PAINE #PANCE Pearl – Dermatology


Vitiligo and tinea versicolor are both hypomelanocytic dermatologic afflications. What are some ways to differentiate these two conditions?


  • Location
    • Tinea versicolor – trunk and proximal extremities
    • Vitiligo – can occur anywhere, but most common on hands and face
  • Color
    • Tinea versicolor – hypopigmented, more prominent with sun exposure
    • Vitiligo – milk or chalk-white, no change with sun exposure
  • Wood’s lamp
    • Tinea versicolor – fluoresce yellow/green
    • Vitiligo – fluoresce blue/white


Langer’s Lines

Other known aliasesLanger’s lines of skin tension, cleavage lines

Definitiontopographical lines on the human body that correspond to the natural orientation of the collagen fibers of the dermis and are parallel to the orientation of the underlying muscle fibers

Clinical SignificanceIncisions made on the skin that run parallel with these lines produce much less tension on the wound, heal better with less scarring, and have a much better cosmetic appearance.  This is important in cosmetic surgery applications, as well as elective surgical procedures when you can select where to make your incision.

HistoryNamed after Karl Langer (1819-1887), an Austrian anatomist, who received his medical doctorate from the Universities of Vienna and Prague.  He worked under Joseph Hyrtl as a prosector for the University of Vienna and later becoming the director in 1874.  In his famous procedure discovering these tension lines, he punctured circular holes on the skin of cadavers and noticed that they would result in ellipisoidal wounds.  By following the direction of these ellipses, he was able to topographically map these lines on the entire body.  He did give credit to Baron Dupuytren as being the first to observe this phenomenon and published his findings in 1861 entitled “Zur Anatomie und Physiologie der Haut. Über die Spaltbarkeit der Cutis”

Karl Langer



Dix-Hallpike Manuever

Other known aliasesNylen-Barany test

DefinitionStarting supine, the patient’s head is rotated to one side and then quickly lowered to supine with the neck extended over the exam table.  Patient is observed for nystagmus for 30 seconds and then returned to supine and observed for another 30 seconds.  This is then repeated for the other side.

Clinical SignificanceThe Dix-Hallpike maneuver is the diagnostic maneuver to induce vertigo and nystagmus in patients with benign paroxysmal positional vertigo by relocating canaliths to the posterior semicircular canals.

HistoryNamed after Margaret Ruth Dix (1902-1991), a British neuro-otologist, and Charles Skinner Hallpike (1900-1979), an English otologist.  Dr. Dix earned her medical doctorate in 1937 from the Royal Free Hospital School of Medicine and Dr. Hallpike earned his from the University of London in 1926.  Dr. Dix was training to become a surgeon when she was injured during the World War II air raids of London and suffered facial and ocular injuries which forced her to change her medical career path.  It was during this time she was hired by Dr. Hallpike to pursue the field of neuro-otology.  Their work resulted in a landmark series in the Proceedings of the Royal Society of Medicine and Annals of Otology, Rhinology, and Laryngology.  It was this series in 1952 where one of the papers describing their eponymous finding  entitled “The Pathology, Symptomatology, and Diagnosis of Certain Common Disorders of the Vestibular System” was published.


  • Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  • Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  • Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved
  • Whonamedit – dictionary of medical eponyms.
  • Up To Date.
  • DIX MR, HALLPIKE CS. The pathology symptomatology and diagnosis of certain common disorders of the vestibular system. Proceedings of the Royal Society of Medicine. 1952; 45(6):341-54. [pubmed]
  • Margaret Ruth Dix – Royal College of Surgeons [link]

#45 – Preseptal vs Orbital Cellulitis



  • Orbital Septum
    • Membranous structure that extends from orbit to the tarsal plate and is the anterior boundary of the orbital compartment
  • Preseptal Cellulitis
    • Infection of the soft tissues ANTERIOR to the orbital septum
  • Orbital Cellulitis
    • Infections of the soft tissues POSTERIOR to the orbital septum


  • Preseptal cellulitis is much more common than orbital (>90%)
  • Both conditions are more common in children than adults


  • Preseptal
    • Usually due to superficial dermatologic infections (though the data has wide variability in reported causes)
  • Orbital
    • Bacterial rhinosinusitis
      • Due to perforations in the lamina papyracea
    • Other causes:
      • Ophthalmologic surgery
      • Dacrocystitis
      • Orbital trauma
      • Dental infections


  • Preseptal
    • Staphylococcus aureus (skin causes)
      • Increasing incidence of MRSA
    • Streptococcus pneumoniae (sinus/nasopharynx causes)
  • Orbital
    • Same as preseptal, but include:
      • Fungal (mucormycosis and Aspergillus spp.)

Signs and Symptoms

  • Both present with unilateral eyepain, erythema, and edema, but:
  • Preseptal
    • No pain with eye movement
    • Sclera is white
Preseptal Cellulitis (sclera is white and quiet)

    • Orbital
      • Painful eye movement
      • Vision changes (acuity, diplopia)
      • Proptosis
      • Sclera injection and chemosis
      • Decreased pupillary response
Orbital cellulitis (notice sclera is red and angry with chemosis)


  • Complications of preseptal cellulitis are rare, but orbital cellulitis can lead to:
    • Vision loss (3-11%)
    • Subperiosteal abscess
    • Orbital abscess
    • Cavernous sinus thrombosis

Diagnostic Studies

  • CBC with differential may be helpful in risk stratification or atypical presentation
  • Preseptal
    • None! –> Clinical diagnosis
  • Orbital
    • Indications for CT scan
      • Inability to assess vision or deteriorating vision
      • Double vision
      • Inability to examine due to age
      • Proptosis
      • Restricted, limited, and/or painfuleye movement
      • Edema extending beyond eyelid margin
      • Lack of improvement in 24 hours on antibiotics
      • Cyclical fevers
      • Signs of CNS involvement
      • ANC > 10,000 cell/microL
a. proptosis, b. soft tissue inflammation, c. choroidal detachment, d. retrobulbar inflammation, e. optic nerve sheet enhancement
medial orbital subperiosteal abscess with left sided ethmoid sinusitis
  • Blood cultures are not routinely recommended but should be entertained in ill appearing children prior to antibiotic administration


  • Preseptal
    • Outpatient
      • > 1 year old and no signs of systemic toxicity
      • Treatment duration typically 5-7days, but treatment should continue until eyelid erythema and swelling have resolved
    • Inpatient
      • < 1 year old, children who can’t cooperate with exam, toxic appearance, or outpatient treatment failing to improve in 24-48 hours
      • Follow orbital cellulitis treatment
  • Orbital
    • Medical
      • Staphylococcal coverage
        • Vancomycin
      • Streptococcal coverage
        • Ceftriaxone
        • Cefotaxime
      • Anaerobic coverage
        • Metronidazole
      • Improvement should occur within24-48 hours
      • Transition to oral therapy when:
        • Afebrile and periorbital signs are resolving
        • Typically 3-5 days
        • Follow culture data (if obtained) or follow outpatient preseptal cellulitis regimen
      • Treat for a total of 2-3 weeks
    • Surgical indications
      • Radiographically identified abscess
        • Typically > 10mm, though small abscesses respond to antibiotics well
      • Intracranial extension
      • Failure to respond to antibiotic treatment
      • Threat to vision


  1. Hauser A, Fogarasi S. Periorbital and orbital cellulitis. Pediatrics in review. 2010; 31(6):242-9. [pubmed]
  2. Botting AM, McIntosh D, Mahadevan M. Paediatric pre- and post-septal peri-orbital infections are different diseases. A retrospective review of 262 cases. International journal of pediatric otorhinolaryngology. 2008; 72(3):377-83. [pubmed]
  3. Horton JC. Disorders of the Eye. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison’s Principles of Internal Medicine, 20e New York, NY: McGraw-Hill;
  4. Chaudhry IA, Shamsi FA, Elzaridi E, Al-Rashed W, Al-Amri A, Arat YO. Inpatient preseptal cellulitis: experience from a tertiary eye care centre. The British journal of ophthalmology. 2008; 92(10):1337-41. [pubmed]
  5. Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. The New England journal of medicine. 2006; 355(7):666-74. [pubmed]
  6. Brook I, Frazier EH. Microbiology of subperiosteal orbital abscess and associated maxillary sinusitis. The Laryngoscope. 1996; 106(8):1010-3. [pubmed]
  7. Erickson BP, Lee WW. Orbital Cellulitis and Subperiosteal Abscess: A 5-year Outcomes Analysis. Orbit (Amsterdam, Netherlands). 2015; 34(3):115-20. [pubmed]
  8. Howe L, Jones NS. Guidelines for the management of periorbital cellulitis/abscess. Clinical otolaryngology and allied sciences. 2004; 29(6):725-8. [pubmed]
  9. Rudloe TF, Harper MB, Prabhu SP, Rahbar R, Vanderveen D, Kimia AA. Acute periorbital infections: who needs emergent imaging? Pediatrics. 2010; 125(4):e719-26. [pubmed]
  10. Tanna N, Preciado DA, Clary MS, Choi SS. Surgical treatment of subperiosteal orbital abscess. Archives of otolaryngology–head & neck surgery. 2008; 134(7):764-7. [pubmed]
  11. Greenberg MF, Pollard ZF. Medical treatment of pediatric subperiosteal orbital abscess secondary to sinusitis. Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology and Strabismus. 1998; 2(6):351-5. [pubmed]



Benign paroxysmal positional vertigo (BPPV) can be quite a debilitating condition for patient it effects.  What are the two maneuvers that are used at the bedside for this condition and how do they differ?


The two maneuvers used clinically in the evaluation and treatment of BPPV are:

  • Dix-Hallpike Maneuver (diagnosis)
    • This is used to diagnosis BPPV and is performed by having the patient starting sitting upright.  The head is then turned to one side and the patient is rapidly lowered to the supine position with their extended over the examination table.  The provider then watches for nystagmus or vertigo symptoms.  If this side is negative, then the maneuver is repeated on the other side.
  • Epley Maneuver (treatment)
    • This is used to treat active vertigo in BPPV by attempting to relocate the canalith back into the utricle by using a series of repositioning techniques.


  • Shim DB, Ko KM, Kim JH, Lee WS, Song MH. Can the affected semicircular canal be predicted by the initial provoking position in benign paroxysmal positional vertigo? The Laryngoscope. 2013; 123(9):2259-63. [pubmed]
  • Furman JM, Cass SP. Benign paroxysmal positional vertigo. The New England journal of medicine. 1999; 341(21):1590-6. [pubmed]
  • Woodworth BA, Gillespie MB, Lambert PR. The canalith repositioning procedure for benign positional vertigo: a meta-analysis. The Laryngoscope. 2004; 114(7):1143-6. [pubmed]
  • White J, Savvides P, Cherian N, Oas J. Canalith repositioning for benign paroxysmal positional vertigo. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology. 2005; 26(4):704-10. [pubmed]


Epley Manuever

Other known aliasescanalith repositioning manuever

Definitionseries of positions and manual manipulations used to reposition free-floating otoconia in the semicircular canals of the inner ear

Clinical SignificanceThe Epley maneuver is used to treat benign paroxysmal positional vertigo (BPPV) by relocating the otoconia back to the utricle where they can no longer stimulate the cupula of the semicircular canal and cause vertigo. 

HistoryNamed after John Epley, an American otolaryngologist from Portland, OR, who received his medical degree from the Oregon Health Sciences University and fellowship from Stanford Medical Center.  He pioneered the “canalith theory” of vestibular disease and published his eponymous maneuver in 1980 in the article entitled “New Dimensions of Benign Paroxysmal Positional Vertigo”.  Dr. Epley is still in practice today.


  • Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  • Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  • Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved
  • Whonamedit – dictionary of medical eponyms.
  • Up To Date.
  • Epley JM. New dimensions of benign paroxysmal positional vertigo. Otolaryngology and head and neck surgery. 1980;88(5):599-605. [pubmed]