Signs and Symptoms

Similar to orbital cellulitis, though may be magnified in scale. Suspect a subperiosteal abscess (SPA) if a patient with orbital cellulitis fails to improve or deteriorates after 48 to 72 hours of intravenous antibiotics.

• Intraorbital abscess: Rare because the periorbita is an excellent barrier to intraorbital spread. May be seen following penetrating trauma, previous surgery, retained foreign body, extrascleral extension of endophthalmitis, extension of SPA, or from endogenous seeding. Treatment is surgical drainage and intravenous antibiotics. Drainage may be difficult because of several isolated loculations.
• Cavernous sinus thrombosis: Rare in the era of antibiotics. Most commonly seen with zygomycosis (i.e., mucormycosis) (see 10.10, CAVERNOUS SINUS AND ASSOCIATED SYNDROMES [MULTIPLE OCULAR MOTOR NERVE PALSIES]). In bacterial cases, the patient is usually also septic and may be obtunded and hemodynamically unstable. Dental infections have a propensity for aggressive behavior and may spread along the midfacial and skull base venous plexuses into the cavernous sinus. Prognosis is guarded in all cases. Manage with hemodynamic support (possibly in an intensive care unit), broad-spectrum antibiotics, and surgical drainage if an infectious nidus is identified (e.g., paranasal sinuses, tooth abscess, and orbit). Anticoagulation can be considered to limit the propagation of the thrombosis into the central venous sinuses.

Workup

See 7.3.1, ORBITAL CELLULITIS, for workup. In addition:

1. Obtain CT with contrast, which allows for easier identification and extent of an abscess. In cases of suspected cavernous sinus thrombosis, discuss with the radiologist before CT, since special CT techniques and windows may help with diagnosis. MRI may also be indicated in cases of skull base spread of infection.

NOTE:

All orbital cellulitis patients who do not improve after 48 to 72 hours of intravenous antibiotic therapy should undergo repeat imaging.

1. Microbes involved in SPA formation vary and are to a degree related to the age of the patient. The causative microbes influence response to intravenous antibiotics and the need for surgical drainage. See Table 7.3.2.1.
2. Leave an orbital drain in place for 24 to 48 hours to prevent abscess reformation.
3. Intracranial extension necessitates neurosurgical involvement.
4. Expect dramatic and rapid improvement after adequate drainage. Additional imaging, exploration, and drainage may be indicated if improvement does not occur rapidly.
5. Do not reimage immediately unless the patient is deteriorating postoperatively. Imaging usually lags behind clinical response by at least 48 to 72 hours.

NOTE:

These are guidelines only. All patients with SPA should be followed closely and managed by appropriate subspecialists, often with a combined approach (e.g., otorhinolaryngology). If an optic neuropathy is present or if the abscess is large, emergent drainage of the abscess is required. Adequate drainage may require orbital exploration. In children, a large SPA (>1250 mm3) with frontal sinus involvement often requires drainage. Simultaneous drainage of both the SPA and the paranasal sinuses appears to decrease the recurrence rate of SPA when compared to SPA drainage alone.