chronically ill children with acute sinusitis Inpatient therapy should be considered for toxic-appearing children, those with facial swelling, or children with suspected or confirmed intracranial extension The AAP recommendations for sinusitis treatment are summarized in e-Table 94.5 Standard precautions should be used Mastoiditis Mastoiditis, an infection of the mastoid air cells, is a rare complication of acute otitis media The most common organism is pneumococcus, followed by S aureus, GAS, and Pseudomonas; historically, Hib has also been implicated The most common signs are fever, ear proptosis, and postauricular redness, pain, and swelling; the tympanic membrane is usually erythematous and bulging Complications can include intracranial extension of the abscess, damage to the facial nerve, labyrinthitis, bacteremia, and osteomyelitis The diagnosis is confirmed by CT of the temporal bone Tympanocentesis cultures reflect etiology of mastoiditis in approximately 50% of cases Treatment is a combination of medical and surgical management Empiric antibiotics should target streptococci and staphylococci In regions where MRSA and penicillin-resistant pneumococci are common, a reasonable regimen would include vancomycin and a third-generation cephalosporin Standard precautions should be used Orbital Cellulitis Orbital cellulitis is an infection posterior to the orbital septum caused primarily by S aureus, streptococci, pneumococcus, and nontypeable H influenzae The most common signs are fever, proptosis, limited ocular range of motion, pain with eye motion, chemosis, and an afferent pupillary defect Blood cultures should be obtained; LP should be considered for young infants and for children with signs of meningitis Contrasted CT of the orbit and brain confirms the diagnosis and allows for evaluation for intracranial extension, which would alter antibiotic management Many children with uncomplicated orbital cellulitis are managed medically; however, early consultation with surgical subspecialists would be advised Empiric antibiotic selection should cover the same organisms as for mastoiditis; if intracranial extension is not evident on CT, substitution of vancomycin for clindamycin can ease the transition of a child from parental to an entirely oral regimen after clinical improvement even if an isolate is not recovered Indications for operative management include intracranial extension, visual loss, or optic nerve dysfunction Standard precautions should be used Botulism Botulism is a neurotoxic disorder caused by Clostridium botulinum that causes a descending flaccid paralysis The most common pediatric manifestation is infantile botulism, most common in children under months of age, caused by ingestion of spores; botulism is the reason that honey is not recommended for infants Affected infants have decreased movement, bulbar nerve palsies, expression-less facies, loss of head control, and descending hypotonia Diagnosis is confirmed by isolation of toxin or spores from stool The mainstay of treatment is supportive therapy; intubation may be necessary Infants with botulism should immediately receive botulism immune globulin (BabyBIG) intravenously Antibiotics are not indicated for infantile botulism, and aminoglycosides may worsen the toxin’s paralytic effects Older patients with wound botulism after penetrating or crush trauma should receive penicillin or metronidazole after receiving an equine-derived Heptavalent Botulinum Antitoxin (HBAT) Standard precautions should be used TABLE 94.11 TETANUS PROPHYLAXIS FOR PATIENTS WITH WOUNDS OR BITES Tetanus Tetanus is caused by another neurotoxin in the Clostridium family, Clostridium tetani Spores are ubiquitous in the environment and can contaminate wounds of unimmunized or underimmunized persons Neonatal tetanus is most