Where should the opening be made to drain a cheek abscess with Methicillin-resistant Staphylococcus aureus (MRSA)?

Incision and Drainage of Cheek Abscess with MRSA

For a cheek abscess with MRSA, the incision should be made at the point of maximal fluctuance, with the incision oriented parallel to natural skin lines and avoiding important facial structures such as the facial nerve and parotid duct.

Anatomical Considerations for Cheek Abscess Drainage

When draining a cheek abscess, several critical factors must be considered:

1. Location of incision:

   • Make the incision at the point of maximal fluctuance
   • Choose the most dependent portion of the abscess to allow for gravity-assisted drainage
   • Align the incision parallel to natural skin lines (Langer's lines) to minimize scarring
   • Avoid facial nerve branches which run horizontally across the cheek
   • Avoid the parotid duct which runs from the parotid gland to the oral cavity

2. Approach based on abscess location:

   • For superficial cheek abscesses: External approach through the skin
   • For deeper abscesses near the oral cavity: Consider intraoral approach if accessible

Drainage Procedure

1. Pre-procedure:

   • Obtain cultures before administering antibiotics 1
   • Consider imaging (CT or ultrasound) if deep space involvement is suspected 2

2. Drainage technique:

   • Incision and drainage is the primary treatment for abscesses 1
   • Complete evacuation of purulent material is essential 2
   • The incision should be adequate to allow complete drainage but not excessive
   • Ultrasonographically guided needle aspiration is insufficient and not recommended (success rate only 25% overall and <10% with MRSA infections) 1, 3

3. Post-drainage management:

   • Consider placing a drain or wick to prevent premature closure 1
   • Simply covering the surgical site with a dry dressing is often sufficient 1
   • Some clinicians close the wound with sutures or pack it with gauze, though one small study found packing caused more pain without improving healing 1

Antibiotic Management

After drainage of a MRSA abscess:

1. Indications for antibiotics:

   • Severe or extensive disease
   • Rapid progression with associated cellulitis
   • Signs of systemic illness
   • Immunocompromised patients
   • Extremes of age
   • Abscess in difficult-to-drain area (face is considered one)
   • Associated septic phlebitis
   • Lack of response to incision and drainage alone 1

2. Antibiotic options for MRSA:

   • Clindamycin
   • Trimethoprim-sulfamethoxazole (TMP-SMX)
   • Doxycycline or minocycline
   • Linezolid 1, 2

Follow-up Care

1. Monitoring:

   • Reassess after 48-72 hours 2
   • Monitor for complications including spread to adjacent structures, bacteremia, and recurrence 2

2. Special considerations for facial abscesses:

   • Facial abscesses require close monitoring due to risk of complications
   • Potential complications include spread to deep facial spaces and cavernous sinus thrombosis 2

Common Pitfalls to Avoid

1. Inadequate drainage:

   • Incomplete evacuation of purulent material leads to high recurrence rates
   • Ensure all loculations are broken down 1, 2

2. Damage to vital structures:

   • Facial nerve branches
   • Parotid duct
   • Blood vessels

3. Inappropriate antibiotic selection:

   • Failure to cover MRSA when indicated
   • Unnecessary antibiotic use for simple, well-drained abscesses 1

4. Delayed treatment:

   • Facial abscesses should be drained promptly, especially with signs of systemic illness 1

By following these guidelines, you can effectively manage a cheek abscess with MRSA while minimizing complications and optimizing outcomes.