From the Guidelines
Surgical drainage is usually necessary for the management of a periosteal abscess, in addition to prompt antibiotic therapy. A periosteal abscess is a localized collection of pus between the periosteum (the membrane covering bone) and the underlying bone, typically caused by bacterial infection. Treatment requires prompt antibiotic therapy and often surgical drainage, as seen in a patient presenting with progressive ankle swelling and fever, where a subperiosteal abscess was revealed by ultrasound 1. For empiric treatment, start with intravenous antibiotics that cover Staphylococcus aureus, the most common causative organism, such as cefazolin 2g IV every 8 hours or clindamycin 600-900mg IV every 8 hours if penicillin-allergic.
The primary management of subperiosteal abscesses is surgical incision and drainage followed by antibiotic therapy, especially in cases involving the sinuses or calvarium 1. Drainage of subperiosteal abscesses is often required for proper management, highlighting the importance of surgical intervention in addition to antibiotic therapy 1. After surgical intervention and clinical improvement, patients can transition to oral antibiotics like cephalexin 500mg four times daily or clindamycin 300-450mg four times daily for a total treatment duration of 4-6 weeks. Regular follow-up is essential to monitor response to therapy. Without proper treatment, the infection can spread to the underlying bone causing osteomyelitis, or into surrounding soft tissues.
Key considerations in the management of periosteal abscess include:
- Prompt initiation of antibiotic therapy
- Surgical drainage to remove purulent material and relieve pressure on the bone
- Transition to oral antibiotics after clinical improvement
- Regular follow-up to monitor response to therapy
- Awareness of potential complications such as osteomyelitis or spread of infection to surrounding soft tissues.
From the Research
Definition and Presentation
- A periosteal or subperiosteal abscess is a collection of pus in the space between the periosteum and the bone, often resulting from the migration and spread of an infection such as sinusitis and ethmoiditis 2.
- This condition typically presents with a collection of pus in the space between the periorbital and the lamina papyracea 2.
Diagnosis and Imaging
- Bone scanning is very sensitive for the detection of early skeletal infection, but a subperiosteal abscess has a distinctive scintigraphic appearance with a "cold" lesion on delayed views, likely due to interrupted vascular supply of the bone 3.
- A central photopenic area on a bone scan is highly suggestive of subperiosteal abscess, and a computed tomographic (CT) scan can be helpful in planning the surgical approach for drainage 3.
- Plain radiographs may be unremarkable even when bone scan and CT findings are dramatic 3.
Treatment Options
- Immediate surgical drainage of the abscess versus more conservative pharmacologic medical treatment are two approaches to treating subperiosteal abscess, with the choice depending on the individual case 2.
- Percutaneous drainage of subperiosteal abscess may be an alternative to surgical drainage when medical therapy alone is inadequate, but development of intraosseous abscess, necrosis, or persistent drainage may require further intervention 4.
- The duration of intravenous antibiotic administration in nonsurgical cases can be relatively short, ranging from 2 to 8 days (mean and median 4 days), with clinical judgment guiding treatment intervals 5.
- Intramedullary drainage in addition to subperiosteal abscess drainage may decrease the risk of needing repeat surgical treatment, with a statistical significance and odds ratio of 6.46 in favor of intramedullary drainage 6.