The review found that antibiotics could be a first line of treatment for some children with subperiosteal orbital abscesses. Surgery was indicated for non-medial abscesses and patients with loss of visual acuity. Potential for biases in the review process and the low quality of the included studies mean that the authors' conclusion should be viewed with caution.

To assess the effectiveness of antibiotic compared to surgical treatment of subperiosteal orbital abscesses (SPOA) in children, identify which children can be cured with antibiotic treatment and identify criteria for surgical treatment.

MEDLINE, EMBASE and The Cochrane Library were searched to June 2007 for papers published in English, German or Dutch. The related articles feature was used to identify further articles. Search terms were reported in the review.

Any study that investigated medical compared to surgical treatment of SPOA in children and reported outcomes of cure, morbidity and/or mortality was eligible for inclusion. Animal studies, reviews and any study unavailable to the authors in full text were not eligible.

The review included prospective and retrospective observational studies of patients up to age 24 (mean age, where reported, ranged from 5.6 to 9 years). The antibiotics used in the included studies were all given intravenously and included (where stated) ampicillin/sulbactam, oxacillin/cefotaxime, third generation cephalosporins and other broad spectrum antibiotics given for between four and 10 days (where stated).

The authors did not state how many reviewers performed the selection.

Studies were assessed according to criteria of representativeness and number of patients, length and completeness of follow-up, clear distinction of subgroups and objectivity of outcome assessment.

The authors did not state how many reviewers performed the validity assessment.

The authors did not state how data were extracted for the review.

Studies were described individually. Results of efficacy outcomes were presented as a range across the studies.

Five studies (134 participants, range 10 to 43) were included in the review: one prospective (37 patients) and four retrospective (97 patients) studies. Mean follow-up ranged from six months to more than 18 months.

Combined surgical and medical treatment had a cure rate of 95.3% to 100% and medical treatment alone was 26% to 93%. Medical treatment used alone when surgery was not indicated had a cure rate of 62% to 93%. The authors stated that it was not possible to directly compare surgical with medical treatment.

Patients who responded to medical treatment all had a medial abscess, many of which were associated with ethmoid sinusitis. These patients tended to be younger (<11 years) and display proptosis or ophthalmoplegia.

Most studies reported that patients with a non-medial abscess, decreased visual acuity, signs of systemic involvement at presentation and failure to respond to medical treatment were indications for surgery.

There was no evidence to directly compare surgical with medical treatment for SPOA. Although the studies included in the review had a low level of evidence, medical treatment for SPOA could be a first line of treatment for some patients. Surgery was indicated for non-medial abscesses and patients with loss of visual acuity.

The review questions were broad, as were study design inclusion criteria. Participant and outcome criteria were vague; although the review was meant to focus on children, one study included patients up to aged 24. It was not clear how cure was defined in the included studies. The search strategy was wide ranging. The review may have been affected by publication and language biases and the omission of papers not available in full text to the authors. The authors did not report whether appropriate methods were used to reduce reviewer error and bias during the review process. The authors reported that they conducted a quality assessment, but they did not report the results and it was not possible to verify the quality of the included studies. The chosen method of synthesis was appropriate. Most of the studies included in the review were retrospective by design and so were subject to multiple biases.

Potential for biases in the review process and the low quality of the included studies mean the authors' conclusions should be viewed with caution.

Practice: The authors stated that with close monitoring of the patient, antibiotics could be a first line of treatment for some children with SPOA.

Research: The authors stated that a direct comparison of surgical with medical treatment for SPOA was only possible in a clinical trial.

Not stated.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.