Surgical management of subperiosteal abscess of the orbit

Subperiosteal abscess is generally defined as the collection of pus between the periorbita and the orbital wall, and usually results from paranasal sinus infection. Early, appropriate evaluation and management observing signs and symptoms of orbital inflammation are required to prevent blindness. We report 5 cases of subperiosteal abscess caused by paranasal sinus problems. We used endoscopic ethmoidectomy with puncture or endonasal endoscopic drainage of the abscess and found orbital complications in 4. We used conservative therapy in 1 with no visual acuity. We discuss pathogenesis and surgical indications and approaches. Three of 4 patients with mild visual acuity and treated with surgical procedure were cured without sequalae. We successfully managed the superior subperiosteal abscess with an endoscopic endonasal approach. One of 4 patients who had severe vision loss, however, was cured without any recovery of loss of vision after surgical drainage to decrease orbital pressure. The endscopic endonasal approach is more useful in managing both sinus disease and orbital complications than external ethmoidectomy.     

Antral-ethmoidal decompression of the orbit in Graves' disease: ten-year experience

The orbital manifestations of Graves' disease usually comprise the most distressing component of this inadequately understood disease entity. Patients with optic neuropathy, exposure keratopathy, or disfiguring proptosis can be helped considerably by decompression of the swollen orbital tissues into the maxillary and sinus cavities. Experience with 104 patients personally operated by the senior author and analyzed by chart review and patient questionnaire indicates that antral-ethmoidal decompression is a successful form of therapy, generally free of serious complications. It is now employed earlier in the course of Graves' ophtholmopathy than in the past.     

Selective non-surgical management of subperiosteal abscess of the orbit: computerized tomography and clinical course as indication for surgical drainage.

Subperiosteal abscess of the orbit (SPA) in childhood is an uncommon but serious sequela of sinusitis, with partial or complete visual loss as the most common complication. Traditional management of SPA has combined systemic antibiotics with immediate surgical drainage. The records of 120 children admitted from 1982-1986 with the diagnosis of periorbital or orbital cellulitis were reviewed. Ten cases of SPA were documented by CT scan (8%). Antecedent ethmoid sinusitis was present in all cases. Five SPA patients were managed with intravenous antibiotics and nasal decongestants alone. All had complete clinical and radiographic resolution without complication. The remaining 5 patients underwent surgical drainage. Two patients required immediate drainage due to total ophthalmoplegia upon presentation. One case of postoperative epidural abscess occurred one week after external fronto-ethmoidectomy among these two patients. The remaining 3 patients did not respond adequately to medical therapy alone and underwent surgical drainage without complication. Length of hospital stay in both medical and surgical groups was similar. We conclude that SPA can be safely managed by medical therapy alone in selected cases. Criteria for surgical intervention of documented SPA while on optimal medical therapy should include: worsening of visual acuity or ocular motility, or failure to improve clinically within 48 h. The presence of SPA alone should no longer be considered an absolute indication for surgery.     

Management of superior subperiosteal orbital abscess

A superior subperiosteal orbital abscess (SSPOA) is a collection of purulent material between the periorbit and the superior bony orbital wall, and is typically a complication of frontal sinusitis. SSPOA is characteristically managed by classic external surgical drainage. The aim of our study was to assess the role of surgical intervention in SSPOA. A retrospective medical chart review of patients diagnosed with SSPOA secondary to rhinosinusitis between the year 2005 and 2013 was conducted. Collected data included age, gender, co-morbidity, clinical presentation, prior antibiotic management, CT scans, surgical approach, outcome and complications. Six patients were included in our study, three males and three females with a mean age of 22.8 (range 9–58). Two patients were treated with amoxicillin clavulanic acid for 3 days prior to admission. Only the youngest patient with the smallest abscess responded successfully to conservative treatment, while the rest were managed surgically: three patients were treated successfully by the endonasal endoscopic approach and two patients were treated by utilizing the combined endonasal endoscopic and external approach. In patients who underwent the combined approach, the abscess was located in a more antero-lateral position than those treated endonasal endoscopically only. The location of a SSPOA dictates the surgical approach. The most antero-lateral SSPOAs should be drained by the combined approach, while more posterior abscesses should be approached endoscopically. Furthermore, a small SSPOA is first to be reported to resolve with conservative treatment. Level 4 (case series).     

Mastoid subperiosteal abscess: a review of 51 cases

OBJECTIVE: To present a large study on subperiosteal abscess (SA) that represents the most frequent complication of acute mastoiditis. METHOD: A retrospective study was conducted on 49 patients who underwent mastoidectomy for SA. RESULTS: The patients ranged in age from 8 months to 21 years. Two patients were re operated on the same side due to recurrent abscess. Forty-five percent of the patients were treated using antibiotics at home and 58.8% of patients had no history of middle ear infection prior to admission. CT underestimated abscess in two patients who were operated on based on their clinical signs. Perisinus abscess was drained during mastoidectomy in one child. Purulent discharge was obtained from the abscess in 41 cases. The most common isolated pathogens were Streptococcus pyogenes and Staphylococcus aureus. Cholesteatoma was found during mastoidectomy in six patients (11.3%). Twenty-four patients (49%) developed postoperative sequela including various middle ear infections, mastoiditis, recurrent SA and impaired hearing. CONCLUSIONS: Mastoid SA is a unilateral mainly children's disease that can recur. Cholesteatoma can associate the abscess and could be found in older children and recurrent abscess. High morbidity rate requires long-term follow-up for these patients.     

Endoscopic surgery for the treatment of pediatric subperiosteal orbital abscess: A report of 10 cases

Introduction

The pediatric subperiosteal abscess is considered an infectious process characterized by an abscess pocket localized between the lamina papiracea and the periorbita. Usually the surgical management is used to drain the collection of pus.

Methods

Between January 2006 and January 2009, 10 patients of age under 18-year-old underwent through a transnasal endoscopic approach at the University of Bologna, Sant’Orsola Malpighi Hospital for the treatment of a subperiosteal orbital abscess. All these patients were taken to the operative room in order to drain the abscess only after that the CT scan was accomplished and it demonstrated the presence of a subperiosteal orbital abscess.

Results

The transnasal endoscopic approach was used alone in 9 cases while it was associated with an external approach in one case for the treatment of a superolateral based subperiosteal orbital abscess. In all cases the exudate was obtained during the surgical procedure for the microbiological examination, although only 2 out of 10 cases had positive abscess cultures for Streptococcus pneumoniae.

Conclusions

The transnasal endoscopic approach is an effective surgical treatment to drain the collection of pus in all medially based subperiosteal orbital abscess, while it can be associated with an external approach for the treatment of a superolateral based subperiosteal orbital abscess.     

Bacteriology of mastoid subperiosteal abscess in children

OBJECTIVE: Subperiosteal abscess (SA) is the most frequent complication of acute mastoiditis (AM). Of pathogens cultured from the external auditory canal or middle ear during myringotomy, 15% may be different from microorganisms isolated from the SA. We suggest, therefore, that only cultures obtained from the abscess cavity can truly reflect the bacteriology of this complication of AM. The purpose of our study was to analyze the infectious agents which cause SA and mastoid cortex erosion in children. MATERIAL AND METHODS: The medical records of 35 children who underwent mastoidectomy for SA between May 1984 and April 2002 were evaluated. RESULTS: Mastoid cortex erosion was found at surgery in 72.7% of abscesses Purulent discharge was obtained from the SA cavity in 28 cases. The commonest pathogens isolated in these cases, as well as in 18 cases of mastoid cortex erosion, were Staphylococcus aureus and Streptococcus pyogenes, followed by Streptococcus pneumoniae. Hemophilus influenzae, Pseudomonas aeruginosa, Escherichia coli and Klebsiella pneumoniae. Sterile culture was found in 25% of cases. CONCLUSIONS: Mastoid SA is a unilateral disease that can recur. Early administration of anti-Staphylococcus medications should be considered for patients with SA as a complication of AM.     

Bacteriology of mastoid subperiosteal abscess in children

Objective Subperiosteal abscess (SA) is the most frequent complication of acute mastoiditis (AM). Of pathogens cultured from the external auditory canal or middle ear during myringotomy, 15% may be different from microorganisms isolated from the SA. We suggest, therefore, that only cultures obtained from the abscess cavity can truly reflect the bacteriology of this complication of AM. The purpose of our study was to analyze the infectious agents which cause SA and mastoid cortex erosion in children.

Material and Methods The medical records of 35 children who underwent mastoidectomy for SA between May 1984 and April 2002 were evaluated.

Results Mastoid cortex erosion was found at surgery in 72.7% of abscesses Purulent discharge was obtained from the SA cavity in 28 cases. The commonest pathogens isolated in these cases, as well as in 18 cases of mastoid cortex erosion, were Staphylococcus aureus and Streptococcus pyogenes, followed by Streptococcus pneumoniae. Hemophilus influenzae, Pseudomonas aeruginosa, Escherichia coli and Klebsiella pneumoniae. Sterile culture was found in 25% of cases.

Conclusions Mastoid SA is a unilateral disease that can recur. Early administration of anti-Staphylococcus medications should be considered for patients with SA as a complication of AM.     

Management of orbital subperiosteal abscess in children

OBJECTIVES: To present guidelines for the management of an orbital subperiosteal abscess (SPA) in children and to assess the efficacy and safety of transnasal endoscopic drainage of an orbital SPA. SETTING: Tertiary care children's hospital. PATIENTS: Nineteen patients treated for an SPA between July 1997 and December 1999. The age of the patients ranged from 17 months to 14 years (mean, 6 years). The male-female ratio was 10:9. Treatment modalities included transnasal endoscopic drainage (n = 11), external drainage (n = 3), and intravenous antibiotics alone (n = 5). RESULTS: Bilateral pansinusitis was the most common cause. All patients received an initial trial of intravenous antibiotics. Based on the Fisher exact test, no statistically significant differences were detected for age, sex, presence of gaze restriction, and radiographic findings. Based on multiple logistic regression, degree of proptosis was the only significant multivariate predictor of surgery (P =.003). The estimated probability of surgery was 6% when there was no proptosis, and 92% for 2 mm of proptosis. The location of the SPA determined the route of surgical drainage. Eleven patients with a medially based SPA underwent drainage via the transnasal endoscopic approach, and 3 with a superior SPA underwent drainage externally. The external approach was associated with a longer hospital stay (median, 7 days) than either the endoscopic or the intravenous antibiotic approach (median, 5 days).     

结核性颈部脓肿外科治疗四例

回顾性分析我院2005年5月至2006年12月收治4例颈部巨大结核脓肿,以供临床参考.     

Pediatric medial subperiosteal orbital abscess: medical management where possible

BACKGROUND: Controversy exists about the optimal management of subperiosteal orbital abscesses (SPOAs) in pediatric patients. Some otolaryngologists advocate immediate surgical drainage while others recommend medical management initially and reserve surgery for nonresponders. We hypothesized that patients who can be managed without surgery have identifiable features on presentation that may aid in predicting their response to medical therapy. METHODS: A retrospective chart review was performed on all patients < or =18 years of age who were admitted to the University of Iowa between 1984 and 2001 with findings consistent with an SPOA on computed tomography imaging. Patients were divided into two groups: group I received medical treatment only while group II underwent surgical drainage of the abscess. Presenting features were compared between the two groups. RESULTS: Forty-two patients were identified with 17 group I patients and 25 group II patients. All patients had resolution of their SPOA and favorable outcomes. The following variables attained significance: group I patients were younger than group II patients (5.1 years versus 11 years; p < 0.0001), had less restriction of ocular motility (-1.0 versus -2.3), and were hospitalized for fewer days (6.5 days versus 9.6 days; p = 0.011). The following clinical variables did not vary significantly between the groups: gender, side of abscess, temperature, total white blood cell count, neutrophil count, chemosis, visual acuity, and proptosis. Culture results predominantly showed growth of anaerobic organisms (7/23). With increasing age, there was an increase in the number of organisms cultured (p = 0.005). CONCLUSION: A subset of patients with SPOAs can be managed medically. These patients tend to be younger and present with minimal restriction of ocular motility.     

The atypical course of subperiosteal abscess of the orbital wall

The authors describe a clinical case of malformation of intranasal structures of the lateral wall and the middle turbinated bone of the nose (bullous middle turbinated bone, lateral position of the middle turbinated bone, hypertrophy of ethmoidal bulla and uncinate process) in combination with expressed deformation of the nasal septum. These malformations were responsible for the development of acute hemisinusitis complicated by subperiosteal abscess of the superomedial orbital wall. Conjunctival chemosis was impossible to remove by traditional medicamental therapy and surgical intervention. Hirudotherapy produced the well-apparent anti-odematous, anti-inflammatory, anti-coagulative, and thrombolytic effects that resulted in reduced conjunctival oedema and marked positive dynamics of the state of the eyeball. Subcutaneous administration of anticoagulants was used to prevent thrombosis of orbital veins and cerebral venous sinuses.     

Surgical anatomy of the orbit

A firm knowledge of orbital anatomy is mandatory for any surgical specialist dealing with this important region. An understanding of orbital anatomy can be acquired systematically by studying each of its component systems (skeletal, fascial, vascular, neural and muscular, and lacrimal). Frequent review of this topic, and the study of anatomic detail in cadaver and surgical dissections, should result in safer, more secure surgery in this complex area.     

Postauricular needle aspiration of subperiosteal abscess in acute mastoiditis

To test the hypothesis that subperiosteal abscess, a complication of acute mastoiditis, can be treated equally well by needle aspiration as by cortical mastoidectomy, we performed a retrospective analysis of 78 pediatric patients hospitalized between 1995 and 2003 and performed an analysis of published data on types and outcomes of treatment approaches for acute mastoiditis. Postauricular pus aspiration resolved the subperiosteal abscess in 14 of 17 patients. The length of the hospital stay of patients who underwent aspiration was shorter than that of patients who underwent cortical mastoidectomy. We conclude that postauricular pus aspiration, a simple and minimally invasive procedure, is an effective treatment modality for subperiosteal abscess. Mastoidectomy should be reserved for nonresponsive cases or those with more serious complications. Broad-spectrum antibiotics, myringotomy with daily toilet of the ear, and postauricular aspiration, when required, minimize the indications for surgery and reduce the hospital stay.     

Transnasal endoscopic drainage of a medial subperiosteal orbital abscess

The exact incidence of orbital complications due to sinusitis in children is unknown. However, a medial subperiosteal orbital abscess is the most common serious complication to occur. Surgical intervention is mandatory whenever antibiotic treatment fails. Most authors prefer open surgical procedures such as external ethmoidectomy, while others recommend transnasal endoscopic drainage as the first attempt at sinus decompression. Five out of 12 children with proven subperiosteal orbital abscess and sinusitis on computed tomographic scans failed antibiotic treatment and required surgical drainage. Transnasal endoscopic drainage of the abscess was performed on four patients, while one child underwent external ethmoidectomy. Our experience with endoscopic surgery in these four cases is discussed, along with a brief review of the advantage of this procedure over external surgery. Received: 7 February 1997 / Accepted: 12 November 1997     

Cosmetic considerations in surgery for orbital subperiosteal abscess in children: experience with a combined transcaruncular and transnasal endoscopic approach

OBJECTIVE: To evaluate the outcomes of a new surgical approach in children with acute sinusitis and medial orbital subperiosteal abscess. DESIGN: Case series. SETTING: Tertiary pediatric hospital. PATIENTS: Eleven children aged 6 weeks to 13 years with orbital subperiosteal abscess and acute sinusitis who met indication for surgery by visual compromise and/or refractory course to medical therapy. INTERVENTION: The medial orbital abscess was drained via a transcaruncular approach, which provided access to the medial orbital wall. An endoscopic ethmoidectomy was also performed. MAIN OUTCOME MEASURES: Judgment of cosmetic appearance by surgeon and family, resolution of symptoms, length of hospital stay, and complications. RESULTS: All children had prompt resolution of symptoms after surgical drainage. Cosmetic outcome was excellent in all patients with no cutaneous scar or eyelid malposition. After edema and cellulitis had resolved, no family member could tell a difference in appearance between the eyes. No complications of these combined procedures were identified. One patient who had initially undergone transnasal endoscopic orbital drainage alone experienced a recurrence of infection 17 days later. He was then treated by the combined transcaruncular and endoscopic approach with prompt resolution of his symptoms. One of 4 patients treated initially with transcaruncular approach alone without endoscopic ethmoidectomy had recurrence of acute sinusitis and orbital abscess 16 months later and was successfully treated with an endoscopic approach. CONCLUSIONS: The combined endoscopic and transcaruncular surgical approach to medial orbital subperiosteal abscess and acute sinusitis provides a cosmetically superior outcome compared with standard orbital approaches requiring a cutaneous incision. The transcaruncular approach can be considered as an alternative or adjunct approach to the medial orbit, with the same cosmetic advantages as transnasal endoscopic drainage.     

Surgical treatment of severe epistaxis: an eleven-year experience

Epistaxis is one of the most prevalent emergencies in ENT practice, and its surgical treatment is part of the routine at services for emergency care, especially in cases refractory to clinical procedures.ObjectiveTo analyze the profile of patients and the results this service has had in the surgical treatment of epistaxis for the last 11 years.MethodData from 98 patients submitted to surgery for epistaxis between 2000 and 2011 were analyzed retrospectively.ResultsMost in the sample were males, and mean age was around 46 years. Hypertension was identified in 58% of patients, and most events occurred during fall and winter. The re-bleeding rate was 13.27%.ConclusionThis study concluded that the surgical treatment for epistaxis, when indicated, had good success rates and low incidence of complications. In our service, it remains as the gold-standard procedure for nosebleeds refractory to initial management measures.