What is the management of periorbital hematoma?

From the Guidelines

Periorbital hematomas are best managed with prompt recognition and treatment of any underlying infection, particularly if related to acute bacterial sinusitis, to prevent serious complications such as permanent blindness or death, as highlighted in the clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years 1. When managing periorbital hematoma, it is crucial to assess for signs of orbital and/or central nervous system involvement, which may necessitate immediate medical attention. Key considerations include:

• The presence of proptosis, impaired visual acuity, or impaired and/or painful extraocular mobility, which warrants hospitalization and a contrast-enhanced CT scan, as well as consultation with specialists such as an otolaryngologist, an ophthalmologist, and an infectious disease expert 1.
• The use of appropriate antimicrobial therapy, such as vancomycin, to cover possible methicillin-resistant S pneumoniae, and tailoring treatment to the results of culture and sensitivity studies when available 1.
• Monitoring for intracranial complications, particularly in previously healthy adolescent males with frontal sinusitis, and obtaining neurosurgical consultation if altered mental status, severe headache, or Pott’s puffy tumor is present 1. In terms of specific management strategies for periorbital hematoma, applying cold compresses for the first 24-48 hours after injury and elevating the head to minimize swelling are recommended. Over-the-counter pain medications like acetaminophen or ibuprofen can help manage pain, though ibuprofen should be avoided immediately after injury as it may increase bleeding. However, the primary focus should be on addressing any underlying infection or serious complications, as emphasized in the guideline for acute bacterial sinusitis 1.

From the Research

Periorbital Haematoma Management

• The management of periorbital haematoma can vary depending on the cause and severity of the condition 2, 3, 4, 5.
• In cases of spontaneous subperiosteal orbital hematoma, surgical incision and drainage of the subperiosteal space may be necessary to prevent vision loss 2.
• Early office-based needle aspiration is a viable approach for the management of subperiosteal hematoma, especially in cases where there is no indication for orbitotomy 3.
• Orbital compartment syndrome (OCS) is a rare but potentially vision-threatening complication of orbital hematoma, and prompt surgical intervention is necessary to prevent permanent vision loss 4.
• The use of corticosteroids in the management of periorbital and orbital cellulitis is still unclear, and more research is needed to determine their effectiveness and safety 6.

Surgical Management

• Surgical decompression of the orbit is recommended when visual deficit arises and when there is no response to pharmacologic therapy 5.
• Lateral canthotomy and/or inferior cantholysis are common techniques used for orbital decompression 5.
• Other procedures, such as transantral ethmoidectomy, transantral sphenoidectomy, and transfrontal craniotomy, may also be used in certain cases 5.

Non-Surgical Management

• Conservative management may be recommended in cases with intact visual function, but complete resorption of the hematoma may take several months 3.
• Early office-based needle aspiration can be used to drain the hematoma and reduce the risk of complications 3.