What is the appropriate treatment for sudden onset unilateral facial soft tissue swelling?

Acute Unilateral Facial Soft Tissue Swelling: Diagnostic and Treatment Approach

For sudden onset unilateral facial soft tissue swelling that started yesterday, you must immediately rule out life-threatening infections (dental abscess, Ludwig's angina, necrotizing fasciitis), vascular emergencies (angioedema with airway compromise), and inflammatory conditions (temporal arteritis in patients >50 years) before considering benign etiologies.

Immediate Assessment Priorities

Critical Red Flags Requiring Emergency Intervention

• Assess airway patency first - any signs of stridor, difficulty breathing, or tongue/floor of mouth involvement requires immediate airway management and emergency consultation 1
• Evaluate for sepsis - calculate NEWS2 score; a score ≥7 indicates high risk of severe illness or death and requires antibiotics within 1 hour 1
• Check for rapidly progressive infection - dental infections can evolve into Ludwig's angina (bilateral submandibular/sublingual space involvement) or descending necrotizing mediastinitis within hours 2

Essential History Elements

• Timing and progression - swelling that develops over hours suggests infection or angioedema; days to weeks suggests inflammatory or neoplastic process 3, 4
• Trauma history - even minor trauma (nose blowing, dental procedures) can cause subcutaneous emphysema or introduce infection 5, 6
• Dental symptoms - toothache, recent dental work, or poor dentition points to odontogenic infection as the most common cause 2
• Medication history - ACE inhibitors, NSAIDs, antibiotics can cause angioedema; recent drug initiation (within 6 weeks) suggests DRESS syndrome 7, 1
• Age >50 years with headache - temporal arteritis must be considered, especially with jaw claudication, vision changes, or polymyalgia symptoms 4

Diagnostic Workup Based on Clinical Presentation

For Suspected Infectious Etiology (Most Common)

• Obtain cultures before antibiotics - aspirate any fluctuant areas; swab any draining wounds 2
• Imaging is essential - CT with IV contrast is the gold standard to identify abscess, assess deep space involvement, and evaluate for gas in tissues 2
• Laboratory studies - complete blood count with differential, comprehensive metabolic panel, blood cultures if febrile or systemically ill 1

For Suspected Inflammatory/Vascular Etiology

• Temporal arteritis workup (age >50) - immediate ESR and CRP; if elevated with high clinical suspicion, start prednisone 40-60 mg daily immediately and obtain temporal artery biopsy within 1-2 weeks 4
• Angioedema assessment - examine for tongue swelling, uvular edema, or laryngeal involvement; discontinue ACE inhibitors immediately if suspected 1

Treatment Algorithm

Odontogenic Infection (Most Common Cause)

Empiric antibiotic therapy should be initiated immediately for suspected odontogenic infection with facial swelling:

• First-line therapy: Amoxicillin-clavulanate 875 mg PO twice daily for 7-10 days 2
• Penicillin allergy: Clindamycin 300-450 mg PO every 6-8 hours 2
• Severe infection requiring hospitalization: Ampicillin-sulbactam 3 g IV every 6 hours or piperacillin-tazobactam 3.375 g IV every 6-8 hours 2

Surgical intervention is required for:

• Fluctuant abscess - requires incision and drainage 2
• Deep space involvement - requires emergency surgical consultation 2
• Airway compromise - may require intubation or tracheostomy 2

Trauma-Related Swelling

• Subcutaneous emphysema - managed conservatively with prophylactic antibiotics (amoxicillin-clavulanate) and observation; typically self-resolves within 48 hours 5
• Soft tissue lacerations - copious irrigation, conservative debridement, primary closure acceptable for facial wounds if thoroughly cleaned 2, 6, 8
• Animal/human bites: Amoxicillin-clavulanate 500-875 mg PO twice daily for 7-10 days; consider rabies prophylaxis for animal bites 2

Non-Infectious Inflammatory Conditions

• Temporal arteritis: Prednisone 40-60 mg daily immediately if high clinical suspicion; do not delay for biopsy results as delay increases risk of blindness 4
• Drug reaction: Discontinue offending agent; for grade 3 reactions, admit and start IV methylprednisolone 1-2 mg/kg 2, 1

Critical Pitfalls to Avoid

• Never delay antibiotics for diagnostic confirmation in suspected severe infection - mortality increases significantly with delayed treatment 1
• Do not miss temporal arteritis in patients >50 years - permanent vision loss can occur within days if untreated 4
• Avoid discharging patients without imaging when deep space infection is possible - CT is essential to rule out abscess requiring drainage 2
• Do not assume angioedema is benign - assess airway carefully and monitor for progression; ACE inhibitor angioedema can occur years after drug initiation 1
• Never close contaminated wounds primarily without thorough irrigation and debridement - infection risk is significantly increased 6, 8

When to Consult Specialists

• Oral surgery/ENT: Any suspected deep space infection, abscess requiring drainage, or airway compromise 2
• Ophthalmology: Periorbital swelling with vision changes, proptosis, or ophthalmoplegia 2
• Hematology/oncology: Progressive painless swelling in older adults to rule out lymphoma or multiple myeloma 3
• Rheumatology: Suspected temporal arteritis for long-term steroid management 4