238. Face and Jaw Emergencies

Diseases/Disorders

Facial Cellulitis: Staph/strep. Redness/warmth/edema/pain. CT can help r/o deep infection/extension. Tx first line with oral abx generally 7-10 days. Tx failure generally due to not covering MRSA (augmentin, keflex, etc) or not covering strep (clindamycin/bactrim).

Erysipelas: usually in lower extremities, due to strep pyogenes. Bullous erysipelas (more severe form) due to MRSA. Red, raised area with sharply demarcated, shiny. Progressives rapidly. Tx: oral abx initially, can be PCN in 100% convinced its strep, though more than likely to trat with augmentin/keflex.

Impetigo: amber crusts or fluid filled vesicles. Usually staph, strep common as well. Well localized. Tx: topical sufficient for uncomplicated cases (mupirocin, retapamulin in resisistant cases). If needing oral abx, erythromycin or cloxacillin.

Viral Parotitis: Mumps, caused by paramyxovirus, though rare with vaccination. Was common in children under 15yo. Usually URI symptoms and then swelling starts. Generally turns into bilateral swelling. Tx: supportive, contagious for 9 days after onset of parotid swelling.

Suppurative Parotitis: bacteria infx of parotid gland. Gland ducts (Stensen’s duct) exit at 2nd upper molar region. RF: recent anesthesia, dehydration, trachesostomy. Drugs: diuretics, antihistamines, TCAs, phenothiazines, beta blockers, barbiturates. Usually staph, sometimes anaerobes. Rapid, tender/red, fever, trismus (jaw pain, hard to open mouth). Tx: hydration, heating pad, sialagogues like lemon drops. Oral abx augmentin, clindamycin, or keflex + metronidazole.

Sialolithiasis: calcium carbonate/phosphate stones in the salivary ducts. 80% in the submandibular gland. Very similiar to parotiditis in clinical presentation and treatment. Can milk the stone out digitally.

Masticator Space Infection: 4 potential spaces connected together by mastication muscles. Bacteria usually from dental, trauma, injection. Strep, peptostrep, bacteroides, prevotella, etc. Typicall polymicrobial and anaerobic. Facial swelling/pain/redness/trismus. CT scan to confirm. Usually no airway involvement. IV abx usually since its a deep infection – Clindamycin; consider Unasyn, cefoxitin, PCN + metro. Erythromycin no longer recommended. ENT consult.

Temporomandibular Joint Dysfunction: pain with chewing with one or both TMJs. Masseter muscle most typically painful muscle. Tx: NSAIDs, soft foots, OMFS referral.

Mandible Dislocation: anterior dislocation MC. Usually bilateral. Promenient lower jaw, preauricular depression, pain with jaw movement. If posterior dislocation, look in ear canal. Can be clinically diagnosed, though panoramic view xray or CT scan confirm. Tx: can inject lidocaine into preauricular depression anterior to tragus and inject 2mL 2% lidocaine. Reduction Techniques: patient’s head against wall/gurney; place layers of gauze over gloved thumbs and place thumbs over occlusal surfaces of mandibular molars, place rest of your fingers wrapping around outside mandible, apply pressure downward and backward. Also can do wrist-pivot method with thumbs placed on mentum, applying upward force to rock the mandible back into place. If dislocation is open, superior, associated with fracture, nerve injury, or irreducible, OMFS consult. Dispo: discharge, soft diet, hold off against opening mouth > 2cm for 2 weeks. OMFS consult.

References

Tintinalli, Seventh Edition, Chapter 238: Face and Jaw Emergencies

Questions

Q. Whats the difference between facial cellulitis vs erysipelas? A. Erysipelas is demarcated, usually strep. Wrong answers: Impetigo symptoms, MRSA blistering, autoimmune rash with steroid tx.

238. Face and Jaw Emergencies

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