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Emergencies of the face and jaw can be separated into infectious and traumatic disorders. This chapter discusses several specific infections of the soft tissues of the face, including cellulitis, erysipelas, and impetigo, as well as infections and abscesses of the salivary glands and deep infections of the masseter space. The chapter also discusses temporomandibular joint (TMJ) dysfunction and trauma (fracture and dislocation). Discussions about other related disorders, such as those of the eye, sinuses, mouth, and throat (including Ludwig angina) can be found in Chapter 236, Eye Emergencies; Chapter 239, Epistaxis, Nasal Fractures, and Rhinosinusitis; and Chapter 240, Oral and Dental Emergencies; and other facial trauma is covered in Chapter 256, Trauma to the Face.

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Infections of the upper and lower face form distinct clinical groups.1 Facial infections can be organized from superficial to deep. Any individual infection may involve multiple layers. Factors contributing to the depth or extent of involvement include the inciting source, length of time before treatment is initiated, and host factors (i.e., diabetes, immune status). Cellulitis, erysipelas, and impetigo are discussed briefly in the following sections and in more detail in Chapter 147, Soft Tissue Infections.

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Cellulitis of the Face

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Pathophysiology

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Cellulitis is a superficial soft tissue infection that lacks anatomic constraints.2,3Risk factors for the development of cellulitis include conditions that make the skin fragile, or inadequate host defenses, such as immunosuppression, systemic disease (e.g., diabetes), or vascular injury, which can result from radiation treatment or trauma. Medical appliances and foreign bodies impair local defenses. Facial piercing combines a foreign body with a renewable source of bacteria.2,3 Facial cellulitis is caused most commonly by Streptococcus pyogenes (Group A β-hemolytic) and Staphylococcus aureus,3 with an increasing predominance of methicillin-resistant Staphylococcus aureus (MRSA).4 Less commonly, cellulitis may represent extension from deep space infections (see Masticator Space Infections discussed below). In children, buccal cellulitis from Haemophilus influenzae, is now very uncommon if children have received the H. influenzae type b vaccine.5

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Clinical Features

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Facial cellulitis is characterized by erythema, edema, warmth, pain, and diminished function. Clinical features of erysipelas, a sharply defined, palpable border, are absent (see Chapter 147, Soft Tissue Infections). The history should address events and exposures that predispose to cellulitis. Ask about chronic illness, trauma (including seemingly minor events), arthropod bites, allergen exposure, dental caries, painful mastication, surgical history, and radiation exposure. Obtain an occupational history, which may help identify unusual pathogens. Perform a thorough head and neck examination. Check for prostheses, nasal drainage, and changes in vision or phonation. Patients with facial cellulitis are generally not ill, but when systemic manifestations are present, more severe illness or sepsis must be considered. Be alert for evidence of systemic, occult, or invasive disease, including high fever, tachycardia, hypotension, or confusion.2

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Diagnosis

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