Early surgical intervention for orbital complications of pediatric acute rhinosinusitis: outcomes and algorithmic approach

BACKGROUND: Orbital complications of acute rhinosinusitis (ARS) in children require prompt intervention, but consensus on optimal surgical timing and approach remains limited. This study defines evidence-based indications and evaluates outcomes of surgical management while proposing a severity-stratified algorithm to guide intervention. METHODS: We conducted a retrospective cohort study of 48 patients aged <15 years who underwent surgery for ARS-related orbital complications (47 subperiosteal abscesses [SPA], 1 orbital abscess) at a tertiary center. Surgical criteria included SPA >4 mm, visual impairment, or intravenous antibiotic failure. Approaches compared were purely endonasal (16.7%) versus combined endonasal/external drainage (83.3%). Outcomes included resolution rates and reoperations. Limitations included retrospective design and variability in preoperative antibiotic regimens. RESULTS: The combined approach group had a 95.8% success rate (46/48 patients), with 2 cases requiring reoperation (4.2%). Exclusive endonasal drainage was successful in all 8 cases where applied. No permanent visual deficits or major complications occurred. Surgical outcomes were independent of preoperative antibiotic heterogeneity, though this variability precluded direct medical-surgical comparisons. CONCLUSIONS: Surgery for pediatric ARS-related orbital complications achieves excellent outcomes when guided by radiographic and clinical criteria. Combined drainage is reserved for extensive abscesses, while endonasal alone suffices for localized cases. These findings support a standardized algorithm (Figure 3) integrating abscess location, volume, and clinical progression to optimize care. Future prospective studies should address antibiotic protocol standardization.