A 20s M cc L facial swelling and mild pain. He was hammering a wall at a construction job two weeks ago when something exploded and hit him in the face. He had no problems afterwards but in the past two days his face has become swollen. The patient had no visual complaints. On exam, his vitals are normal. There is a puncture wound on his left cheek with a little bit of soft tissue swelling. There is a palpable something when you push on the cheek, and some pus comes out of the puncture wound when you push. His visual acuity is normal as are his extraocular movements. How do we proceed?
Sono. Go looking for that ‘palpable something’. Eh, use lots of gel, don’t push too hard..
I agree with performing a POCUS, but would also consider further imaging with XR facial bones to rule out osteomyelitis, Fx and other foreign bodies that could be missed with sono.
Likely infected – agree with Halperin, can start investigating with sono to see what the object is or how deep it goes, but will probably require CT. Given the location, if it’s a deep object there is concern for maxillary sinus involvement. This sounds like it’s infected – while investigating what it is, I would start empiric antibiotics.