Drainage of 5 Cases of Subperiosteal Abscesses

This is a relatively long (10 minutes) video of 5 cases of subperiosteal orbital abscesses.  Each of the abscesses is located in a different area of the orbit:  inferior, medial, superior medial, superior, and superior lateral.  Imaging is also shown for each of the abscesses.  All of these abscesses are secondary to adjacent sinusitis, and it is important to always have the sinuses addressed by the otolaryngologist.  The videos demonstrates how to access each of these areas for drainage of the abscess. 

This is Richard Allen in Houston, TX.  This video demonstrates 5 cases of subperiosteal orbital abscesses located at different areas in the orbit and the surgical approach to each of these abscesses. All of these cases area also performed with concurrent sinus surgery.  The first is an inferior abscess associated with maxillary and ethmoid sinusitis.  It is always important to consider an odontogenic origin of inferior abscesses.  This case had no tooth issue and was due to sinusitis in a COVID positive patient.  4-0 silk sutures are placed through the lower eyelid at the level of the tarsus to provide traction during the case.  A needle tip cautery is then used to make an incision inferior to the inferior border of the tarsus. Dissection is then carried out between the orbicularis muscle and orbital septum to the inferior orbital rim.  Cotton tip applicators are used to palpate and identify the inferior orbital rim.  Exposure is improved with a Jaeger lid plate.  The needle tip cautery is then used to make an incision through the periosteum of the inferior orbital rim.  As soon as the periosteum is breached, the abscess is encountered.  Using suction, the abscess is collected in a trap.  The periosteum is then elevated from the orbital floor to expose the entire abscess.  It is important to examine the imaging closed to ensure that the entire area of the abscess has been drained.  The area can then be irrigated.  The incision is then closed with interrupted 7-0 Vicryl sutures placed in an interrupted fashion.

The second case is a medial abscess associated with ethmoid sinusitis and maxillary sinusitis.  In this case, both a CT and MRI were performed.  A retrocaruncular incision will performed to gain access to the medial orbital wall.  An incision is made with Westcott scissors posterior to the caruncle.  The caruncle and plica are grasped with toothed forceps.  The incision should be extended inferiorly and superiorly, taking care not to violate the canaliculus.  Blunt dissection is then performed with Steven’s scissors toward the posterior lacrimal crest.  Small malleable retractors and a Desmarres retractor are used to aid in exposure.  The periosteum of the medial orbital wall is then identified and a freer periosteal elevator is used to incise the periosteum and elevate it from the medial orbital wall.  The abscess is encountered and collected in a trap.  The subperiosteal space is then completely exposed, remembering to be careful superiorly where the anterior and posterior ethmoidal arteries are located. The suction tip can be used relatively liberally in this area.  Addition material is removed.  The retrocaruncular incision is then closed with interrupted 7-0 Vicryl sutures. 

The third case is a superior medial abscess.  I prefer to approach these abscesses through an upper eyelid crease incision.  It can be difficult to approach it through a retrocaruncular incision due to the location of the ethmoidal arteries.  This abscess is associated with ethmoid sinusitis.  A 15 blade is used to make an incision along the predicated lid crease.  Dissection is then carried out through the orbicularis muscle to the underlying orbital septum.  Dissection is then carried out superiorly along the surface of the orbital septum to the superior orbital rim.  A cotton tip applicator can be used to palpate and expose the superior orbital rim.  The needle tip cautery is used to make an incision through the periosteum to the underlying superior orbital rim.  It is important to stay lateral to the area of the supraorbital neurovascular bundle.  The freer periosteal elevator is then used to elevate the periosteum of the superior orbital rim to expose the subperiosteal space along the orbital roof.  Dissection is then carried out with the suction tip in a medial direction along the orbital roof where the abscess is encountered and collected.  The suction tip is used to perform further dissection.  The specimen is sent for evaluation.  The area is irrigated.  With transcutaneous incisions, I usually place a rubber band drain in the subperiosteal space that will stay in place for 24-48 hours.  The drain is sutured to the forehead with 5-0 fast absorbing sutures.  The incision is then closed with interrupted 5-0 fast absorbing sutures. 

The fourth case is a superior abscess with tenting of the globe associated with ethmoid sinusitis.  This is a large abscess and one can understand why the globe was at risk.  This will also be approached through an upper eyelid crease incision.  Dissection is carried out through the orbicularis muscle to the underlying orbital septum.  Dissection is then carried out superiorly along the surface of the orbital septum to the superior orbital rim.  The rim is palpated and exposed with a cotton tip applicator and incised with a needle tip cautery.  The freer periosteal elevator is then used to elevate the periosteum from the superior orbital rim.  As this was a large abscess, there was a lot of pressure as demonstrated by the egress.  In slow motion, the egress can be better appreciated.  The abscess is then collected in a trap with the suction.  The orbital roof in the area of the abscess is completely exposed.  Irrigation is performed.  And the closure is performed as demonstrated in the last case.

The fifth and last case is a superior lateral abscess associated with ethmoid, maxillary, and frontal sinusitis.  The upper eyelid is inspected and the area of the lid crease marking noted.  It can be difficult to predict the correct position of the eyelid crease.  Some colleagues prefer a sub-brow incision, but I almost exclusively use an eyelid crease incision for superior abscesses.  The 15 blade is again used to make an incision and dissection is carried out to the underlying orbital septum.  Dissection then continues as demonstrated in the previous two cases to the superior orbital rim.  The superior orbital rim is palpated and exposed.  The needle tip cautery then makes an incision through the periosteum to the underlying bone.  The freer periosteal elevator elevates the periosteum and an abscess under high pressure is encountered.  Again, in slow motion, the volume and pressure of the abscess are appreciated.  The abscess is collected in a trap and sent for evaluation.  The orbital roof is exposed and the area is irrigated followed by placement of a rubber band drain.  The drain is sutured above the brow and removed in 1-2 days.  The upper lid crease incision is then closed with interrupted 5-0 fast absorbing sutures.  It is important to remember that all of these cases were performed in coordination with sinus surgery to control the source of the abscess.  Due to the lateral chemosis in this case, a temporary suture tarsorrhaphy was placed with 5-0 fast absorbing suture.  Antibiotic/steroid ointment is placed over then incision and into the eye.  All of these patients were admitted to the hospital for intravenous antibiotics.