What is the appropriate management for a cheek abscess?

Management of Cheek Abscess

Incision and drainage is the primary treatment for a cheek abscess, with antibiotics reserved only for cases with systemic signs of infection, extensive surrounding cellulitis (>5 cm beyond abscess margins), immunocompromised patients, or incomplete source control. 1

Primary Treatment: Incision and Drainage

• Perform incision and drainage as the definitive treatment for simple cheek abscesses, making the incision as close as possible to the affected area to ensure complete evacuation of all purulent material. 1, 2
• Simple abscesses are defined as those with induration and erythema limited only to the defined abscess area, not extending into deeper tissues or having multiloculated extension. 1
• Complete evacuation of all purulent material and loculations is essential, as incomplete drainage leads to recurrence rates as high as 41%. 2
• The procedure can typically be performed under local anesthesia in the outpatient setting. 2

When Antibiotics Are NOT Needed

• Do not prescribe antibiotics after adequate drainage if the patient has:
  • No systemic signs of infection (fever >38°C, heart rate >90 bpm, or other SIRS criteria) 1, 2
  • Erythema limited to <5 cm beyond the abscess margins 2
  • Normal immune function 1, 2
  • Complete drainage achieved 1

When Antibiotics ARE Indicated

Add empiric antibiotic therapy if any of the following are present:

• Systemic signs of infection (fever, tachycardia, SIRS criteria) 1, 2
• Extensive surrounding cellulitis extending >5 cm beyond the abscess borders 1, 2
• Immunocompromised status (diabetes, HIV/AIDS, immunosuppressive medications) 1, 2
• Incomplete source control or inability to adequately drain the abscess 1

Antibiotic Selection

For empiric coverage (assuming community-acquired MRSA prevalence):

• First-line oral options: 2

  • Trimethoprim-sulfamethoxazole (TMP-SMX): 1-2 double-strength tablets twice daily
  • Doxycycline: 100 mg twice daily
  • Clindamycin: 300-450 mg three times daily

• Duration: 5-10 days, adjusted based on clinical response 2

• In areas where CA-MRSA is not prevalent, oral beta-lactams may be sufficient. 1

Special Consideration: Complex Cheek Abscesses

If the cheek abscess is complex (submasseteric, deep fascial involvement):

• These require broad-spectrum antibiotic coverage for Gram-positive, Gram-negative, and anaerobic bacteria in addition to surgical drainage. 1
• Submasseteric abscesses present with marked trismus and cheek tenderness, requiring adequate surgical drainage and parenteral antibiotics. 3
• Consider imaging (CT or ultrasound) to define the extent and rule out deeper involvement. 3

Post-Procedure Management

• Do NOT routinely pack the wound - packing is costly, painful, and provides no proven benefit for healing time or recurrence rates. 2
• Exception: Consider packing for wounds larger than 5 cm, as this may reduce recurrence. 4
• Culture the purulent material if: 2
  • Recurrent abscesses
  • Failure to respond to initial treatment
  • Risk factors for MRSA
  • Immunocompromised status

Follow-Up and Reassessment

• Reassess within 48-72 hours if no clinical improvement occurs. 2
• Lack of improvement may indicate inadequate drainage, resistant organisms, or deeper infection requiring surgical consultation. 2
• Among patients initially cured, new infections at 1 month are less common with clindamycin (6.8%) compared to TMP-SMX (13.5%) or no antibiotics (12.4%). 5

Critical Pitfalls to Avoid

• Do not prescribe antibiotics reflexively - incision and drainage alone achieves high cure rates (approximately 69%) for simple abscesses. 5
• Do not make inadequate incisions - ensure complete drainage of all loculations to prevent recurrence. 2
• Do not miss deeper infections - submasseteric or parapharyngeal involvement requires more aggressive management. 3
• Do not forget to consider differential diagnoses including parotitis, parotid tumor, or temporomandibular joint arthritis when evaluating cheek swelling. 3