Facial Swelling
This section looks at ‘internal’ causes of facial swelling rather than superficial skin conditions, which are dealt with in other sections. This problem is usually a major concern to the patient because of the disfigurement, which it is impossible to hide. The causal conditions are often very painful too.
Differential diagnosis
Common Diagnoses
- Mumps (Viral Parotitis)
- Angioneurotic Oedema (Allergy)
- Dental Abscess
- Trauma (Especially Fractured Zygoma)
- Salivary Gland Stone
Occasional Diagnoses
- Bacterial Parotitis
- Cellulitis (Including Orbital)
- Masseteric Hypertrophy (Caused by Bruxism)
- Dental Cyst
- Myxoedema
- Herpes Zoster (May be Swelling Rather Than Blistering Initially)
Rare Diagnoses
- Parotid Tumour
- Maxillary or Mandibular Sarcoma
- Cushing’s Syndrome
- Nasopharyngeal Carcinoma
- Burkitt’s Lymphoma
Ready reckoner
Key distinguishing features of the most common diagnoses
| Mumps | Angioneurotic | Dental Abscess | Trauma | Parotid Stone | |
|---|---|---|---|---|---|
| Bilateral | Yes | Yes | No | Possible | No |
| Swells when Eating | No | No | No | No | Yes |
| Skin Erythema | No | Yes | Possible | Possible | No |
| Tapping Tooth Painful | No | No | Yes | No | No |
| Fever | Yes | No | Possible | No | No |
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.
- Beware the overdiagnosis of mumps in children – since the advent of the 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.