Objective: To evaluate the outcomes of a new surgical approach in children with acute sinusitis and medial orbital subperiosteal abscess., Design: Case series., Setting: Tertiary pediatric hospital., Patients: Eleven children aged 6 weeks to 13 years with orbital subperiosteal abscess and acute sinusitis who met indication for surgery by visual compromise and/or refractory course to medical therapy., Intervention: The medial orbital abscess was drained via a transcaruncular approach, which provided access to the medial orbital wall. An endoscopic ethmoidectomy was also performed., Main Outcome Measures: Judgment of cosmetic appearance by surgeon and family, resolution of symptoms, length of hospital stay, and complications., Results: All children had prompt resolution of symptoms after surgical drainage. Cosmetic outcome was excellent in all patients with no cutaneous scar or eyelid malposition. After edema and cellulitis had resolved, no family member could tell a difference in appearance between the eyes. No complications of these combined procedures were identified. One patient who had initially undergone transnasal endoscopic orbital drainage alone experienced a recurrence of infection 17 days later. He was then treated by the combined transcaruncular and endoscopic approach with prompt resolution of his symptoms. One of 4 patients treated initially with transcaruncular approach alone without endoscopic ethmoidectomy had recurrence of acute sinusitis and orbital abscess 16 months later and was successfully treated with an endoscopic approach., Conclusions: The combined endoscopic and transcaruncular surgical approach to medial orbital subperiosteal abscess and acute sinusitis provides a cosmetically superior outcome compared with standard orbital approaches requiring a cutaneous incision. The transcaruncular approach can be considered as an alternative or adjunct approach to the medial orbit, with the same cosmetic advantages as transnasal endoscopic drainage.