Purpose Subperiosteal abscess (SA) is one entity in a spectrum of orbital infectious processes associated with sinusitis, the differentiation of which is made clinically and radiologically. Management of this entity varies in adults versus children as a result of differing sinus physiology and microbial flora. This case series demonstrates these differences and outlines challenges in management.
Methods Interventional case series.
Results Case 1: A 50 year-old male with a history of sinusitis and Sampter’s triad (aspirin sensitivity, asthma, nasal polyps) presented with fever, right periorbital swelling and erythema, proptosis, globe displacement, and intermittent diplopia. He had been treated with oral ciprofloxacin and intravenous (IV) unasyn without clinical improvement. He had previously undergone multiple functional endoscopic sinus surgeries (FESS) for nasal polyposis and sinusitis, and had been found to have a right lamina papyrycea erosion. Orbital CT demonstrated right ethmoiditis and an adjacent SA in the superomedial orbit. After 48 hours of worsening symptoms despite broad-spectrum (aerobic and anaerobic) antibiotic coverage, he underwent FESS and right endonasal polypectomy with drainage of the abscess. This resulted in clinical resolution of his symptoms. Case 2: A 20 month-old male presented with fever and right periorbital swelling. Orbital CT showed bilateral ethmoiditis with an eroded right lamina papyrycea and adjacent orbital SA. He improved clinically on IV unasyn alone, without any need for surgical drainage. Orbital complications of sinusitis primarily affect children, with SA comprising less than ten percent of cases. Ethmoiditis is the most frequent source, and preseptal cellulitis is the most frequent orbital complication. Other more ominous sequelae include cavernous sinus thrombosis and cerebral abscess. Diagnosis is made by orbital CT, and treatment includes broad-spectrum IV antibiotics. Children usually have monomicrobial infections that respond to IV antibiotics alone, while adults often have polymicrobial (including anaerobic) infections that may require additional surgical drainage. This difference in microbial population has been attributed to larger sinus ostia in children, allowing for more sinus aeration.
Conclusions Subperiosteal abscess is managed differently in adults versus children due to differing sinus physiology and microbial flora. Expectant medical management for children is usually adequate, while adults may require surgical intervention. Frequent monitoring of the disease course after initiating broad-spectrum IV antibiotics will aid in determining the need for surgery.
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