What causes facial swelling?

Facial Swelling: Causes and Clinical Approach

Facial swelling arises from diverse etiologies that can be systematically categorized by clinical presentation pattern and time course, with infectious/inflammatory conditions, angioedema, and allergic reactions representing the most common causes requiring immediate differentiation to prevent morbidity and mortality.

Categorization by Clinical Presentation

Acute Swelling with Inflammation

Infectious causes dominate acute presentations and include:

• Bacterial sinusitis with facial swelling indicates potential complications requiring imaging; look for severe headache, cranial nerve palsies, or proptosis as red flags for orbital or intracranial extension 1
• Cellulitis and erysipelas present with rapidly spreading edema, redness, and heat, often with peau d'orange appearance; systemic signs (fever, tachycardia, hypotension) may precede visible skin changes 1
• Odontogenic infections causing maxillary swelling, particularly when dental pain accompanies facial swelling 1, 2
• Lymphadenitis in pediatric patients, often presenting with localized tender swelling 2

Critical pitfall: Acute sinusitis with facial swelling, orbital involvement, or severe headache requires CT imaging with contrast to rule out complications—do not rely on clinical criteria alone in these cases 1

Angioedema (Non-Inflammatory Swelling)

Hereditary angioedema (HAE) presents with:

• Episodic swelling of extremities, face, oropharynx, or larynx following a stereotypical 24-hour worsening pattern, peaking, then 48-hour resolution 1
• Onset typically in childhood, worsening at puberty, with positive family history in most cases 1
• Epinephrine, corticosteroids, and antihistamines are NOT efficacious for HAE—this is a critical distinction from histamine-mediated angioedema 1

ACE inhibitor-associated angioedema is bradykinin-mediated and similarly unresponsive to standard allergy treatments 1

Anaphylactic angioedema presents with flushing, facial swelling, dyspnea, and potential progression to shock within seconds to hours; requires immediate epinephrine 1, 3

Allergic/Contact Reactions

• Allergic contact dermatitis causes facial erythema and swelling, distinguished from angioedema by presence of pruritus, vesiculation, and clear exposure history 4, 5
• Food allergy rarely causes isolated facial swelling; look for urticarial rash, lip swelling, or bronchospasm suggesting IgE-mediated reaction 1
• DRESS syndrome (drug reaction with eosinophilia and systemic symptoms) presents as red swollen face with systemic involvement—a potentially life-threatening condition 5

Chronic/Progressive Swelling

Slowly progressive swelling suggests:

• Vasomotor rhinitis with nasal congestion and facial fullness triggered by temperature changes, odors, or irritants 1
• Giant cell arteritis (temporal arteritis) in patients over 50 presenting with facial swelling, new-onset headache, tender temporal artery, and polymyalgia rheumatica symptoms; requires immediate high-dose corticosteroids and temporal artery biopsy to prevent blindness 6
• Granulomatous conditions, autoimmune diseases (dermatomyositis), or neoplasms in the differential for persistent facial edema 4, 5

In pediatric patients specifically:

• Nonprogressive midfacial swelling suggests congenital anomalies (cephalocele, nasal glioma, dermoid cyst) 2
• Rapidly progressive swelling with cranial nerve deficits raises concern for rhabdomyosarcoma, Langerhans cell histiocytosis, or other malignancies 2

Diagnostic Approach Algorithm

Step 1: Assess for life-threatening conditions

• Airway compromise (laryngeal angioedema)? → Secure airway, epinephrine if anaphylaxis 1
• Signs of severe infection (hypotension, altered mental status, orbital signs)? → CT with contrast, broad-spectrum antibiotics 1

Step 2: Determine time course and pattern

• Acute (<24 hours) with fever/erythema → Infectious etiology most likely; examine for purulent nasal discharge in middle meatus, dental source, or skin entry point 1
• Acute without inflammation, episodic pattern → Consider angioedema; check medication list for ACE inhibitors, assess family history for HAE 1
• Subacute to chronic → Consider vasculitis (temporal arteritis if age >50), autoimmune disease, or neoplasm 6, 4

Step 3: Key physical examination findings

• Purulent secretions in middle meatus = bacterial sinusitis; if accompanied by facial swelling, obtain CT to assess for complications 1
• Peau d'orange skin texture with warmth = cellulitis/erysipelas 1
• Tender, cord-like temporal artery with new headache = giant cell arteritis requiring immediate treatment 6
• Pale boggy turbinates with clear secretions = allergic rhinitis, not infectious 1

Step 4: Imaging decisions

• CT with contrast indicated for: suspected sinusitis complications (severe headache, facial swelling, proptosis, cranial nerve findings), abscess requiring drainage, or rapidly progressive swelling 1, 2
• Plain radiographs are inadequate—CT is the optimal modality for paranasal sinus evaluation 1
• MRI useful for suspected fungal sinusitis or differentiating inflammatory disease from malignancy 1

Common Pitfalls to Avoid

• Do not treat HAE with epinephrine, antihistamines, or corticosteroids—these are ineffective and delay appropriate C1-inhibitor replacement therapy 1
• Do not assume all facial swelling with purulent nasal discharge is uncomplicated sinusitis—facial swelling itself suggests possible complication requiring imaging 1
• Do not delay corticosteroids in suspected giant cell arteritis while awaiting biopsy confirmation in patients over 50 with characteristic features—risk of blindness outweighs treatment risks 6
• Do not obtain sinus imaging for straightforward acute bacterial rhinosinusitis meeting clinical criteria without complications—imaging is unnecessary and not cost-effective 1