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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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Cellulitis is a superficial soft tissue infection that lacks anatomic
constraints.2,3 Risk 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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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