Osteomyelitis of the Maxilla Secondary to Periorbital Cellulitis

in a Neonate: A Case Report

Osteomielitis del maxilar secundaria a celulitis periorbitaria en un

neonato: reporte de un caso

Revista Ecuatoriana de Pediatría

Editorial: Sociedad Ecuatoriana de Pediatría (Núcleo de Quito, Ecuador)

Tipo de estudio: Reporte de Caso

Área de estudio: Pediatría

Páginas: 45-51

Codígo DOI: https://doi.org/10.52011/RevSepEc/e351

URL: https://rev-sep.ec/index.php/johs/article/view/351

RESUMEN

La osteomielitis es la infección del tejido y médula ósea, causado principalmente por bacterias, microorganis-

mos que pueden diseminarse por tres vías: hematógena, por contigüidad o directa. En la etapa neonatal es

una entidad grave y poco frecuente, que puede causar secuelas osteoarticulares permanentes, presentándose

en esta etapa de la vida con características etiopatogénicas e histológicas diferentes a las presentaciones en

otros grupos etarios. Su presentación en el macizo facial es poco y puede ser secundaria a infecciones de

tejidos blandos de la cara. Se presenta el caso de un neonato femenino de 20 días de vida que desencadenó

osteomielitis del maxilar superior secundaria a celulitis facial y periorbitaria, con determinación de Staphylo-

cocus aureus en hemocultivos y secreción ocular, manejado con cobertura antibiótica de amplio espectro y

manejo quirúrgico expectante, con evolución clínica favorable, en seguimiento actual por ambulatorio.

Palabras clave: Celulitis periorbitaria, osteomielitis, neonatal, infección bacteriana, celulitis.

ABSTRACT

Osteomyelitis is an infection of bone tissue and bone marrow, primarily caused by bacteria, which may spread

through three main routes: hematogenous dissemination, contiguous spread, or direct inoculation. In the neo-

Jean Carlos Delgado Macías

, Miguel Ángel Hernández Cedeño

, Ambar Noemi Armijos Cevallos

Alex Villalta Herrera

, Aurora Chávez Veliz

, Reyma Mosquera Peña

Reporte de Caso

1. Resident Physician in Pediatrics, Hospital de Niños Dr. Roberto Gilbert Elizalde, Guayaquil, Ecuador.

2. Resident Physician in Pediatrics, Hospital de Niños Dr. Roberto Gilbert Elizalde, Guayaquil, Ecuador.

3. Resident Physician in Pediatrics, Hospital de Niños Dr. Roberto Gilbert Elizalde, Guayaquil, Ecuador.

4. Attending Physician, Department of Diagnostic Imaging, Hospital de Niños Dr. Roberto Gilbert Elizalde, Guayaquil, Ecuador.

5. Attending Physician, Department of Neonatology, Hospital de Niños Dr. Roberto Gilbert Elizalde, Guayaquil, Ecuador.

6. Attending Physician, Department of Neonatology, Hospital de Niños Dr. Roberto Gilbert Elizalde, Guayaquil, Ecuador.

Jean Carlos Delgado Macías https://orcid.org/0009-0007-0289-4596

Miguel Ángel Hernández Cedeño https://orcid.org/0000-0002-2307-8981

Ambar Noemi Armijos Cevallos https://orcid.org/0000-0002-1768-0925

Alex Villalta Herrera https://orcid.org/0000-0001-8333-2307

Auror Chávez Veliz https://orcid.org/0009-0000-9861-6628

Reyma Mosquera Peña https://orcid.org/0009-0008-7252-1557

Correspondencia: Jean Carlos Delgado Macías; Cdla. Atarazana, Av. Roberto Gilbert y Nicasio Safadi, Guayaquil, Ecuador;

090514; maciasjeancarlosdelgado@gmail.com

Recibido: 10/oct/2025 - Aceptado: 12/nov/2025 - Publicado: 29/dic/2025

Revista Ecuatoriana de Pediatría | ISSNe: 2737-6494

Pagína 46 | VOL.26 N°3 (2025)Septiembre - Diciembre

natal period, it represents a rare but severe condition with the potential to cause permanent osteoarticular

sequelae. During this stage of life, osteomyelitis exhibits etiopathogenic and histological features that diﬀer from

those observed in other age groups. Involvement of the facial skeleton is uncommon and is usually secondary

to contiguous soft tissue infections of the face. We report the case of a 20-day-old female neonate who de-

veloped osteomyelitis of the maxilla secondary to facial and periorbital cellulitis, with Staphylococcus aureus

isolated from blood cultures and ocular discharge. The patient was treated with broad-spectrum antibiotic

therapy and conservative surgical management, showing favorable clinical evolution and currently remaining

under outpatient follow-up.

Keywords: Periorbital cellulitis; osteomyelitis; neonatal period; bacterial infection; cellulitis.

Reporte de Caso

Introducción

Osteomyelitis (OM) is an infection of bone

tissue and bone marrow, primarily caused by

bacteria, which may spread through three

main routes: hematogenous dissemination,

contiguous spread, or direct inoculation

. In

the neonatal period, hematogenous spread

represents the predominant mechanism of

infection. During the early phase of the di-

sease, increased bone vascularity occurs

as a result of the inﬂammatory response,

whereas reduced vascularity is observed in

chronic cases

2,5

Identiﬁed risk factors include prematurity

and prolonged stays in critical care units,

often associated with catheter-related in-

fections. In neonates, OM presents with

etiopathogenic and histological characteris-

tics that diﬀer from those observed in older

patients

Maxillary osteomyelitis predominantly aﬀects

infants and young children and may arise

from hematogenous dissemination or as a

complication of adjacent staphylococcal

skin infections

. The most commonly repor-

ted etiologic agents include Staphylococcus

aureus, Bacteroides spp., and Streptococcus

spp

. Clinical presentation is usually nonspe-

ciﬁc and includes prolonged fever, irritabi-

lity, edema, erythema, pain, and functional

impairment

The diagnosis of maxillary osteomyelitis re-

lies on clinical evaluation, imaging studies,

biopsy, and microbiological cultures

, with

blood cultures considered the gold stan-

dard for etiologic identiﬁcation. Treatment

is primarily based on broad-spectrum an-

tibiotic therapy

, with surgical intervention

reserved for selected cases.

Case Presentation

A 20-day-old female neonate, born to a

23-year-old mother, ﬁfth pregnancy, delive-

red via uncomplicated vaginal delivery at

39 weeks of gestation, was admitted with

a 48-hour history of fever up to 38 °C, im-

mediate postprandial vomiting, abdominal

distension, right-sided periorbital edema,

and greenish discharge from the upper ri-

ght gingival region.

On admission, the patient was irritable, fe-

brile, and tachycardic. Physical examination

revealed edema and erythema of the right

eyelid, induration of the right cheek, yellowi-

sh discharge from the right nostril, and a

violaceous mass approximately 0.5 cm in

diameter in the upper right gingiva, asso-

ciated with greenish discharge and whitish

spots on the mucosa.

Given the presentation of a febrile neonate,

an initial diagnostic approach for late-on-

set neonatal sepsis and periorbital cellulitis

was initiated. Blood and site cultures were

obtained. Chest radiography showed right

perihilar reinforcement, while abdominal

radiography revealed poor air distribution

and mild interloop edema. Transfontanellar

ultrasound was normal, whereas abdominal

ultrasound demonstrated hepatomegaly

and splenomegaly.

Laboratory evaluation showed leukocytosis

with neutrophilia (absolute neutrophil count

of 15,200), reactive thrombocytosis, elevated

acute-phase reactants, and indirect hyper-

bilirubinemia. Immunoglobulin and comple-

ment levels were normal for age, as were

organ function tests. Urine and cerebrospi-

nal ﬂuid cultures were negative, and echo-

cardiography was unremarkable.

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Contrast-enhanced computed tomography

(CT) of the orbits and facial bones was

performed (Figure 1). Ophthalmologic eva-

luation revealed a normal fundoscopic

examination and ﬁndings consistent with

right periorbital cellulitis, recommending

conservative management and ophthal-

mic antibiotic therapy. In conjunction with

neonatology, the infectious diseases team

maintained ampicillin and added vancomy-

cin. Maxillofacial surgery recommended

gingival cleansing with Dakin’s solution and

continuation of antibiotic therapy.

Subsequent clinical deterioration included

worsening right periorbital edema with in-

ability to open the eye, marked proptosis,

and purulent discharge. Blood cultures and

ocular secretion cultures yielded methici-

llin-resistant Staphylococcus aureus. Leuko-

cytosis and elevated inﬂammatory markers

persisted. Following multidisciplinary discus-

sion, conservative management and anti-

biotic therapy were continued.

After 14 days of antibiotic treatment, clinical

improvement of periorbital edema was no-

ted, with improvement in blood counts but

persistent elevation of inﬂammatory mar-

kers. Follow-up CT of the face and orbits

was performed (Figures 2 and 3), followed

by contrast-enhanced magnetic resonance

imaging (MRI) of the right orbit (Figure 4).

Based on clinical and radiological evidence

of osteomyelitis, and considering the pa-

tient’s age and surgical risks, conservative

management with continued vancomycin

therapy and close monitoring of inﬂam-

matory markers was maintained.

Figure 1. Non-contrast coronal computed

tomography demonstrating mucosal thicke-

ning of the right maxillary sinus and adja-

Figures 2 and 3. Contrast-enhanced axial

computed tomography showing extension

of inﬂammatory changes to the adjacent

canthal region (white arrows), mild protru-

sion of the right globe (interzygomatic line–

anterior corneal border distance: 14.3 mm

on the right and 11.3 mm on the left), and

millimetric bone fragments within the extra-

conal fat associated with the inﬂammatory

process (yellow arrow).

Reporte de Caso

cent osteomeatal complex, associated with

irregularity of the medial wall and ﬂoor of

the ipsilateral orbit, as well as inﬂammatory

changes in the anterior third of the conti-

guous extraconal fat, consistent with compli-

cated sinusitis with associated osteomyelitis.

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Reporte de Caso

Figure 4. Axial contrast-enhanced T1-wei-

ghted magnetic resonance imaging de-

monstrating inﬂammatory changes involving

the extraconal fat and the medial canthal

regions.

to contiguous spread related to trauma,

penetrating wounds, surgical procedures, or

joint replacement; and osteomyelitis secon-

dary to vascular insuﬃciency, with the he-

matogenous route being the most frequent,

particularly in neonates

. Nevertheless, other

predisposing factors have been described

in the literature, including genetic conditions

such as sickle cell anemia and osteopetro-

sis, as well as toxic and environmental fac-

tors, including birth-related trauma

12,13

Factors associated with maxillary osteom-

yelitis include infections of the orofacial

region, eyes, nose, paranasal sinuses, and

ears, as well as alveolodental infections

14,15

In the present case, the presence of a ru-

dimentary tooth in the palatal region with

subsequent abscess formation represented

a signiﬁcant risk factor for the development

of maxillary osteomyelitis.

Clinical presentation during the neonatal

period is highly variable and often nons-

peciﬁc, and may manifest solely as irritabi-

lity, fever, or even gastrointestinal symptoms

such as diarrhea

. Purulent nasal discharge

or drainage from the canine fossa may also

be observed

. In hematogenous acute os-

teomyelitis, symptom onset typically occurs

within less than two weeks

, consistent with

the clinical course observed in our patient.

Once the maxilla is involved, rapid spread

to adjacent structures may occur, including

the orbital region, dental follicles, nasal ca-

vity, and medial maxillary sinus. Clinically,

this results in erythema and edema of the

periorbital region, usually involving the me-

dial aspect, as well as cheek and periorbital

soft tissue swelling

14,15,17

. In more severe cases,

proptosis, chemosis, and ophthalmoplegia

may develop

, ﬁndings that were consistent

with the clinical deterioration and right-eye

proptosis observed in our patient.

The most frequently isolated pathogen

across all age groups is Staphylococcus

aureus, followed by Streptococcus agalac-

tiae, enteric gram-negative bacteria, and

Candida spp., particularly in infants youn-

ger than one year

. In the present case,

S. aureus was isolated, in agreement with

global literature. It is important to highlight

In view of the improvement in clinical and

laboratory ﬁndings, it was decided to com-

plete 30 days of antibiotic therapy with

vancomycin, followed by a switch to oral

clindamycin to complete a total of six wee-

ks of antimicrobial treatment. After joint re-

assessment by the neonatology, ophthal-

mology, maxillofacial surgery, and infectious

diseases teams, the patient was discharged

with a plan for multidisciplinary outpatient

follow-up.

Discussion

Osteomyelitis is an inﬂammatory process of

bone caused by bacterial or fungal infec-

tion. Maxillary osteomyelitis in the neonatal

period and early infancy is an exceptionally

rare condition; the ﬁrst case was described

in 1847 by Jacob and Sagorin

. The inciden-

ce of acute osteomyelitis (AO) is estimated

at 1 to 3 cases per 1,000 children

. Howe-

ver, in our country, there are no precise

epidemiological data regarding prevalence

or incidence, likely due to the rarity of this

clinical presentation.

According to etiopathogenic classiﬁcation,

AO is divided into three types: hematoge-

nous osteomyelitis; osteomyelitis secondary

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Reporte de Caso

the increasing emergence of antimicrobial

resistance and methicillin-resistant strains

(MRSA). In our patient, the isolated strain

was methicillin-susceptible, which represents

a favorable prognostic factor.

The diagnosis of maxillary osteomyelitis is

primarily clinical and supported by labo-

ratory and imaging studies. Inﬂammatory

markers such as leukocyte count and C-re-

active protein (CRP) are useful for monito-

ring disease progression; CRP values below

20 mg/L have been associated with crite-

ria for discontinuation of antibiotic therapy.

However, independent predictors of MRSA

infection have been described, including

elevated body temperature, low hematocrit,

leukocytosis, and increased CRP levels

Computed tomography and magnetic reso-

nance imaging are essential tools for asses-

sing changes in tissue density, lytic lesions,

and periosteal involvement associated with

maxillary osteomyelitis

. In our patient, initial

imaging demonstrated increased density of

the maxillary and ethmoidal sinuses and

hypertrophy of the nasal turbinate mucosa,

followed by progression to lytic lesions of

the maxillary bone, conﬁrmed on subse-

quent imaging studies.

The treatment of maxillary osteomyelitis re-

mains controversial, as there is no absolute

consensus regarding exclusive conservati-

ve management with antibiotics versus the

need for surgical intervention. Since the ﬁrst

reported cases, treatment has been gui-

ded by microbiological sensitivity; penicillin

has historically been used as ﬁrst-line thera-

14,16

. In our patient, empirical therapy with

an aminopenicillin and an aminoglycoside

was initiated to cover S. aureus and enteric

gram-negative bacteria. However, deﬁnitive

antimicrobial selection depends on the iso-

lated pathogen, its susceptibility proﬁle, and

local resistance patterns; in cases of sus-

pected or conﬁrmed MRSA infection, van-

comycin is the treatment of choice

The duration of antibiotic therapy depends

on the association with acute bacterial ar-

thritis and the presence of osteomyelitis.

In cases without osteomyelitis, a 10–14-day

course of antibiotics is recommended

. In

patients with osteomyelitis and isolation of

S. aureus, treatment should be extended to

3–4 weeks, with longer courses required for

resistant organisms

13,21

. In the present case,

with methicillin-susceptible S. aureus isolated

from blood and maxillary secretion cultures,

three weeks of vancomycin therapy were

completed due to initial concern for MRSA,

considering risk factors such as age and

extensive involvement of adjacent structu-

res. The patient showed favorable clinical

evolution without neurological complica-

tions and was discharged on oral linco-

samide therapy, in accordance with inter-

national guidelines for the management of

osteomyelitis

Conclusion

Maxillary osteomyelitis in the neonatal pe-

riod is an uncommon condition but is asso-

ciated with signiﬁcant morbidity and morta-

lity. Early diagnosis is often challenging due

to the nonspeciﬁc nature of initial clinical

manifestations and the rapid progression to

orbital and systemic complications. This case

highlights the importance of maintaining a

high index of suspicion in infants with facial

or periorbital cellulitis showing poor respon-

se or refractory evolution to initial therapy,

as well as the need for a multidisciplinary

approach involving neonatology, infectious

diseases, and maxillofacial surgery to opti-

mize clinical outcomes. Timely recognition

and early initiation of appropriate antibiotic

therapy remain critical in preserving func-

tion, preventing aesthetic sequelae, and im-

proving overall prognosis.

Author contributions

Armijos Cevallos: Preparation of the original

manuscript drafts. Delgado Macías: Con-

ceptualization and manuscript writing. Her-

nández Cedeño: Critical review and con-

tent validation. Villalta Herrera: Resource

provision. Chávez Aurora: Study supervision.

Mosquera Reyma: Study supervision.

Ethical Statement

This clinical case is presented anonymously,

ensuring protection of patient identity and

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Reporte de Caso

conﬁdentiality. Informed consent was obtai-

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and the right to privacy was respected at

all times.

Data availability statement

The data are not publicly available due to

patient conﬁdentiality considerations. Howe-

ver, data may be made available for aca-

demic purposes upon reasonable request

to the corresponding author.

Conﬂict of interest

The authors declare no conﬂicts of interest.

Funding

The authors received no ﬁnancial support

for the conduct of this study.

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Para referenciar aplique esta cita:

Delgado Macías JC, Hernández Cedeño M Ángel, Armijos Cevallos AN, Villalta Herrera A, Chávez Veliz A,

Mosquera Peña R. Osteomielitis del maxilar secundaria a celulitis periorbitaria en un neonato: reporte de un

caso. REV-SEP [Internet]. 12 de diciembre de 2025; 26(3):45-51. Disponible en: https://rev-sep.ec/index.php/johs/

article/view/351

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