. OSTEOMYELITIS OF THE MAXILLA IN INFANCYBY

J. C. HAWORTH

(From the Children's Hospital, and the Department of Child Health, Birmingham)

Acute suppurative infection in infancy is ofpeculiar interest in the special clinical featuresaccording to (a) the bacteriology, and (b) thelocalization. Osteomyelitis is by no means a rarityin the early months of life. The staphylococcus isa prevalent micro-organism, and its mode of entryinto the tissue is often difficult to trace; but fortu-nately a prompt cellular defence is rapidly mobilized,and, with the advent of chemotherapy, and anti-biotic remedies, recovery from such infection is nowvery much more hopeful. Acute osteomyelitis ofthe maxilra is an example; it may occur in the earlyweeks of infancy. During the past fifteen monthsfive cases of this condition have been admitted tothe Children's Hospital, Birmingham, and this shortpaper is a record of their progress.

The local anatomy is of some interest; the antrumis present at birth, and the superior maxilla is ahighly vascular area of diploic bone, having as itsupper boundary the lower border of the orbit, andextending down to the dental ridge containing theprimordial follicles in which are embryonic teethenclosed within a vascular bed. The infectingorganism may gain entrance to the superior maxillain a variety of ways: (1) from the adjacent maxillaryantrum, which in infancy is always very prone toinfection; (2) from the lachrymal duct and sac;(3) from a primary infection of the embryonic teethfollicles, which may occur from the blood stream orby trauma to the overlying gum occurring at, orsoon after, birth. It is in the latter way that infec-tion occurred in two of the following cases, as theinfected dental radicle was removed surgically.This of course disturbs the primary dentition, andoccasionally the permanent dentition may also beaffected.

Jacoby and Sagorin have recently reviewed thesubject and recorded the favourable progress inthree cases. Their commentary on the treatmentis important, especially in regard to the desirableminimal surgical attention, bearing in mind that thedental areas may suffer interference; also cosmeticeffects must be'kept in mind. These authors havenoted the remarkable and rapid effects of penicillinin this particular disease; healing was obtained inone or two weeks, as compared with an illness ofmonths' duration and high mortality with formerlines of treatment.

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Case ReportsCase 1. A male baby of four weeks, breast-fed,

was admitted to hospital because three dayspreviously the mother had noticed a swelling on theleft side of his face and over the eye. Thereappeared to be some discharge from the eye and thenose on the same side. No diarrhoea or vomitingwas present.EXAMINATION. The baby weighed 5 lb. 9 oz.

There was proptosis of the left eye, chemosis, andsome purulent discharge from the lachrymal duct.The left cheek was reddened and markedly swollen,and gentle pressure caused a purulent discharge tocome from the left nostril. A small sinus wasdischarging in the left alveolus. Temperature was1010 F., and the pulse rate 148 per minute.TREATMENT. Penicillin, 1,500 units three-hourly,

was given intramuscularly, and sulphadiazine,04 g., followed by 02 g., six-hourly. The baby'scondition improved, and forty-eight hours later asmall incision was made over the left alveolus and adiseased tooth follicle was removed. A largeamount of pus was evacuated, and the swellingappeared to diminish in size and become much lesstense. Culture of the pus revealed a heavy growthof staphylococcus aureus. In a further forty-eighthours there was a vast improvement, and penicillintreatment ceased. In still another forty-eight hoursthe swelling of the face had disappeared; the babycould open and close the eye. Twenty-four hourslater there was slight recurrence of swelling in thecheek below the left eye, and another twenty-fourhours' course of penicillin was given, with theresult that the signs of local infection completelysubsided and the baby was discharged clinicallywell six weeks after admission. A total of 120,000units of penicillin was given in the first course, and156,000 units in the second course.Case 2. A male baby, aged four weeks, had

been ill for ten days before admission to hospital,the parents having noticed a swelling below the lefteye for several days.EXAMINATION. A small dehydrated. infant,

weighing 7 lb. 9 oz., had a firm smooth swellingin the left srde of the face which seemed to involvethe whole maxilla. This swelling extended into themouth and the palate on the left side, where therewas a small discharging sinus. There was markedconjunctivitis and chemosis on the same side. Nodiarrhoea or vomiting was present.TREATMENT. On tle date of admission free

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ARCHIVES OF DISEASE IN CHILDHOOD

drainage was established by opening into the leftside of the palate and alveolus. Thick pus wasreleased. Culture showed haemolytic staphylo-coccus aureus, and a few pneumococci. Intra-muscular penicillin, 1,500 units three-hourly, wasgiven over a period of five days, and penicillin wasapplied locally for a few days. The inflammatoryswelling- quickly subsided; the incision healed, andrapid clinical progress was made. The baby wasdischarged from hospital after a stay of fifteen days.A total dose of 96,000 units of penicillin was givenover eight days.Case 3. A male baby, aged seven weeks, who

had been artificially fed, had had a septic fingerduring the first week of life, and a swelling belowthe left eye had developed ten days before admissionto the Children's Hospital. The child was referredfrom the Birmingham and Midland Eye Hospitalwith a history of a left-sided nasal discharge andswelling of the left cheek and left upper alveolus.Penicillin had been given, and an incision made intothe lower lid.EXAMINATION. The baby was well nourished,

weighed 7 lb. 12 oz., and had a temperature of100° F., and a pulse rate of 130. There was aswelling under the left lower lid, and pressure overthis area caused a blood-stained serous dischargeto appear from the nostril. There was no diarrhoeaor vomiting.TREATMENT. An incision was made over the left

upper alveolar labial fold, and thick pus evacuated.Cultures gave a heavy growth of staphylococcusaureus. Several small sequestra were removed.From the lateral nasal wall and the region of thezygoma one infected dental radicle was enucleated.Intramuscular penicillin was continued, 1,500 units,three-hourly, for six days. The baby made favour-able progress and the swelling rapidly subsided.After seventeen days' treatment in the Children'sHospital the baby was discharged home clinicallyrecovered and gaining weight satisfactorily.

Case 4. A male baby, aged twelve weeks, hadbeen breast-fed for one month, and weighed11 lb. 7 oz. Twenty-four hours before admissionhe became extremely frefful, and a few hours laterit was noticed that the left eye was swollen, and thisgradually became worse during the day. There wasno diarrhoea or vomiting.EXAMINATION. The baby was pale but well

nourished, with marked oedema and swelling aboutthe left cheek and eyelid; the left eye appearedpartly proptosed and the conjunctival sac purulent.There was a sinus discharging thick pus in the upperleft alveolar region, and also a purulent dischargefrom the left nostril.TREATmENT. Penicillin, 20,000 units, was given

intramuscularly three-hourly; this was later reducedto 8,000 units. Sulphadiazine was also given. Onthe same day the alveolus was opened up a littleand pus allowed to escape, and the diseased toothradicle was removed. Culture of the pus grewhaemolytic staphylococcus ftureus. In forty-eight

hours the swelling diminished; the eyelids were stillvery oedematous. Temperature became normal,and forty-eight hours later the swelling practicallydisappeared though it recurred slightly round theeye two days later, and a course of 20,000 units ofpenicillin was again given for forty-eight hours.The baby was discharged from hospital seventeendays from the date of admission; he was clinically-well. (See Plate III.)

Case 5. A female baby, aged fifteen weeks, hadpreviously been well and, fed on a milk and watermixture, had reached the weight of 14 lb. 5 oz.A few days after the baby had had a ' cold ' someswelling of the left face and eye was noticed.EXAMINATION. A well-nourished infant, with

obvious proptosis of the left eye and gross oedemaspreading down to the lower part of the face, hadsigns of bronchitis, a temperature of 1030 F., apulse rate of 160, and respiration rate 60. Osteo-myelitis of the left maxilla was diagnosed.TREATM2NT. Penicillin, 10,000 units three-hourly

intramuscularly, and sulphadiazine 0 5 g. six-hourlyorally, were given on admission, and the generalcondition began to improve. After three days therewas less oedema of the face, but a small incisionwas made in the nasal side of the maxilla andpurulent fluid was evacuated. Radiographs showedthat the ethmoids were dim. After eight days- oftreatment the temperature subsided and the swellingwas much less. The baby's condition was poor, andthere were frequent watery stools. Three days latervomiting occurred and became severe, and deteriora-tion set in with rapid loss of weight. Signs ofnasopharyngitis and otitis media appeared. Bilateralmyringotomy was performed but no pus wasobtained. Intravenous fluid supplements weregiven, and 50 c.cm. of fresh blood transfused.Unfortunately the ' gastro-enteritis ' persisted. Afew days later right mastoidectomy was performedunder local anaesthesia. The general state deteri-orated further and death occurred thirty days fromthe beginning of the illness. Post-mortem examina-tion showed left mastoiditis and haemorrhage, andtoxic fatty changes in the liver and myocardium.

DiscussionThe bacteriology in these cases was essentially

that of a haemolytic staphylococcus aureus. Aninfected tooth radicle was removed in two cases,and it was in this infected radicle that the infectionpresumably started, having been carried thereprobably by the blood stream, as suggested byJacoby and Sagorin (1945).With the exception of one case (which was

complicated by mastoid infection and a generalizedtoxaemia giving rise to enteritis and fatty changes inthe liver and heart, and which eventually provedfatal) the infection was essentially a local one andwas effectively cured by chemothefapy and aminimum of surgery to create free drainage.

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OSTEOMYELITIS OF THE MAXILLA 177In view of the known susceptibility of infants of

this age to develop gastro-enteritis in conjunctionwith parenteral infections, it is interesting that in allthe cases excepting the fifth there was no diarrhoeaor vomiting. This bears out the impression thatthe most obvious and frankly purulent infectionsin infancy, such as osteomyelitis, empyema, etc., donot tend to give rise to such severe alimentarydisturbances as the more concealed neonatalinfections of the middle ears, sinuses, mastoid antra,and umbilicus.

I am indebted to the Physicians and Surgeons ofthe Children's Hospital, Birmingham, for permissionto publish -these cases, and to Dr. A. V. Neale andMr. Stirk Adams who have kindly reviewed thispaper.

REFERENCE

Jacoby, N. M., and Sagorin, L. (1945). Arch. Dis.Childh., 20, 166.

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ABSORPTION COLLAPSE BY STANLEY GRAHAM AND JAMES H. HUTCHISON 187

(j). Antero-posterior view showing obstructiveemphysema of the left lower lobe, with return ofmediastinium to the normal position (case 6).

(k).-Showing cylindrical bronchiectasis of theleft lower lobe, with narrowing of the left mainbronchus (case 6).

OSTEOMYELITIS OF THE MAXILLA IN INFANCY BY J. C. HAWORTH

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PLATE HII

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