SURGICAL TREATMENT OF PEDIATRIC SUBPERIOSTEAL ABSCESS SECONDARY TO ACUTE BACTERIAL RHINOSINUSITIS-A CASE REPORT

Abstract

Introduction: Rhinosinusitis, an inflammation of the mucosal lining of the nasal cavity and paranasal sinuses, can be classified by the European Rhinologic Society as acute or chronic, based on the duration of symptoms and signs. Acute bacterial rhinosinusitis (ABRS), caused by bacterial invasion of the nasal and paranasal sinus mucosa, may lead to severe complications if untreated. Among these, orbital complications are the most common, including pre-septal cellulitis, orbital cellulitis, subperiosteal abscess (SPA), orbital abscess, and cavernous sinus thrombophlebitis. They can be associated with visual impairment and intracranial extension. SPA is a rare but serious complication in children. It arises from infection spreading to the subperiosteal space, often following ABRS involving the ethmoid sinuses, due to developmental, anatomical, and immunological factors. Early diagnosis and intervention are critical to prevent long-term sequelae.

Case presentation: A 14-year-old boy presented with complications of ABRS, including progressive right eyelid swelling and impaired ocular mobility. Imaging revealed complete opacification of the right ethmoid and maxillary sinuses with bony erosion of the ethmoidal bony septa and lamina papyracea, but without signs of intracranial extension. Laboratory findings showed elevated white blood cell count, elevated C-reactive protein (CRP), and prior exposure to cytomegalovirus and Epstein-Barr virus, with immunoglobulin G (IgG) levels >500.00 IU/mL. Despite initial antibiotic therapy with amoxicillin-clavulanic acid and metronidazole, clinical deterioration required a change in antimicrobial therapy and surgical intervention. Endoscopic sinus surgery (ESS) was performed, successfully evacuating the purulent collection within the SPA, as well as from the ethmoid and maxillary sinuses. Postoperatively, a combination of broad-spectrum intravenous antibiotics, including vancomycin, meropenem, and clindamycin, guided by bacteriological analysis of the pus sample, was administered to target potentially resistant microorganisms, resulting in near-complete resolution of symptoms.

Conclusion: SPA, especially in the pediatric population, requires prompt and aggressive treatment to prevent life-threatening complications. Initial therapy includes intravenous antibiotics, but surgical drainage becomes essential if there is no improvement within 48 hours or if there is impending visual loss. ESS is a safe, minimally invasive technique for managing SPA unresponsive to conservative treatment. Early surgical intervention should be further explored to optimize outcomes and minimize morbidity in pediatric cases.