The Medical Consumer's Advocate

Lymphadenitis: lymph node swelling and pain; facial cellulitis

 

Q: Four days ago, a lymph node behind my right ear started to harden and swell up. After a couple of days, I was seen by a nurse practitioner, who told me I had an ear infection and gave me antibiotics. I've taken three doses of the medication--Augmentin 875 mg--but the condition seems to be worsening. This morning, the right side of my face is starting to get puffy and red and my ear hurts worse than ever. The lymph node is also swollen more than before. How long before the antibiotic starts to kick in? Is there anything else I can or should do?

[N.B.: the following answer was sent promptly to the letter-writer by the editor at allHealth.com.

A: There is no easy answer to your first question. The answer to your second question is much easier: report this change in your condition to your physician IMMEDIATELY. To understand why your condition is potentially so urgent, read on...

Lymph nodes are scattered throughout the body. Usually they are pea-sized or even smaller, but in response to infection they may grow to enormous size. Lymph nodes are most appropriately thought of as "white blood cell factories." White blood cells, which are critical for fighting infection, are actually produced in the bone marrow. After leaving the bone marrow, some white blood cells circulate in the blood, and others take up residence in the lymph nodes, spleen or thymus. When you have a serious infection, white blood cells in nearby lymph nodes multiply in order to fight the infection. Many of these white blood cells produce antibodies, which are fairly large proteins that are capable of neutralizing the infectious agent (be it bacterium, fungus or virus.) Other white blood cells can directly engulf and destroy infectious agents.

A typical history for ear infection would be ear pain and decreased hearing, followed soon after by one or more swollen lymph nodes near the ear. The infection you describe is almost certainly bacterial (as opposed to viral or fungal.) Just as your body is trying to win this little war by producing lots of white blood cells and lots of antibodies, the bacteria are trying to win by dividing (reproducing themselves) and by emitting toxins designed to create a more hospitable environment for the bacteria.

If your body starts "losing the war," one early sign is spread of inflammation to nearby tissues. In your case, I know that this occurred because you stated, "the right side of my face is starting to get puffy and red, and my ear hurts worse than ever." The cardinal signs of infection are PAIN, SWELLING, REDNESS, and HEAT. You have mentioned three of these signs, which suggests to me that the infection has begun to spread to adjacent parts of your face. The medical term for spread of infection into adjacent tissues is "cellulitis."

If the bacteria manage to infect the blood, the early signs of this will be headache, spiking fevers, shaking chills, severe fatigue, muscle aches and cold sweats. The medical term for this infection of the blood is "sepsis." If the infection progresses further, blood pressure drops precipitously, and "septic shock," coma and death may follow.

Fortunately, far fewer people die of infection nowadays thanks to the availability of antibiotics. Oral antibiotics are the first line in a physician’s armamentarium to combat infection, but if these fail, intravenous antibiotics are the next line. Intramuscular antibiotic injections are an intermediate step which is sometimes taken if the physician is trying to avoid admitting his/her patient to the hospital (intravenous antibiotics are typically, although not always, administered in an inpatient setting.)

Every physician has a different threshold for deciding when an infection is so dangerous that hospital admission and intravenous antibiotics are necessary. I have a much lower threshold for admitting a patient with cellulitis of the "danger triangle" (eyes, nose, cheeks and upper lip) since these infections can spread intracranially (into the space around the brain.) I also have a low threshold for admitting patients with airway swelling, since such patients could potentially asphyxiate (choke to death) from their infection. Infections of the outer ear or scalp can often be managed without intravenous antibiotics, but if the infection appears to be spreading despite strong oral antibiotics, I would consider at least advancing to intramuscular antibiotic injections. If you had any of the early symptoms of sepsis, I would definitely admit you for intravenous antibiotics.

I certainly hope that your infection resolved without major problems. It is important to realize that, even in the "antibiotic era," many thousands of people still die from infection.

 

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