What is the appropriate diagnosis and treatment for a pediatric patient presenting with swollen cheeks?

Pediatric Swollen Cheeks: Diagnosis and Treatment

Primary Diagnosis: Mumps

The most common cause of bilateral swollen cheeks in a pediatric patient is mumps, a vaccine-preventable viral infection characterized by parotid gland swelling. 1

Differential Diagnosis by Clinical Presentation Pattern

Acute Swelling with Inflammation

• Mumps (parotitis): Bilateral parotid swelling is the hallmark, though not present in all cases; diagnosis confirmed by IgM antibodies or viral nucleic acid detection 1
• Bacterial lymphadenitis: Unilateral presentation more common, with tender cervical or preauricular nodes; contrast-enhanced CT identifies abscesses requiring surgical drainage 2
• Acute sinusitis: Maxillary sinusitis rarely causes cheek swelling unless there is a coexisting anterior antral wall defect, fungal infection, or dental abscess 3
• Odontogenic infection: Localized to tooth-bearing areas, with dental examination revealing carious teeth or periodontal disease 2
• Acute mastoiditis: Can present as preauricular/cheek swelling when infection spreads through zygomatic arch air cells; requires urgent CT and may necessitate mastoidectomy 4

Nonprogressive Swelling (Congenital)

• Congenital anomalies: Midfacial location suggests cephalocele, nasal glioma, or dermoid/epidermoid cyst; MRI is preferred for characterization 2

Slowly Progressive Swelling

• Vascular lesions: Hemangioma or lymphangioma present with gradual enlargement; MRI with contrast delineates extent 2
• Cutaneous mastocytosis: Rare cause; presents with red-brown macules/plaques that urticate with stroking (positive Darier's sign); diagnosis by skin biopsy with tryptase staining 5

Rapidly Progressive Swelling

• Malignancy: Rhabdomyosarcoma, Langerhans cell histiocytosis, or metastatic neuroblastoma; associated with cranial nerve deficits; requires urgent MRI and biopsy 2

Diagnostic Workup Algorithm

1. History: Vaccination status (mumps), trauma history, fever, pain, duration of swelling, unilateral vs bilateral 1, 2
2. Physical examination:
   • Palpate parotid glands bilaterally for tenderness and consistency 1
   • Examine oral cavity for dental disease and Stensen's duct inflammation 3
   • Assess for Darier's sign if skin lesions present 5
   • Evaluate for cranial nerve deficits if rapidly progressive 2
3. Laboratory testing:
   • Mumps IgM antibody or viral PCR if parotitis suspected 1
   • Serum tryptase if mastocytosis suspected 5
   • Blood culture if bacterial infection suspected 2
4. Imaging:
   • Contrast-enhanced CT: First-line for acute inflammatory swelling to detect abscesses, sinusitis, or mastoiditis 2, 4
   • MRI: Preferred for congenital anomalies, vascular lesions, or suspected malignancy 2

Treatment by Etiology

Mumps

• Supportive care only: No specific antiviral therapy available 1
• Analgesics for pain, hydration, soft diet 1
• Monitor for complications: aseptic meningitis, orchitis (post-pubertal males), pancreatitis, deafness 1
• Isolation precautions for 5 days after parotid swelling onset 1

Bacterial Infections

• Lymphadenitis/abscess: Surgical drainage if abscess identified on CT; empiric antibiotics covering Staphylococcus aureus and Streptococcus species 2
• Mastoiditis: Urgent ENT consultation; IV antibiotics and myringotomy ± mastoidectomy; CT essential to assess bone destruction 4
• Sinusitis with cheek swelling: Requires investigation for underlying structural defect or fungal infection; broad-spectrum antibiotics and possible surgical intervention 3

Cutaneous Mastocytosis

• Symptomatic management: H1 and H2 antihistamines to control mast cell mediator symptoms 5
• Avoid triggers: temperature changes, friction, certain medications 5
• Educate parents on anaphylaxis risk (rare but possible); prescribe epinephrine auto-injector for severe cases 5
• Prognosis: 75% of mastocytomas and 56% of urticaria pigmentosa resolve by puberty 5

Trauma-Related

• Penetrating foreign body: Requires CT to identify trajectory; surgical removal under general anesthesia with antibiotic prophylaxis and tetanus immunization 6

Critical Pitfalls to Avoid

• Do not dismiss bilateral parotid swelling as mumps without serologic confirmation, as other conditions (HIV, Sjögren's syndrome, sarcoidosis) can mimic this presentation 1
• Do not delay CT imaging in acute inflammatory swelling, as abscesses require urgent surgical drainage to prevent complications 2
• Do not overlook mastoiditis presenting as cheek swelling; failure to recognize this can lead to extensive temporal bone osteomyelitis 4
• Do not assume maxillary sinusitis alone causes cheek swelling; investigate for coexisting dental infection, fungal disease, or structural defect 3
• Do not perform skin biopsy on suspected mastocytosis lesions without preparation for potential severe degranulation; pretreat with antihistamines 5

When to Refer

• Immediate ENT referral: Mastoiditis, penetrating trauma, or abscess requiring drainage 4, 6, 2
• Urgent oncology referral: Rapidly progressive swelling with cranial nerve deficits 2
• Dermatology referral: Suspected mastocytosis for biopsy and long-term management 5
• Infectious disease consultation: Atypical infections (fungal, mycobacterial) or immunocompromised patients 3