viridans, and Klebsiella pneumonia. One
patient required repeated aspiration externally. All patients had eventual resolution of their disease
without any surgical complications.
Conclusion: The selection of surgical approach for pediatric SPOAs according to their radiographic
location was proved successful in all our patients.
Keywords: Surgical; Subperiosteal; Children
Introduction
Orbital subperiosteal abscesses with resulting eyelid and periorbital skin cellulites in children,
inclusively termed orbital (or postseptal) cellulites, have always been considered acute surgical
emergencies by pediatricians [1]. Pediatric subperiosteal orbital abscesses (SPOAs) and orbital
cellulites are infectious process in which the abscess pocket is described as lying between the
periorbita and the lamina papyracea. The source of the infection is believed to originate most
frequently from ethmoid and maxillary sinusitis, although vascular spread from the adjacent
orbital, cranial, and facial structures is also possible [2-4]. A SPOA requires timely treatment for the
potential complications, which include visual loss, endophthalmitis, cavernous sinus thrombosis,
intracranial spread (e.g. meningitis, cerebritis, brain abscess), and ultimately death [3,5-7].
While medical treatment of pediatric orbital cellulitis results in excellent outcomes [8], surgical
drainage has traditionally been recommended for SPOA secondary to sinusitis [9,10]. There are
several reports of the successful management of selected SPOA solely with medical therapy [4,11-
17]. Generally, nonsurgical treatment is reserved for patients without signs of significant ocular
deficits such as vision loss. Patients with CT-confirmed PSOA who had orbital or intracranial
complications or who failed to respond to antibiotic treatment would need surgical drainage to
prevent morbidities [12,18].
Traditionally, orbital abscesses were treated with external
surgical drainage [9,10]. Surgical options include traditional external
approaches to the orbit, and more cosmetically appealing procedures
including the transcaruncular external approach (EXT) [19]. and
endoscopic drainage [20,21]. While EXT approach providing direct
access to medial SPOA, the cutaneous incision may result in cosmetic
complications such as webbing [22]. Recent techniques including
transnasal endoscopic surgery (TNE) [20,21,23] could provide a
safe way for drainage. However, in the situation that SPOA extends
superiorly and laterally, TNE has some limitations in this situation.
The EXT approach [19] provide access to medial abscesses without
cosmetic morbidity. In patients that the abscesses are not adequately
drained through the above 2 approaches, we used an alternative
approach that combined TNE and EXT for SPOA. In this study, we
retrospectively reviewed 22 SPOAs receiving drainage through the
above 3 methods and analyzed the clinically relevant results.
Table 1
Methods and Material
A retrospective medical chart review of all patients 18 years or
younger surgically treated for a subperiosteal abscess (SPOA) at Chang
Gung Memorial Hospital from 1996 to 2007 was performed. Clinical
examinations confirmed the presence of a SPOA in all patients. All
the patients received orbital or sinus Computed Tomographic (CT)
scans confirming the diagnosis of SPOA and concomitant sinusitis.
The orbital abscesses secondary to trauma or surgery and those with
anatomic abnormalities of the eye, malignancy or other immune
suppressed states were excluded. All patients initially received
parenteral antibiotics and supportive measures. Surgical intervention
was indicated only with failed medical therapy, progression of
symptoms, or onset of complications (e.g. visual changes, cavernous
sinus thrombosis, and intracranial involvement). Those patients
receiving surgeries were determined according to the location of
SPOA. (I) If the SPOAs were localized in the medial aspect of orbit,
then surgery would be transnasal endoscopic approach (TNE). (II)
If the SPOA involves the superior orbital region and most part of
SPOAs were in the periphery of superior region which could not
be successfully drained endoscopically, an EXT approach would be
chosen. (III) If the abscess involved both medial and superior and
extends more laterally, then a combined approach would be done. The
presenting signs and clinical course of each patient were reviewed.
Medical charts were reviewed specifically for age at presentation,
presentation duration of periorbital edema before presentation, and
White Blood Cell (WBC) count and temperature at initial presentation.
Preoperative CT scans were reviewed for the location of the SPOA.
Possible descriptors included medial, superior, or laterally based
SPOAs.
In our hospital, patients presenting with significant ocular
findings, progression of ocular signs or failure to improve after 48 h
of medical therapy should be treated with surgical drainage.
TNE approach
During operation, decongestion of the inferior turbinate and
middle turbinate was achieved by using 2% oxymetazoline–soaked
cotton pledgets. The inferior portion of the uncinate process was
uniformly excised. Using curettage, the ethmoid sinus air cells
were opened and diseased mucosa was removed. Identification and
incision of lamina papyracea were done and part of the bone was
removed until most of the pus discharged. Usually we compressed
gently over ipsilateral eyelids to ensure the abscess was adequately
drained. After surgery, small pieces of Surgical®
were paved over the
surgical wounds and a long piece of Vaseline loosely packed over the
wound. The packing’s were removed 2 days later.
External approach
An injection with 2~3 ml of 2% xylocaine with 1:100000
adrenaline was given in the medial bulbar conjunctiva and plica.
After retraction of lids with speculum, a Westcott scissors was used
to make the incision through caruncle. The traction sutures on each
side of the caruncle incision wound were made by 4-0 silk. Gentle
dissection with the tips of Stevens scissors in an anteroposterior
direction helped to identify the posterior side of the posterior lacrimal
crest and prevent the iatrogenic injury of lacrimal sac. Scissors were
used to bluntly dissect a plane to the medial orbital wall. A Desmarres
vein retraction and a narrow Sewall retractor could be used to provide
a better surgical view. The periobita was cut and elevated with a freer
elevator. The wall of abscess could be incised with 11# knife and
turbid pus was drained out with suction tube. The wound closure only
required continuous conjunctival sutures with 8-0 vicryl.
Twenty-two patients met the criteria for the study and had
available medical records for review (Table 1). Overall, 14/22 patients
were male (63.6%), and 8/22 were female (36.4%, p=0.201, Chi square
test). The average age was 5.45 years (median 3.58, range 12 days -18
years). Patients were symptomatic for an average of 3.73 days prior to
admission (median 3, range 1-7). The mean length of hospitalization
was 15.64 days (median 11, range 7-56). In 22 patients, 10 in group I,
8 in group II and 4 in group III.
The mean ages in 3 groups of patients were 8.83 yrs, 1.92 yrs and
4.04 yrs (Table 2). The age of group 2 is significantly younger than
group I (t test: P=0.012). The mean duration of symptoms prior
to admission in 3 groups of patients were 2.90 (range 2-5) days,
4.13 (range 1-7) days and 5.00 (range 1-7) days respectively. No
significantly different exists between 3 groups (ANOVA, P=0.157).
The hospitalization in 3 groups of patients was 13.00 days, 16.25 days
and 21.00 days respectively. No significantly difference exists between
3 groups (ANOVA, P=0.578) The WBC count 3 groups of patients
were 15550/μl, 13100/μl and 14600/μl respectively. No significantly
different exists between 3 groups (ANOVA, P=0.123).
Physical exam findings in the 22 patients included fever in 22
(100%), chemosis in 14 (63.6%), proptosis in 15 (68.2%), diplopia in
11 (50%), purulent rhinorrhea in 10 (45.5%) and visual acuity affected
in 3 (13.6%). The frequency of involved sinuses was greater in the
order of maxillary sinus, ethmoid sinus, frontal sinus and sphenoid
sinus (Table 3).
Surgical cultures were obtained in 19 patients and were positive
in 16 patients (84.2%). Organisms isolated are listed in (Table 4).
The most frequent isolates were Staphylococcus aureus, Streptococcus
viridans, Klebsiella pneumonia and Eikenella corredens. Coag (-)
Staphylococcus was considered to be contaminant. Blood cultures
was positive in 1/17 (5.88%).The positive culture was concordant with
the surgical culture for Staphylococcus aureus (ORSA).
One patient receiving combined approach underwent repeated
aspiration of orbital abscess. All of patients resolved without sequelae
or mortalities.
Table 2
Table 2
Comparison between 3 surgical approaches.
TNE: Transnasal Endoscopic Approach
EXT: External Approach
Combined: combined TNE and EXT approach
*One way ANOVA
Table 3
Table 4
Table 4
Organism isolated from pus culture.
†Including 4 oxacillin-resistant Staphylococcus aureus (ORSA)
‡ The isolate was ORSA
Discussion
Occular complications from rhinosinusitis arise from close
anatomic relationships shared by the orbits, paranasal sinuses, and
facial venous system [2]. The reason why orbital involvement is
usually unilateral is probably related to asymmetry in the dehiscence
of the lamina papyracea, the so-called Zuckerkandl dehiscence [24].
Retrograde thrombophlebitis through valveless channels could cause
infection spreading to the brain or cavernous sinus thrombosis.
In Tanna N et al. [18] study, 6 patients treated initially as
TNE recurred and received an EXT approach later [18]. The other
patient received external approach recurred. The overall recurrence
rate in that study was 7/13 (53.85%). In Oxford’s study, 3 in 25
(12%) patients receiving surgery (endoscopic or external approach)
recurred [25]. In the above 2 studies, the authors approached the
SPOA either endoscopically or externally. For endoscopic drainage
of orbital abscesses, Mann et al. [ 26] found 23% (6/26) of children
required revision procedures. In our study, the overall recurrence
rate was 4.55% (1/22) and the recurrent patient needed repeated
aspiration externally. The most common reason of recurrence was
either inadequate removal of the lamina papyracea or an abscess
that was positioned superiorly or laterally in the orbit which was
difficult to drain endoscopically [27]. SPOAs which lie superiorly
in the orbits are difficult to reach intranasally. Combined FESS and
drainage through the eyelids externally is the procedure of choice
in these patients. We have 4 patients received combined approach.
This prevents the residual abscess from either approaches and thus
lowered the overall recurrence rate.
Given the medically successful cases in the literature, it appears
that many SPOAs seen on CT scan s are in fact curable by antibiotics
[8,28]. However, in Eustis’s study, patients receiving surgery resolved
promptly, whereas patients who were treated medically need a
longer hospitalization [29]. Surgeries did not increase the risks
of complications. In our study, all the patients recovered without
morbidities even in one patient with concomitant frontal lobe
abscess. In Oxford’s study, 2 patients after external approach had
complications of persistent proptosis and restriction of extraocular
motility [25]. In other studies, no complications were reported [18].
Drainage of these abscess in SPOAs was “a safe effective means to
quick recovery” [29].
Blood culture has a low yield of positive culture [18,22,25]. On the
contrary, pus culture gives clinician microbiologic information and
can thus switch to appropriate antibiotics. The most frequent isolates
from our study is Staphylococcus aureus and Streptococcus viridans
which is similar to previous reports [25]. From our data, most
antibiotics could be chosen from our isolates. The recently proposed
treatment for SPOAs is medications alone and our data could give
clinicians a good guidance for choosing appropriate antibiotics.
From our experience, our paradigm of treating pediatric SPOA
is reasonable. No evident sequelae or complication rate were met
if treating these patients promptly and appropriately. Cosmetic
concerns could be overcome in external approach patients by
experienced ophthalmologists.
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