What is the next best step for managing a patient with a swollen right cheek, where the complete blood count (CBC) suggests infection and the computed tomography (CT) scan shows soft tissue swelling without an abscess?

Management of Swollen Right Cheek with Suspected Infection

Empiric antibiotic therapy with coverage for both aerobic and anaerobic organisms is the next best step for managing a patient with a swollen right cheek, where CBC suggests infection and CT shows soft tissue swelling without abscess.

Assessment of Soft Tissue Infection

When evaluating a patient with facial swelling and suspected infection, the following considerations are important:

• The CT scan showing soft tissue swelling without abscess indicates a cellulitis or early-stage infection rather than an abscess requiring drainage
• CBC findings suggesting infection (likely elevated WBC count) confirm an infectious process
• Facial/cheek infections can progress rapidly due to the rich vascular supply and proximity to critical structures

Treatment Algorithm

First-line Management:

1. Empiric antibiotic therapy:

   • For facial cellulitis without abscess, initiate broad-spectrum antibiotics covering both aerobic and anaerobic organisms 1
   • Recommended regimens include:
     • Amoxicillin-clavulanate
     • Clindamycin (if penicillin allergic)
     • For more severe cases: combination of a beta-lactam plus metronidazole

2. Route of administration:

   • For mild to moderate infections: oral antibiotics with close follow-up
   • For moderate to severe infections (significant swelling, systemic symptoms): intravenous antibiotics 1

3. Duration of therapy:

   • Continue antibiotics until clinical improvement is observed
   • Typically 7-14 days depending on response

Monitoring and Follow-up:

• Reassess within 24-48 hours to evaluate response to therapy
• Monitor for:
  • Progression of swelling
  • Development of fluctuance (suggesting abscess formation)
  • Systemic symptoms (fever, increased pain)
  • Signs of deep space involvement

Special Considerations

Warning Signs Requiring Urgent Reassessment:

• Rapid progression of swelling
• Development of trismus (limited mouth opening)
• Visual changes or orbital involvement
• Neurological symptoms
• Respiratory compromise
• Failure to improve within 48 hours of antibiotic therapy

Imaging Considerations:

• Initial CT scan has already excluded abscess formation, which is appropriate as the first imaging study 2
• Ultrasound can be considered for follow-up if abscess is suspected during treatment 3
• Repeat CT may be necessary if:
  • Patient fails to respond to antibiotics
  • There is concern for deeper space involvement
  • Complications are suspected 1

Potential Complications to Monitor

• Progression to abscess formation
• Extension to deep facial spaces
• Osteomyelitis of adjacent bones
• Cavernous sinus thrombosis
• Airway compromise

Indications for Surgical Intervention

Surgical drainage would be indicated if:

• Abscess formation occurs during treatment
• Patient fails to respond to appropriate antibiotic therapy
• Development of fluctuance on examination
• Evidence of necrotizing infection 1

The absence of an abscess on initial CT scan makes immediate surgical intervention unnecessary, and antibiotic therapy is the appropriate next step in management 1, 2.