Orofacial infections are a common A&E presentation and are often due to a dental source. Due to the proximity of the airway and the potential for compromise, it is essential to be able to distinguish between abscesses which need further attention and swellings that can be treated by dentists in the community.
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Differentials for Orofacial Infections
| Causes | Examination/history | |
| Dentoalveolar | Tooth decay As a result of infected necrotic bone (osteonecrosis) | Painful teeth on gentle pressing – patient’s will often be able to localise the causative tooth May have fullness of the sulcus adjacent to the causative tooth May have restriction of mouth opening Swelling is usually submandibular, submental, buccal or canine space/maxillary regions although can track to parapharyngeal area and is less obvious on examination |
| Salivary | Sialoliths (salivary stones) Salivary duct strictures | Mealtime syndrome (swelling worsening when eating/drinking) Swelling in preauricular area, or submandibular region, may be tender and erythematous May be able to express pus from the duct orifice on examination |
| Cutaneous | Infected sebaceous cyst Insect bite Infected hair follicle | Discrete, fluctuant swelling in skin anywhere on the face/neck May have central punctum |
History
For any patient presenting with a swelling in the face or neck, it’s essential to try and establish the source as this will affect the specialty involved in their treatment, and subsequently the management of the infection.
For dental abscesses, patients may complain of preceding toothache, or a recent visit to the dentist.
For cutaneous abscesses, patients may give a history of a spot they may have squeezed, or an ingrown hair.
For salivary gland swellings, patients may already be aware of salivary stones (sialoliths) or may already be under the care of specialists for this. They may notice the swelling gets worse on eating (mealtime syndrome).
For all patients who come into the emergency department with a swelling, it is helpful to know if they have seen their GP or dentist recently and if they have had any treatment or recent courses of antibiotics.
Certain patients are at increased risk of serious infection:
- Diabetic patients
- Immunocompromised patients
Examination
Orofacial and neck abscesses have the potential to cause airway compromise so it’s essential to examine patients with the A-E approach. Any concerns over loss of airway, urgent referral to anaesthetics and ENT/OMFS is required.
The site, extent and fluctuance of all facial swelling should be assessed on examination.
General examination
- Fever
- Tachycardia
- Is the patient able to speak in full sentences?
- Is there any hoarseness of the voice?
- Are they able to swallow their own saliva or are they leaning forward drooling?
Site of swelling
- Submandibular
- Submental
- Sublingual
- Buccal
- Maxillary/canine space
Of the above, submandibular and submental abscesses have the highest risk of airway compromise and should be urgently discussed with the on-call maxillofacial surgeons. For submental and submandibular swellings, note if the swelling crosses the midline and if the floor of the mouth is raised with a protruding tongue. These signs are indicative of Ludwig’s angina and requires urgent attention and escalation.
Examination of swelling
- Is the swelling discrete/appears limited to the cutaneous skin layers?
- Can you palpate the lower border of the mandible if a buccal or submandibular swelling?
- If you are suspecting a skin abscess, is there a draining sinus or punctum on the skin?
- Is there erythema? Is this limited to the abscess, or does it travel down the neck?
- Palpate the swelling: is it firm, hot and fluctuant? Or does it feel soft?
Intraoral examination
- Is the floor of the mouth raised?
- Is there trismus? (Limitation of mouth opening – anything under 10mm is concerning)
- Is the tongue in a neutral position and able to move freely?
- Is there any asymmetry/fullness in the pharyngeal area?
- Is there tenderness of teeth to percussion/palpation?
- Is there any ‘fullness’ of the sulcus adjacent to the suspected causative tooth?
Note:
Painful teeth in well patients with mild, soft swellings with no palpable collection are often treatable with a course of oral antibiotics and seeking emergency dental treatment in the community via NHS111.
Investigations
| Bedside | Observations Where there is an abscess with pus formation, the temperature will be swinging up and down Capillary blood glucose if diabetic |
| Laboratory | Venous blood gas if haemodynamically unstable Full blood count C-reactive protein Blood cultures if patient haemodynamically unstable Pus swab if discharging pus present for MC&S |
| Imaging | If dental cause is suspected, an orthopantomogram (OPG) x-ray to provide a view of the teeth and surrounding structures to identify any dental infections or underlying pathology If swelling is severe or there are signs of airway compromise, a CT of the head and neck with contrast to assess involvement of the deeper neck spaces This will provide cross-sectional images to assess the extent of infection, location of pus collections and involvement of adjacent structures For salivary swellings, ultrasound may help and can occasionally get image-guided drainage/aspiration by the radiologist If airway compromise is suspected, liaising with ENT for flexible nasoendoscopy to assess for oedema or visible stenosis in the airway |
Immediate Management
If referring to maxillofacial surgery, initial management can be commenced:
- Fluid resuscitation if patient is dehydrated
- Analgesia
- Stat dose of IV co-amoxiclav (clarithromycin in penicillin allergies however local guidance may vary)
- Stat dose of IV dexamethasone if signs of airway compromise
- Keep patients NBM in case they need to go to theatre
Definitive treatment if referred to maxillofacial surgery is incision and drainage, either under local anaesthetic if a milder case, or admission for IV antibiotics and drainage under general anaesthetic if the deeper fascial spaces are involved and the patient is acutely unwell.
Conclusion
Orofacial and neck infections are common presentations in the emergency department, and many patients can be managed with a course of oral antibiotics and emergency dental treatment in the community.
However, it’s extremely important to be able to distinguish these straightforward cases with patients who need urgent management.
When seeing patients in the emergency department with facial swelling, it’s imperative to keep the signs of imminent airway compromise in mind:
- Swelling crossing the midline in submental and submandibular swellings
- Hoarse voice
- Inability to swallow own saliva/drooling
- Raised floor of mouth
- Protruding tongue
- Dysphagia
References
Payne, K.F.B. et al. (2015) ‘Emergency Department’, in On-call in Oral and Maxillofacial Surgery. 2nd edn. Libri.
Written by Dr Ruby Fussell BDS MFDS(Ed)
