Chapter 150. Face and Jaw Emergencies

Facial Cellulitis

Cellulitis is a soft tissue infection that involves the skin and subcutaneous tissues. Facial cellulitis is most commonly caused by Streptococcus pyogenes and Staphylococcus aureus, with an increasing predominance of methicillin-resistant Staphylococcus aureus (MRSA). Less commonly, cellulitis may represent an extension from a deeper facial infection. Cellulitis is characterized by erythema, edema, warmth, pain, and loss of function. Clinical features of a well-defined, palpable border are absent.

The diagnosis of cellulitis is clinical. Laboratories and blood cultures may be needed for severe illness, immunocompromise, or other significant comorbidities. Ultrasound and computed tomography (CT) may be used to evaluate for abscess. In most cases, treatment involves analgesics and oral antibiotics for 7 to 14 days. Antibiotic recommendations are listed in Tables 150-1 and 150-2. Consider hospitalization and parenteral antibiotics for patients with signs of systemic illness, failed outpatient therapy, or significant comorbidities.

Erysipelas

Erysipelas is a superficial form of cellulitis, involving the epidermis, upper levels of the dermis, and the lymphatic system. Most cases are caused by S pyogenes; S aureus is a rare etiology. Clinical features include a red, raised, puffy appearance with a sharply defined, palpable border. The diagnosis is clinical. Most patients are treated with oral antibiotics, but hospitalization and parenteral antibiotics should be considered for failed outpatient therapy, immunocompromise, or evidence of systemic illness. Antibiotic recommendations are listed in Tables 150-1 and 150-2.

Impetigo

Impetigo is a superficial epidermal infection that can be divided into bullous and nonbullous presentations. Bullous impetigo is caused by S aureus and nonbullous impetigo is caused by S aureus and S pyogenes. Clinical features of nonbullous impetigo include an erythematous rash with vesicles that break and form the characteristic honey crusts. Bullous impetigo presents as vesicles that enlarge to form bullae with clear yellow fluid. Topical therapy with mupirocin is appropriate for simple, nonbullous disease. Oral antibiotics are prescribed for more extensive or bullous lesions. Antibiotic recommendations are listed in Tables 150-1 and 150-2.

Viral Parotitis (Mumps)

Viral parotitis is an infection that can present with unilateral or bilateral swelling of the parotid glands. Clinical features may include a prodrome of fever, malaise, myalgias, and headache followed by parotid gland swelling. The gland is tense and painful, but lacks erythema, warmth, and pus cannot be expressed from Stensen duct.

The diagnosis is clinical. Viral serology can be ordered but does not affect acute management. Treatment is supportive. Swelling may persist for 5 days and the patient is contagious for approximately 9 days after the onset of parotid swelling. Extrasalivary gland involvement includes epididymoorchitis in 20% to 30% of males and oophoritis in 5% of females. Other systemic complications include pancreatitis, aseptic meningitis, hearing loss, myocarditis, arthritis, hemolytic anemia, and thrombocytopenia. Consider hospitalization for those with systemic complications.

Suppurative Parotitis

Suppurative parotitis is a serious bacterial infection that occurs in patients with diminished salivary flow. Retrograde transmission of bacteria leads to infection. Factors that lead to decreased salivary flow include recent anesthesia, dehydration, prematurity, advanced age, medications (eg, diuretics, β-blockers, antihistamines, phenothiazines, and tricyclic antidepressants), and certain disorders (Sjögren syndrome, diabetes, hypothyroidism, and human immunodeficiency virus). Clinical features may include fever, trismus, erythema, and pain over the parotid gland. Pus may be expressed from Stensen duct.

The diagnosis is clinical. Ultrasound or CT may be ordered if an abscess is suspected. Treatment should optimize salivary flow by using sialogogues such as lemon drops and stopping any medications that cause dry mouth. Oral antibiotics (see Tables 150-1 and 150-2) are appropriate for those tolerating oral intake, and without trismus. Hospitalization is appropriate for those with signs of systemic illness, inability to tolerate oral intake, or those that have failed outpatient therapy. Close follow-up should be arranged.

Sialolithiasis

Sialolithiasis is the development of stones in a stagnant salivary duct. Eighty percent of stones occur in the submandibular duct. Sialolithiasis is typically unilateral and presents with pain, swelling, and tenderness that may be exacerbated with eating. The diagnosis is clinical and a stone may be palpated within the duct and the gland is firm. Treatment involves analgesics, massage, sialogogues such as lemon drops, and antibiotics if a concurrent infection is suspected. Palpable stones may be milked from the duct. Persistent retained calculi may be removed by an otolaryngologist.

Masticator Space Abscess

The masticator space consists of potential spaces bounded by the muscles of mastication. Infection is usually polymicrobial and is commonly associated with an odontogenic source. Clinical features include facial swelling, pain, erythema, and trismus. In advanced cases, signs of sepsis may be present. The diagnosis is made with contrast-enhanced CT scan. Because the masticator spaces ultimately communicate with tissue planes that extend into the mediastinum, early treatment is imperative. ED treatment includes stabilization, antibiotics, otolaryngology consult, and hospitalization. Antibiotic recommendations are listed in Tables 150-1 and 150-2.

Temporomandibular Joint Dysfunction

The temporomandibular joint (TMJ) combines a hinge and a gliding action. Anatomic derangements or systemic disease can cause dysfunction of this joint. Clinical features include pain over the muscles of mastication or in the region of the TMJ and there may be a limited range of motion. The diagnosis is usually clinical. For patients with acute trauma, imaging with CT or panoramic tomography (Panorex) may be warranted. Treatment for nontraumatic conditions consists of analgesics, soft diet, and referral to dental specialist. An oral-maxillofacial surgeon manages fractures.

Dislocation of the Mandible

The mandible can be dislocated in an anterior, posterior, lateral, or superior position. Anterior dislocation is the most common. Patients with an acute jaw dislocation present with pain, difficulty swallowing, and malocclusion. In anterior dislocations, a history of extreme mouth opening is typical and there is difficulty with jaw movement. Other dislocations usually require significant trauma.

The diagnosis of atraumatic anterior dislocations is clinical. Imaging with mandibular radiographs, Panorex, or CT is indicated for all other dislocations. Treatment of anterior dislocations without fracture is closed reduction and this is made easier with analgesia, muscle relaxants, or procedural sedation. Reduction of dislocated mandible technique is most commonly done in a seated patient. The thumbs are placed over the molars, and pressure is applied downward and backward. Patients with open or nonreducible dislocations, fractures, or nerve injury should be referred emergently to an oral-maxillofacial surgeon. After reduction, patients should be instructed to not open their mouth more than 2 cm for 2 weeks.