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.

Published: 2nd August 2022 | Updated: 15th August 2022

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

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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Website disclaimer

Pulse Reference is based on the best-selling book Symptom Sorter.

The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.