Disclaimer: This blog post is based on my experiences as a patient. I am on a long-haul journey to find answers and resolution to a chronic condition that I have suffered with for 11 years. I am not medically trained. While I have researched this subject matter carefully, this post does not provide medical advice. If you are suffering from symptoms that you think Facial cellulitis may be the cause of, then please consult a medical professional.

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 Summary

Cellulitis is ‘an acute bacterial infection of the skin, involving the dermis and subcutaneous tissues.’[1] It is characterised by pain, warmth and swelling. ‘Facial cellulitis is a form of Cellulitis that occurs on the face, typically striking only one side of the face.’[2] This post asks whether my undiagnosed facial pain is caused by Facial cellulitis, with secondary soft tissue and lymphatic drainage damage.

Symptoms and Causation

Symptoms of Facial cellulitis include; swelling of the infected area, abnormal warmth in the face, tight and tender skin, facial pain, chills, fever and weakness. Facial cellulitis is caused when bacteria enter the body through a cut, an open sore, or via an animal or human bite. The two bacteria, which cause this infection are; Group A Streptococci and Staphylococcus Aureus.

‘The situation grows serious, when bacteria, migrate deeper into skin tissues.’ [3]

Complications Of Cellulitis

The main complications resulting from Cellulitis are soft tissue damage and lymphatic drainage damage. Dr Jay Khorsandi, explains in his article on byte.com, that if Facial cellulitis is left untreated, it can spread to the lymph nodes, which can develop into long-term chronic swelling. The infection can also spread to the bones and lymph system, which can lead to low blood pressure. It can also spread to the deeper layer of tissue and fascial lining, and this may eventually damage the lymphatic drainage system, which can also cause long-term chronic swelling; (lymphoedema/angioedema.) Dr Khorsandi makes clear that, without the correct treatment, the bacteria can spread to the neighbouring tissues. ‘If it gets deeper into the tissues, it can cause tissue damage and tissue death.’[4]

Misdiagnosis

‘Making the correct diagnosis is key to management.’[5]

Sullivan and De Barra explain in Diagnosis and management of cellulitis, that misdiagnosis of Cellulitis is common. ‘Approximately 30% of cellulitis patients are misdiagnosed. Commonly encountered alternate diagnoses include lymphoedema.’ They explain that, positive blood cultures are found in less than 10% of cases, and ‘tissue cultures are negative in up to 70% of cases. Streptococcal A infection is an important cause of culture negative cellulitis.’[6]

Admission to Hospital

In Soft Tissue Infections, Cellulitis, Nottinghamshire Area Prescribing Committee, summarise conditions that lead to a patient needing an urgent hospital admission. These include; if the patient has Class iii cellulitis, has signs of systemic illness, has severe pain, has Facial cellulitis, or has suspected orbital or Periorbital cellulitis. A doctor should admit a patient into hospital if the patient has infection near the eyes, or has an infection that is not responding to antibiotics.

My Causation

This infection started with an opening to the skin, (an insect bite to my lower left eyelid.)  My GP immediately diagnosed with me Orbital cellulitis. Straightaway, I had abnormal White Blood Count. This was particularly high with my neutrophils, which have been consistently abnormal for 11 years, (when I am not taking antibiotics.) I have had regular raises with my Red blood count and Haemoglobin count, and when my skin is burning hot, my Mean corpuscular haemoglobin concentration (MCHC) is abnormal. My Erythrocyte sedimentation rate (ESR,) has also been high. These raised blood markers are all indicative of underlying or chronic infection and inflammation. I first consulted with an Ophthalmologist in January 2014. He said, that ‘whilst we may never nail what the bacteria is, Staphylococcus Aureus is the most likely cause.’

My Symptoms

My symptoms are consistent with those of Facial cellulitis. From the outset, I had connected pain and swelling in my cheek and eye. The pain and inflammation spread to the left side of my head, after I applied a steroid eyedrop, called Maxitrol to my eye. I have swelling on the left side of my face, and around my left eye. My skin is burning hot. I have continual facial pain, my skin feels tight, and I often feel weak and tired.

When Things Went Wrong

In January 2014, I had the signs that Nottinghamshire prescribing area say require an admission into hospital. I had diagnosed Orbital Cellulitis, I was systemically unwell, and I was not responding to oral antibiotics. I had tried many rounds of oral Clarithromycin, Erythromycin and oral Doxycycline, (100mg twice daily) but none of these worked. In Loose Cannon, I explain that an Oculoplastic surgeon admitted me for 48 hours of Intravenous Ciprofloxacin, and a one-week course of oral Linezolid, (600mg, twice daily.) The intravenous antibiotics had a therapeutic effect. I felt more energised. They made me feel better. Sadly, having found clinical evidence of infection, the Oculoplastic surgeon kicked me off the ward, and stopped all of my medication, without doing a blood test first, to see if my bloods had normalised.

I had no antibiotics or anti-inflammatory medication for five months. I became severely ill; with pain, boiling hot skin, chills and fever. Knocking on door after door, I eventually found a private clinician, who began empirical treatment. He also kept my bloods under regular observation. If the Loose cannon had continued my care, and given me a much longer round of intravenous antibiotics, I may be in a very different situation today. He has a lot to answer for, not least, an £18,000 bill, that I had to front, to pay for care and treatment privately.

Parotid Gland Anatomy

My parotid gland is a major cause of my facial pain. Investigations and histology reports have found malfunction, reactive lymph nodes, and parenchymal damage (sialolithiasis,) in the gland. As Dr Khorsandi explains, Facial cellulitis can spread to the lymph nodes, and to the deeper layer of tissue and fascial lining. The parotid gland ‘consists of lobules of glandular tissue. The lobules are interspersed with adipose tissue and are covered in a layer of fascia (connective tissue), which forms the parotid capsule. The parotid gland contains superficial and deep lymph nodes. Drainage of these nodes occurs through the deep lateral cervical nodes, primarily the internal jugular nodes, via the infra-auricular nodes.’[7]

Question 1

Soft tissue is effectively what makes up the parotid gland. The parotid gland is also a main source of lymphatic drainage in the face. If I am suffering with Facial cellulitis and it has spread to the lymph nodes and deep tissue in my parotid gland, could this explain my pain and the pathology found? Looking at the anatomy of the gland and how cellulitis spreads deep into the tissue, this seems a possible explanation for my symptoms.

Anatomical Relations

The parotid region is bordered by many significant fascial spaces. It is bordered, as follows;

• Superiorly- Zygomatic Arch
• Inferiorly- Inferior border of the mandible
• Anteriorly- Masseter Muscle
• Posteriorly- External Ear and Sternocleidomastoid. [8]

My Pain

In My Facial pain, I explain that the pain on the left side of my face extends up to the zygomatic arch and into the centre of my cheek. Scans have shown an enlarged masseter muscle. A Radiology report from July 2022, detected abnormality in the retromolar area, which is close to the mandible, and in the buccal fat pad. I also explain in; My Ear Pain that I have severe pain in my left ear; a feeling of fullness/pressure, muffled hearing, and a penetrating pain in the bone behind my ear. I believe this bone is the mastoid space. The CT images do show an enlarged mastoid on the left side, but I have never received an answers about this.

Question 2

I explain in On Parotid Gland Surgery #2 that I the outgoing surgeon has left a lot of my parotid gland remaining. As the gland is bordered with a) the zygomatic arch, which is swollen and painful, b) the mandible and the masseter muscle, where pathology has been found and c) the external ear and the mastoid process, where I have severe and worsening symptoms, is it possible that my symptoms with my left ear and face, are being caused by my remaining parotid gland? If that was fully removed, would that solve my pain elsewhere?

My Periocular Pain

I have acute and persistent pain around my left eye, particularly in the region of  my temporal artery. My artery on the left side throbs and it is getting worse. This is the artery, that supplies blood to the eye. I am concerned, as my vision is blurry in that eye. I have no medical care, and the last ophthalmologist who I saw, was dismissive and answered none of my questions. The original diagnosis, in May 2013, was Orbital cellulitis. Is that not then a good reference point to go back to? Is my Periocular pain, chronic Periorbital cellulitis, with secondary Temporal Arteritis?

My Left Sided Head Pain

I have unyielding pain around the left side of my head. My head feels soft to touch on the affected side. When I push on it, it makes an indentation, that does not go away for a couple of seconds. I have a stabbing pain at the top of my head. It feels like someone is twisting a cork screw into my head. I have asked four Ear Nose and Throat, (ENT) consultants what this pain could be, but they have provided me with no answers.

Question 3

Dr Khorsandi explains that Facial cellulitis can spread to neighbouring tissues and bones. If Facial cellulitis is the cause of my pain, may it have spread to the soft tissue on my head? Could swelling of the connective tissue that makes up the scalp, be causing my left-sided head pain? Is it possible that potential Facial cellulitis has spread to my temporal bone? Could an enlarged temporal bone be causing my head pain? Or, if the lymphatic drainage is damaged, (Lymphoedema) could my head pain be caused by fluid that has built up in the soft tissue in my head?

My Low blood pressure

I have had low blood pressure during this 11-yr medical episode, but doctors have overlooked these readings. Dr Khorsandi explains that cellulitis can spread to the lymph system and cause low blood pressure. I am wondering whether Facial Cellulitis could be the cause of my low blood pressure? Raised infection markers and low blood pressure are useful clues. It has been very difficult, therefore, when Infectious Disease Consultants disregard this clinical evidence, instead of using it as a compass to find an accurate diagnosis.

Lymphoedema

In on Lymphoedema, I explain that I consulted with a rheumatologist. He thought that my facial pain and swelling was caused by a soft tissue infection, that has damaged the lymphatic drainage system. This explanation correlates with what Dr Jay Khorsandi says about Facial cellulitis spreading to the deeper layer of tissue and fascial lining, which can damage the lymphatic drainage system, and cause long-term swelling.

Final Reflection

My symptoms are consistent with Facial cellulitis, as are the pathology findings. My final question is, whether I could be suffering with Facial cellulitis, caused by Streptococcal A, or Staphylococcus Aureus, with secondary lymphoedema? Is it possible, that Cellulitis has spread to the deep layers of tissue and fascial lining? And with a delayed diagnosis of 11-yrs, has Facial cellulitis now permanently damaged my facial soft tissue?

I am looking for a microbiologist or Infectious Diseases consultant, who has an interest in complex soft tissue infections, who can diagnose and treat my condition. I am also calling out for Ophthalmologists and Head and Neck surgeons, (ENT or Maxillofacial surgery, who may be able to help. You can reach me via the contact form on my website, by email; info@myfacialpain.com or on X, (formerly Twitter) @myfacialpain.

Foot Notes

[1] Sullivan T & De Barra E; Diagnosis and management of cellulitis, Clinical Medicine 2018 Vol 18. No 2: 160-3, ©Royal College of Physicians, 2018.

[2] Dr Jay Khorsandi; Facial cellulitis: Symptoms, Causes, and Treatment, byte.com

[3] Dr Jay Khorsandi; Facial cellulitis: Symptoms, Causes and Treatment, byte.com

[4] Same source as footnote 2 and 3.

[5] Sullivan T & De Barra E; Diagnosis and management of cellulitis, Clinical Medicine 2018 Vol 18. No 2: 160-3, ©Royal College of Physicians, 2018.

[6] Sullivan S & De Barra E; Diagnosis and management of cellulitis, Clinical Medicine 2018 Vol 18. No 2:160-3, ©Royal College of Physicians, 2018.

[7] Parotid Gland| Complete Anatomy, Elsevier.com

[8] The Parotid Gland – Position – Vasculature – Innervation; Teach Me Anatomy

Photo Credits; Eric W, Pixabay, RDNE Stock Project, and Ann H on Pexels. Lidia Zajdzinska and CDC, and Rohit  on Unsplash.

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Ten years, suffering with acute facial pain. 15 NHS Trusts have closed my case. I am on a quest to find answers and medical treatment for my condition. Please contact me if you can help, thank you! #facialpain #newblog #eyepain #earpain #headpain #medicalhelp #medicalnews #delayeddiagnosis #delayedtreatment #chronicillness #invisibleillness

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