Letters to the Editor Typical changes in the viscerocranium in acromegaly
50 %, the sinus frontalis enlargement shows no difference. That means that there are as many normal patients who have a very large sinus frontalis as acromegaly patients, so that there is no specific change in these patients. Of course in the treatment of the acromegalic face, the changes of the neuro- and viscero-cranium have to be considered.
Sir, Regarding the recent article by Kiinzler and Farmand J. Cranio-Max.-Fac. Surg. 19 (1991) 332, regarding'Typical changes in the viscerocranium in acromegaly ', one is always disappointed to see an incomplete article. The article obviously has much more to do with the mandible and probably should be titled such. No comment has been made regarding the cranial changes other than basically in the summary, where the statement is made 'although several remarkable changes of the facial skeleton were observed, statistically significant changes could be found only in the lower jaw,' and they do state in the introduction that they were looking for changes related to acromegaly in lateral cephalometry of the entire skull. "Yet it does not seem that any discussion was given to the area of the frontal sinus. In an article in your journal, Volume 17, 2-8, Ian Jackson discusses the forehead deformity. That forehead deformity was previously discussed by him in an article in the Journal of the American Medical Association, Volume 253, 682, 1985. That surgical treatment was first described, I believe, by myself and Dr Penoff in the Annals of Plastic Surgery, Volume 7, 68, 1981. There is no question in my mind that this is not a rare deformity. In fact in looking at the articles by Ktinzler and Farmand, I could not help but wonder if the patients in Figures 5b and 6 did not indeed show frontal sinus hypertrophy typical of the condition, as well as the patients in Figure 4b and 4c when seen from the lateral view. Certainly frontal deformities are not present in all cases but it is frequent enough to warrant its recognition.
Priv. -Doz. M. Farmand, DDS, MD Erlangen Germany
Surgical treatment of facial dog bite injuries in children Sir, After reading the interesting article by Lackmann et al. J. ofCranio-Max.-Fac. Surg. 20 (1992) 81 entitled: Surgical treatment of facial dog bite injuries in children, I remembered having read another article focussing on the dangers of dog bites, caused by other Gram-negative-microorganisms: Capnocytophaga canimorsus (Cc) (Krol-Van Straaten and De Maat, 1991). Infection with Cc can cause fulminating septicaemia, serious peripheral gangrene, meningitis, endocarditis and arthritis• The interval between the bite and symptoms of disease is usually less than 8 days, but may be longer. Predisposing factors are asplenia, alcohol abuse and corticosteroid medication; but also in previously healthy patients a fulminant course may develop. Mortality is about 30 % (Kullberg et al., 1991). Prophylactic antibiotic treatment is indicated in cases with these predisposing factors, and seems advisable in a wider sense.
Prof. D. K. Ousterhout, MD, DDS, PhD San Francisco USA
P. A. Van Damme, MD, DMD Nijmegen The Netherlands
Reply, Letters to the Editor give the opportunity to repeat already published data. Therefore, we thank Dr Ousterhout for his letter regarding our article 'Typical changes in the viscerocranium in acromegaly'. Regarding the anatomical differentiation between the viscerocranium and neurocranium, we have published in the present paper only the changes in the middle and lowerface, since we have not emphasised the treatment of the acromegalic changes. Although there are several changes, such as the 'hanging columella', statistically significant changes in these two facial parts could indeed only be found in the lower jaw. As we have written in our introduction, the findings in the neurocranium, and thus the changes of the forehead, have been published in a previous paper (Farmand et al., 1991). In that paper we have evaluated metrically the following parameters: length and depth of the sella, thickness of the calvarium, prominence of the supraorbital rim, surface of the pneumatisation of the mastoid cells and of the frontal sinus. The difference between the acromegaly group and the control group was also analysed statistically. Depth and length of the sella and thickness of the calvarium show a difference of over 70 % between the acromegaly patients and false positive changes in the control group. The supraorbital rim differs in about
References Krol-Van Straaten, M. d., C. E. M. De Maat : Purpura fulminans en perifeer gangreen na een hondebeet. Ned. Tijdschr. Geneeskd. 135 (1991) 2449 Kullberg, B. d., R. G. J. Westendorp, J. W. van 't Wout, A. E. Meinders: Purpura fulminans and symmetrical peripheral gangrene caused by Capnocytophaga canimorsus (formerly DF-2) septicaemia--a complication of dog bite. Medicine (Baltimore) 70 (1991) 287-292 Lackmann, G-M., W. Draf, G. Isselstein, U. T6llner: Surgical treatment of facial dog bite injuries in children. J. CranioMax.-Fac. Surg. 20 (1992) 81-86
Sir, I read the article by Drs Lackmann, Draf, Isselstein and T6llner on the surgical treatment of facial dog bite injuries in children with great interest. One detail, which surprised me though, was the position of the suction drain, which was placed in the middle of the right cheek of a 6-year-old child (Fig. 2b). Did the authors have any specific reason for doing so? If not, why didn't they lead it out post-auricularly? Shouldn't basic principles 362
Letters to the Editor 363 of aesthetic facial surgery be respected by all specialities operating in the cervicofacial area ? '
Ch. loannides, MD, DMD, PhD Leuven Belgium Reply, We express our thanks for the interest in, and favourable response to, our article concerning the surgical treatment of facial dog bite injuries in children. The incidence of wound infection following facial dog bites is only 4 % (Callaham, 1978): Today, infection with organisms of the normal flora of the dog's mouth and throat are most frequent (Arons et a l . , 1982). Staphylococcus aureus (70 %), Pasteurella multocida (30-50%), and anaerobic cocci (40%) are the top-ranking agents. Marcy (1982) and Dankner et al. (1987) described for the first time infections with DF-2 (Dysgonic fermenter-2, also called Capnocytophago canimorsus) following dog bite injuries in children. As stated in the Letter to the Editor of Van Damme, DF-2 normally infects only patients with any type of immunodeficiency, but the predisposing factors listed in this letter, although quite common in adults, are very rare in childhood. Based upon similar considerations to those of Van Damme, and t h e experience of their case report, Dankner et ah recommended that all children with dog bite injuries be treated like patients with immunodeficiencies. In contradistinction, we hold, according to Job et al. (1989) and Kenevan et al. (1985) that, in view of the rarity of infection with DF-2 and of unrecognized immunodeficiencies in childhood (Laekmann et al., 1990), antibiotics are not indicated in principle. Such therapy only should be administered either under the conditions described in our article or in the case of proven infection with DF-2. Moreover, it must be taken into account that severe complications of infected dog bite injuries are very rare. The only and most dangerous complication found in the literature (Klein and Cohen, 1978) was a brain abscess
caused by Pasteurella multocida following a dog bite injury (stage IV B according to our classification). The loannides' question can only be answered with the intraoperative situation of our patient A.D., male, ~ years. He suffered a 6 cm long, arched, partly gaping, partly lacerated, strongly bleeding and spurting wound, extending from the left upper auricle to the tragus with involvement of the posterior cheek. A different positioning of the suctiondrain was not possible intraoperatively. Of course, especially in the case of facial injuries, basic principles of aesthetic plastic surgery should be respected as stated in our article.
Dr Med. G.-M. Lackmann Fulda Germany
References Arons, M. S.~ L. Fernando, I. M. Polayes : Pasteurella multocidaThe major cause of hand infections following domestic animal bites. J Hand Surg 7 (1982) 4%52 Callaham, M. L. : Treatment of common dog bites : Infection risk factors. JACEP 7 (1978) 83-87 Dankner, W. M., C. E. Davis, M. A. Thompson ." DF-2 bacteriemia following a dog bite in a 4-months-old child. Pediatr Infect Dis J 6 (1987) 695-669 Job, L., J. T. Horman, J. K. Grigor, E. Israel: Dysgonic fermenter-2: A clinico-epidemiologic review. J. Emerg Med 7 (1989) 185-192 Kenevan, R. J., Y. D. Rich, V. GottIieb, A. G. Muench." A dog bite injury with involvement of cranial content: Case report. Milit Med 150 (1985) 502-50 Klein, D. M., M. F. Cohen: Pasteurella multocida brain abscess following perforating cranial dog bite. J Pediatr 92 (1978) 588-9 Lackmann, G. M., U. Tdllner, K. Knobloch ." 'Chirurgisch kranke' Kinder in einer Kinderklinik--Neudiagnosen im Rahmen der p~idiatrischen Betreuung. Kinderarzt 21 (1990) 1053-1057 Marcy, S. M. : Infections due to dog and cat bites. Pediatr Infect Dis 1 (1982) 351-356
Erratum Please n o t e t h a t the w o r d ' i n c i d e n c e ' s h o u l d have r e a d ' p r e v a l e n c e ' t h r o u g h o u t the text o f the following article:
Some epidemiological data on oral clefts in the northern Netherlands M a r t i n a C. Cornel, J o h a n n a A. Spreen, I d a Meijer, P a u l H. M. S p a u w e n , Bal K. D h a r , L e o P. ten K a t e J o u r n a l o f C r a n i o - M a x i l l o - F a c i a l S u r g e r y (1992) 20, 147-152
50 %, the sinus frontalis enlargement shows no difference. That means that there are as many normal patients who have a very large sinus frontalis as acromegaly patients, so that there is no specific change in these patients. Of course in the treatment of the acromegalic face, the changes of the neuro- and viscero-cranium have to be considered.
Sir, Regarding the recent article by Kiinzler and Farmand J. Cranio-Max.-Fac. Surg. 19 (1991) 332, regarding'Typical changes in the viscerocranium in acromegaly ', one is always disappointed to see an incomplete article. The article obviously has much more to do with the mandible and probably should be titled such. No comment has been made regarding the cranial changes other than basically in the summary, where the statement is made 'although several remarkable changes of the facial skeleton were observed, statistically significant changes could be found only in the lower jaw,' and they do state in the introduction that they were looking for changes related to acromegaly in lateral cephalometry of the entire skull. "Yet it does not seem that any discussion was given to the area of the frontal sinus. In an article in your journal, Volume 17, 2-8, Ian Jackson discusses the forehead deformity. That forehead deformity was previously discussed by him in an article in the Journal of the American Medical Association, Volume 253, 682, 1985. That surgical treatment was first described, I believe, by myself and Dr Penoff in the Annals of Plastic Surgery, Volume 7, 68, 1981. There is no question in my mind that this is not a rare deformity. In fact in looking at the articles by Ktinzler and Farmand, I could not help but wonder if the patients in Figures 5b and 6 did not indeed show frontal sinus hypertrophy typical of the condition, as well as the patients in Figure 4b and 4c when seen from the lateral view. Certainly frontal deformities are not present in all cases but it is frequent enough to warrant its recognition.
Priv. -Doz. M. Farmand, DDS, MD Erlangen Germany
Surgical treatment of facial dog bite injuries in children Sir, After reading the interesting article by Lackmann et al. J. ofCranio-Max.-Fac. Surg. 20 (1992) 81 entitled: Surgical treatment of facial dog bite injuries in children, I remembered having read another article focussing on the dangers of dog bites, caused by other Gram-negative-microorganisms: Capnocytophaga canimorsus (Cc) (Krol-Van Straaten and De Maat, 1991). Infection with Cc can cause fulminating septicaemia, serious peripheral gangrene, meningitis, endocarditis and arthritis• The interval between the bite and symptoms of disease is usually less than 8 days, but may be longer. Predisposing factors are asplenia, alcohol abuse and corticosteroid medication; but also in previously healthy patients a fulminant course may develop. Mortality is about 30 % (Kullberg et al., 1991). Prophylactic antibiotic treatment is indicated in cases with these predisposing factors, and seems advisable in a wider sense.
Prof. D. K. Ousterhout, MD, DDS, PhD San Francisco USA
P. A. Van Damme, MD, DMD Nijmegen The Netherlands
Reply, Letters to the Editor give the opportunity to repeat already published data. Therefore, we thank Dr Ousterhout for his letter regarding our article 'Typical changes in the viscerocranium in acromegaly'. Regarding the anatomical differentiation between the viscerocranium and neurocranium, we have published in the present paper only the changes in the middle and lowerface, since we have not emphasised the treatment of the acromegalic changes. Although there are several changes, such as the 'hanging columella', statistically significant changes in these two facial parts could indeed only be found in the lower jaw. As we have written in our introduction, the findings in the neurocranium, and thus the changes of the forehead, have been published in a previous paper (Farmand et al., 1991). In that paper we have evaluated metrically the following parameters: length and depth of the sella, thickness of the calvarium, prominence of the supraorbital rim, surface of the pneumatisation of the mastoid cells and of the frontal sinus. The difference between the acromegaly group and the control group was also analysed statistically. Depth and length of the sella and thickness of the calvarium show a difference of over 70 % between the acromegaly patients and false positive changes in the control group. The supraorbital rim differs in about
References Krol-Van Straaten, M. d., C. E. M. De Maat : Purpura fulminans en perifeer gangreen na een hondebeet. Ned. Tijdschr. Geneeskd. 135 (1991) 2449 Kullberg, B. d., R. G. J. Westendorp, J. W. van 't Wout, A. E. Meinders: Purpura fulminans and symmetrical peripheral gangrene caused by Capnocytophaga canimorsus (formerly DF-2) septicaemia--a complication of dog bite. Medicine (Baltimore) 70 (1991) 287-292 Lackmann, G-M., W. Draf, G. Isselstein, U. T6llner: Surgical treatment of facial dog bite injuries in children. J. CranioMax.-Fac. Surg. 20 (1992) 81-86
Sir, I read the article by Drs Lackmann, Draf, Isselstein and T6llner on the surgical treatment of facial dog bite injuries in children with great interest. One detail, which surprised me though, was the position of the suction drain, which was placed in the middle of the right cheek of a 6-year-old child (Fig. 2b). Did the authors have any specific reason for doing so? If not, why didn't they lead it out post-auricularly? Shouldn't basic principles 362
Letters to the Editor 363 of aesthetic facial surgery be respected by all specialities operating in the cervicofacial area ? '
Ch. loannides, MD, DMD, PhD Leuven Belgium Reply, We express our thanks for the interest in, and favourable response to, our article concerning the surgical treatment of facial dog bite injuries in children. The incidence of wound infection following facial dog bites is only 4 % (Callaham, 1978): Today, infection with organisms of the normal flora of the dog's mouth and throat are most frequent (Arons et a l . , 1982). Staphylococcus aureus (70 %), Pasteurella multocida (30-50%), and anaerobic cocci (40%) are the top-ranking agents. Marcy (1982) and Dankner et al. (1987) described for the first time infections with DF-2 (Dysgonic fermenter-2, also called Capnocytophago canimorsus) following dog bite injuries in children. As stated in the Letter to the Editor of Van Damme, DF-2 normally infects only patients with any type of immunodeficiency, but the predisposing factors listed in this letter, although quite common in adults, are very rare in childhood. Based upon similar considerations to those of Van Damme, and t h e experience of their case report, Dankner et ah recommended that all children with dog bite injuries be treated like patients with immunodeficiencies. In contradistinction, we hold, according to Job et al. (1989) and Kenevan et al. (1985) that, in view of the rarity of infection with DF-2 and of unrecognized immunodeficiencies in childhood (Laekmann et al., 1990), antibiotics are not indicated in principle. Such therapy only should be administered either under the conditions described in our article or in the case of proven infection with DF-2. Moreover, it must be taken into account that severe complications of infected dog bite injuries are very rare. The only and most dangerous complication found in the literature (Klein and Cohen, 1978) was a brain abscess
caused by Pasteurella multocida following a dog bite injury (stage IV B according to our classification). The loannides' question can only be answered with the intraoperative situation of our patient A.D., male, ~ years. He suffered a 6 cm long, arched, partly gaping, partly lacerated, strongly bleeding and spurting wound, extending from the left upper auricle to the tragus with involvement of the posterior cheek. A different positioning of the suctiondrain was not possible intraoperatively. Of course, especially in the case of facial injuries, basic principles of aesthetic plastic surgery should be respected as stated in our article.
Dr Med. G.-M. Lackmann Fulda Germany
References Arons, M. S.~ L. Fernando, I. M. Polayes : Pasteurella multocidaThe major cause of hand infections following domestic animal bites. J Hand Surg 7 (1982) 4%52 Callaham, M. L. : Treatment of common dog bites : Infection risk factors. JACEP 7 (1978) 83-87 Dankner, W. M., C. E. Davis, M. A. Thompson ." DF-2 bacteriemia following a dog bite in a 4-months-old child. Pediatr Infect Dis J 6 (1987) 695-669 Job, L., J. T. Horman, J. K. Grigor, E. Israel: Dysgonic fermenter-2: A clinico-epidemiologic review. J. Emerg Med 7 (1989) 185-192 Kenevan, R. J., Y. D. Rich, V. GottIieb, A. G. Muench." A dog bite injury with involvement of cranial content: Case report. Milit Med 150 (1985) 502-50 Klein, D. M., M. F. Cohen: Pasteurella multocida brain abscess following perforating cranial dog bite. J Pediatr 92 (1978) 588-9 Lackmann, G. M., U. Tdllner, K. Knobloch ." 'Chirurgisch kranke' Kinder in einer Kinderklinik--Neudiagnosen im Rahmen der p~idiatrischen Betreuung. Kinderarzt 21 (1990) 1053-1057 Marcy, S. M. : Infections due to dog and cat bites. Pediatr Infect Dis 1 (1982) 351-356
Erratum Please n o t e t h a t the w o r d ' i n c i d e n c e ' s h o u l d have r e a d ' p r e v a l e n c e ' t h r o u g h o u t the text o f the following article:
Some epidemiological data on oral clefts in the northern Netherlands M a r t i n a C. Cornel, J o h a n n a A. Spreen, I d a Meijer, P a u l H. M. S p a u w e n , Bal K. D h a r , L e o P. ten K a t e J o u r n a l o f C r a n i o - M a x i l l o - F a c i a l S u r g e r y (1992) 20, 147-152
