Surgical or medical management of subperiosteal orbital abscess in children: a critical appraisal of the literature.

OBJECTIVE: Subperiosteal orbital abscesses (SPOA) are a complication of sinusitis. Traditional treatment of SPOA is surgical. Recently, a number of studies report successful medical treatment. To our knowledge, it is unclear which patients can benefit from medical management alone. Therefore, we questioned (1) what is the outcome of medical versus surgical treatment? (2) which patients can be cured with antibiotics alone? (3) what are the absolute criteria for surgical treatment? METHODS: A structured search was conducted in PubMed, EMBASE and the Cochrane Library for relevant papers which were critically appraised. RESULTS: Five studies addressing our clinical questions were included, one prospective case series and four retrospective studies. Evidence levels varied from 2b to 3. Overall, a high cure rate was achieved with combined modality treatment (95.3-100%). The cure rate of medical treatment alone varied between 26% and 93%. The outcome of medical treatment improved after prior selection of surgical cases. In general, responders to medical treatment had a medial abscess associated with ethmoid sinusitis. Criteria for initial surgical or medical management differed among authors. Most authors agreed upon initial surgical treatment for patients with non-medial abscesses, decreased visual acuity and signs of systemic involvement. Surgery was also indicated when lack of improvement or worsening of symptoms and signs after 48-72 hours of medical treatment were observed. CONCLUSIONS: The outcome of surgical versus medical management of SPOA within and between studies could not be compared. Higher cure rates were observed when both modalities were combined. There is some evidence that medical treatment can cure medially located SPOA. Loss of visual acuity, non-medial abscess, clinical detoriation and failure to improve within 48 hours of antibiotic treatment can be considered as criteria for surgical treatment. In the absence of these criteria a trial of antibiotic treatment can be considered with close monitoring of the patient.