Face and jaw emergencies

Facial cellulitis

• Di/flucloxacillin or Cephalexin
  • Penicillin allergy: Clindamycin
• Suspected MRSA: Bactrim, clindamycin, doxycycline
  • Penicillin allergy: Clindamycin

Erysipelas

• 70% lower extremities
• Classically described as disease of the face
• Nasopharynx is the typical source of bacteria
• Mostly S. pyogenes
• More severe form due to MRSA (bullous)
• Rx: Amoxicillin

Impetigo

• Discrete, superficial bacterial epidermal infection characterised by amber crusts or bullae
• Mostly in children
• S. aureus +- S. pyogenes (Group A beta-haemolytic)
• Bullous always staph aureus
• If uncomplicated, topical muporicin recommended
• If extensive or bullous – Flucloxacillin
• MRSA: Bactrim or clindamycin

Salivary gland infection

• Anatomy
  • Parotid, submandibular and sublingual
  • Facial nerve passes through superficial portion of parotid gland
  • Stensen’s duct (from parotid) opens into mouth opposite second upper molar
  • Submandibular and sublingual glands lie below tongue
  • Submandibular ducts open into mouth either side of frenulum
  • Multiple sublingual ducts open into the sublingual fold or directly into the submandibular duct
• Signs of infections
  • Unilateral or bilateral facial swelling
  • Multiple gland involvement suggests infection
  • Palpable tender mass may be a sign of tumor or stone
• Dry mouth and eyes, recurrent episodes or joint symptoms suggest underlying Sjogren’s/collagen vascular disorders or immunological conditions

Salivary gland

• DDx of salivary gland swelling
  • Infectious
    • Viral parotitis (mumps) – Unilateral tense swelling; absent warmth
    • Buccal cellulitis – Hib in non-immunised. Erythematous/tender
    • Suppurative parotitis – Fever, pain, swelling, pus expression from Stensen’s duct
    • Masseter space abscess: Dental infection with trismus, posterior inferior facial swelling
    • TB – Chronic crusting plaques
  • Immunologic
    • Sjogren’s – Dry eyes/mouth/sclerosis
    • Systemic lupus
    • Sarcoidosis
  • Neoplasm – No warm/erythema
  • Sialolithiasis – Dehydration, chronic illness, swelling, tenderness, no warmth/fluctuance

Viral parotitis (mumps)

• Unilateral or bilateral parotid swelling
• Mostly paramyxovirus or less commonly influenzae, parainfluenza, coxsackie, echovirus, HIV
• Most common under 15yo
• For mumps (paramyxovirus)
  • Prodromal fever, malaise, headache, myalgias, arthralgias, anorexia for 3-5 days
  • The salivary gland swelling with tense and painful parotid (but no erythema/warmth)
  • Stensen’s duct may be inflamed but no pus expressed
  • Resolves over 1-5 days
  • Contagious for 9 days from onset of parotid swelling
  • Unilateral orchitis can occur in 20-30% of adult males
  • Oophoritis in only 5% of females

Suppurative parotitis

• Serious bacterial infection in salivary gland with compromised salivary flow
• Caused by retrograde migration of oral bacteria into salivary ducts and parenchyma
• Risk factors
  • Recent anaesthesia, dehydration, advanced age
  • Sialolithiasis, oral neoplasms, salivary duct strictures, tracheostomy and ductal foreign bodies
  • Medications that cause dehydration or decreased salivary flow
    • Diuretics, antihistamines, TCA’s, phenothiazines, beta-blockers and barbiturates
  • Chronic illnesses
    • Renal failure, HIV, hepatic failure, DM, hypothyroidism, malnutrition, Sjogren’s, depression, anorexia, bulimia, hyperuricaemia and CF

Suppurative parotitis

• Mostly S. aureus +- S. pneumoniae, S. pyogenes, H. influenzae and anerobes (Bacteroides, Peptostreptococcus, fusobacteria) in 43%
• In immunocompromised, E. coli and Pseudomonas are common
• Red, tender parotid gland with rapid onset
• Pus from Stensen’s
• Often fever and trismus
• US and CT can rule out abscess but otherwise unhelpful

Suppurative parotitis

• Treatment aims at optimising salivary flow with hydration, massage and heat application to gland
• Lemon drops
• Discontinue drugs that cause dry mouth
• Oral antibiotics if not systemically unwell
• IV antibiotics if trismus, cannot tolerate oral liquids, immunocompromised or failed outpatient therapy
• Rx – Augmentin or Cephalexin + Metronidazole
  • Add vancomycin if risk of MRSA

Sialolithiasis

• Calcium carbonate or calcium phosphate sialoliths in stagnant duct
• Mostly men in 3^rd to 6^th decades
• 80% occur in submandibular gland with rest in parotid
• Difficult to differentiate this from suppurative parotitis
• Colicky pain exacerbated by meals (salivation)
• Stone may be palpated in duct and gland feels firm
• Intra-oral radiographs are more sensitive than extra-oral films for visualising stone
• Calculi are radio-opaque in 70%
• US and thin-cut CT may also identify sialoliths but usually only done to rule out abscess formation
• Treatment
  • Outpatient analgesia, antibiotics if suspicious for infection, lemon drops, digital milking of palpable stones

Masticator space infection

• Four potential spaces surrounded by muscles of mastication
  • Masseteric, superficial temporal, deep temporal and pterygomandibular spaces
  • All contiguous
• Bacteria may gain entry from dental infections, trauma, surgery or injections
• Polymicrobial and often anaerobic
  • Strep, peptostreptococcus, Bacteroides, Prevotella, Fusobacterium, Actinomyces

Masticator space infection

• Presentation
  • Acute unilateral facial swelling, pain, erythema and trismus
  • Masster space infection
    • Swelling appears posteroinferiorly on face with mild to moderate trismus
  • Temporal space infection
    • Soft tissue swelling of temporalis muscle is seen
  • Trismus without swelling suggests pterygomandibular space infection
  • May have constitutional signs or sepsis

Masticator space infection

• USS
  • Can help differentiate abscess from cellulitis and to identify internal jugular thrombosis
• Contrast CT is prefered to rule out deep space infection (not sensitive for retropharyngeal space however)
• MRI can be considered if infection thought to reach the skull base
• Treatment 
  • Tissue planes extend down to neck/mediastinum so need to identify extent of infection early and begin treatment promptly (depending on clinical presentation)
  • IV antibiotics – Clindamycin 600mg TDS
  • PO Augmentin

Temporomandibular joint disorders

• Synovial joint with meniscus and hinge/glide action
• TMJ dysfunction
  • Pain of joint and surrounding anatomical structures
  • Degenerative joint disease can occur with chronic internal derangement or RA/SLE
  • Chief complaint is usually pain with chewing
  • Masseter muscle is most frequently identified painful area, then temporalis, SCM, splenius capitis and trapezius
  • May have limited mandibular movement on examination
  • DDx: Dental infection/trauma, jaw fracture/dislocation, otologic referred pain, temporal arteritis
  • OPG is good first line imaging
  • CT is useful for assessment of possible neoplasm, complex fractures or infections
• Simple analgesics are first-line if no evidence of infection/fracture with GP follow-up +- maxillofacial referral for definitive care

Trigeminal neuralgia

• Unknown cause
• Paroxysms of severe unilateral pain lasting only seconds with normal neurological examination
• No pain between paroxysms
• Classic
  • Idiopathic cases and those due to microvascular compression
• Secondary
  • Due to tumor, MS or other structural abnormalities
• History is key as pain is shocking, stabbing, brief, lasting seconds to minutes
• Triggers include light touching, chewing or light breeze
• Treatment
  • Carbamzapine 100mg BD increased as required is useful
  • Baclofen also proven successful
• Refer to neurology

Bell’s palsy

• Acute unilateral upper and lower facial palsy, posterior auricular pain, decreased tearing, hyperacusis and otalgia
• Can develop some symptoms prior to paralysis
• Peak of symptoms within 48 hours
• Careful neuro exam to rule out stroke, examine ear for Ramsay-Hunt
• Stroke, GBS and Ramsay-Hunt constitute 85% of misdiagnoses
• Treatment
  • Prednisone 1mg/kg for 7 days then 10-day taper if within 72 hours of onset as improves chance of recovery
  • Antivirals may be useful with steroids but not proven
• Ocular lubricants, tape patients eyelid in sleep and ophthal follow-up

Mandible dislocation

• May be anterior, posterior, lateral or superior
• Anterior dislocation is most common when mandibular condyle is forced in front of articular eminence
• Muscular spasm then traps mandible in this position
• Risk factors include shallow glenoid fossa, seizure and loss of joint capsule tone from previous trauma
• Usually bilateral
• Posterior dislocations are rare with condylar head in external auditory canal
• Lateral dislocations often associated with fracture, with condylar head forced laterally and then superiorly into temporal space
• Superior dislocations forces condylar head up into temporal space

Mandible dislocation

• If dislocation is unilateral, there will be deviation of jaw away from dislocation
• If posterior dislocation considered, examine the external auditory canal
• Posterior, lateral and superior dislocations = severe trauma
• If cooperative, atraumatic spontaneous anterior dislocation, diagnosis is clinical
• In all others, get OPG +- CT
• Perform reduction in ED for closed anterior dislocations without fracture
• Short-acting IV muscle relaxant e.g. midazolam may assist with muscle spasm
• LA using 21G needle into preauricular depression just anterior to tragus 2mL 2% lignocaine may obviate need for procedural sedation

Reduction of anterior TMJ dislocation

• Patient seated with head firmly against wall or chair back
• Apply gauze over gloved thumbs in case mandible snaps shut after relocation
• Facing patient, place thumbs over occlusal surface of mandibular molars as far back as possible
• Apply pressure down and back
• Slight opening of jaw may help disengage condyle from anterior eminence
• If bilateral, relocate one side at a time
• If successful, should be able to close mouth immediately. Post-reduction radiographs not mandatory
• D/C home, soft diet, caution in opening mouth >2cm for 2 weeks
• Support mandible with hand when yawning
• Elective referral to maxfax is recommended

Last Updated on October 6, 2020 by Andrew Crofton