What is the initial management and physical exam checklist for a patient with cellulitis of the buccal space and an inflamed face?

Management of Buccal Space Cellulitis

For a patient with cellulitis of the buccal space and right-sided facial inflammation, immediate antibiotic therapy targeting Gram-positive bacteria should be initiated, with consideration for hospital admission if systemic signs of toxicity are present. 1, 2

Physical Examination Checklist

Vital Signs Assessment

• Temperature (fever may indicate systemic involvement)
• Heart rate (tachycardia >100 beats/min suggests systemic toxicity)
• Blood pressure (hypotension <90 mmHg systolic indicates severe infection)
• Respiratory rate

Facial Examination

• Extent and borders of erythema and swelling
• Presence of warmth and tenderness
• Fluctuance (indicating possible abscess formation)
• Skin changes: violaceous bullae, hemorrhage, sloughing (warning signs of necrotizing infection)
• Skin sensation (anesthesia may indicate deeper infection)
• Presence of gas in tissue (crepitus on palpation)
• Trismus (limited mouth opening)

Intraoral Examination

• Dental examination for potential source of infection
• Swelling of buccal mucosa
• Presence of purulent drainage
• Floor of mouth involvement
• Tongue position and mobility
• Uvula position (deviation may indicate deeper space involvement)

Ocular Examination

• Assess for orbital involvement: proptosis, pain with eye movements, restriction of extraocular movements, vision changes, severe eyelid swelling 2

Lymph Node Examination

• Submandibular, submental, and cervical lymphadenopathy

Neurological Examination

• Facial nerve function
• Pain disproportionate to physical findings (warning sign of deeper infection) 1

Laboratory Evaluation (if systemic signs present)

• Blood cultures
• Complete blood count with differential (marked left shift indicates severe infection)
• C-reactive protein (>13 mg/L suggests severe infection)
• Creatinine, bicarbonate, creatine phosphokinase levels 1

Management Algorithm

Step 1: Assess Severity

• If any of these present, consider hospital admission:
  • Systemic toxicity (fever, tachycardia, hypotension)
  • Rapid progression
  • Extensive facial involvement
  • Airway compromise concerns
  • Immunocompromised state
  • Significant comorbidities
  • Warning signs of necrotizing infection 1, 2

Step 2: Determine if Abscess is Present

• If fluctuance is detected, surgical consultation for incision and drainage is required
• For complex abscesses, both drainage and antibiotics are necessary 1

Step 3: Antibiotic Selection

For Outpatient Management (mild infection):

• First-line options:

  • Clindamycin 300-450 mg orally three times daily for 5-7 days 2
  • Cephalexin 500 mg orally four times daily for 5-7 days 3

• If MRSA suspected (based on risk factors or local prevalence):

  • Clindamycin 300-450 mg orally four times daily 2
  • Doxycycline 100 mg orally twice daily (adults only) 2

For Inpatient Management (moderate to severe infection):

• IV Clindamycin 600-900 mg every 6-8 hours 2
• IV Vancomycin 15-20 mg/kg/dose every 8-12 hours (if MRSA suspected) 2

Step 4: Monitor Response

• Reassess in 24-48 hours for outpatients
• Mark borders of erythema to track progression/resolution
• Extend therapy until 2-3 days after clinical resolution if inadequate improvement occurs 2

Special Considerations

• Buccal cellulitis in young children (especially <12 months) has historically been associated with Haemophilus influenzae bacteremia, though this is less common with widespread vaccination 4

• Facial cellulitis carries risk of spread to orbital or intracranial structures, requiring vigilant monitoring and prompt escalation of care if deterioration occurs

• Misdiagnosis is common with cellulitis; consider differential diagnoses including contact dermatitis, venous stasis, and deep vein thrombosis 5, 6

• For recurrent facial cellulitis, investigate and address predisposing factors such as dental disease, sinusitis, or immunocompromised state 2

The management of buccal space cellulitis requires prompt recognition and appropriate antibiotic therapy. Early surgical consultation should be obtained if abscess formation is suspected or if the patient shows signs of severe infection or necrotizing process.