Incidence of Drainage of Sinogenic Subperiosteal Orbital Abscess Following Initial Management with Intravenous Antibiotic Therapy in Pediatric Patients. A Systematic Review and Meta-Analysis

Subperiosteal orbital abscess (Chandler stage III) represents the zone of greatest clinical uncertainty in pediatric orbital complications of sinusitis. Conservative management with intravenous antibiotics is recommended for select patients, but adherence to these criteria in practice remains unclear. This systematic review and meta-analysis aimed to estimate the incidence of abscess drainage following failed initial intravenous antibiotic therapy in pediatric patients. Medline, Scopus, Embase, Web of Science, BIREME-BVS, and SciELO were searched, along with grey literature and manual screening, without restrictions (PROSPERO CRD420261417232). Cohort studies and RCTs including pediatric patients (< 18 years) with radiologically confirmed sinogenic subperiosteal orbital abscess who failed initial intravenous antibiotics within 48 h were eligible. Risk of bias was assessed with the JBI checklist and certainty of evidence with GRADE. Pooled incidence was estimated using a random-effects model with Freeman-Tukey transformation; subgroup analysis was performed by abscess location. Seven retrospective cohort studies (229 patients, 31% female, age range 0.2–15 years) were included. The pooled incidence of drainage was 23% (95% CI: 13–36%; 95% PI: 3–53%), with substantial heterogeneity (I²=60.0%). Subgroup analysis showed a lower incidence in medial abscesses (16%; 95% CI: 4–34%) compared with superomedial abscesses (35%; 95% CI: 29–41%; p < 0.01). Nearly one in four pediatric patients with subperiosteal orbital abscess managed conservatively ultimately require drainage, with higher risk in superomedial locations. Given the very low certainty of evidence, these findings should guide, but not replace, individualized clinical judgment.