Search

This report includes 14 patients with rhinocerebral mucormycosis treated at the UCLA Medical Center since 1970. This disease has an extremely high mortality and morbidity. It is of interest to dentists because of the common presenting symptoms of periorbital cellulitis and sinusitis and the occasional presenting symptoms of dental pain or subperiosteal swelling. It is of further interest because of the intraoral and extraoral midfacial defects that result from disease extension and the necessary surgical debridement. The resultant facial and oral defects are far more difficult to restore than similar defects secondary to resection of head and neck neoplasms.

Two cases of initially undiagnosed silent fractures of the medial wall of the maxillary sinus complicated by a delayed osteomyelitis are presented. The presenting feature was periorbital cellulitis. The etiopathogenesis of this process is based on an interference with the sinus ostium function by ingrowth of hypertrophic scar tissue.

Forty-seven infants and children with a variety of infections including bacteremia, ethmoiditis, and periorbital cellulitis, soft tissue infection, pneumonia, and lymphadenitis were treated with intravenous cefamandole. The infections were due to Staphylococcus aureus, Streptococcus pyogenes, Streptococcus pneumoniae , and Haemophilus influenzae . The clinical response was prompt, and, with the exception of two cases who developed skin rash, significant side effects were not noted. In vitro cefamandole was very effective in inhibiting the growth of H. influenzae , including ampicillin-resistant isolates.

Twenty-six children received a single daily intravenous dose of ceftriaxone, 50 mg/kg, for a variety of bacterial infections including abscess (5), cellulitis (5), periorbital cellulitis (5), bacteremia without focus (4), osteomyelitis (2), pneumonia (2), pyelonephritis (2) and otitis media (1). Organisms isolated from infectious foci were Staphylococcus aureus (9), Streptococcus pneumoniae (6), Streptococcus pyogenes (3), Escherichia coli (2); and Haemophilus influenzae type b, nontypable H. influenzae, Group B streptococcus, Pasteurella multocida, Haemophilus parainfluenzae and satelliting streptococcus (1 each). Microbiologic cure was achieved in 20 of 22 (91%) infections and clinical cure in 25 of 26 (96%). Fifteen possible adverse reactions occurred in 34 patients evaluable for drug safety; most were mild and self-limited. Neutropenia developed in two patients necessitating discontinuation of ceftriaxone in one, followed by prompt resolution. Seventeen children received ceftriaxone, 75 mg/kg/day, in two divided doses for a similar variety of infections. Bacteriologic and clinical cure rates of 100 and 94%, respectively, were demonstrated. Leukopenia developed in one patient and resolved when ceftriaxone was discontinued. Once a day dosing of ceftriaxone in pediatric patients provides greater ease of administration combined with efficacy equal to that achieved with a divided dosage schedule.

The proper management of patients with orbital and periorbital cellulitis represents a distinct challenge to the clinician. A retrospective study is presented of 165 patients with the diagnosis of orbital or periorbital cellulitis admitted to the Children's Hospital of Philadelphia (CHOP) from January 1975 through December 1980. Sinusitis, trauma, local skin inflammations, and otitis were the most common etiologies. Twenty-three of the patients had orbital cellulitis, all of which were secondary to sinusitis. There was one death in this series. No patients had permanent ocular sequelae related to orbital or periorbital cellulitis. A discussion of etiology and management is presented, with emphasis on the usefulness of computerized tomography (CT).

The clinical features, microbiologic data, complications, and treatment in 137 children with periorbital cellulitis and 21 children with orbital cellulitis is presented. Periorbital cellulitis was more frequent (87%) than orbital cellulitis (13%). Periorbital cellulitis is a heterogeneous disease that may complicate trauma of the eyelids, external ocular infection, and upper respiratory infection. Children with periorbital cellulitis related to trauma or external infection tended to be less than 5 years old with negative blood cultures (99%) and positive cultures of percutaneous aspirates (42%); while children with periorbital cellulitis related to upper respiratory infection also tended to be less than 5 years of age, but blood cultures were frequently positive (42%) and cultures of percutaneous aspirates were usually negative (92%). Three children in the latter group developed meningitis. Intravenous antibiotic alone was effective treatment in most patients (90%). Orbital cellulitis was more frequent in children older than 5 years and frequently associated with sinusitis (90%). Blood and skin cultures were usually negative. Intravenous antibiotics alone were effective management in many patients (62%), but a significant proportion required paranasal sinus or orbital surgery (38%).

Article abstract—In 17 cases of sinusitis-induced subdural empyema, all but 5 occurred in boys or men aged 13 to 33 years. Clinical features were headaches and fever (14 patients), nuchal rigidity (10)., and seizures (8). Seven patients had periorbital cellulitis, and 15 had radiographic clouding of at least one sinus. Only five patients had a history of sinusitis. CT identified the empyema accurately in seven patients but failed in two patients who developed subdural empyema while being treated for sinusitis-induced cerebritis. Ten patients had specific bacteriologic etiologies determined by culture of empyema, blood, or sinuses.

Segregation analysis of brown oculoeutaneous albinism King RA, Rich SS. Clin Genet 1986;29:496-501 Type 4 or brown oculocutaneous albinism seems to be an auto- somal reessive disorder as studied in eighteen Nigerian families. Philip C. Anderson, M.D. Congenital parotid gland fistula Yarnasaki H, Tashiro H, Watanabe T. Int J Oral Maxillofac Surg 1986;15:492-4 A small fistula on the face just behind the commissure of the lips might be a congenital parotid gland fistula. Saliva comes from the opening. The correct treatment is to transloeate the duct back to the inside of the mouth. Philip C. Anderson, M.D. Treatment and visual prognosis in Beh~;et's disease Benezra D, Cohen E. Br Y Ophthalmol 1986;70:589-92 Beh~et's disease is fascinating. The eye findings are especially useful as a "sentinel" to decide the value of therapy. Unhappily, the value of therapy is modest and variable, as shown in this study of forty-nine patients, 74% of whom lost useful visual acuity. Philip C. Anderson, M.D. Detection of carriers of cerebrotendinous xanthomatosis Koopman BJ, Waterreus RJ, Van den Brekel HW, et al. Clin Chim Acta 1986;158:179-85 You will recall that cerebrotendinous xanthomatosis is a terrible recessive inborn error causing cholestane derivatives to be excreted and deposited. The skin lesions often resemble the tuberous and tendinous xanthomas of familial hypercholesterolemia. Dementia, paresis, and early death are usual. This tidy article concerns detection of the carrier state by treatment with cholestyramine, which causes a distinctive cholestane metabolite to appear in urine. Philip C. Anderson, M.D. Periorbital cellulitis: presenting feature of undiagnosed old maxillary fracture Gatot A, Tovi F, Moshiashvili A. Int J Pediatr Otohinolaryngol 1986;2:129-34 Do not forget useful dermatologic roentgenology, This report of persisting facial cellulitis emphasizes the underlying silent maxillo- facial fracture. Skin infections may suggest underlying bone injury or even osteomyelitts, Philip C. Anderson, M.D.

Periorbital celluiitis is a common complication of sinusitis in children. At some hospitals lumbar puncture is routinely done as part of the complete evaluation of children admitted with periorbital cellulitis. Presumably, the lumbar puncture is done to rule out meningitis which could be the result of extension of infection from the orbit to the central nervous system (CNS). However, the degree to which periorbital celluiitis is associated with CNS complication is not known and the necessity for routine lumbar puncture is questioned. Therefore, records of 102 children admitted to the Children's Hospital National Medical Center from 1975 to 1982 with the diagnosis of periorbital cellulitis were reviewed. There were two cases of meningitis and one case of bilateral subdural effusions. Review of the literature and the findings in this study suggests that routine lumbar puncture in seemingly uncomplicated cases of periorbital celluiitis probably is not indicated in children 6 months of age or older.

Cefamandole nafate was effective in the treatment of a variety of infections caused by Staphylococcus aureus, Streptococcus pyogenes group A, Streptococcus pneumoniae, and Haemophilus influenzae in infants and children. The infections included periorbital cellulitis and ethmoiditis, bacteremia, cellulitis, pneumonia, and lymphadenitis. In vitro, cefamandole was effective in inhibiting the growth of H. influenzae isolated from blood or cerebrospinal fluid of patients with meningitis or sepsis. In two patients rash developed and cefamandole was discontinued. Other significant adverse effects were not noted.

The terms periorbital (preseptal) and orbital cellulitis are often used interchangeably, obscuring important differences in their pathogenesis, bacterial etiology, clinical presentation and appropriate therapy. A review of 56 cases of periorbital cellulitis indicated that the patients could be divided into three groups: Group 1, cases secondary to paranasal sinusitis, more correctly termed inflammatory edema because the periorbital swelling is due to venous obstruction (a specific bacterial etiology is rarely documented in these patients because aspiration and culture of the sinuses are usually not performed and the infection is not associated with bacterial invasion of either the soft tissue or the blood stream); Group 2, cases associated with disruption of local skin integrity which are usually due to Staphylococcus aureus or Group A streptococci; and Group 3, cases associated with bacteremia usually occurring in infants and young children without other apparent foci of infection and caused by Haemophilus influenzae type b or Streptococcus pneumoniae. Actual infection of the orbital contents (orbital cellulitis or abscess), marked by proptosis and ophthalmoplegia, is rare and is due either to advanced purulent sinusitis or to penetrating orbital trauma.

Facial and periorbital cellulitis require emergent recognition and treatment. Hemophilus influenzae type B is the most common pathogen, with Streptococcus pneumoniae being cultured less frequently. Infections following injury are usually caused by Staphylococcus aureus and group A streptococci. Initial evaluation must exclude more severe orbital involvement. Appropriate bacteriological specimens should be obtained. Management requires parenteral antibiotics and careful monitoring for a clinical response or dissemination to other sites of infection.

Periorbital cellulitis is an acute infection of the periorbital soft tissues with potential sight and life threatening complications that most commonly occurs in children[1]. Post-septal abscess formation can cause loss of sight; furthermore, posterior spread of infection may progress to cavernous sinus thrombosis and intracranial infection[1, 2]. In England April 2014-March 2015, 3687 patients attended hospital with periorbital cellulitis costing the National Health Service over £9.5 million per annum before considering the cost of treating its complications[3]. This article is protected by copyright. All rights reserved.

OBJECTIVE: To evaluate changes in prescribing behaviour after distribution of antibiotic guidelines printed on a 9 x 6 cm laminated card suitable for clipping to a hospital identification badge. INTERVENTION: Guidelines for appropriate antibiotic prescribing for 20 common and important paediatric infections were printed on a laminated 9 x 6 cm card suitable to clip to a hospital identification badge and distributed to all medical staff. DESIGN: We collected data from medical records for three marker conditions (tonsillitis, pneumonia, and orbital/periorbital cellulitis) on samples of patients from the six-month periods either side of the month in which the cards were distributed. Prescribers were unaware of the study and investigators analysed the prescriptions without knowledge of the period in which they were written. Prescriptions were rated for appropriate choice of antibiotic and appropriate dose. Data were also collected on antibiotic costs. MAIN OUTCOME MEASURES: Proportion of cases in which antibiotic choice was appropriate; proportion of cases in which antibiotic dose was appropriate; annualised costs of third-generation cephalosporins. RESULTS: For tonsillitis there was little change in prescribing practice after the cards were introduced. For pneumonia, cases with appropriate choice increased from 77% to 92% (P = 0.028) and cases with appropriate dose increased from 48% to 81% (P = 0.001). For orbital/periorbital cellulitis, cases with appropriate choice increased from 19% to 78% (P < 0.001) and cases with appropriate dose increased from 30% to 51% (P = 0.11). Annualised costs of third-generation cephalosporins were $193 245 pre-cards and $89 814 post-cards. CONCLUSION: The cards appeared to have a beneficial effect on prescribing practice for the three marker conditions. This simple intervention is likely to be cost-effective and useful in reducing inappropriate use of antibiotics.

A case of periorbital cellulitis induced by acupuncture is presented. A 44-year-old man developed erythema and swelling of the lid and conjunctival chemosis of his right eye after acupuncture treatment. Drainage of the lid, administration of broad spectrum antibiotics and radical operation for paranasal sinusitis resolved the infection.

• Medical records of 144 children hospitalized for 146 episodes of periorbital cellulitis were reviewed. During 44 episodes, systemically administered antibiotics were given before hospitalization. Bacterial pathogens were isolated in only two (5%) of 44 episodes in pretreated patients compared with 33 (32%) of 102 episodes in patients who were not pretreated. Thirty-one children who were not pretreated were bacteremic. Compared with nonbacteremic children who were not pretreated, bacteremic children were younger, more often had a history of upper respiratory tract infection and fever, had a higher white blood cell count and temperature at admission, and more often had a violaceous cellulitis. No difference between groups existed in the frequency of a history of trauma or a local lesion near the affected eye. Tear specimens from 13 of 89 children tested by countercurrent immunoelectrophoresis (CIE) to detect Haemophilus influenzaetype b capsular polysaccharide were positive. Compared with positive blood culture results, tear CIE has a sensitivity of 50% and a specificity of 93%.Streptococcus pneumoniaeinfections were not detected by CIE. (AJDC1988;142:853-857)

From May 1973 through April 1974, a total of 83 children with severe Haemophilus influenzae infections were treated in three Denver pediatric hospitals. Although meningitis was the most common clinical manifestation (45 cases), other foci of infection were also noted (pneumonia, 12 cases; cheek cellulitis, eight cases; epiglottitis, eight cases; empyema, seven cases; pericarditis, three cases; arthritis, one case; periorbital cellulitis, one case; and abscess, one case). Nine children had positive blood cultures with H influenzae without an initial detectable focus of infection. Two patients developed clinically apparent sites of infection (osteomyelitis and scalp abscesses).

• Twenty-six children, aged 2 months to 15 years, were treated with intravenous ceftriaxone sodium, 37.5 mg/kg every 12 hours, for an average of seven days. Clinical and microbiologic cures occurred in 19 of 21 patients, from whom bacterial pathogens were cultured. Ceftriaxone was not effective in treating an 18-month-old infant with periorbital cellulitis caused by relatively resistant Staphylococcus aureus . A relapse occurred in a 2-month-old infant with meningitis caused by ceftriaxone-sensitive Salmonella . Eleven patients had transient diarrhea, superficial candidiasis developed in ten patients, and one patient experienced skin flushing during administration of the antibiotic. Transient asymptomatic laboratory abnormalities were detected in 15 patients; nine patients had elevated serum concentrations of transamlnases or bilirubin, 11 had thrombocytosis, three experienced eosinophilia, and one had thrombocytopenia. Transient suppression of normal flora of the intestine occurred in 21 patients. Side effects were not serious enough to warrant discontinuing ceftriaxone therapy in any patient. ( Am J Dis Child 1983;137:1048-1051)

Important differences between periorbital cellulitis (PC),orbital cellulitis or abscess (OC), and periorbital swelling (PS) associated with sinusitis have been obscured because these terms are often used interchangeably. All cases of PC and OC with a positive blood,tissue aspirate,or abscess culture seen at Children's or Eye and Ear Hospital in the past 10 years were analyzed. Results (including median age): PC caused by HIB and SP, characterized by bacteremia, fever and periorbital swelling, discoloration, induration and pain, is a distinct clinical entity occurring in young children;sinus radiographs frequently demonstrated “cloudy” sinuses,but interpretation of the radiographs was complicated by the small size and indistinct bony margins of the sinuses of infants, and by concurrent upper respiratory infection and overlying soft tissue swelling. Ophthalmoplegia and proptosis, never present in cases of PC, always accompanied OC as did radiographic evidence of sinusitis. OC due to HIB has not been documented in this study or in the literature. PS secondary to sinusitis is characterized by non-tender, non-indurated edema due to venous congestion, not bacterial cellulitis. Careful differentiation of PC,OC and PS secondary to sinusitis is necessary for the selection of appropriate therapy.

Sir .—Periorbital (preseptal) cellulitis is a soft-tissue infection often associated with a history of antecedent coryza, trauma, or local skin inflammation. 1 Recent reports emphasize management rather than pathogenesis. The role of sinusitis as a predisposing factor has been controversial, with some authors regarding it as a complication of the process that initiates the cellulitis 2,3 and others implying a direct causation. 1,4 The most frequently encountered pathogens have been Haemophilus influenzae in those patients with an upper respiratory tract infection; staphylococci and streptococci are etiologic with adjacent trauma or skin inflammation. 2 The question of whether or not viruses can predispose to periorbital cellulitis has been raised 5 but, with the exception of Herpesvirus varicellae mentioned in connection with eyelid infection, 3,4 not one known to produce rhinitis has been identified. We encountered a 13-month-old child with pharyngoconjunctival fever caused by type 7a adenovirus in whom cellulitis developed in

Recent reports have described an increase in the incidence ofHaemophilus influenzaeinfection.1.2Ampicillin-resistant strains ofH influenzaehave recently been reported from many states.3This is the report of a 6-month-old infant in whom, within a 28-day period, periorbital cellulitis and bacteremia followed by meningitis developed, both infections having been caused byH influenzae. The organism isolated from the first infection was sensitive to and the second resistant to ampicillin sodium. Report of a Case.—A previously well 6-month-old male infant was admitted to Columbus Children's Hospital with left periorbital edema, erythema, and a temperature of 40 C. Blood culture yieldedH influenzaetype b, sensitive to both ampicillin sodium and chloramphenicol. The infant was initially treated with ampicillin sodium (200 mg/kg/day) and methicillin sodium (200 mg/kg/day) administered intravenously for six days, at which time he was placed on a regimen of oral ampicillin (100 mg/kg/day)

Observation chez un nourrisson de 9 mois presentant de la fievre et un ecoulement periorbital droit depuis quelques heures

Hemophilus influenzae soft tissue infections produce a variety of specific and dangerous pathologic manifestations in the head and neck. Problems include periorbital cellulitis and abscess, sinusitis, supraglottitis and otitis media. Complications include meningitis, airway obstruction and death. Pediatric patients are especially susceptible to these infections and complications. Effective management includes correct diagnosis, prevention of complications, and high doses of appropriate antibiotics. Increasing ampicillin resistance necessitates alternative antibiotic regimens. Specific physical findings, diagnostic studies and appropriate current treatments are discussed with illustrative cases from Children's Hospital Medical Center, Boston, and reference to pertinent recent literature.