• Written By: Shimon Rumelt, MD

    Several indications have been suggested for drainage of subperiosteal abscesses. These include age of 9 years or older, large abscess, frontal sinusitis, non-medial abscess, chronic sinusitis, dental infection, optic nerve involvement, suspicion of anaerobic infection and recurrence after drainage. This study’s authors retrospectively evaluated subperiosteal abscess (SPA) volume as an indicator for surgical management of pediatric orbital cellulitis and compared the importance of SPA volume to other indications for surgery.

    They reviewed the charts of 29 patients aged 14 years and younger who presented to a single center with orbital cellulitis secondary to sinusitis with SPA; eight were managed surgically and 21 medically.

    SPA volume was the most important criterion in determining medical versus surgical management, with the mean volume of abscesses needing surgery larger (3,446.3 mm3) than those not needing surgery (420.5 mm3; P < 0.04). Cases with SPA volumes of less than 1,250 mm3 did not require surgical management (P < 0.001). Patients younger than 9 years and those 9 years and older required surgical intervention. The mean age of patients undergoing surgical management was 7 years versus 6.1 years for those who were medically managed (P < 0.001).

    Since the authors included only patients with SPA secondary to sinusitis, they could not evaluate and compare the other indications for drainage. Therefore, it cannot be concluded that abscess volume is the most important indication for drainage. Furthermore, this was a retrospective study in which the authors reviewed the findings of the drained versus the medical treated abscesses. It would have been good to know if certain patients were first treated medically and when the decision that medical treatment had failed was made and whether this was the indication for drainage.

    The authors did not mention the size of the computerized tomography cuts. In normal 3 to 4 mm cuts, the peak dimensions of the abscess may be missed. The small number of patients limits the power of the study. In addition, statistically similar results should have a P value of more than 0.05 and not less than 0.001, but this might be just a printing error.

    Most cases of SPA with concurrent frontal sinusitis did not require surgical intervention, and those that did always had concurrent SPA volumes of at least 1,250 mm3. Since frontal sinusitis carries an increased risk of developing an intracranial abscess, the authors agree with prior studies indicating that frontal sinusitis should still be a criterion in the decision-making process for surgical drainage. Furthermore, they argue that SPA, regardless of volume size, coupled with frontal sinusitis should make the clinician have an even lower threshold for surgical drainage than would normally be used in the same case without the presence of frontal sinusitis.