Orofacial cellulitis may emanate from any of the sources and sites given earlier.The principal micro-organism that precipitate cellulitis produce diverse toxins, enzymes, and cytokines that destroy tissue to facilitate infection, which spreads through the contagious fascial planes. In this way there is always the danger of the sillage of the infection into the bloodstream (septicaemia) and any adjacent vital organs and structures. When an acute infection emanates from the mandibular structures or the floor of the mouth and rapidly spreads to involve the bilateral fascial planes, it often culminates in a deadly condition referred to as Ludwig’s Angina.
Note: IMPORTANT: All clinicians must endeavor to recognize these conditions most promptly, since death can occur in a matter of hours.
There is massive bilateral upper neck swelling with bord-like feel on palpation. Tongue is raised towards the roof of the mouth and the floor is heavily indurated,the tissues having a cauterized-like surface. The patient is severely distressed because of respiratory embarrassment, and onset of stridor is ominous because it implies impending death.
The following management should be carried out:
- Admit the patient and institute specialist consultation promptly.
- Institute potential antimicrobial administration immediately as below.
- Ensure secure airway during referral and provide competent escort.
- If Ludwig’s Angina is diagnosed, then clinicians consulted may consider surgical intervention including surgical decompression, and/or tracheostomy.
- Where an abscess is diagnosed, incision and drainage must be performed promptly and antibiotics commenced after culture and sensitivity report.
For most acute bacterial infections in the orofacial area, the following should be done:
- Give amoxicillin 500mg orally 8 hourly for adults and amoxicillin suspension 125-250mg for children remain the most useful for empirical management. In case of allergy, erythromycin 500mg orally 8 hourly.
- Consider metronidazole 400mg orally 8 hourly (for children metronidazole suspension 100mg orally 8 hourly) for 5-7 days, in addition to amoxicillin where anaerobic microorganisms are suspected to play a major role.
- In cases of severe infections, benzylpenicillin 2.4 IV 6 hourly+metronidazole 500mg 8 hourly. For severe pain diclofenac 75mg IM 12 hourly+gentamicin 80mg IV 8 hourly.
- Analgesics: Ibuprofen 400mg orally 8 hourly. For severe pain diclofenac 75 mg IM 12 hourly
- Rehydrate the patient with 5% dextrose alternating with normal saline.
IMPORTANT: Clinicians must note that massive antimicrobial administration does not eliminate pus from tissues. Incision and drainage of the establishing pus is mandatory.