Subperiosteal abscess of the orbit: evolving pathogens and the therapeutic protocol

Because of widespread antibiotic use, immunization against selective species, and the emergence of hypervirulent organisms, we sought to determine changes over time in the bacteriology of sinusitis-related subperiosteal abscess (SPA) of the orbit and their impact on patient outcomes under a uniform management protocol.

Comparative case series.

Patients≤18 years of age with sinusitis-related SPA treated from 2002 to 2012; comparable cohorts from earlier time frames.

We analyzed culture results and outcomes in surgical cases, compared overall and age-specific results with those in a 1977 through 1992 patient series, and compared the proportion of patients<9 years old requiring surgery among 1988 through 1998, 1999 through 2008, and current cohorts.

Patients requiring surgery; prevalence of pathogens; criteria prompting surgery; visual and systemic outcomes.

Ninety-four patients met inclusion criteria: 53 (56%) recovered with medical therapy alone and 41 (44%) underwent surgical drainage. Compared with the 1977 through 1992 cohort, there was increased representation of Streptococcus anginosus group, S aureus, and group A β-streptococci. Methicillin-resistant S aureus (MRSA) accounted for 4 of 7 S aureus isolates. Of 94 patients, 74 (79%) were <9 years of age: 53 (72%) recovered without surgery and 21 (28%) underwent drainage. Comparable figures were 67.5% versus 32.5% and 85% versus 15% in 1988 through 1998 and 1999 through 2008 cohorts, respectively. Whereas patients≥9 years old in the 1977 through 1992 cohort had a higher proportion of positive cultures and more varied pathogens than younger patients, in the current series both groups had similar culture yields and aerobic constituencies. Anaerobes were isolated from only patients≥9 years old in both series. In cases positive for MRSA and other aggressive aerobes, initial findings prompted early drainage; outcomes were not compromised by adherence to the treatment protocol.

The proportion of children<9 years requiring surgery for sinusitis-related SPA has remained a minority (15%-32.5%), without a clear upward trend over 25 years. Anaerobes continue not to factor in the younger subgroup, but more aggressive aerobic pathogens, including MRSA, have emerged. In such cases, surgical criteria that supersede age are triggered under the current treatment algorithm, and modification is not recommended.