- Email: [email protected]
Endoscopic management of subperiosteal abscesses
Accepted Manuscript
Endoscopic Management of Subperiosteal Orbital Abscesses Christopher Pool MD , Johnathan McGinn MD PII: DOI: Reference:
S1043-1810(18)30086-1 https://doi.org/10.1016/j.otot.2018.10.008 YOTOT 835
To appear in:
Operative Techniques in Otolaryngology - Head and Neck Surgery
Please cite this article as: Christopher Pool MD , Johnathan McGinn MD , Endoscopic Management of Subperiosteal Orbital Abscesses, Operative Techniques in Otolaryngology - Head and Neck Surgery (2018), doi: https://doi.org/10.1016/j.otot.2018.10.008
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Endoscopic Management of Subperiosteal Orbital Abscesses Christopher Pool MD, Johnathan McGinn MD [email protected]
AN US
CR IP T
Abstract While the progression of acute rhinosinusitis to orbital infections has decreased in the modern antibiotic era, they still occur, particularly in the pediatric population. Infection may spread from the nasal cavity and sinuses via direct extension into the orbit through the thin lamina papyracea or through the valveless veins in the bony orbital wall.1 Congenital dehiscence and trauma also allow for direct extension of the infection to the orbit.1 Most of these orbital infections originate in the ethmoid sinuses and subperiosteal abscesses most commonly occur along the medial orbital wall. However, the frontal sinus is implicated in superior abscesses in older children and adults. Postseptal orbital infections require prompt diagnosis and treatment as they may impact vision and progress centrally, manifesting as cavernous sinus and intracranial infections associated with significant morbidity and mortality.2,3
ED
M
Introduction Otolaryngologists, ophthalmologists, and infectious disease specialists play an active role in managing orbital infections. In the past, subperiosteal orbital abscesses (SPOA) were drained via Lynch or transcaruncular incisions. Today, endoscopes, advancements in sinus surgery, image guidance, and angled endoscopes allow for incision-less management of this infectious process while simultaneously addressing the sinuses responsible for the infection. While techniques and equipment have made these procedures viable management options, these cases remain challenging related to the hypervascular inflamed tissue associated with the suppurative infection, as well as edematous, narrow sinonasal passages. This chapter will focus on the surgical management of medial and superomedial SPOA.
AC
CE
PT
Indications for surgery The most common form of orbital infection secondary to rhinosinusitis is preseptal cellulitis, which is confined anterior to the orbital septum.4 The orbital septum acts as a barrier to the posterior spread of infection. Infection posterior to the orbital septum is termed orbital cellulitis, or Chandler Class 2. Patients may present with proptosis, chemosis, visual changes, ophthalmoplegia and an afferent pupillary defect. Management of orbital cellulitis is typically parenteral antibiotics with aggressive use of decongestants, mucolytics, and nasal saline irrigation. If symptoms worsen (e.g. vision compromise) or do not improve over the course of 24 hours, surgical intervention should be considered, especially if progressive vision deficits are present. As the infection progresses posteriorly, it occupies the space between the bone and the periosteum of the orbit. Subperiosteal abscesses, Chandler Class 3 infections, present with chemosis, possible proptosis, restriction of extraocular movements, and visual changes. Some authors suggest trialing antibiotics for smaller abscesses that do not affect vision while others suggest early surgical intervention of SPOAs.5 Surgical intervention is generally warranted for SPOAs associated with worsening symptoms, vision impairment, bilateral involvement, or large size.6-9 While there is some debate on size criteria as an indication for surgical management of SPOA, the Triological Society recommends surgical intervention in cases >10mm while other authors suggest surgery when the abscess is >5% of total orbital volume.7,9
ACCEPTED MANUSCRIPT
AN US
CR IP T
Surgical Technique The patient is positioned supine and placed under general anesthesia. The patient may be positioned flat, although positioning in reverse Trendelenburg or the raising the head of the bed 15 degrees is preferred to reduce blood loss. The anesthesiologist is asked to maintain the patient at low mean arterial pressures in order to decrease intraoperative bleeding. Vasoconstrictivesoaked pledgets (i.e. 1:10,000 epinephrine or 0.05% oxymetazoline per surgeon preference) are placed in the nasal cavity for general decongestion, and if possible, into the middle meatus, lateral to the middle turbinate. Given the inflamed mucosa in light of an acute purulent infection, the surgeon should allow adequate time for the vasoconstrictive agent to function. The vasoconstrictive-soaked pledgets are then removed and 1% lidocaine with 1:10,000 epinephrine is injected into the middle turbinate and lateral nasal wall. It is prudent to avoid multiple sticks as this may cause unnecessary bleeding that may obscure the endoscope and operative field. 4mm, 0 degree endoscopes are routinely used in adults. These endoscopes, or smaller, 2.9 mm scopes, may be used in pediatric populations based on surgeon preference and nasal cavity size. The use of irrigating sheaths may aid in keeping the scope clear, but increases scope diameter slightly. Image guidance can be helpful given the extent of inflammation typically present, which can distort normal anatomic landmarks. Additionally, image guidance can aid in identifying the abscess cavity and confirm adequacy of drainage.
PT
ED
M
Once vasoconstriction has been allowed to occur, any purulence encountered should be sent for culture for further speciation and sensitivity to direct future antibiotic therapy. The uncinate process should be removed in a standard surgeon-preferred technique and a maxillary antrostomy performed. Any purulence within the maxillary sinus should be evacuated. The ethmoid bulla is then entered inferomedially and dissection carried out with microdebrider and/or through-cutting instruments as in traditional functional endoscopic sinus surgery. While the extent of ethmoidectomy may be varied depending on the acute sinus disease and SPOA location, typically an anterior and posterior dissection are performed with proper identification and skeletonization of the complete length of the lamina papyracea (Figure 1). The sphenoid sinus may be entered and formal sphenoidotomy performed if the sinus is involved, or if orbital apex access is required.
AC
CE
With this dissection complete, the lamina should be visible from the face of the sphenoid to the nasolacrimal system. The nasolacrimal system can be safely avoided by staying posterior to the maxillary line, the mucosal projection along the lacrimomaxillary suture. If the abscess is along the medial orbital wall, the lamina is then entered with a Cottle or Freer dissector immediately posterior to the nasolacrimal system and anterior to the abscess cavity (Figure 2). The lamina is removed piecemeal with a Freer, spoon curette, or through-cutting instrument to identify the periorbita. Care should be taken not to violate the periorbita, as the subsequent herniated orbital fat complicates further dissection. The SPOA may begin draining as soon as the lamina is opened. If it is not, continue removing lamina until the entire abscess is unroofed. The extent of lamina resection may be directed by the location and extent of the abscess, but can be removed as needed posteriorly to the face of the sphenoid and superiorly to the frontoethmoid suture. Any adhesions in the abscess cavity that may have formed should be lysed by developing a plane between the bony orbital wall and the periorbita(Figure 3). After the plane has been well developed, the surgeon may gently ballotte the eye to express any residual purulence. If image
ACCEPTED MANUSCRIPT
CR IP T
guidance has been used, it may be employed to confirm successful and complete drainage of the SPOA. Drain placement in the subperiosteal space is typically not needed, given the adjacent lamina resection providing free drainage into the sinus cavity. The nasal cavity may be irrigated with copious sterile saline solution to clear purulent secretions. Middle meatal spacers can be used to prevent lateralizing scar of the middle turbinate. Absorbable materials (not requiring removal) are recommended given the pediatric predominance of these abscesses. However, the surgeon should be mindful not to pack the middle meatus completely as this may interfere with free drainage from the abscess cavity.
M
AN US
Superior Subperiosteal Abscesses Superiorly located SPOAs have traditionally been addressed via an external approach. However, superomedial SPOAs, and even some true superiorly located SPOA may also be treated endoscopically. While lamina removal is limited by the frontoethmoid suture in order to avoid violation of the skull base, the surgeon may dissect superiorly through the resected lamina further in the superior subperiosteal space. If the abscess is located along the mid to posterior superior orbit, this may be accomplished via the aforementioned laminal resection with blunt dissection between the periorbita and orbital roof. However, abscesses located anterior to the anterior ethmoid artery will require additional maneuvers. A wide frontal sinusotomy should be carried out, with identification of the anterior ethmoid artery along its posterior border.10 The surgeon should stay anterior to the anterior ethmoid artery when continuing with the removal of the lamina papyracea (Figure 4).10 Angled endoscopes provide improved visualization in this region. A dissection plane is continued over the superior periorbita and the abscess is entered and drained. Curved or malleable instruments can be helpful in this maneuver to avoid undo pressure on the orbital contents.
PT
ED
Special Circumstances In cases that present with significant persistently elevated orbital pressures, urgent orbital decompression may be necessary. In such cases, a wide decompression of the medial orbital wall is generally recommended, with possible extension into the sphenoid sinus when necessary based on patient anatomy and relation to the orbital apex.
AC
CE
Some medial extraconal intraorbital abscesses may be amenable to endoscopic drainage. Similar lamina resection is performed, followed by incisions of the periorbita. These incisions should be made in a posterior to anterior direction, paralleling the medial rectus muscle. Inadvertent deep incisions into the periorbital can cause injury to the medial rectus, but if done in this axial fashion, they will be in the plane of the muscle and less likely cause a more severe transection injury. Blunt dissection through the orbital fat can then be performed, being cognizant of the medial rectus muscle. Intraorbital abscesses should always be discussed with ophthalmology colleagues and consideration for cooperative surgery entertained.
Postoperative Care The postoperative hospital stay will be based on response to surgical drainage and ongoing antibiotic care. Once clinical improvements indicate a positive trajectory, consideration to outpatient management can be made. Routine postoperative nasal care should be started in
ACCEPTED MANUSCRIPT
CR IP T
adults and cooperative pediatric patients that can tolerate it. This includes nasal saline irrigations twice a day and endoscopic debridement sometime within the first week, as per surgeon preference. Patients should continue parental antibiotics covering typical sinogenic flora while in the hospital and should be maintained on oral antibiotics for 7 – 10 days, with variation by response, culture results, extent of initial infection, and presenting signs.11 The majority of chemosis and proptosis should resolve within the first 24-72 hours following surgical management, with residual swelling and edema persisting for up to 1 week.
M
AN US
Conclusion Management of SPOA has evolved with a more conservative approach recommended for small abscesses and those patients without vision threatening signs and appropriate response to medical management. Surgical management is indicated for those SPOAs with larger dimensions as they are less likely to resolve without drainage, and for those patients with poor prognostic visual signs or worsening status. Modern endoscopic techniques allow for concomitant minimally invasive approach to the abscess while simultaneously allowing the offending sinuses to be addressed. The surgeon should be mindful of the proximity to the skull base, anterior ethmoid artery, and periorbita during their dissection and can employ angled endoscopes and image guidance as adjuncts to a successful procedure. The dissection and visualization in these patients can be challenging given the acute purulent inflammatory state, but with hemostatic efforts, diligent identification of anatomic landmarks, and use of image-guidance as necessary, these abscesses can be managed with limited morbidity.
REFERENCES:
4.
AC
5.
ED
3.
PT
2.
Arjmand EM, Lusk RP, Muntz HR. Pediatric sinusitis and subperiosteal orbital abscess formation: diagnosis and treatment. Otolaryngol Head Neck Surg. 1993;109(5):886-894. Herrmann BW, Forsen JW, Jr. Simultaneous intracranial and orbital complications of acute rhinosinusitis in children. Int J Pediatr Otorhinolaryngol. 2004;68(5):619-625. Botting AM, McIntosh D, Mahadevan M. Paediatric pre- and post-septal peri-orbital infections are different diseases. A retrospective review of 262 cases. Int J Pediatr Otorhinolaryngol. 2008;72(3):377-383. Chang YS, Chen PL, Hung JH, et al. Orbital complications of paranasal sinusitis in Taiwan, 1988 through 2015: Acute ophthalmological manifestations, diagnosis, and management. PLoS One. 2017;12(10):e0184477. Gavriel H, Jabarin B, Israel O, Eviatar E. Conservative management for subperiosteal orbital abscess in adults: A 20-year experience. Ann Otol Rhinol Laryngol. 2018;127(3):162-166. Le TD, Liu ES, Adatia FA, Buncic JR, Blaser S. The effect of adding orbital computed tomography findings to the Chandler criteria for classifying pediatric orbital cellulitis in predicting which patients will require surgical intervention. J AAPOS. 2014;18(3):271277. Bedwell JR, Choi SS. Medical versus surgical management of pediatric orbital subperiosteal abscesses. Laryngoscope. 2013;123(10):2337-2338.
CE
1.
6.
7.
ACCEPTED MANUSCRIPT
8. 9.
10.
CE
PT
ED
M
AN US
CR IP T
11.
Coenraad S, Buwalda J. Surgical or medical management of subperiosteal orbital abscess in children: a critical appraisal of the literature. Rhinology. 2009;47(1):18-23. Tabarino F, Elmaleh-Berges M, Quesnel S, Lorrot M, Van Den Abbeele T, Teissier N. Subperiosteal orbital abscess: volumetric criteria for surgical drainage. Int J Pediatr Otorhinolaryngol. 2015;79(2):131-135. Roithmann R, Uren B, Pater J, Wormald PJ. Endoscopic drainage of a superiorly based subperiosteal orbital abscess. Laryngoscope. 2008;118(1):162-164. Rahbar R, Robson CD, Petersen RA, et al. Management of orbital subperiosteal abscess in children. Arch Otolaryngol Head Neck Surg. 2001;127(3):281-286.
AC
Figure 1. Endoscopic view of skeletonization of the lamina papyracea, left nasal cavity. L, lamina; M, maxillary sinus; S, sphenoid sinus; SB, skull base.
M
AN US
CR IP T
ACCEPTED MANUSCRIPT
AC
CE
PT
ED
Figure 2. Removal of the medial orbital wall, left nasal cavity.
M
AN US
CR IP T
ACCEPTED MANUSCRIPT
AC
CE
PT
ED
Figure 3. Exposure of the SPOA and development of plane between periorbita and bone, left nasal cavity.
AN US
CR IP T
ACCEPTED MANUSCRIPT
AC
CE
PT
ED
M
Figure 4. Direct visualization of the skull base at the level of the frontal sinus ostium, left nasal cavity. LP, lamina papyracea; FO, frontal ostium; AE, anterior ethmoid artery; OP, orbital periosteum.
Endoscopic Management of Subperiosteal Orbital Abscesses Christopher Pool MD , Johnathan McGinn MD PII: DOI: Reference:
S1043-1810(18)30086-1 https://doi.org/10.1016/j.otot.2018.10.008 YOTOT 835
To appear in:
Operative Techniques in Otolaryngology - Head and Neck Surgery
Please cite this article as: Christopher Pool MD , Johnathan McGinn MD , Endoscopic Management of Subperiosteal Orbital Abscesses, Operative Techniques in Otolaryngology - Head and Neck Surgery (2018), doi: https://doi.org/10.1016/j.otot.2018.10.008
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Endoscopic Management of Subperiosteal Orbital Abscesses Christopher Pool MD, Johnathan McGinn MD [email protected]
AN US
CR IP T
Abstract While the progression of acute rhinosinusitis to orbital infections has decreased in the modern antibiotic era, they still occur, particularly in the pediatric population. Infection may spread from the nasal cavity and sinuses via direct extension into the orbit through the thin lamina papyracea or through the valveless veins in the bony orbital wall.1 Congenital dehiscence and trauma also allow for direct extension of the infection to the orbit.1 Most of these orbital infections originate in the ethmoid sinuses and subperiosteal abscesses most commonly occur along the medial orbital wall. However, the frontal sinus is implicated in superior abscesses in older children and adults. Postseptal orbital infections require prompt diagnosis and treatment as they may impact vision and progress centrally, manifesting as cavernous sinus and intracranial infections associated with significant morbidity and mortality.2,3
ED
M
Introduction Otolaryngologists, ophthalmologists, and infectious disease specialists play an active role in managing orbital infections. In the past, subperiosteal orbital abscesses (SPOA) were drained via Lynch or transcaruncular incisions. Today, endoscopes, advancements in sinus surgery, image guidance, and angled endoscopes allow for incision-less management of this infectious process while simultaneously addressing the sinuses responsible for the infection. While techniques and equipment have made these procedures viable management options, these cases remain challenging related to the hypervascular inflamed tissue associated with the suppurative infection, as well as edematous, narrow sinonasal passages. This chapter will focus on the surgical management of medial and superomedial SPOA.
AC
CE
PT
Indications for surgery The most common form of orbital infection secondary to rhinosinusitis is preseptal cellulitis, which is confined anterior to the orbital septum.4 The orbital septum acts as a barrier to the posterior spread of infection. Infection posterior to the orbital septum is termed orbital cellulitis, or Chandler Class 2. Patients may present with proptosis, chemosis, visual changes, ophthalmoplegia and an afferent pupillary defect. Management of orbital cellulitis is typically parenteral antibiotics with aggressive use of decongestants, mucolytics, and nasal saline irrigation. If symptoms worsen (e.g. vision compromise) or do not improve over the course of 24 hours, surgical intervention should be considered, especially if progressive vision deficits are present. As the infection progresses posteriorly, it occupies the space between the bone and the periosteum of the orbit. Subperiosteal abscesses, Chandler Class 3 infections, present with chemosis, possible proptosis, restriction of extraocular movements, and visual changes. Some authors suggest trialing antibiotics for smaller abscesses that do not affect vision while others suggest early surgical intervention of SPOAs.5 Surgical intervention is generally warranted for SPOAs associated with worsening symptoms, vision impairment, bilateral involvement, or large size.6-9 While there is some debate on size criteria as an indication for surgical management of SPOA, the Triological Society recommends surgical intervention in cases >10mm while other authors suggest surgery when the abscess is >5% of total orbital volume.7,9
ACCEPTED MANUSCRIPT
AN US
CR IP T
Surgical Technique The patient is positioned supine and placed under general anesthesia. The patient may be positioned flat, although positioning in reverse Trendelenburg or the raising the head of the bed 15 degrees is preferred to reduce blood loss. The anesthesiologist is asked to maintain the patient at low mean arterial pressures in order to decrease intraoperative bleeding. Vasoconstrictivesoaked pledgets (i.e. 1:10,000 epinephrine or 0.05% oxymetazoline per surgeon preference) are placed in the nasal cavity for general decongestion, and if possible, into the middle meatus, lateral to the middle turbinate. Given the inflamed mucosa in light of an acute purulent infection, the surgeon should allow adequate time for the vasoconstrictive agent to function. The vasoconstrictive-soaked pledgets are then removed and 1% lidocaine with 1:10,000 epinephrine is injected into the middle turbinate and lateral nasal wall. It is prudent to avoid multiple sticks as this may cause unnecessary bleeding that may obscure the endoscope and operative field. 4mm, 0 degree endoscopes are routinely used in adults. These endoscopes, or smaller, 2.9 mm scopes, may be used in pediatric populations based on surgeon preference and nasal cavity size. The use of irrigating sheaths may aid in keeping the scope clear, but increases scope diameter slightly. Image guidance can be helpful given the extent of inflammation typically present, which can distort normal anatomic landmarks. Additionally, image guidance can aid in identifying the abscess cavity and confirm adequacy of drainage.
PT
ED
M
Once vasoconstriction has been allowed to occur, any purulence encountered should be sent for culture for further speciation and sensitivity to direct future antibiotic therapy. The uncinate process should be removed in a standard surgeon-preferred technique and a maxillary antrostomy performed. Any purulence within the maxillary sinus should be evacuated. The ethmoid bulla is then entered inferomedially and dissection carried out with microdebrider and/or through-cutting instruments as in traditional functional endoscopic sinus surgery. While the extent of ethmoidectomy may be varied depending on the acute sinus disease and SPOA location, typically an anterior and posterior dissection are performed with proper identification and skeletonization of the complete length of the lamina papyracea (Figure 1). The sphenoid sinus may be entered and formal sphenoidotomy performed if the sinus is involved, or if orbital apex access is required.
AC
CE
With this dissection complete, the lamina should be visible from the face of the sphenoid to the nasolacrimal system. The nasolacrimal system can be safely avoided by staying posterior to the maxillary line, the mucosal projection along the lacrimomaxillary suture. If the abscess is along the medial orbital wall, the lamina is then entered with a Cottle or Freer dissector immediately posterior to the nasolacrimal system and anterior to the abscess cavity (Figure 2). The lamina is removed piecemeal with a Freer, spoon curette, or through-cutting instrument to identify the periorbita. Care should be taken not to violate the periorbita, as the subsequent herniated orbital fat complicates further dissection. The SPOA may begin draining as soon as the lamina is opened. If it is not, continue removing lamina until the entire abscess is unroofed. The extent of lamina resection may be directed by the location and extent of the abscess, but can be removed as needed posteriorly to the face of the sphenoid and superiorly to the frontoethmoid suture. Any adhesions in the abscess cavity that may have formed should be lysed by developing a plane between the bony orbital wall and the periorbita(Figure 3). After the plane has been well developed, the surgeon may gently ballotte the eye to express any residual purulence. If image
ACCEPTED MANUSCRIPT
CR IP T
guidance has been used, it may be employed to confirm successful and complete drainage of the SPOA. Drain placement in the subperiosteal space is typically not needed, given the adjacent lamina resection providing free drainage into the sinus cavity. The nasal cavity may be irrigated with copious sterile saline solution to clear purulent secretions. Middle meatal spacers can be used to prevent lateralizing scar of the middle turbinate. Absorbable materials (not requiring removal) are recommended given the pediatric predominance of these abscesses. However, the surgeon should be mindful not to pack the middle meatus completely as this may interfere with free drainage from the abscess cavity.
M
AN US
Superior Subperiosteal Abscesses Superiorly located SPOAs have traditionally been addressed via an external approach. However, superomedial SPOAs, and even some true superiorly located SPOA may also be treated endoscopically. While lamina removal is limited by the frontoethmoid suture in order to avoid violation of the skull base, the surgeon may dissect superiorly through the resected lamina further in the superior subperiosteal space. If the abscess is located along the mid to posterior superior orbit, this may be accomplished via the aforementioned laminal resection with blunt dissection between the periorbita and orbital roof. However, abscesses located anterior to the anterior ethmoid artery will require additional maneuvers. A wide frontal sinusotomy should be carried out, with identification of the anterior ethmoid artery along its posterior border.10 The surgeon should stay anterior to the anterior ethmoid artery when continuing with the removal of the lamina papyracea (Figure 4).10 Angled endoscopes provide improved visualization in this region. A dissection plane is continued over the superior periorbita and the abscess is entered and drained. Curved or malleable instruments can be helpful in this maneuver to avoid undo pressure on the orbital contents.
PT
ED
Special Circumstances In cases that present with significant persistently elevated orbital pressures, urgent orbital decompression may be necessary. In such cases, a wide decompression of the medial orbital wall is generally recommended, with possible extension into the sphenoid sinus when necessary based on patient anatomy and relation to the orbital apex.
AC
CE
Some medial extraconal intraorbital abscesses may be amenable to endoscopic drainage. Similar lamina resection is performed, followed by incisions of the periorbita. These incisions should be made in a posterior to anterior direction, paralleling the medial rectus muscle. Inadvertent deep incisions into the periorbital can cause injury to the medial rectus, but if done in this axial fashion, they will be in the plane of the muscle and less likely cause a more severe transection injury. Blunt dissection through the orbital fat can then be performed, being cognizant of the medial rectus muscle. Intraorbital abscesses should always be discussed with ophthalmology colleagues and consideration for cooperative surgery entertained.
Postoperative Care The postoperative hospital stay will be based on response to surgical drainage and ongoing antibiotic care. Once clinical improvements indicate a positive trajectory, consideration to outpatient management can be made. Routine postoperative nasal care should be started in
ACCEPTED MANUSCRIPT
CR IP T
adults and cooperative pediatric patients that can tolerate it. This includes nasal saline irrigations twice a day and endoscopic debridement sometime within the first week, as per surgeon preference. Patients should continue parental antibiotics covering typical sinogenic flora while in the hospital and should be maintained on oral antibiotics for 7 – 10 days, with variation by response, culture results, extent of initial infection, and presenting signs.11 The majority of chemosis and proptosis should resolve within the first 24-72 hours following surgical management, with residual swelling and edema persisting for up to 1 week.
M
AN US
Conclusion Management of SPOA has evolved with a more conservative approach recommended for small abscesses and those patients without vision threatening signs and appropriate response to medical management. Surgical management is indicated for those SPOAs with larger dimensions as they are less likely to resolve without drainage, and for those patients with poor prognostic visual signs or worsening status. Modern endoscopic techniques allow for concomitant minimally invasive approach to the abscess while simultaneously allowing the offending sinuses to be addressed. The surgeon should be mindful of the proximity to the skull base, anterior ethmoid artery, and periorbita during their dissection and can employ angled endoscopes and image guidance as adjuncts to a successful procedure. The dissection and visualization in these patients can be challenging given the acute purulent inflammatory state, but with hemostatic efforts, diligent identification of anatomic landmarks, and use of image-guidance as necessary, these abscesses can be managed with limited morbidity.
REFERENCES:
4.
AC
5.
ED
3.
PT
2.
Arjmand EM, Lusk RP, Muntz HR. Pediatric sinusitis and subperiosteal orbital abscess formation: diagnosis and treatment. Otolaryngol Head Neck Surg. 1993;109(5):886-894. Herrmann BW, Forsen JW, Jr. Simultaneous intracranial and orbital complications of acute rhinosinusitis in children. Int J Pediatr Otorhinolaryngol. 2004;68(5):619-625. Botting AM, McIntosh D, Mahadevan M. Paediatric pre- and post-septal peri-orbital infections are different diseases. A retrospective review of 262 cases. Int J Pediatr Otorhinolaryngol. 2008;72(3):377-383. Chang YS, Chen PL, Hung JH, et al. Orbital complications of paranasal sinusitis in Taiwan, 1988 through 2015: Acute ophthalmological manifestations, diagnosis, and management. PLoS One. 2017;12(10):e0184477. Gavriel H, Jabarin B, Israel O, Eviatar E. Conservative management for subperiosteal orbital abscess in adults: A 20-year experience. Ann Otol Rhinol Laryngol. 2018;127(3):162-166. Le TD, Liu ES, Adatia FA, Buncic JR, Blaser S. The effect of adding orbital computed tomography findings to the Chandler criteria for classifying pediatric orbital cellulitis in predicting which patients will require surgical intervention. J AAPOS. 2014;18(3):271277. Bedwell JR, Choi SS. Medical versus surgical management of pediatric orbital subperiosteal abscesses. Laryngoscope. 2013;123(10):2337-2338.
CE
1.
6.
7.
ACCEPTED MANUSCRIPT
8. 9.
10.
CE
PT
ED
M
AN US
CR IP T
11.
Coenraad S, Buwalda J. Surgical or medical management of subperiosteal orbital abscess in children: a critical appraisal of the literature. Rhinology. 2009;47(1):18-23. Tabarino F, Elmaleh-Berges M, Quesnel S, Lorrot M, Van Den Abbeele T, Teissier N. Subperiosteal orbital abscess: volumetric criteria for surgical drainage. Int J Pediatr Otorhinolaryngol. 2015;79(2):131-135. Roithmann R, Uren B, Pater J, Wormald PJ. Endoscopic drainage of a superiorly based subperiosteal orbital abscess. Laryngoscope. 2008;118(1):162-164. Rahbar R, Robson CD, Petersen RA, et al. Management of orbital subperiosteal abscess in children. Arch Otolaryngol Head Neck Surg. 2001;127(3):281-286.
AC
Figure 1. Endoscopic view of skeletonization of the lamina papyracea, left nasal cavity. L, lamina; M, maxillary sinus; S, sphenoid sinus; SB, skull base.
M
AN US
CR IP T
ACCEPTED MANUSCRIPT
AC
CE
PT
ED
Figure 2. Removal of the medial orbital wall, left nasal cavity.
M
AN US
CR IP T
ACCEPTED MANUSCRIPT
AC
CE
PT
ED
Figure 3. Exposure of the SPOA and development of plane between periorbita and bone, left nasal cavity.
AN US
CR IP T
ACCEPTED MANUSCRIPT
AC
CE
PT
ED
M
Figure 4. Direct visualization of the skull base at the level of the frontal sinus ostium, left nasal cavity. LP, lamina papyracea; FO, frontal ostium; AE, anterior ethmoid artery; OP, orbital periosteum.