Download Facial Soft Tissue Infections

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
Erythema/edema
Periorbital
Around eye, eyelid
Occular pain at rest
-
Visual Acuity/fundi
Proptosis
EOM
N
Full EOM
Non painful
Conjunctiva
Occ. ecchymosis
Orbital
+/- Around eye,
eyelid
+
abN
+
Limited EOM
Painful
+/-
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