Abscess size determines treatment course for pediatric orbital cellulitis

Ophthal Plast Reconstr Surg. 2011; 27(4):255-259.

Issue: October 25, 2011

Volume of subperiosteal abscess rather than patient age appeared to be the guiding factor in physicians' decisions to pursue medical or surgical treatment of pediatric orbital cellulitis, a study found.

"Pediatric orbital cellulitis occurs most commonly secondary to ethmoid sinusitis," the study authors said. "Early diagnosis and aggressive proper management of orbital cellulitis are essential to avoid life- or vision-threatening complications such as permanent blindness, cavernous sinus thrombosis, optic neuropathy, exposure or neurotrophic keratitis, carotid occlusion, exudative retinal detachment, central retinal artery occlusion, septic embolus, brain abscess, and meningitis."

The retrospective study included 29 patients with orbital cellulitis secondary to sinusitis. Eight patients underwent surgery, and 21 received medical treatment. Mean patient age overall was 6.4 years (range: 4 months to 13.4 years). Mean age of patients undergoing surgery was 7 years; mean age of patients receiving medical treatment was 6.1 years.

Study results showed that the mean volume of abscesses requiring surgery was 3,446.3 mm³. Mean volume of abscesses not requiring surgery was 420.5 mm³. The between-group difference was statistically significant (P < .04). Volumes lower than 1,250 mm³ did not require surgery (P < .001).

Patients younger and older than 9 years with abscess volumes exceeding 1,250 mm³ required surgery.

Computed tomography scan identified frontal sinusitis in 11 patients, four of whom underwent surgical drainage and two of whom had positive culture results. The two patients with positive cultures had abscess volumes of 1,250 mm³ or greater, the authors reported.

The authors offer a very nice review of their series of pediatric patients treated both surgically and non-surgically for orbital cellulitis. They draw very appropriate conclusions and offer very useful guidelines for this population considering the evolving antibiotic treatments and evolving organisms treated. The series reminds all of us that each one of these cases is unique and is often scary to treat until we see clinical improvement producing the “sigh of relief.” All of us have had surprises treating these patients, and I have personally seen more success than I saw 25 years ago with non-surgical treatment. I commend the authors for their comments, especially in the last paragraph and for their assembling the data for this retrospective analysis.

– Anthony P. Johnson, MD
Jervey Eye Group, Greenville, S.C.
Disclosure: Dr. Johnson has no relevant financial disclosures.