The Journal of Craniofacial Surgery
Correspondence
6. Ceci A, De Terlizzi M, Toma MG, et al. Heterogeneity of immunological patterns in Langerhans’ histiocytosis and response to crude calf thymic extract in 11 patients. Med Pediatr Oncol 1988;16:111Y115 7. Kelly KM, Pritchard J. Monoclonal antibody therapy in Langerhans cell histiocytosisVfeasible and reasonable? Br J Cancer 1994;70:54Y55 8. Brenner M. Current status of gene transfer into haematopoietic progenitor cells: application to Langerhans cell histiocytosis. Br J Cancer 1994;70:56Y57 9. Becker G, Bu¨cheler M, Paulsen F, et al. Multimodal treatment strategy for Langerhans cell histiocytosis at head and neck manifestations. HNO 2003;51:55Y60 10. Moralis A, Kunkel M, Kleinsasser N, et al. Intralesional corticosteroid therapy for mandibular Langerhans cell histiocytosis preserving the intralesional tooth germ. Oral Maxillofac Surg 2008;12:105Y111 11. Murata S, Yoshida Y, Adachi K, et al. Solitary, late-onset, self-healing Langerhans cell histiocytosis. Acta Derm Venereol 2011;91:103Y104 12. Cho YA, Yoon HJ, Hong SD, et al. Hypothetical pathogenesis of eosinophilic infiltration in Langerhans cell histiocytosis of the jaw. Oral Surg Oral Med Oral Pathol Oral Radiol 2013. doi:pii: S2212-4403 (13)00194-6. 10.1016/j.oooo.2013.04.012. [Epub ahead of print] 13. Nicollas R, Rome A, BelaBch H, et al. Head and neck manifestation and prognosis of Langerhans’ cell histiocytosis in children. Int J Pediatr Otorhinolaryngol 2010;74:669Y673
Management of Orbital Infections Related to Sinusitis To the Editor: We read with interest the recently published study from Kinis et al1 regarding the management of orbital infections secondary to sinusitis in children. As per authors’ discussion, bacteria causing sinusitis can penetrate into the orbit through the thin lamina papyracea of the ethmoid; however, it remains unclear why they included in their series 13 patients (50% of the sample) affected with a preseptal cellulitis. Although the authors referred to the classification proposed by Chandler in 1970,2 it is well known that the orbital septum defines the anterior boundaries of the orbital space. In fact, it is an extension of the periosteum of the periorbital bones and inserts into the tarsal plates of the lids; unless this is mechanically breached, an infection does not penetrate from front to back or vice versa through this tough structure. Accordingly, infections in front of the orbital septum (preseptal or periorbital cellulitis) should not be considered ‘‘orbital’’ infections, which instead relate to processes developing posterior to the orbital septum (post-septal or orbital cellulitis). This has an important clinical value, as the etiology and treatment of these 2 conditions is completely different. Focusing then on the group of patients with subperiosteal orbital abscesses, who the authors advocated a strict observation and a prompt diagnosis and treatment for, a number of details remain uncertain. Specifically, it was not clear whether visual acuity, ocular motility, intraocular pressure, and degree and type of proptosis were all part of the ophthalmic examination, and details concerning the preoperative and postoperative ophthalmic assessment would be of interest. Also, the criteria prompting the surgical management were not specified: some have showed how the volume of abscess and its position can guide towards medical or surgical management,3,4 while others have suggested to administer a 48-hour course of antibiotics as first-line treatment in all patients presenting with orbital complications from sinusitis unless they present at hospital admission with marked visual impairment, intracranial complications, suspected anaerobic involvement, or large abscesses which would require surgery.5 Age and type of responsible pathogen might also play a role.6,7 Finally, an important part of the management of infections in these young patients is determining the correct timing for the discharge: did
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the author repeat the CT scanning to determine the effect of the medical treatment first and surgical intervention afterwards, or did they only rely on clinical signs? Marco Carifi, MD Department of Otolaryngology A.O.R.N ‘‘A.Cardarelli’’ Naples, Italy [email protected] Gianluca Carifi, MD Moorfields Eye Hospital London, UK
REFERENCES 1. Kinis V, Ozbay M, Bakir S, et al. Management of orbital complications of sinusitis in pediatric patients. J Craniofac Surg 2013;24:1706Y1710 2. Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of orbital complications in sinusitis. Laryngoscope 1970;80:1414Y1428 3. Todman MS, Enzer YR. Medical management versus surgical intervention of pediatric orbital cellulitis: the importance of subperiosteal abscess volume as a new criterion. Ophthal Plast Reconstr Surg 2011;27:255Y259 4. Coenraad S, Buwalda J. Surgical or medical management of subperiosteal orbital abscess in children: a critical appraisal of the literature. Rhinology 2009;47:18Y23 5. Gavriel H, Yeheskeli E, Aviram E, et al. Dimension of subperiosteal orbital abscess as an indication for surgical management in children. Otolaryngol Head Neck Surg 2011;145:823Y827 6. Bedwell J, Baumann NM. Management of pediatric orbital cellulitis and abscess. Curr Opin Otolaryngol Head Neck Surg 2011;19:467Y473 7. Pena MT, Preciado D, Orestes M, et al. Orbital complications of acute sinusitis: changes in the post-pneumococcal vaccine era JAMA Otolaryngol Head Neck Surg 2013;139:223Y227
A Simple Approach to Reduction and Stabilization of Segmental Fractures of the Alveolar Housing in Complex Facial Trauma To the Editor: Segmental fractures of either the maxillary or mandibular alveolar arches can occur in isolation or as part of a more complex facial fracture pattern.1 Traditional approaches to their management have included interdental wiring and bonding, arch bars, or open reduction and internal fixation with miniplates and screws.2 Moreover, all these options share a similar complication profile with respect to deleterious effects on the periodontal soft tissues, particularly when traditional Erich arch bars are used.3 We would like to present a simple way of treating segmental fractures of the maxillary alveolar arch that aims to minimize damage to the dentition and its soft tissue elements. Occlusal splints and wafers can be fashioned easily preoperatively. The time required restoring the native occlusion is better spent in the laboratory rather than during the operation, when focus and energy can be directed to more complex surrounding fractures. The Hybrid MMF system (Stryker, MI, USA) has proven itself to be a worthy addition to our arsenal in managing maxillofacial trauma. The system consists of mandibular and maxillary rigid arch bars, functionally similar to Erich arch bars, but instead of being secured to the teeth by interdental wires, the metal arches are secured in place by self-drilling locking screws. Albeit anecdotally, but based on first principles, its improved safety profile, time-saving * 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Correspondence
6. Ceci A, De Terlizzi M, Toma MG, et al. Heterogeneity of immunological patterns in Langerhans’ histiocytosis and response to crude calf thymic extract in 11 patients. Med Pediatr Oncol 1988;16:111Y115 7. Kelly KM, Pritchard J. Monoclonal antibody therapy in Langerhans cell histiocytosisVfeasible and reasonable? Br J Cancer 1994;70:54Y55 8. Brenner M. Current status of gene transfer into haematopoietic progenitor cells: application to Langerhans cell histiocytosis. Br J Cancer 1994;70:56Y57 9. Becker G, Bu¨cheler M, Paulsen F, et al. Multimodal treatment strategy for Langerhans cell histiocytosis at head and neck manifestations. HNO 2003;51:55Y60 10. Moralis A, Kunkel M, Kleinsasser N, et al. Intralesional corticosteroid therapy for mandibular Langerhans cell histiocytosis preserving the intralesional tooth germ. Oral Maxillofac Surg 2008;12:105Y111 11. Murata S, Yoshida Y, Adachi K, et al. Solitary, late-onset, self-healing Langerhans cell histiocytosis. Acta Derm Venereol 2011;91:103Y104 12. Cho YA, Yoon HJ, Hong SD, et al. Hypothetical pathogenesis of eosinophilic infiltration in Langerhans cell histiocytosis of the jaw. Oral Surg Oral Med Oral Pathol Oral Radiol 2013. doi:pii: S2212-4403 (13)00194-6. 10.1016/j.oooo.2013.04.012. [Epub ahead of print] 13. Nicollas R, Rome A, BelaBch H, et al. Head and neck manifestation and prognosis of Langerhans’ cell histiocytosis in children. Int J Pediatr Otorhinolaryngol 2010;74:669Y673
Management of Orbital Infections Related to Sinusitis To the Editor: We read with interest the recently published study from Kinis et al1 regarding the management of orbital infections secondary to sinusitis in children. As per authors’ discussion, bacteria causing sinusitis can penetrate into the orbit through the thin lamina papyracea of the ethmoid; however, it remains unclear why they included in their series 13 patients (50% of the sample) affected with a preseptal cellulitis. Although the authors referred to the classification proposed by Chandler in 1970,2 it is well known that the orbital septum defines the anterior boundaries of the orbital space. In fact, it is an extension of the periosteum of the periorbital bones and inserts into the tarsal plates of the lids; unless this is mechanically breached, an infection does not penetrate from front to back or vice versa through this tough structure. Accordingly, infections in front of the orbital septum (preseptal or periorbital cellulitis) should not be considered ‘‘orbital’’ infections, which instead relate to processes developing posterior to the orbital septum (post-septal or orbital cellulitis). This has an important clinical value, as the etiology and treatment of these 2 conditions is completely different. Focusing then on the group of patients with subperiosteal orbital abscesses, who the authors advocated a strict observation and a prompt diagnosis and treatment for, a number of details remain uncertain. Specifically, it was not clear whether visual acuity, ocular motility, intraocular pressure, and degree and type of proptosis were all part of the ophthalmic examination, and details concerning the preoperative and postoperative ophthalmic assessment would be of interest. Also, the criteria prompting the surgical management were not specified: some have showed how the volume of abscess and its position can guide towards medical or surgical management,3,4 while others have suggested to administer a 48-hour course of antibiotics as first-line treatment in all patients presenting with orbital complications from sinusitis unless they present at hospital admission with marked visual impairment, intracranial complications, suspected anaerobic involvement, or large abscesses which would require surgery.5 Age and type of responsible pathogen might also play a role.6,7 Finally, an important part of the management of infections in these young patients is determining the correct timing for the discharge: did
1136
& Volume 25, Number 3, May 2014
the author repeat the CT scanning to determine the effect of the medical treatment first and surgical intervention afterwards, or did they only rely on clinical signs? Marco Carifi, MD Department of Otolaryngology A.O.R.N ‘‘A.Cardarelli’’ Naples, Italy [email protected] Gianluca Carifi, MD Moorfields Eye Hospital London, UK
REFERENCES 1. Kinis V, Ozbay M, Bakir S, et al. Management of orbital complications of sinusitis in pediatric patients. J Craniofac Surg 2013;24:1706Y1710 2. Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of orbital complications in sinusitis. Laryngoscope 1970;80:1414Y1428 3. Todman MS, Enzer YR. Medical management versus surgical intervention of pediatric orbital cellulitis: the importance of subperiosteal abscess volume as a new criterion. Ophthal Plast Reconstr Surg 2011;27:255Y259 4. Coenraad S, Buwalda J. Surgical or medical management of subperiosteal orbital abscess in children: a critical appraisal of the literature. Rhinology 2009;47:18Y23 5. Gavriel H, Yeheskeli E, Aviram E, et al. Dimension of subperiosteal orbital abscess as an indication for surgical management in children. Otolaryngol Head Neck Surg 2011;145:823Y827 6. Bedwell J, Baumann NM. Management of pediatric orbital cellulitis and abscess. Curr Opin Otolaryngol Head Neck Surg 2011;19:467Y473 7. Pena MT, Preciado D, Orestes M, et al. Orbital complications of acute sinusitis: changes in the post-pneumococcal vaccine era JAMA Otolaryngol Head Neck Surg 2013;139:223Y227
A Simple Approach to Reduction and Stabilization of Segmental Fractures of the Alveolar Housing in Complex Facial Trauma To the Editor: Segmental fractures of either the maxillary or mandibular alveolar arches can occur in isolation or as part of a more complex facial fracture pattern.1 Traditional approaches to their management have included interdental wiring and bonding, arch bars, or open reduction and internal fixation with miniplates and screws.2 Moreover, all these options share a similar complication profile with respect to deleterious effects on the periodontal soft tissues, particularly when traditional Erich arch bars are used.3 We would like to present a simple way of treating segmental fractures of the maxillary alveolar arch that aims to minimize damage to the dentition and its soft tissue elements. Occlusal splints and wafers can be fashioned easily preoperatively. The time required restoring the native occlusion is better spent in the laboratory rather than during the operation, when focus and energy can be directed to more complex surrounding fractures. The Hybrid MMF system (Stryker, MI, USA) has proven itself to be a worthy addition to our arsenal in managing maxillofacial trauma. The system consists of mandibular and maxillary rigid arch bars, functionally similar to Erich arch bars, but instead of being secured to the teeth by interdental wires, the metal arches are secured in place by self-drilling locking screws. Albeit anecdotally, but based on first principles, its improved safety profile, time-saving * 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
