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Chapter 243: Face and Jaw Emergencies

Stephanie A. Lareau; Corey R. Heitz

INTRODUCTION

This chapter will discuss facial infections and disorders involving the mandible. Bell’s palsy is discussed in Chapter 172, “Acute Peripheral Neurologic Disorders.” Trigeminal neuralgia is discussed in Chapter 38, “Chronic Pain.” Nonfacial cellulitis and erysipelas are discussed in Chapter 152, “Soft Tissue Infections.” Impetigo in children is discussed in Chapter 142, “Rashes in Infants and Children.” Orbital cellulitis is discussed in Chapter 241, “Eye Emergencies.”

FACIAL CELLULITIS, ERYSIPELAS, AND IMPETIGO

The differential diagnosis of facial infections is provided in Table 243-1.1

TABLE 243-1Differential Diagnosis of Superficial Facial Infection
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TABLE 243-1 Differential Diagnosis of Superficial Facial Infection
  Historical Features  
  Onset/Timing Risk/Inciting Factors Physical Findings
Infectious
Cellulitis Gradual Skin breaks, foreign bodies, prostheses, immunosuppression Diffuse erythema without clear borders, pain
Impetigo Acute Infants, children Discrete vesicles or bullae; patches of crusty skin
Erysipelas Acute Elderly, infants and children, immune deficiency, diabetes, alcoholism, skin ulceration, impaired lymphatic drainage Well-defined, raised area of erythema, pain
Viral exanthem Often acute Preceding or concurrent viral illness, fever Variable
Parotitis Gradual Dehydration, diabetes, immunosuppression Swollen angle of mandible, potentially visible sialolith
Necrotizing fasciitis Rapid Trauma, may be minor or not apparent Crepitus, skin necrosis, may be subtle
Cutaneous anthrax Gradual Animal contact Black eschar with surrounding erythema
Herpes zoster Acute Elderly, immunosuppression Exquisitely tender erythematous or vesicular rash following a dermatome
Malignant otitis externa Gradual Diabetes, water exposure Ear pain with drainage, facial swelling, tragal tenderness
Inflammatory
Insect envenomation Acute Environment supporting insect life Diffuse, red, puffy
Apical abscess with secondary buccal swelling Gradual Usually associated dental pain/caries Similar to cellulitis; may have intraoral/gingival findings
Contact dermatitis Gradual or acute Often identifiable exposure Variable; maculopapular, itchy rash
Immunologic 
Systemic lupus erythematosus Gradual Female-to-male ratio, 9:1 Erythema in classic “malar” distribution
Angioneurotic edema Acute Exposure to angiotensin-converting enzyme inhibitor, allergen Lip, oral mucosal swelling, sometimes facial
Vancomycin flushing reaction Acute Recent exposure to vancomycin Facial erythema, warmth

CELLULITIS

Cellulitis is a superficial soft tissue infection that lacks anatomic constraints.2-4 Facial cellulitis is caused most commonly by Streptococcus species,5 including Streptococcus pyogenes (group A β-hemolytic) and group G Streptococcus, and Staphylococcus aureus,4 with an increasing predominance of methicillin-resistant S. aureus.6 An important consideration for facial cellulitis is the potential for an odontogenic source of the infection in the midface. Anaerobic bacteria account for 24% to 62% of the odontogenic infections.4,7 Methicillin-resistant S. aureus is the most common cause of purulent cellulitis, identified by purulent drainage, purulent bulla, or suspected abscess.3 Methicillin-resistant S. aureus also is suspected when risk factors are present (see Chapter 152, “Soft Tissue Infections”). Less commonly, cellulitis may represent extension from deep space infections (see “Masticator Space Infection” section later in this chapter). ...

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