Medical management versus surgical intervention of pediatric orbital cellulitis: the importance of subperiosteal abscess volume as a new criterion.

PURPOSE: To investigate age and frontal sinusitis as indications for the surgical management of pediatric orbital cellulitis with subperiosteal abscess (SPA) and to create an SPA volume criterion that would favor nonsurgical management.

METHODS: A retrospective chart review was performed to find all patients age 18 years and younger who presented to Hasbro Children's Hospital with orbital cellulitis secondary to sinusitis with an SPA from 2005 to 2009. SPA volume was measured using a CT ruler at the largest axial, coronal, and sagittal dimensions. Student t testing was used for statistical analysis.

RESULTS: Twenty-nine patients were included: 8 (27.6%) were managed surgically and 21 (72.4%) were managed medically. The mean age of patients undergoing surgical management was 7.0 years old versus medical management 6.1 years old and was statistically similar (p < 0.001). The age range of patients undergoing surgical management was 17 months to 11 years versus 4 months to 13.4 years for medical management. The mean volume of abscesses needing surgery were larger (3,446.3 mm) than abscesses not needing surgery (420.5 mm) (p < 0.04). Volumes of <1,250 mm did not require surgical management (p < 0.001). The frontal sinuses were visualized on CT scan in 17 patients; frontal sinusitis was found in 11 of 17 (64.7%) patients; of these 11 patients, 4 (36.4%) underwent surgical drainage and only 2 (18.2%) showed positive culture results. The 2 (18.2%) patients who had positive culture results had an SPA volume that was ≥ 1,250 mm.

CONCLUSIONS: The volume of SPA seemed to be the most important criterion in determining medical versus surgical management. The volumes of abscesses needing surgery were larger than the volumes of abscesses not needing surgery. Volumes of <1,250 mm did not require surgical management. Most cases of SPA with concurrent frontal sinusitis do not require surgical intervention. The cases of frontal sinusitis requiring surgical intervention always had concurrent SPA volumes of ≥ 1,250 mm. Patients both under 9 years old and ≥ 9 years old required surgical intervention with SPA volumes of <1,250 mm being a consistent determining factor.