The Use of Superomedial Conjunctival Approach in Drainage of Large Medial Subperiosteal Abscess Secondary to Ethmoiditis in Children: A Simple, Fast and Safe Technique

Abstract

Purpose: To evaluate the superomedial conjunctival approach in management of large-sized medial subperiosteal abscess (MSPA) secondary to ethmoiditis in children. Methods: This prospective, non-randomized, clinical intervention case study was conducted at the Orbital Clinic of Assiut University Hospital, the referral center of Upper Egypt in the period between October, 2015 and March, 2018. The study included 9 children with MSPA secondary to ethmoiditis that met the criteria for surgical drainage. In all cases, the MSPA was large (more than 2 cm in its greatest dimension or more than 4 mm in width) and in 3 cases there was relative afferent papillary defect (RAPD). Children with small MSPA without any signs of compressive optic neuropathy that may improve with intravenous broad-spectrum antibiotics were excluded. Under general anesthesia and coverage of intravenous antibiotics, the conjunctiva between the superior and medial recti was incised 8 mm from the limbus with application of tractional sutures to both recti to pull the globe down and out. With malleable orbital retractor the superomedial conjunctiva was retracted medially and the abscess was easily opened with blunt scissors, suctioned and followed by repeated irrigation and suction with solution containing broad spectrum antibiotics. The tractional sutures were removed and followed by application of broad-spectrum antibiotic ointment and eye bandage for 6 h. Results: The age of the patients ranged from 1 to 10 y with an average of 6 y. 7 were males and 2 were females. The left side was involved in 6 cases while the right side was in 3 cases. On CT, the large MSPA was located posteriorly in 7 cases while it was anterior in 2 cases. In all cases and after drainage, the general symptoms were markedly improved within 48 h and the clinical signs were completely resolved in 1-2 weeks. The hospital stay was 2 d in 8 cases and 3 d in one case only. During the follow-up period of minimum 6 months (ranged from 6-30 m), no corneal complications or re-accumulation of MSPA with recurrence were reported. Conclusion: The excellent results we have achieved make the superomedial conjunctival approach highly recommended for drainage of large-sized MSPA secondary to ethmoiditis in children especially if it is located posteriorly where the external approach is far away from the lesion. The technique is a few minutes approach with no facial scar. Also, it carries no risk of medial rectus or optic nerve damages as reported with transnasal endoscopic approach with its long learning curve. However, extension of the study to involve more cases with longer follow-up is recommended.