Is it recommended to drain a small abscess on the cheek in the Emergency Room (ER)?

Management of Small Facial Abscesses in the Emergency Room

Small abscesses on the cheek can be safely and effectively drained in the Emergency Room setting, as incision and drainage is the standard treatment for superficial abscesses. 1

Diagnostic Approach

Before proceeding with drainage, proper assessment is essential:

• Differentiate between abscess and hematoma using:

  • Pain characteristics: Abscesses typically present with progressive, throbbing pain
  • Physical findings: Look for significant erythema, marked warmth, fluctuance with surrounding induration
  • Systemic symptoms: Fever, malaise, elevated WBC may indicate abscess 2

• Ultrasound can be helpful to:

  • Confirm the presence of an abscess (heterogeneous internal echoes, peripheral hyperemia)
  • Rule out a hematoma
  • Identify any deeper extension or proximity to vital structures 2

Treatment Procedure

For small facial abscesses:

1. Procedural steps:

   • Use appropriate local anesthesia
   • Make an adequate incision to allow complete drainage
   • Express all purulent material
   • Explore the cavity to break up loculations
   • Irrigate the cavity with sterile saline 3

2. Post-procedure management:

   • For small facial abscesses (<5 cm), packing is generally unnecessary 1, 4
   • Omitting packing reduces pain and anxiety while maintaining equivalent outcomes 4
   • Instruct on warm soaks/compresses 2-3 times daily
   • Clean with warm water or saline regularly 2

Antibiotic Considerations

• Antibiotics are usually unnecessary for simple, adequately drained abscesses 3
• Consider antibiotics if:
  • Patient is immunocompromised
  • Extensive surrounding cellulitis is present
  • Systemic symptoms are significant
  • Abscess is in a high-risk facial area (central face/danger triangle)

Follow-up Care

• First follow-up within 48-72 hours after drainage
• Monitor for:
  • Recurrent abscess formation
  • Delayed healing
  • Signs of ongoing infection 2

Special Considerations for Facial Abscesses

• Facial abscesses require particular attention due to:
  • Cosmetic concerns (consider placement of incision along skin lines)
  • Proximity to vital structures
  • Risk of spread to cavernous sinus if in the "danger triangle" of the face
  • Higher risk of scarring in visible areas

Pitfalls to Avoid

• Inadequate drainage leading to recurrence
• Damage to adjacent facial structures (nerves, vessels)
• Misdiagnosis of other conditions that may mimic abscess
• Failure to recognize deeper extension of infection
• Overlooking the need for follow-up in facial infections

While the evidence presented primarily discusses anorectal abscesses 2, the principles of abscess management apply broadly, and multiple studies confirm that small, uncomplicated abscesses can be safely managed in the emergency department setting 1, 3.