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Home Books Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e

Chapter 243: Face and Jaw Emergencies

Stephanie A. Lareau; Corey R. Heitz

FACIAL CELLULITIS, ERYSIPELAS, AND IMPETIGO

Cellulitis and erysipelas are discussed in detail in the chapter 147, "Soft Tissue Infections." Impetigo is discussed in the chapter 136, "Rashes in Infants and Children." 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 Gradual 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
Trauma
Soft tissue contusion Acute Associated trauma Tender swelling
Burn Acute Occupational, recreational exposure May be difficult to distinguish from cellulitis
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 is a superficial soft tissue infection that lacks anatomic constraints.2,3,4 Facial cellulitis is caused most commonly by Streptococcus pyogenes (group A β-hemolytic) and Staphylococcus aureus,4 with an increasing predominance of methicillin-resistant S. aureus.5 Less commonly, cellulitis may represent extension from deep space infections (see "Masticator Space Infection" section below). In children, buccal cellulitis from Haemophilus influenzae is now very uncommon if children have received the H. influenzae type b vaccine.6

Bedside US can exclude or identify facial abscess (Figure 243-1). CT can identify deep-seated, extensive infections that involve the soft tissues of the neck or pharynx.

FIGURE 243-1.

Cellulitis versus abscess. The image on the left shows the cobblestoned appearance of cellulitis, while the one on the right shows a heterogenous fluid collection of abscess. [Photo contributed by R. Gordon, MD.]

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Treatment is provided in Table 243-2. Duration of therapy is not well ...

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