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

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

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

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

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

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