Management of Unilateral Facial Swelling
The appropriate management of unilateral facial swelling requires immediate assessment for life-threatening causes (airway compromise, infection requiring drainage, giant cell arteritis in patients >50 years), followed by systematic evaluation based on the temporal pattern of swelling (acute inflammatory, nonprogressive, slowly progressive, or rapidly progressive) to guide imaging selection and definitive treatment.
Initial Assessment and Red Flags
Immediate Life-Threatening Considerations
Airway compromise: Assess for dyspnea, stridor, drooling, or difficulty swallowing that may indicate impending airway obstruction requiring urgent intervention 1.
Giant cell arteritis (GCA): In patients over 50 years with temporal region pain or facial swelling, consider GCA urgently as it requires immediate corticosteroid treatment to prevent blindness 2, 3. Look for new-onset headaches, polymyalgia rheumatica symptoms, tender or cord-like temporal artery, jaw claudication, and visual symptoms 3.
Severe infection: Evaluate for signs of abscess, cellulitis, necrotizing fasciitis, or erysipelas requiring immediate surgical drainage or IV antibiotics 4, 5.
Critical Physical Examination Findings
Facial nerve function: Test all branches of the facial nerve including forehead movement to distinguish peripheral (Bell's palsy) from central causes 1. Peripheral facial nerve palsy involves the forehead; central palsy spares it 1.
Cranial nerve assessment: Evaluate all cranial nerves, particularly trigeminal nerve function (sensation, motor), as involvement suggests more extensive pathology 2, 5.
Lymphadenopathy and systemic signs: Palpate for cervical lymph nodes, assess for fever, and examine for signs of systemic disease 1, 5.
Skin examination: Inspect for erythema, warmth, vesicles (herpes zoster), pustules, or signs of trauma 1, 4.
Classification-Based Diagnostic Approach
Acute Swelling with Inflammation (<72 hours)
Most common causes: Lymphadenitis, sinusitis, odontogenic infection, abscess, angioedema 5, 6.
Imaging: Contrast-enhanced CT is the modality of choice for detecting abscesses requiring surgical drainage 5, 6.
Management priorities:
Nonprogressive Swelling
Consider congenital anomalies: Cephalocele, nasal glioma, dermoid or epidermoid cyst 5.
Slowly Progressive Swelling
Differential includes: Neurofibroma, hemangioma, lymphangioma, vascular malformation, fibrous dysplasia, parotid tumors 1, 5, 6.
Imaging: MRI with contrast for soft tissue masses; CT for osseous involvement 1, 6.
Special consideration: Multiple myeloma can rarely present as unilateral facial swelling and should be considered in appropriate clinical context 7.
Rapidly Progressive Swelling
High concern for malignancy: Rhabdomyosarcoma, Langerhans cell histiocytosis, Ewing sarcoma, osteogenic sarcoma, metastatic neuroblastoma 5.
- Associated findings: Cranial nerve deficits suggest aggressive pathology requiring urgent evaluation 5.
Specific Clinical Scenarios
Bell's Palsy (Acute Unilateral Facial Nerve Paralysis)
Definition: Acute unilateral facial nerve paresis or paralysis with onset in less than 72 hours without identifiable cause 1.
Clinical features: Ipsilateral facial paralysis including forehead, possible ear pain, taste disturbance, hyperacusis, dry eye or mouth 1.
Imaging indications: Generally not needed unless symptoms are atypical, recurrent, or persist for 2-4 months 1. When imaging is indicated, MRI with contrast is preferred to evaluate the facial nerve course 1.
Management: Most patients recover completely by 6 months; steroids may hasten recovery 1.
Trigeminal Neuralgia vs. Facial Swelling with Pain
Key distinction: Trigeminal neuralgia presents with sudden, unilateral, severe, brief stabbing pain without visible swelling 2.
If swelling present with trigeminal distribution pain: Consider herpes zoster, infection, or structural lesion 2.
Imaging: MRI is preferred for investigating trigeminal nerve pathology 2.
Facial Trauma
Assessment priorities: Evaluate for fractures of nasal bones, orbital floor, zygomaticomaxillary complex, maxillary sinuses, mandibular ramus 1.
Imaging: High-resolution CT is the primary modality for facial bone evaluation 1.
Associated injuries: Always assess for cervical spine, intracranial, and cerebrovascular injuries in high-energy trauma 1.
Thermal Burns with Facial Swelling
Urgent concerns: Airway obstruction from thermal injury, inhalation injury 1.
Clinical indicators of airway risk: Hoarseness, dysphagia, drooling, wheeze, carbonaceous sputum, soot in airway, singed facial/nasal hairs 1.
Management:
Drug-Induced Facial Swelling
DRESS syndrome (Drug Reaction with Eosinophilia and Systemic Symptoms): Can present with facial swelling and requires immediate recognition 1, 4.
- Management: Hold offending medication, systemic corticosteroids for severe cases 1.
EGFR inhibitor-related: Can cause facial edema as part of skin toxicity 1.
Imaging Algorithm
First-Line Imaging Selection
Acute inflammatory process with suspected abscess: Contrast-enhanced CT 5, 6
Facial nerve palsy (when imaging indicated): MRI with contrast to evaluate entire facial nerve course 1
Facial trauma: High-resolution CT of facial bones 1
Suspected vascular or soft tissue mass: MRI with contrast 1, 6
Temporal bone pathology: High-resolution temporal bone CT (complementary to MRI) 1
Advanced Imaging Considerations
MRI advantages: Superior soft tissue characterization, evaluation of neural structures, assessment of perineural spread 1, 2, 6.
CT advantages: Excellent osseous detail, rapid acquisition in unstable patients, detection of abscesses 1, 5, 6.
Common Pitfalls to Avoid
Missing GCA in elderly patients: Always consider in patients >50 with facial/temporal swelling; delay in treatment risks blindness 2, 3.
Underestimating airway risk: Facial swelling from burns, infection, or angioedema can rapidly progress to airway compromise 1, 4.
Imaging Bell's palsy unnecessarily: Most cases do not require imaging unless atypical features present 1.
Overlooking dental sources: Odontogenic infections are common causes of facial swelling requiring specific dental evaluation 1, 5.
Delaying temporal artery biopsy: In suspected GCA, biopsy should be obtained promptly after starting steroids (sensitivity decreases with delay) 3.