Orbital cellulitis is a serious complication of sinusitisthat follows bacterial spread into the orbit through the wallof the infected sinus. It typically begins as ethmoid sinusitisand spreads through the lamina papyracea, a thin, bony platethat separates the medial orbit and the ethmoid sinus. Orbitalinvolvement can lead to subperiosteal abscess, ophthalmoplegia, cavernous sinus thrombosis, and vision loss. Manifestations of orbital cellulitis include orbital pain, proptosis,chemosis, ophthalmoplegia and limited extraocular muscle motion, diplopia, and reduced visual acuity. Infection of the orbit must be differentiated from that of the preseptal (anterior to the palpebral fascia) or periorbital space. Preseptal (periorbital) cellulitis usually occurs in children younger than 3 years of age; these children do not have proptosis or ophthalmoplegia. Periorbital cellulitis may be associated with a skin lesion or trauma and usually is caused by S. aureus or group A streptococcus.
The diagnosis of orbital cellulitis is confirmed by a computed tomography scan of the orbit, which determines the extent of orbital infection and the need for surgical drainage. Disorders to be considered in the differential diagnosis are zygomycosis (mucormycosis), aspergillosis, rhabdomyosarcoma, neuroblastoma, Wegener granulomatosis, inflammatory pseudotumor of the orbit, and trichinosis. Therapy for orbital cellulitis involves broad-spectrum parenteral antibiotics, such as vancomycin and ceftriaxone.
More than half of children with acute bacterial sinusitis recover without any antimicrobial therapy. Fever and nasal discharge should improve dramatically within 48 hours of initiating treatment. Persistent symptoms suggest another etiology.
The best means of prevention are good hand washing to minimize acquisition of colds and management of allergic rhinitis.
Otitis media (OM) is a suppurative infection of the middle ear cavity. Bacteria gain access to the middle ear when the normal patency of the eustachian tube is blocked by upper airway infection or hypertrophied adenoids. Air trapped in the middle ear is resorbed, creating negative pressure in this cavity and facilitating reflux of nasopharyngeal bacteria. Obstructed flow of secretions from the middle ear to the pharynx combined with bacterial reflux leads to infected middle ear effusion.
Both bacteria and viruses can cause OM. The common bacterial pathogens are Streptococcus pneumoniae, nontypable Haemophilus influenzae, Moraxella catarrhalis, and, less frequently, group A streptococcus. S. pneumoniae that is relatively resistant to penicillin (minimal inhibitory concentration 0.1 to 1 μg/mL) or highly resistant to penicillin (minimal inhibitory concentration ≥2 μg/mL) is isolated with increasing frequency from young children, particularly those who attend day care or have received antibiotics recently. Viruses, including rhinoviruses, influenza, and respiratory syncytial virus, are recovered alone or as co-pathogens in 20% to 25% of patients.