Facial Swelling

Differential Diagnosis

Common Diagnoses

  • Mumps (Viral Parotitis)
  • Angioneurotic Oedema (Allergy)
  • Dental Abscess
  • Trauma (Especially Fractured Zygoma)
  • Salivary Gland Stone

Occasional Diagnoses

Rare Diagnoses

Ready Reckoner

Key distinguishing features of the most common diagnoses

MumpsAngioneuroticDental AbscessTraumaParotid Stone
BilateralYesYesNoPossibleNo
Swells when EatingNoNoNoNoYes
Skin ErythemaNoYesPossiblePossibleNo
Tapping Tooth PainfulNoNoYesNoNo
FeverYesNoPossibleNoNo

Possible Investigations

Likely:Facial X-ray (if trauma).

Possible:TFT (if patient looks myxoedematous).

Small Print:FBC, ESR/CRP, sialogram.

  • Plain facial X-ray important in trauma (view may depend on site). Also may reveal rare cases of bony tumour.
  • TFT, FBC, ESR/CRP: TFT will reveal hypothyroidism; WCC raised in infective process; ESR/CRP raised in infection and tumour.
  • Parotid sialogram will show obstruction of duct (stone, tumour).

Top Tips

  • New gruff voice with diffuse facial swelling should prompt investigation for likely hypothyroidism.
  • Don’t over-diagnose mumps in children – since the advent of MMR vaccination, this is becoming more uncommon; cervical adenitis is much more likely.
  • Whenever possible, direct patients with dental problems straight to the dentist, who will be able to prescribe any necessary antibiotics and analgesics.

Red Flags

  • Painless, progressive facial swelling suggests tumour or dental cyst. Urgent oral surgical referral is indicated.
  • Bloodstained nasal discharge in association with a unilateral facial swelling is an ominous sign suggesting malignancy.
  • Severe angioedema may cause respiratory tract obstruction – treat vigorously as for anaphylactic shock.
  • Orbital cellulitis requires urgent assessment and intravenous antibiotics.
  • Parotid swelling with a facial palsy suggests parotid tumour with involvement of the facial nerve.
  • Suspected herpes zoster in the ophthalmic division of the trigeminal nerve requires urgent antiviral treatment and ophthalmological referral.

Published: 2nd August 2022 Updated: 10th April 2024

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Based on the best-selling book Symptom Sorter, Nursing in Practice Reference is designed to help nurses working in primary and community care make sense of patient presentations. Written by GPs and adapted by nurses, it covers the vast majority of symptoms seen in primary care to inform different nursing disciplines with a range of responsibilities. Each symptom is organised into common, occasional or rare differentials, with distinguishing features, possible investigations and key points. It also provides guides on managing more than 350 conditions. The perspective is very much grass roots primary care, informed by the latest evidence and guidance.

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Disclaimer

Nursing in Practice Reference is based on the best-selling book Symptom Sorter. The experts behind Nursing in Practice Reference are Marilyn Eveleigh who is Nursing in Practice’s editorial advisor and a primary care nurse in East Sussex, Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.