Facial swelling

Background

• Facial swelling in the ED requires rapid assessment to identify potentially life-threatening causes
• The primary concern is airway compromise — conditions like angioedema, Ludwig's angina, and deep space neck infections can progress to airway obstruction
• Anatomic location and timing of onset guide the differential

Clinical Features

• Key history: onset (minutes = allergic; hours-days = infectious; chronic = neoplastic), location, trauma, dental history, medications (ACE inhibitors), allergies, associated symptoms (fever, dysphagia, trismus)
• Red flags:
  • Stridor, voice changes, drooling → impending airway compromise
  • Floor of mouth swelling/tongue elevation → Ludwig's angina
  • Lip/tongue/periorbital swelling without urticaria → angioedema
  • Trismus → deep space infection
  • Periorbital swelling with ophthalmoplegia/proptosis → orbital cellulitis
• Physical exam:
  • Assess airway patency first
  • Palpate for fluctuance (abscess), crepitus (necrotizing infection, or dental/orbital wall fracture)
  • Intraoral exam for floor of mouth elevation, dental caries, gingival swelling
  • Eye exam if periorbital involvement

Differential Diagnosis

Facial Swelling

• Buccal space infections
• Dental problems
• Canine space infection
• Facial cellulitis
• Herpes zoster
• Masticator space infections
• Maxillofacial trauma
• Neoplasm
• Parapharyngeal space infection
• Salivary gland diagnoses
  • Parotitis
    • Bilateral parotitis
    • Suppurative parotitis
    • Viral parotitis (Mumps)
  • Ranula
  • Sialoadenitis
  • Sialolithiasis
• Superior vena cava syndrome

Evaluation

• CT face/neck with IV contrast — for suspected abscess, deep space infection, or orbital cellulitis
• CT maxillofacial without contrast — for suspected fracture
• Labs: CBC, BMP, blood cultures if septic
• If angioedema suspected: consider tryptase level (to differentiate from anaphylaxis), C4 level, C1 esterase inhibitor level (outpatient)
• Dental panorex or dedicated dental imaging for suspected odontogenic source

Management

• Airway first — if any concern for airway compromise, prepare for difficult airway management
• Angioedema: epinephrine, antihistamines, steroids; if ACE inhibitor-related, icatibant or C1 esterase inhibitor concentrate; see Angioedema
• Odontogenic/dental abscess: I&D, antibiotics, dental follow-up
• Deep space neck infection: IV antibiotics, CT imaging, ENT/oral surgery consultation for possible operative drainage
• Ludwig's angina: Emergent airway management, IV antibiotics, surgical consultation
• Orbital cellulitis: IV antibiotics, ophthalmology consultation, consider surgical drainage if subperiosteal abscess
• Periorbital cellulitis: Oral or IV antibiotics depending on severity
• Traumatic: Manage per fracture type; ice, elevation, pain control

Disposition

• Admit: Deep space infection, Ludwig's angina, orbital cellulitis, angioedema with airway concern, any case requiring IV antibiotics or surgical intervention
• Discharge: Isolated periorbital cellulitis (mild), simple dental abscess after I&D, resolved angioedema with outpatient follow-up

See Also

• Angioedema
• Ludwig's angina
• Periorbital cellulitis
• Orbital cellulitis
• Facial paralysis
• Dental problems
• Parotitis