1. Facial Soft Tissue Infections Heather Patterson PGY-4 November 13, 2008

2. 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

3. Cellulitis Def ’ n: –Soft tissue infection of the skin and subcutaneous tissue Risk Factors: –Skin trauma –Lymphatic or venous stasis –FB –Immunosuppression

4. 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

5. Cellulitis Ddx: –Orbital/preorbital –Erysipelas –Impetigo –Folliculitis –FB –Fascitis –Myositis –Post surgical healing –Burn

6. Cellulitis Bugs and Drugs: –Staph and Strep –Gram negative –MRSA

7. Erysipelas What is erysipelas? What does it look like? Who get erysipelas? How do we treat it?

8. Erysipelas What is erysipelas? –Superficial cellulitis involving dermis, lymphatics, and most of the superficial subcutaneous tissue

9. 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

10. 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

11. Erysipelas How do we treat it? –MCC Group A Strep Pen G or erythromycin –Cephalosporins, macrolides, fluoroquinolones for more severe cases

12. Orbital and Periorbital Cellulitis Anatomic differences Epidemiology Pathophysiology Clinical Features Management Complications

13. Orbital and Periorbital Cellulitis What is the difference in the location of infection? –Periorbital - preseptal –Orbital - posterior to the orbital septum

14. Orbital and Periorbital cellulitis

15. 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

16. 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

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

18. Orbital and Periorbital Cellulitis

19. 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

20. 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

21. 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

23. Cavernous Sinus Thrombosis

24. 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

25. Cavernous Sinus Thrombosis Management: –Early diagnosis –Early Abx –Anticoagulation? Bhatia et al 2002 –Steroids –Surgery is NOT indicated