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

  • Parotid Tumour
  • Maxillary or Mandibular Sarcoma
  • Cushing’s Syndrome
  • Nasopharyngeal Carcinoma
  • Burkitt’s Lymphoma

Ready Reckoner

Key distinguishing features of the most common diagnoses

MumpsAngioneuroticDental AbscessTraumaParotid Stone
Swells when EatingNoNoNoNoYes
Skin ErythemaNoYesPossiblePossibleNo
Tapping Tooth PainfulNoNoYesNoNo

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.
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