Subperiosteal Abscess

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A 3-year-old boy was brought to the emergency department with left eye swelling, which had doubled in size since it appeared the day before, and purulent crusting (A). On the first day of the swelling, the child was evaluated at another facility and given the diagnosis of periorbital contusion, conjunctivitis, and left otitis media for which erythromycin ophthalmic ointment and oral cefuroxime were prescribed.

On admission, the child was afebrile. Treatment with intravenous nafcillin and ceftriaxone was started. Over the next 24 hours, the swelling and redness around the eye increased. There was slight proptosis and some limitation of all ranges of eye movement.

A CT scan showed left maxillary and left anterior ethmoid sinus opacification with a small (0.9 cm³) subperiosteal abscess (B).

Subperiosteal abscess results from progression or spread of orbital cellulitis beneath the periosteum of the ethmoid, frontal, or maxillary bones. Both preseptal and orbital cellulitis may present with swelling and erythema. The presence of fever is variable. Children with preseptal cellulitis may have clinical evidence of local trauma, bites, or foreign body penetration.¹ Clinical factors supporting the diagnosis of orbital cellulitis include proptosis, limitation of eye movement, decreased visual acuity, pain with eye movement, and chemosis.^1,2

CT has been the modality of choice for evaluating suspected orbital cellulitis because it can indicate extension of infection and inflammation into the orbit as well as evaluate sinus disease and the presence of abscesses. In a review of patients with suspected orbital cellulitis, of 240 (87%) who underwent CT, findings indicated subperiosteal abscess in 68 (28%) and orbital abscess in 2 (1%).³

Historically, subperiosteal orbital abscesses have been treated with surgical drainage either via external approaches or endoscopically. However the majority of small subperisoteal abscesses can be treated medically with close follow-up.^3,4

After surgical and infectious disease consultation, this child was treated with clindamycin and ceftriaxone (100 mg/kg/d IV). Over the next 3 days, the edema greatly decreased and extraocular movement returned to normal. At follow-up with his primary care physician
3 days after discharge, examination findings were normal. He completed 10 full days of antibiotic therapy with oral clindamycin and cefdinir.

REFERENCES:

1. Givner LB. Periorbital versus orbital cellulitis. Pediatr Infect Dis J. 2002;21(12):1157-1158.

2. Uzcátegui N, Warman R, Smith A, Howard CW. Clinical practice guidelines for the management of orbital cellulitis. J Pediatr Ophthalmol Strabismus. 1998;35(2):73-79; quiz 110-111.

3. Ryan JT, Preciado DA, Bauman N, et al. Management of pediatric orbital cellulitis in patients with radiographic findings of subperiosteal abscess. Otoloaryngol Head Neck Surg. 2009;140(6):
907-911.

4. Oxford LE, McClay J. Medical and surgical management of subperiosteal orbital abscess secondary to acute sinusitis in children. Int J Pediatr Otorhinolaryngol. 2006;70(11):1853-1861.