Case 4 - Pediatric Subperiosteal Abscess
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Here are two children with the same
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diagnosis. On the left hand side,
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what you see are the three images from a non contrast CT
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scan. Here are the three images from a non contrast CT scan.
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And what we see is, as typically seen with children,
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is the ethmoid sinusitis accounting for the
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source of the inflammation. But this collection
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along the medial aspect of the orbit is a manifestation
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of orbital cellulitis and more importantly,
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of a subperiosteal abscess. In this situation,
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we don't have contrast on board but even if there wasn't a
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peripheral rim of enhancement, we would suggest
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that this represents a subperiosteal abscess.
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On the right-hand image,
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a single image from a post-contrast scan,
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we're a little bit more impressed with the size of this
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collection compressing the optic nerve, and that there
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does appear to be a faintly enhancing wall.
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This wall is actually the periorbita. That is,
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that the periorbita,
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which is a fibrous septum around the orbit, is being displaced
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medially by the purulent collection that is arising
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from the ethmoid sinusitis. In this case,
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there would be a very close observation to make sure that
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there wasn't any optic nerve pallor on the fundoscopic
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examination, which would suggest that this optic nerve might be
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in jeopardy by the compressive effect
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down here at the orbital apex.
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In either case,
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both of these patients would receive intravenous antibiotics
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with the hope that this would drain naturally without
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surgical intervention required, particularly in a child.
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Here is a patient who has a periorbital abscess.
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In this case, it's in the periorbital space,
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the preseptal space, and where you can see it is actually in
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the cheek. So the inflammation is here over the left eye.
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But you notice that there is a collection here which is also
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seen on the reconstruction in the sagittal plane of a rim
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enhancing low density center and that is an
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abscess which is in the subcutaneous fat.
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So this would be a periorbital abscess, not the same as a
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periosteal abscess, which is usually seen in the medial
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aspect of the orbit secondary to the ethmoid sinusitis.
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The Chandler classification is often referred to when dealing
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with orbital inflammation, and it separates those inflammatory
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conditions into the most benign of them, which is our preseptal
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cellulitis or periorbital cellulitis, the postseptal
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cellulitis or the orbital cellulitis,
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the subperiosteal abscess and then the orbital abscess.
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By this,
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we are talking about an intraconal abscess, an abscess
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that is affecting the muscles or the intraconal space as opposed
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to being in the extraconal space of the subperiosteal space.
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And finally, we have the cavernous sinus
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inflammation or thrombophlebitis.
David M Yousem, MD, MBA
Professor of Radiology, Vice Chairman and Associate Dean
Johns Hopkins University
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