Combined drainage of subperiosteal orbital abscess complicating ethmoiditis

A 4 year-old boy presented to our tertiary center with acute left ethmoiditis and a subperiosteal orbital abscess. He presented with exophtalmia but had no visual impairment or limitation of ocular mobility.

CT-scan found a 8 mm large subperiosteal orbital abscess with no further complications.

Surgery was decided using a combined approach to drain the abscess and to obtain a bacterial sample: first external (incision in the inner canthus area) and then endonasal (functional endoscopic sinus surgery – FESS) to open the middle meatus and ethmoid.

External approach: 10 mm incision in the inner canthus region, elevation of the lamina papyracea periosteum until the abscess was reached. Rubber drain was put in place for irrigation.

Endonasal approach: after careful CT-scan examination, endonasal surgery was performed with a 30° rigid endoscope. The middle turbinate was medialised to expose the middle meatus, uncinectomy and antrostomy followed by anterior and posterior ethmoidectomy was performed.

Antibiotics were given intravenously for 5 days and saline irrigation on the drain was performed during 2 days. Patient was discharged after 5 days.

- External drainage: 10 mm cutaneous incision in the inner canthus area. The lamina papyracea periosteum is elevated to reach the abscess. A rubber Delbet corrugated drain (Peters Surgical, Bobigny, France) is left in the abscess during two days for irrigation (saline irrigation). - Endonasal drainage: Opening of the ipsilateral ethmoidal cells by transnasal endoscopic approach, using a 30° rigid endoscope. The extent of the ethmoidectomy can vary from one surgeon to the other. In this video anterior and posterior ethmoid was opened. The surgery may be limited to the opening of the anterior ethmoidal cells and of the bulla, until a flow of pus appears. Also, direct exposure of the abscess through a small opening of the lamina papyracea can be achieved. - Surgeons may choose either an external or endonasal approach, or a combined technique as in this video can be preferred. The literature has not shown any significant difference of failure rates between endoscopic, external or combined approaches.
The indications for surgical drainage in our department are the following: - abscess width > 5 mm; - absence of improvement in signs and symptoms after 48–72 h of intravenous antibiotics; - severe clinical complications such as epidural empyema, loss of visual acuity or cavernous sinus thrombophlebitis
- Standard instruments for the external approach and rubber Delbet corrugated drain (Peters Surgical, Bobigny, France). - Standard functional endoscopic sinus surgery (FESS) instruments and 30° rigid endoscope for endonasal approach.
- Clinical examination of the patient especially concerning the eye (exophtalmia, visual acuity, ocular mobility, pupillary reflex) - Study of CT-scan: . measurement of abscess width (drainage if > 5 mm) . Other ethmoiditis complications (subdural abscess, etc.) . FESS anatomical landmarks (see here-after)
As in any FESS, endonasal anatomical landmarks must be noted on the CT-scan. This pathology mostly concerns young children, therefore the development of the different sinuses must be explored. Insertion of the uncinate process and inferior turbinate must be noted. Position of the orbit and anterior skull base in relation to the maxillary and ethmoid sinus must be examined.
- Advantages: Drainage of the abscess is necessary for healing. - Disadvantages: External approach: scar Endonasal approach: risks due to FESS (anterior skull base, orbit) in an inflammatory environnement, requires experience.
- External approach: Risks and complications are rare if the elevator is correctly positioned against the bone. - Endonasal approach: Risks are those of any FESS: anterior skull base breach, orbit and bleeding. In inexperienced hands, the drainage can be insufficient requiring a second procedure. Overall, the main risk is failure which is why a combined approach may be preferred.
None to declare.
- Rubin F., Pierrot S., Lebreton M., Contencin P. et Couloigner V. (2013) Drainage of subperiosteal orbital abscesses complicating pediatric ethmoiditis: Comparison between external and transnasal approaches. International Journal of Pediatric Otorhinolaryngology 77:796-802. - Coudert A., Ayari-Khalfallah S., Suy P. et Truy E. (2018) Microbiology and antibiotic therapy of subperiosteal orbital abscess in children with acute ethmoiditis. Int J Pediatr Otorhinolaryngol 106:91-95.

Review Combined drainage of subperiosteal orbital abscess complicating ethmoiditis.

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