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Inflammatory Diseases and Tumours of the Face 

1. INFLAMMATORY DISEASES

Phlegmon

  • Acute, diffuse purulent inflammation of soft tissue
  • Characterised by rapid spread and necrosis – can penetrate anatomical orifices

Etiology

  • Most commonly due to bacterial infection of soft tissue
    • Agents – staphylococcus, streptococcus, bacteroides
  • Starts as purulent inflammation process in oral, nasal cavity or maxillary sinuses

Clinical features

  • Constant pain in area
  • Spreading, swelling
  • Fever, chills, weakness, rapid breathing, palpitations
  • Hyperaemia of skin – no clear boundaries

Investigations

  • History, physical exam
  • Bloods – ↑CRP and ESR, leukocytosis
  • Microbiology study at puncture site

Treatment

  • Antibiotics, detoxification
  • Local treatment – start with conservative
    • Dissection of phlegmon (take precaution of CN VII) → excision of necrotic tissue → debride wound → drain with solutions of antiseptics → apply flow-rinsing drain

Ludwig’s angina

  • Life threatening infection of tissue of the floor of the mouth – spreads to retrosternal space
  • Usually after concomitant dental infection

Etiology

  • Bacterial infection – actinomyces israelii
    • Most common in the submandibular space
    • Then enters into submaxillary space and further into retrosternal area
  • Piercings of floor of mouth

Clinical features

  • Swelling, pain – neck, sublingual and submandibular region
  • Malaise, fever, stridor, dysphagia

Treatment

  • Antibiotics and monitoring
  • Drain and incision
  • Maxillofacial surgery

Lymphadenitis

  • Inflammation of lymph node – most commonly due to a complication of bacterial infection of a wound
  • Can be generalised (affects many nodes) or localised
  • Can be accompanied by lymphangitis

Etiology

  • Streptococcus and staphylococcus, TB, tularaemia
  • Viral, fungi
  • Dental abscess, tonsillitis, infected acne
  • General lymphadenitis is caused by – mononucleosis, CMV, toxoplasmosis, brucellosis

Clinical features

  • Nodal swelling – pain on palpation
  • Fever, chills, loss of appetite, rapid pulse, general weakness
  • If lymph node is not sore cat scratch disease is likely

Treatment

  • Antibiotics for bacterial etiology – penicillin G, nafcillin, cephalosporins, erythromycin
  • Supportive care – hot moist compress

Dental abscess

  • Inflamed pus filled lump in bone or soft tissue of the jaw
  • Cause by tooth decay or injury to tooth

Clinical features

  • Pain, red gums, swollen gums and cheeks
  • Fever
  • Patient unable to close mouth properly

Pericoronitis

  • Wisdom teeth (3rd molars) – erupt in late adolescence
  • If there is not enough room it can lead to pericoronitis (inflammation of tissue surrounding teeth)
    • Good nidus for bacteria
  • Prevention – good oral hygiene and removal of flap of gum tissue

Clinical features

  • Pain, swollen gums, bad taste/smell, pus discharge
  • Swollen side of face and lymph nodes
  • Muscle spasms in jaw

Treatment

  • Drain and clean area from pus
  • Oral antibiotics
  • Brushing, flossing, rinsing – several times a day
  • Extraction

Arthritis

  • Osteoarthritis – aching jaw pain increases with talking/eating, stops with rest
    • Crepitus heard over TMJ, enlarged joints, decreased range of motion
  • Rheumatoid arthritis – symmetrical pains in all joints and jaw
    • Decreased ROM and stiff after inactivity (especially in the morning)
    • Myalgia, weight loss, anorexia

Osteomyelitis

  • Inflammation of bone (medullary space) and muscles around it
  • Commonly affects the mandible

Etiology

  • Polymicrobial – G-rods, anaerobes, A.israelii

Clinical features

  • Restricted jaw motion, pseudoparalysis
  • Hyperaemic , warm, oedematous tissue around infected bone
  • Localised swelling

Investigations

  • CT, MRI, bone scan with gallium (detects early disease)
  • Needle aspiration – sulphur granules seen in A.israelii

Prevention

  • Good dental hygiene, prompt treatment of oral/dental inf

Suppurative parotits

  • S.aureus infection of the parotid gland
  • Abrupt onset jaw pain, high fever, chills, erythema, edema of overlying skin
  • Swollen, tender gland and pus at 2nd top molar (Stensen’s ducts)

2. TUMOURS

Face tumours

Hemangioma

  • Abnormal build up of blood vessels in the skin or internal organs
    • Capillary hemangioma – on the skin
    • Cavernous hemangioma – in deeper tissues/viscera
  • Present at birth, disappear in some patients
  • Course
    • Rapid growth phase → rest phase → disappear fully
  • Large hemangiomas are prone to bleed and ulcerate – bacterial infection can superimpose
  • Clinical features – red/purple raised lesion, massive raised tumour with blood vessels
  • Treatment
    • Topical beta blockers – timolol
    • Corticosteroids
    • Laser surgery

Bowen’s disease

  • Squamous cell carcinoma in situ
  • Etiology – HPV, AIDs, sun damage, arsenic
  • Clinical features – slow growing red scaly plaque
  • Treatment – if not excised then turns in to squamous cell carcinoma

Squamous cell carcinoma

  • Sun exposure is the biggest risk factor
  • Clinical features – ulcerated, raised edges, central scab
  • Spreads by lymph and local extension
  • Treatment – wide excision and radiotherapy

Basal cell carcinoma

  • Superficial slow growing malignant tumour, derived from keratinocytes
    • Locally destructive, but doesn’t metastasise
  • Etiology – sun exposure, most common in Caucasians
  • Clinical features
    • Metastases are rare but eroding ulcer can be highly destructive
    • Scabbing, erosion of nose, eyes and face
  • Investigation
    • Biopsy – typical appearance is shiny pearly border, lesion alternatively crust and heal
  • Treatment – excision and radiotherapy

Melanoma

  • Arises from melanocytes – in skin, nail beds, mucosa, conjunctiva
  • Highest mortality rate
  • Atypical moles can be a sign of malignancy
    • Enlargement, darkening, ulceration, bleeding, indistinct borders
  • Metastasis correlates with depth of dermal invasion
  • Treatment – wide excision, radio/chemo for systemic disease

Jaw tumours

Ameloblastoma

  • Benign tumour of odontogenic epth
  • Ameloblasts form the outside part of teeth during development
  • Clinical features – painless swelling, un-erupted teeth, blocked nasal or airway
  • Investigations – XR and biopsy
  • Treatment – wide excision and reconstruction

Odontoma

  • Dental harmatoma – composed of normal dental tissue
  • Most common in young people
  • Types
    • Complex – unrecognisable as dental tissue
    • Compound – composed of 3 dental tissues – enamel, dentin, cementum

Osteosarcoma

  • Osteosarcoma of the jaw has different characteristics than osteosarcoma of the long bones
    • It presents at older age, has longer survival and metastases is rarer than in the long bones
  • Clinical features – swelling (osteosarcoma of long bones presents as pain instead), facial dysesthesia, loosening of the teeth
  • Linked to previous tooth extraction
  • Treatment – wide resection. Adjuvant chemo/radio
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