The Libyan Journal of Surgery

Case Report

CARBUNCLE OF THE CHIN: A CASE R

REPORT
PORT AND
LITERATURE
ERATURE REVIEW
1 2 3 3
Ganasan Chelliah , Azhar bin Amir Hamzah , Mohamad Zikri Ahmad , Rashidi Ahmad
1)Department of Emergency,, Hospital Sultan Ismail, Johor Bahru, Mal
Malaysia, 2) Department of Surgery
and, 3) Department of Emergency Medicine, Hospital Universiti Sains Malay
Malaysia,
sia, Kelantan, Malaysia.
M
Received: 13 January 2013, Accepted in revised form: 6 April 2013, Published: 9 April 2013
201
Corresponding author: Azhar bin
in Amir Hamzah
Hamzah, e-mail: drazhar786@hotmail.com

ABSTRACT:
Carbuncles are superficial soft tissue infections related to hair follicles. Most common areas of
involvement include the back of neck, back, buttock and axillary region. If carbuncle is left untreated,
bacteria from carbuncle can penetrate into the blood stream and may cause serious complications,
including
cluding sepsis and infections in other parts of the body. We highlight a case of a 48 year-old
year diabetic
lady who suffered from the carbuncle
arbuncle that arises from the uncommon site (chin). Its clinical presentation
and management
agement along with a review of literatures are presented.
Key words: carbuncles, common site, chin

:‫الملخص العربي‬
‫ تقرير حالة ومراجعة األدب الطبي‬:‫جمرة في الذقن‬
3 3 2 1
‫ رشدي أحمد‬، ‫ محمد زكريا أحمد‬، ‫ أزھر بن أمير حمزة‬، ‫غنسان تشيليا‬

‫المناطق األكثر شيوعا تشمل ظھر الرقبة األرداف والظھر‬. ‫الدمامل ھي إخماجات لألنسجة السطحية الرخوة ومرتبطة ببصيالت الشعر‬
‫ بما في‬،‫ يمكن للبكتيريا الوصول إلى مجرى الدم ومن ثم يمكن أن تسبب مضاعفات خطيرة‬،‫إذا ما تركت دون عالج‬. ‫ومنطقة اإلبطين‬
‫ مصابة بداءالسكري التي أصيبت‬48 ‫نسلط الضوء على حالة سيدة عمرھا‬. ‫ذلك تسمم الدم وإخماجات في أجزاء أخرى من الجسم‬
‫ في ھذه الورقة تم عرض الحالة الطبية والعالج مع مراجعة األدب الطبي المتعلق بھذه‬.‫بإخماج الجمرة في مكان غير مألوفوھو الذقن‬
.‫الحالة‬
‫ الذقن‬،‫ مواقع شائعة‬،‫ جمرات‬:‫الكلمات المفتاحية‬
INTRODUCTION: CASE REPORT:

C
arbuncles are cluster of furuncles In-
volving hair follicles connected Subcu-
taneously, causing deeper Suppuration
[ smelling greenish discharged. She denied any
and scarring. It is often broad, swollen
swollen, erythe-
matous, deep and painful ful mass that usually open
and drain through multiple1. Carbuncles may
develop any where including the head, bu buttock
and neck region. However carbun carbuncles show
predilection for the back of neck, probably due
to relative frequency of hair follicles in that
region2. We describe
scribe a case of a 48 year
year-old lady
who suffered from the carbuncle of the chin. To
the author’s best knowledge, there was only one
case reportt on carbuncle of the chin avaiavailable in
the Medline-indexed
indexed literature in the last 50
years3.
Gradually increased swelling and localized Pain
over the chin that were associated with Foul
fever, sore-throat or tooth-ache. ache. She applied
herbal medications over the Chin which she
sought from the traditional healer. There was no
sign of improvement despite the treatment. She
was diagnosed with hypertension and hyper-
cholesterolemia a few years ago. On examination,
she was alert and in minimal pain. Her blood
pressure, pulse rate, temperature, oxygen
saturation
tion and pain score were 217/100 mmHg,
84 beats per min, 37° C, 100% and 6/10
respectively. There was a superficial 8cm x
10cm swelling over the chin extending extend to
submental region. It was firm in consistency,
con
warm,

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Citation: Libyan J Surg & 2013, 2:839571 - http://dx

/dx.doi.org/10.5542/LJS.v3i0. 839571
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Erythematous and tender on palpation. Minimal
greenish discharged was noted, figure1. She had
no difficulty to open and close her mouth. Oral
and neck mobility examination revealed no
abnormalities.
Figure 1. Showing a huge carbuncle on the chin
Full blood count results revealed a feature of
leukocytosis(white cells 16X109 cells/liter). Her
random blood sugar was elevated (22 mmol/L).
Other electrolytes were within a normal range.
Plain radiograph of skull was normal with no
signs of periosteal reaction and soft tissue gas.
She was diagnosed with submental carbuncle
and uncontrolled diabetes mellitus. She was
referred to surgical team for saucerization.
Insulin infusion and oral captopril 25 mg was
administered to control the blood sugar and
blood pressure. Subsequently, saucerization was
performed under general anesthesia. The carbuncle
was confined to the mental region with slight
extension into the superficial area of submental
triangle. The area of infection involved the deep
cervical fascia. There were multiple abscess
pockets deep to the carbuncle and 20 ml of pus
was drained out.There were discharging sinuses
that bleed once in contact with the hemostat. The
hemostat was used to break up any loculations
within the abscess. The surgical Procedure went
off uneventfully and she was doing very well
post surgery, figure 2.
Figure 2. Showing the wound post saucerisation
Citation: Libyan J Surg & 2013, 2:839571 - http://dx.doi.org/10.5542/LJS.v3i0. 839571
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Azhar bin Amir Hamzah et al
Intravenous Cloxacillin 500 mg every 6 hours
was administered. The intravenous antibiotic
was converted to oral form on day 6 after fever
and surrounding inflammation seemed to settle
down. It was continued for 2 weeks. Daily
dressing was performed until healthy granulation
tissue was evident. It was observed that a tight
glycaemic control and stabilization of blood
pressure control hastened the recovery. Pus from
carbuncle culture and sensitivity yielded
Staphylococcus aureus that is sensitive to
methicillin. During her one week follow up, the
wound was clean and dry. After few months
theWound healed with keloid scar and skin
conTraction, figure 3.
Figure3. Showing skin contraction and keloid scar over
the chin
DISCUSSION:
Bacterial infections of the skin and adjacent
ubcutaneous tissues are common presentation to
emergency department4. The spectrum of these
infections may vary from a simple, selfcontained
cellulitis to a severe, life threatening, and rapidly
evolving necrotizing fasciitis. Carbuncle is seen
between these 2 extremes. Carbuncles belong to
a group of superficial soft tissue infections
related to infection of hair follicles. Most
Common areas of involvement include the back
of neck, back, axillary region and buttocks. It
rarely involves the chin or the medial third of
face (around eyes and nose) 1, 5.There are 3
possible mechanisms of carbuncle in our patient.
First, there is a violation of the barrier from
mechanical injury in the form of cuts, abrasions,
punctures, or thermal injury that introduces the
microbes into the soft tissue. Second, there is
obstruction to the flow of sweat, oils, and
sebaceous secretions that lead to proliferation of
the pathogens. Third, the fact that she is
diabetic, making her more susceptible to
contract infection. According to Tobias et al,
diabetic patients have impaired leukocyte

function, and the metabolic abnormalities of
diabetes lead to inadequate migration of
neutrophils and macrophages to the site of
infection, along with reduced chemotaxis. Such
cellular changes would predispose diabetic
patients to an increased risk of skin infection6.
Other possible risk factors for developing
carbuncle includes poor hygiene, elderly, staphy
lococcal nasal carriage, hot/tropical climate and
contact with community-onset MRSA carriers3.
Carbuncle over the face requires urgent attention
compared to those on the neck and trunk as it
may be potentially life threatening. Anatomical
differences include loose subcutaneous tissues,
constantly moving facial muscle and valveless
veins communicate with intra-cranial sinuses are
associated with a greater risk of intracranial
spread of infection7. Therefore, early and radical
surgery, appropriate antimicrobial drugs, good
control of blood glucose and the treatment of
associated disorders may prevent such serious
complication8, 9. Most common attributes of
carbuncles are Staphylococcus aureus, both
methicillin- susceptible and methicillin-resistant
strains7, 9. Staphylococcus aureus is a gram-
positive bacterium that colonizes the skin and is
present in the anterior nares in about 25–30% of
healthy people10. The fact that our patient had
skin infection by methicillin-sensitive strains of
Staphylococcus aureus, the choice of antibiotic
is various. Among the antibiotic of choice
include s penicillin derivatives amoxicillin-
clavulanate, cloxacillin and ampicillin sublactam,
# disfigurement or diminished function of the area.
first generation cephalosporin cephalexin,
clindamycin and trimethoprim/ sulfamethoxazole.
Surgical approach for carbuncle is similar
regardless of anatomical location of infection.
Most authors from past and present recommended
wide excision of lesion until healthy tissue is
exposed1, 3, 5, 11. It requires extensive removal of
chronically undermined skin with wide exci-
sion8. Traditionally, surgical treatment of
carbuncle is divided into incision or excision1
Donald Barlow describes a method of cruciate
incision of the infected tissue and flaps of
maximum thickness are recommended for
preservation of blood supply in face and neck
region3. In contrast, Donald Gordon advocated a
wedged shaped excision of infected tissue until
the deep fascia to aid wound closure and healing
5
. In our case, we preferred prompt wide
excision of infected tissue till the deep cervical
fascia in order to eradicate all infective tissue
and to minimize the risk of intracranial
infection. The management of carbuncle of the
Citation: Libyan J Surg & 2013, 2:839571 - http://dx.doi.org/10.5542/LJS.v3i0. 839571
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Azhar bin Amir Hamzah et al
chin may not be very straight forward as treating
carbuncle at the back, buttock, trunk and neck.
In our case, carbuncle arises from an exposed
area, near to the face that might have some
cosmetic and psychological implication if the
healing undergoes severe scar tissue fibrosis or
keloid formation. Surgeons have to meticulous
during the excision of the carbuncle of this area,
as the end result might not be pleasing
experience for the patient as well as the surgeon.
Multidisciplinary approach involving the
general, plastic and maxillofacial surgeons
during the planning and surgery is recommended
in case of a large carbuncle arising from this
‘sensitive’ area. Skin grafting after saucerization
is a controversial issue. In most instances, skin
grafting is rarely required due to excellent
wound healing after removal of source of
infection1. Carbuncle wound post saucerization
usually contracts to a smaller scar and heal via
fibrosis and does not usually require skin
grafting. This is because carbuncle tends to
involve the loose tissue of the skin where the
contraction is the predominant form of repair
especially over the neck, back and buttock. Skin
grafting wound be indicated if the contraction or
the healing process is hampered or slow. There
are two methods of grafting - split skin grafting
and transpositional local skin flaps. A Split
thickness skin graft is a simple quick surgical
solution for certain defects if it involves a wide
area and contraction process will cause severe
Local skin flaps has an extra advantage than
split thickness skin grafts whereby it covers such
defects effectively and at the same it gives a
better cosmetic result. 11.
CONCLUSION:
Carbuncle of the chin is not uncommon. The
commonest responsible organism is Staphylococcus
aureus. The management poses a great challenge
to the surgeon because it involves the face that
might have some cosmetic and psychological
implication if the healing undergoes scar tissue
fibrosis or keloid formation. Multidisciplinary
approach is recommended for difficult cases.
REFERENCE:
1) J.K. Berman. Carbuncle. The American
Journal of Surgery, Volume 40, Issue 2, May
1938, Pages 419-425
2) Barlows D. Septic infections of the neck.
Post-Grad Med Jour. 1940 Jan:(3-10)
3) Harnisch H.Carbuncle of the chin. Quintessenz.
1967 Apr: 18(4):34.
 Azhar bin Amir Hamzah et al
4) Centers for Disease Control and Prevention.
Soft tissue infections among injection drug
users—San Francisco, California, 1996-2000.
MMWR Morb Mortal Wkly Rep. 2001;50:381-
38
5) Donald Gordon. Treatment of boils and
carbuncles. The American Journal of Surgery,
Volume 36, Issue 1, April 1937, Pages 107-117
6) Tobias Hirsch, Malte Spielmann, Baraa
Zuhaili, et al. Enhanced susceptibility to infec-
tions in a diabetic wound healing model. BMC
Surg. 2008; 8: 5:1-8
7) Liu C et al: Clinical practice guidelines by
the infectious diseases society of America for
the treatment of methicillin-resistant
8) Staphylococcus aureus infections in adults
and children: executive summary. Clin Infect
Dis 52:285, 2011 Feb. 1
9) Stevens DL et al: Practice guidelines for the
diagnosis and management of skin and
soft-tissue infections. Clin Infect Dis 41:1373,
10) 2005 Nov. 15
11) Jamal A Mohammad, Salem Al-Ajmi,
Abdul-Aziz Al-Rasheed. Surgical Management
of Post Carbuncle Soft Tissue Defect in Diabetic
Patients. MEJour Fam Med June 2007 5:(4)
12) Grundmann H, Aires-de-Sousa M, Boyce J,
Tiemersma E: Emergence and resurgence
13) of meticillin-resistant Staphylococcus aureus
as a public-health threat. 133 2006, 368
(9538):874-885.
14) Benfield T, Jensen JS, Nordestgaard BG.
Influence of diabetes and hyperglycemia on
infectious disease hospitalization and outcome.
Diabetologia. 2006 Dec 23

Citation: Libyan J Surg & 2013, 2:839571 - http://dx.doi.org/10.5542/LJS.v3i0. 839571

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