Rosen & Barkin's 5-Minute Emergency Medicine Consult (530 page)

TREATMENT

Rarely associated with airway emergencies, but if any signs of airway compromise are present:

• Intubation equipment at bedside
  
• Transport in sitting position
  
• Supplemental oxygen
  
• Suction secretions as needed
  

• Assess for airway patency
  
• Establish definitive airway via endotracheal intubation or cricothyrotomy/tracheostomy in the presence of:
  
  • Respiratory distress
    
  • Inability to handle secretions
    
  • Oropharyngeal tissue swelling that impairs or threatens airway
    

• Analgesia with NSAIDs or opiates may be required
  
• Incision and drainage:
  
  • Anesthetize gingiva superficially with 2% lidocaine with 1:100,000 epinephrine until blanching occurs
    
  • Make a 1 cm stab incision using a scalpel blade toward alveolar bone
    
  • Blunt dissection using mosquito hemostat
    
  • Irrigate cavity with saline
    
  • If abscess cavity sufficiently large, place 1/4 in iodoform gauze drain or fenestrated Penrose drain for 24–48 hr:
    
    • To prevent its aspiration, secure gauze or drain with silk suture
      
• Antibiotics:
  
  • Indicated if abscess extensive or if systemic signs present
    
  • Penicillin considered first-line empiric therapy
    
  • Erythromycin, azithromycin, clindamycin for penicillin-allergic patients
    
  • Clindamycin for penicillin-allergic patients or patients not responding to penicillin
    
  • Ampicillin/sulbactam for severe infections
    
• Warm salt water rinses hourly while awake for 24–48 hr
  

• Penicillin VK: 250–500 mg PO q6h (peds: 25–50 mg/kg/d PO div. q6h)
  
• Azithromycin: 500 mg (peds: 10 mg/kg) PO 1st day, then 250 mg (peds: 5 mg/kg) PO per day × 4 days (for penicillin-allergic patients)
  
• Clindamycin: 150–450 mg PO q6h (peds: 10–25 mg/kg/d div. PO q6h)
  
• Clindamycin: 300–900 mg IV q8h (peds: 15–25 mg/kg/d IV div. q8h)
  
• Erythromycin: 250–500 mg PO q6–8h (peds: 30–50 mg/d PO div. q6h)
  

• Ampicillin/sulbactam IV: 1.5–3 g IV q6h (peds >1 yr, <40 kg: 300 mg/kg/d IV div. q6h)
  
• Amoxicillin/clavulanate: 875 mg PO q12h (peds: 25–45 mg/kg/d div. q12h) (oral conversion)
  
• Moxifloxacin: 400 mg PO or IV QD (not routinely recommended for pediatric use)
  

FOLLOW-UP

• Severe infection or complication requiring parenteral antibiotics
  
• Necrosis or cellulitis involving areas with potential airway compromise
  
• Cavernous sinus thrombosis
  
• Osteomyelitis
  
• Outpatient therapy failure
  
• Immunocompromised patients:
  
  • Neutropenia
    
  • Uncontrolled diabetes
    
  • Advanced HIV
    
  • Cancer patients undergoing chemotherapy
    
• Ludwig angina
  
• Systemic involvement with significant dehydration
  
• Patients unable to handle secretions
  
• Patients unable to manage infection at home because of physical or mental disability or psychosocial factors
  

• Uncomplicated cases
  
• Dental follow-up available in 24–48 hr
  

Dental follow-up useful for:

• Viability of affected tooth
  
• Dental extraction
  
• Root canal therapy
  
• Removal of Penrose drain or wic
  

Dental follow-up in 24–48 hr:

• Lacking dental follow-up, patients should have alternative follow-up in 24–48 hr with provider familiar with disease process (oral surgeon, ED, urgent care, primary care)
  

Maxillary sinusitis may be incorrectly diagnosed without adequate oral exam:

• Dental follow-up is essential for short-term resolution of symptoms and long-term tooth viability and oral hygiene issues
  

• Beaudreau RW. Chapter 240. Oral and dental emergencies. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds.
  Tintinalli’s Emergency Medicine: A Comprehensive Study Guide
  . 7th ed. New York, NY: McGraw-Hill; 2011.
  
• Benko K Chapter 22. Dental emergencies. In: Adams JG, ed.
  Emergency Medicine
  . 1st ed. Philadelphia, PA: Saunders Elsevier; 2008.
  
• Capps EF, Kinsella JJ, Gupta M, et al. Emergency Imaging assessment of acute nontraumatic conditions of the head and neck.
  Radiographics.
  2010;30:1335–1352.
  
• Gould J. Dental abscess. Medscape. Updated May 30, 2012.
  
• Levi ME, Eusterman VD. Oral infections and antibiotic therapy.
  Otolaryngol Clin North Am.
  2011;44:57–78.
  
• Patel PV, Kumar S, Patel A. Periodontal abscess: A review.
  J Clin Diagn Res
  . 2011;5:404–409.
  
• Robertson D, Smith AJ. The microbiology of the acute dental abscess.
  J Med Microbiol
  . 2009;58(Pt 2):155–162.
  
• Schaad UB. Will fluoroquinolones ever be recommended for common infections in children?
  Pediatr Infect Dis J.
  2007;26:865–857.
  
• Sobottka I, Wegscheider K, Balzer L, et al. Microbiological analysis of a prospective, randomized, double-blind trial comparing moxifloxacin and clindamycin in the treatment of odontogenic infiltrates and abscesses.
  Antimicrob Agents Chemother
  . 2012;56:2565–2569.
  

See Also (Topic, Algorithm, Electronic Media Element)

Toothache

CODES

• 522.5 Periapical abscess without sinus
  
• 522.7 Periapical abscess with sinus
  
• 523.31 Aggressive periodontitis, localized
  

BASICS

• An inflammatory, typically infectious condition affecting the eyelid(s)
  
• It is anatomically distinguished by its location, isolated to the tissues anterior to the orbital septum:
  
  • Orbital septum is the connective tissue extension of the orbital periosteum that is reflected into the upper and lower eyelids
    
  • Extension to the deep tissues is rare because the septum represents a nearly impenetrable barrier but it may be incomplete
    
• Most commonly presents as a complication of upper respiratory tract infection (URTI) and sinusitis:
  
  • Swelling is caused by inflammatory edema from vascular and lymphatic congestion
    
• May occur as a complication of a localized inflammation/infection in the eyelid or adjacent structures:
  
  • Blepharitis
    
  • Hordeolum
    
  • Dacryocystitis
    
  • Surrounding skin disruptions:
    
• Insect bites
  
• Minor trauma
  
• Impetigo or other dermatologic disorders
  

• Inflammatory process in the structures deep to the orbital septum
  
• Typically occurs secondary to extension from an adjacent structure:
  
  • Sinusitis:
    
    • Most commonly ethmoiditis penetrating through the thin lamina papyracea
      
  • Dental abscess
    
  • Retained foreign body in the orbit
    
  • Puncture wounds
    
  • Orbital fracture
    
  • Postoperative infection
    
  • Hematogenous spread from a remote source due to valveless orbital veins
    
  • Rare cause—direct extension of periorbital cellulitis
    

• Streptococcus pneumoniae
  
• Staphylococcus aureus
  
• Streptococcus pyogenes
  
• Moraxella catarrhalis
  
• Haemophilus influenzae
  
• Gonococcus – rare
  
• Consider nonbacterial cause