Facial Soft Tissue Infections Heather Patterson PGY-4 November 13, 2008
Facial Soft Tissue Infections
Heather Patterson
PGY-4
November 13, 2008
Objectives
• By the end of this session the learner will be able to outline clinical features, management strategies, and complication of facial infections including:– Cellulitis– Erysipelas – Orbital Cellulitis– Periorbital Cellulitis
Cellulitis
• Def’n:– Soft tissue infection of the skin and subcutaneous tissue
• Risk Factors:– Skin trauma– Lymphatic or venous stasis– FB– Immunosuppression
Cellulitis
• Clinical Features:– Skin:
• Red, swollen, warm, painful
• Blanching • +/- lymphadenopathy
– Vitals• +/- tachycardia, otherwise normal vitals
– Labs:• Minimal change to WBC
– Pertinent negatives• Fever uncommon• No crepitus or bullae
Cellulitis
• Ddx:– Orbital/preorbital– Erysipelas– Impetigo– Folliculitis– FB– Fascitis– Myositis– Post surgical healing– Burn
Cellulitis
• Bugs and Drugs:– Staph and Strep– Gram negative– MRSA
Erysipelas
• What is erysipelas?• What does it look like?• Who get erysipelas?• How do we treat it?
Erysipelas
• What is erysipelas?– Superficial cellulitis involving dermis, lymphatics, and most of the superficial subcutaneous tissue
Erysipelas
• What does it look like?– Sharply demarcated border +/- vessicles at margin
– Raised– Dark erythema– Indurated
• Other features:– Toxic appearing pt with prodrome of fever, chills, malaise,vomiting
– Rapid spread, very painful, itchy, burning
– Prominent lymphadenopathy
Erysipelas
• Who gets this?– Young or >50y– Risk factors:
• EtOH abuse, venous stasis, DM, nephrotic syndrome
– Associated with small breaks in the skin, post operative infections
Erysipelas
• How do we treat it?– MCC Group A Strep
• Pen G or erythromycin
– Cephalosporins, macrolides, fluoroquinolones for more severe cases
Orbital and Periorbital Cellulitis
• Anatomic differences
• Epidemiology• Pathophysiology• Clinical Features• Management• Complications
Orbital and Periorbital Cellulitis
• What is the difference in the location of infection?– Periorbital - preseptal– Orbital - posterior to the orbital septum
Orbital and Periorbital cellulitis
Orbital and Periorbital Cellulitis
• What is the population at risk? (i.e. epidemiology)– Children / adolescents + older pts
• Pathophysiology:– Extension from surrounding infections:
• Coexisting sinusitis in 80% • Dental infections
– Direct innoculation: • Facial trauma
– Hematogenous spread– Vascular lesions, chemical agents
Orbital and Periorbital Cellulitis
• What are the common bugs involved?– Staph and strep– Hflu (if unimmunized)
• Differentiate between the clinical presentation of the 2 entities:– Skin findings– Occular findings
Orbital and Periorbital Cellulitis
Periorbital Orbital
Erythema/edema
Around eye, eyelid
+/- Around eye, eyelid
Occular pain at rest
- +
Visual Acuity/fundi
N abN
Proptosis - +
EOM Full EOMNon painful
Limited EOMPainful
Conjunctiva Occ. ecchymosis
+/-
Orbital and Periorbital Cellulitis
Orbital and Periorbital Cellulitis
• What are the complications associated with orbital and periorbital cellulitis?– Orbital cellulitis:
• Orbital abscess• Subperiostal abscess• Loss of vision• Optic neuritis• Retinal vein thrombosis
– CNS extension• Meningitis, abscess• Cavernous sinus thrombosis
Orbital and Periorbital Cellulitis
• What are the management strategies?– Orbital
• Rapid dx - CT • Ophtho consult• Abx: amp/gent/flagyl or Clinda/gent or Ceftriaxone/flagyl
• What about lateral canthotomy? Indications? Procedure?
– Periorbital• R/O orbital ceullulitis• Abx: Cefuroxime x 2/7 and then po• Admit if unwell or indicated by social situation
Lateral Canthotomy
• Goals: – Rapidly decrease IOP– Reinstitute retinal artery blood flow
• Steps– Simple, rapid saline cleaning of lids– Anesthetize with 1-2% lidocaine with epi– Crush lateral canthus 1-2min with hemostat– Incise lateral canthus with iris scissors– Incision extends toward orbital rim– Identify superior and inferior crus of lateral canthal tendon
– Release inferior canthal tendon
Cavernous Sinus Thrombosis
Cavernous Sinus Thrombosis
• Clinical Presentation– Headache, fever, malaise– Face:
• Midface infection or sinusitis
• Periorbital edema, proptosis, ptosis, orbital pain, chemosis
– Occular exam• Sluggish pupillary response, decreased acuity, papilledema,
– CNS:• CN findings (CN VI first)
EOM• Mental status changes, confusion, drowsiness
Cavernous Sinus Thrombosis
• Management:– Early diagnosis – Early Abx– Anticoagulation?
• Bhatia et al 2002
– Steroids– Surgery is NOT indicated