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Dimension of Subperiosteal Orbital Abscess as an Indication for Surgical Management in Children

Haim Gavriel, Eyal Yeheskeli, Eliad Aviram, Lior Yehoshua and Ephraim Eviatar
Otolaryngology -- Head and Neck Surgery 2011 145: 823 originally published online 21 July 2011
DOI: 10.1177/0194599811416559

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416559
el et alOtolaryngology–Head and Neck Surgery
© The Author(s) 2010
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OTOXXX10.1177/0194599811416559Gavri
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Original Research—Pediatric Otolaryngology
Dimension of Subperiosteal Orbital
Abscess as an Indication for Surgical
Management in Children
Haim Gavriel, MD1, Eyal Yeheskeli, MD1, Eliad Aviram, MD1,
Lior Yehoshua, MD1, and Ephraim Eviatar, MD1
No sponsorships or competing interests have been disclosed for this article.
Abstract
Objective. Eyelid edema in children is one of the signs of orbital
complications secondary to acute rhinosinusitis, and identi-
fying abscess formation is crucial for management decision.
The objective of this study is to determine whether there are
different computed tomography scan abscess dimensions and
volumes in children requiring medical versus surgical manage-
ment for subperiosteal orbital abscess (SPOA).
Study Design. Case series with chart review.
Setting. The study was conducted at Assaf Harofeh Medical
Center.
Subjects and Methods. Clinical and radiological parameters
of 95 children admitted with eyelid edema between January
2005 and December 2007 were studied.
Results. Of 95 cases of orbital cellulitis, a total of 48 children
with sinogenic orbital complications with a mean (SD) age of
4.03 (3.46) years were included. No significant difference was
found between the surgically and medically treated SPOA groups
regarding the use of preadmission antibiotic and clinical
presentation. Statistically significant larger abscesses in the
surgically treated group were noted (mean volume 1.389 vs
0.486 mL in the conservatively treated group; P = .013) and a
longer mean anterior-posterior and medial-lateral dimension
(P = .001 and .017, respectively).
Conclusion. Children presenting with significant or progressing
ocular findings or failure to improve after 48 hours of medical
therapy, together with an abscess volume of more than 0.5 mL, a
length greater than 17 mm, and a width greater than 4.5 mm,
should be strongly considered to have surgical drainage.
Keywords
subperiosteal orbital abscess, sinusitis, CT scan, surgical
treatment
Received March 12, 2011; revised May 31, 2011; accepted June 21, 2011.
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Otolaryngology–
Head and Neck Surgery
145(5) 823­–827
© American Academy of
Otolaryngology—Head and Neck
Surgery Foundation 2011
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DOI: 10.1177/0194599811416559
http://otojournal.org
A
cute rhinosinusitis (ARS) is one of the common
causes of orbital infections in children. Orbital com-
plications (OC) secondary to ARS can result in per-
manent blindness or death if not treated promptly and
appropriately.1 In the preantibiotic era, 17% of the patients
with OC died of meningitis, and the other 20% became perma-
nently blind in the affected eye.2 Over time, complication
rates have declined; the incidence of vision loss has been
reported to be 3% to 11%, and mortality stands at 1% to 2.5%.3
The severity of orbital complications secondary to rhinosinus-
itis can be grouped into stages according to Chandler’s clas-
sification, which was introduced in the early 1970s (Table 1)
and is the most popular [SA] system used for staging sino-
genic OC.4 OC may result from osteitic bone destruction, con-
genital or acquired bony defects, or thrombophlebitis of
communicating veins.5,6
Although surgical drainage has traditionally been recom-
mended for subperiosteal orbital abscess (SPOA) secondary
to sinusitis,7,8 more recent studies have recommended more
conservative treatment consisting of intravenous antibiotics
and close monitoring of visual status, whereas surgical drain-
age has been indicated in cases of failure to improve under
medical treatment for 48 hours or when visual compromise is
suspected.4-6,9-11
Identification of cases amenable to nonsurgical manage-
ment is important to avoid unnecessary drainage procedures.
Conversely, surgical treatment may be expedited for those
patients identified as unlikely to benefit from prolonged
observation on antibiotics. Surgical drainage was recom-
mended in previous studies based mainly on evidence of
abscess formation on the computed tomography (CT) scan,
visual impairment on initial evaluation or severe orbital
1
Department of Otorhinolaryngology–Head and Neck Surgery, Assaf
Harofeh Medical Center, Zerifin, Israel, affiliated with the Sackler Faculty of
Medicine, Tel Aviv University, Ramat Aviv, Israel
Corresponding Author:
Haim Gavriel, MD, Department of Otolaryngology–Head and Neck Surgery,
Assaf Harofeh Medical Center, Zerifin 70300, Israel
Email: haim.ga@012.net.il
824 Otolaryngology–Head and Neck Surgery 145(5)
Table 1. Chandler’s Classification
Stage Description
1 Inflammatory edema (preseptal cellulitis)
2 Orbital cellulitis
3 Subperiosteal abscess
4 Orbital abscess
5 Cavernous sinus thrombosis
complications, and lack of improvement within 48 hours
despite appropriate medical therapy.3,12 There are no clear
guidelines regarding the actual size of an SPOA up to which
conservative treatment is effective and from which surgery is
required. Harris13 claimed that medial SPOA of modest size
can be treated successfully medically. Since then, only a few
authors have addressed the size of the SPOA as a possible
indication for surgery.14-16 The aim of this study is to investi-
gate in a historical prospective method the influence of abscess
dimensions according to the CT scan on management deci-
sions in cases of children with a sinogenic OC, including the
need for surgical intervention, as well as the influence of clini-
cal presentation.
Patients and Methods
The study was approved by the Assaf Harofeh Medical Center
Institutional Review Board. A historical prospective study on
95 children (from birth to 18 years) with orbital cellulitis
admitted to our institute, from January 2005 to December
2007, was carried out.
Forty-eight children with symptoms and physical findings
suggesting ARS were included in our study, whereas 47 chil-
dren had a history suggestive of local trauma, insect bite, for-
eign bodies, allergic reaction, and conjunctivitis and thus were
excluded (Figure 1). The selected children were divided into
4 groups: CT scan–proven SPOA needing surgical evacuation,
CT scan–proven SPOA treated conservatively, CT scan–
proven preorbital cellulitis treated conservatively, and clini-
cally diagnosed (without CT scan) preorbital cellulitis treated
conservatively. Analysis of the parameters of the first 2 groups
of children with radiologically proven SPOA was the essence
of this study.
Age, gender, symptoms, physical findings, body tempera-
ture, complete white blood count and differential, C-reactive
protein (CRP) levels, CT findings, treatment before and dur-
ing admission, surgical treatment, outcome, and the final diag-
nosis were analyzed and compared between the groups. When
the CT scan report indicated an abscess, CT scans were
reevaluated by one of the senior authors (E.E.) and reviewed
for the number of sinuses involved, abscess location (medial,
lateral, superior, inferior), orbital fat changes (yes/no), and
abscess measurements and volume calculations. The volumes
of the abscess were calculated by using the ellipsoid formula
4  p . abc, which better correlates with the ellipsoid shape of an
3
abscess on the CT scan findings, rather than a simple multiple
of the abscess linear dimensions.
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Patients admitted with Non sinusitis (local
periorbital cellulitis trauma, insect bite,
95
foreign bodies,
allergic reaction and
conjunctivitis)
47
Clinically proven
sinusitis
48
CT scan obtained No CT scan obtained
29 19
SPOA surgically SPOA conservative Periorbital cellulitis Periorbital cellulitis
treated treatment Radiologically proven Clinically proven
10 11 8 19
Figure 1. Evaluation and treatment of 95 patients with orbital
cellulitis. CT, computed tomography; SPOA, subperiosteal orbital
abscess.
All children were evaluated and followed by the ophthal-
mology service. Ocular exams included assessment of vision
when possible, pupillary function, periorbital edema, peri-
orbital erythema, chemosis, proptosis, intraocular pressure,
and retinal appearance.
Endonasal endoscopic drainage, when indicated, was per-
formed under general anesthesia in all surgically treated chil-
dren, performing complete ethmoidectomy and removing
extensively the lamina papyracea. The nasal cavity was irri-
gated and the nose packed with a Merocele tampon.17
For statistical purposes, χ2 with Fisher exact test and the
Mann-Whitney test were used to compare categorical data,
whereas continuous variables were analyzed with the Student
t test.
Results
A total of 48 children with eyelid edema, 29 males and 19
females, who fit the criteria were included in our study. The
mean (SD) age was 4.03 (3.46) years (range, 1 month to 18
years), with the largest group younger than age 4 years. Our
cohort was divided into 4 groups. Group 1 included 19
(39.5%) children in which preseptal cellulitis (Chandler’s
stage 1) was clinically diagnosed, and group 2 included 8
patients in which preseptal cellulitis was radiologically
proven (16.6%). Twenty-one (43.7%) children were included
in groups 3 and 4 in which medial SPOA was proven radio-
logically; 10 (47.6%) of them (group 3) were operated on, and
11 were treated conservatively (group 4) (Figure 1). The
right and left sides were equally involved in the entire group
and in each subgroup. All children were examined by a pedia-
trician, ophthalmologist, and otolaryngologist.
Nineteen (37.2%) children in the entire cohort received
oral systemic antibiotic treatment because of symptoms and
signs of ARS prior to admission either before or after the pre-
sentation of eyelid edema. Most of the children were treated
with amoxicillin-clavulanate, followed by amoxicillin, cepha-
lexin, and ceftriaxone. No correlation was found between the
Gavriel et al 825
Table 2. Mean Abscess Values in the Conservatively and Surgically Treated SPOA Groups
SPOA Groups Abscess Volume, mL
Medically treated SPOA 0.486
Surgically treated SPOA 1.389
P value .013
Abbreviation: SPOA, subperiosteal orbital abscess.
use of preadmission antibiotics and the presence of an abscess
or the need for surgical treatment (P = .475).
Clinical signs and symptoms could not be retrieved from
all patient files as they were not documented in all children’s
notes, and therefore the rates were calculated according to
whether positive or negative signs or symptoms were reported.
These included rhinorrhea, which was found in 39 of 46 chil-
dren (84.7%), fever in 39 of 45 (86.6%), cough in 16 of 40
(40%), and headache in 10 of 11, with no significant differ-
ence between the subgroups. Proptosis and ophthalmoplegia
were found in 7 (14.5%) and 9 (18.7%) children, respectively,
but only in those with radiologically proven SPOA, and were
statistically significantly more common in children who
underwent a CT scan (P = .015 and .03, respectively). The fact
that these signs were observed only in the CT scan–proven
SPOA group and not in children in other groups (negative pre-
dictive value [NPV] = 100%) makes these parameters most
important in the decision to perform a CT scan. Yet, no cor-
relation was found between these signs and the type of treat-
ment, neither conservative nor surgical.
Leukocytosis, which was present in most children, did not
differ significantly in the groups, nor did granulocytosis, lym-
phocytosis, monocytosis, and the mean levels of CRP.
A CT scan was performed in all 21 SPOA cases and in 8
children who presented with clinical periorbital cellulitis, but
no SPOA was demonstrated on the CT scan. Abscess mea-
surements were available in 19 (90.4%) of the 21 children
with proven SPOA, 9 of 11 children treated conservatively,
and in all 10 children treated surgically (Table 2).
Significantly larger abscesses in the surgically treated
group were noted, with a mean abscess volume of 1.389 mL in
the surgically treated group compared to only 0.486 mL in the
conservatively treated group (P = .013). When comparing the
3 dimensions of the abscess between the groups, significantly
longer mean anterior-posterior dimensions and lateral-medial
dimensions were measured in the latter group (P = .01 and
.017, respectively), as was a tendency toward longer mean
inferior-superior dimensions.
Radiological findings of sinusitis were demonstrated in all
children with available CT scans. Ethmoid sinuses were opaci-
fied in all cases, 23 of 25 (92%) had maxillary involvement, 9 of
25 (36%) had sphenoid sinus involvement, and 7 of 23 (30.4%)
had frontal sinus involvement. However, no statistical difference
was found in sinus involvement between our subgroups.
All children were hospitalized and received intravenous
(IV) antibiotics. Forty (83.3%) received amoxicillin/clavulanate,
5 (10%) received Rocephin (ceftriaxone), (8.3%) received
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Medial Lateral Superior Inferior Anterior Posterior
Dimensions, mm Dimensions, mm Dimensions, mm
4.31 11.13 16.52
6.46 14 25.54
.017 .315 .01
concomitant clindamycin and 1 concomitant metronidazole,
and only 1 (2%) received cefuroxime. Sixteen (33.3%) children
received topical nasal decongestants in addition.
Discussion
Sinogenic OC can lead to catastrophic outcomes if not treated
appropriately. SPOA is one of the most common yet severe
stages of sinogenic OC as described by Chandler et al4 in
1970, whereas the more advanced and dangerous complica-
tions, meaning orbital abscess and cavernous sinus thrombo-
sis, are far more rare. Although stages 1 and 2 in Chandler’s
classification are usually treated conservatively, and
Chandler’s stages 4 and 5 are usually treated surgically, a
controversy exists regarding the most appropriate treatment
modality for Chandler’s stage 3 SPOA.
The first step while treating patients with sinogenic OC is
to establish their clinical staging. The presence of a serious or
deteriorating ophthalmologic status and no response to medi-
cal therapy will eventually move the treating physician for-
ward to imaging evaluation because the presence of an
abscess, either subperiosteal (Chandler’s stage 3) or orbital
(Chandler’s stage 4), will be highly suspected and surgery
might be considered.
Many have advocated the use of different clinical parame-
ters when deciding whether to use the CT scan to demonstrate
a suspected abscess formation.3,18,19 In our study, we found a
strong statistical correlation between the presence of ophthal-
moplegia and proptosis and the presence of an SPOA, as chil-
dren who did not have these clinical signs did not have an
SPOA according to the CT scan findings (NPV = 100%). This
shows the importance of a routine ophthalmological evalua-
tion to rule out the presence of these 2 signs and, when one of
them is observed, the importance of performing a CT scan to
prove the presence of an abscess.
The exact role and timing of surgical intervention for
SPOA remain controversial. Several authors have suggested
that all patients with a proven SPOA should be treated surgi-
cally,3,8 whereas others in more recent studies have shown that
SPOA in children younger than age 9 years is amenable to
medical treatment with close observation and serial ophthal-
mological examinations, with high success rates.2,12,13,20,21
Only a couple of articles in the English literature have demon-
strated a correlation between abscess size and the success
rates of medical treatment. Ryan et al16 reported that 81% of
patients with a radiographic abscess width smaller than 10
mm were successfully treated medically, whereas 92% of
those with an abscess width larger than 10 mm underwent
826 Otolaryngology–Head and Neck Surgery 145(5)
surgical intervention. Oxford and McClay14 evaluated all
abscess dimensions according to the CT scan, as we did in our
study. However, the volume calculation comprised a simple
multiple of linear dimensions, which provided a less accurate
estimation of the abscess volume than our calculation.
According to our observation of the CT scan findings, we con-
cluded that the abscess formation is always elliptical in shape,
and thus all our volume calculations of the abscess were
according to the ellipsoid formula 4  p . abc. In the studies by
3 parameters differentiating OC due to the formation of an
Oxford and McClay14 and Ryan et al,16 a significant difference
was found in all dimensions of the abscesses between the
medically and surgically treated groups. The mean calculated
volume in the medically treated group in their study was 0.25
mL (or 0.105 mL when calculated according to the ellipsoid
formula used by us) compared to 0.486 mL in our study. In
addition, the mean calculated volume in their surgically
treated group was 4.380 mL (or 1.918 mL when calculated
according to the ellipsoid formula) compared to 1.389 mL in
our group. The enormous difference of more than 17-fold
between the surgically and medically treated groups in their
study compared to less than 5-fold difference between these
groups in our study suggests narrower selective criteria for
medical treatment in the Oxford and McClay14 study com-
pared to ours, which might explain why in our study, only
47% of the patients were operated upon compared to 58% in
the Oxford and McClay14 study.
Although much bigger abscesses in the presented study were
treated medically, a significant difference was noted with regard
to 2 of the measured dimensions of the abscess and the calculated
volume. However, one of the abscess dimensions did stand out
with a very high statistically significant difference between the
surgically and medically treated groups—the length of the
abscess (P = .01). We assume that the possible correlation of the
length of the SPOA with the need for surgical treatment lies in the
anatomical structure of the orbit. The orbit has roughly the shape
of a quadrilateral pyramid whose base corresponds to the orbital
margin and whose apex is the bar of bone between the optic fora-
men and the medial end of the superior orbital fissure, the length
of which is approximately 42 mm2 and contains the optic nerve
and associated vessels.22 Pathophysiologically, a space-occupy-
ing lesion at the orbital apex will have a greater impact on the
inner pressure of the contents of the orbital apex than a similar
lesion of the same volume situated more superficially, implying
that a longer SPOA will have a greater impact on the clinical pre-
sentation of the patient than the other dimensions and hence on
the decision-making process of the treating surgeon. Although
the use of the ellipsoid formula for calculating the abscess vol-
ume is feasible, the width and length of the abscess might be as
effective for management decisions.
Our approach to patients with suspected orbital complica-
tions secondary to sinusitis includes broad-spectrum intrave-
nous antibiotics; intranasal saline irrigation and decongestants;
ophthalmology consultation, including frequent ocular exami-
nations; and contrasted axial and coronal CT scans when clini-
cal signs suggest ophthalmoplegia or proptosis and in cases of
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failure of conservative treatment. According to the presented
results, children presenting with significant or progressing
ocular findings or failure to improve after 48 hours of medical
therapy together with an abscess volume of more than 0.5 mL,
a length greater than 17 mm, or a width greater than 4.5 mm
should be strongly considered for surgical drainage.
Conclusion
We present a historical prospective study that clarifies the
abscess from less dangerous stages of sinogenic OC. The
volume, anterior-posterior axis, and medial-lateral axis of the
abscess were proven to be significantly longer in the surgi-
cally treated children and might serve as an indicator for sur-
gical treatment of SPOA. Ophthalmologic signs are proven in
our study to be an indication for performing a CT scan.
Author Contributions
Haim Gavriel, planner of conception and design, analysis and inter-
pretation of data, drafting the article, and final approval of the version
to be published; Eyal Yeheskeli, contribution to conception and
design, acquisition of data, revising article critically for important
intellectual content, and final approval of the version to be published;
Eliad Aviram, contribution to conception and design, acquisition of
data, revising article critically for important intellectual content, and
final approval of the version to be published; Lior Yehoshua, contri-
bution to conception and design, acquisition of data, revising article
critically for important intellectual content, and final approval of the
version to be published; Ephraim Eviatar, planner of conception and
design, analysis and interpretation of data, revising the article, and
final approval of the version to be published.
Disclosures
Competing interests: None.
Sponsorships: None.
Funding source: None.
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