What is the appropriate treatment for an elderly male with a swollen left cheek?

Swollen Left Cheek in an Elderly Male: Diagnostic and Treatment Approach

The most critical first step is determining whether the swelling represents infection (most likely), malignancy, or inflammatory disease through targeted history, physical examination, and risk stratification based on specific clinical features. 1

Immediate Assessment Priorities

Key Historical Features to Elicit

• Duration and progression: Mass present ≥2 weeks without fluctuation, or rapid progression over days suggests different etiologies 1
• Associated symptoms: Fever, pain, dental problems, difficulty swallowing, weight loss, night sweats 2
• Red flag symptoms: Hoarseness, dysphagia, odynophagia, otalgia, or unexplained weight loss mandate urgent workup for malignancy 1
• Risk factors: Tobacco/alcohol use (especially if age >40), recent dental work, skin lesions, immunosuppression 1, 2
• Systemic disease history: Diabetes, tuberculosis exposure, sarcoidosis, Crohn's disease 3, 4

Critical Physical Examination Elements

• Characteristics of swelling: Size (>1.5 cm concerning), consistency (firm/hard vs fluctuant), fixation to adjacent tissues, overlying skin changes or ulceration 1
• Intraoral examination: Dental abscess, parotid duct obstruction, oral ulceration, masses 3
• Skin examination: Scalp lesions, auricular skin changes, facial nerve function 1, 5
• Lymph node examination: Palpation of all cervical lymph node chains bilaterally for additional adenopathy 1

Most Likely Diagnoses by Clinical Pattern

Infectious Causes (Most Common in Elderly)

Bacterial sialadenitis/parotitis: Presents with acute painful swelling, fever, purulent discharge from Stensen's duct 2

• Treatment: Amoxicillin-clavulanate 875/125 mg every 12 hours for adults with serious infections 6, or clindamycin 300-450 mg every 6 hours for severe infections or penicillin allergy 7
• Hydration, warm compresses, sialagogues, massage of gland 2

Dental abscess: Associated with dental pain, poor dentition, fluctuant swelling 2

• Treatment: Dental referral for source control plus antibiotics as above 6, 7

Mycobacterial lymphadenitis: In elderly, >90% is M. tuberculosis (not NTM), requires drug therapy and public health tracking 1

• Tuberculin skin test mandatory, chest radiograph to exclude pulmonary TB 1

Malignant Causes (Must Exclude)

Critical warning: Most adult neck/facial masses are neoplastic, not infectious—empiric antibiotics should be avoided without clear infectious signs 1

Concerning features mandating imaging:

• Firm consistency, size >1.5 cm, fixation to tissues, ulceration 1
• Age >40 with tobacco/alcohol use 1
• Progressive growth over weeks to months 5

Inflammatory/Granulomatous Causes

Orofacial granulomatosis/Cheilitis granulomatosa: Persistent idiopathic swelling with non-caseating granulomas, may be early manifestation of Crohn's disease or sarcoidosis 4

Diagnostic Algorithm

For Acute Presentation with Infectious Features (Fever, Pain, Erythema)

1. Clinical diagnosis of bacterial infection if clear source identified (dental, salivary gland) 2
2. Initiate empiric antibiotics immediately: Amoxicillin-clavulanate 875/125 mg every 12 hours 6 OR clindamycin 300-450 mg every 6 hours for severe infections 7
3. Reassess in 48-72 hours: If no improvement, proceed to imaging 2

For Subacute/Chronic Presentation or High-Risk Features

1. CT neck with contrast is mandatory for risk stratification and surgical planning—do not delay imaging 1
2. Fine-needle aspiration (FNA) is recommended rather than open biopsy if diagnosis remains uncertain after imaging 1
3. Never perform open biopsy before imaging and FNA in high-risk patients 1

For Suspected Mycobacterial Disease

1. Tuberculin skin test mandatory for all patients 1
2. Chest radiograph to exclude pulmonary TB 1
3. Screen family members with PPD tests 1

Critical Management Pitfalls to Avoid

• Never assume infection without clear signs: Most adult facial masses are neoplastic 1
• Never use empiric antibiotics for >7-10 days without reassessment: If no improvement, imaging is mandatory 1, 2
• Never perform incision and drainage alone for suspected mycobacterial disease—leads to fistula formation 1
• Never assume cystic masses are benign: Cystic metastases are common in head and neck cancers 1
• In elderly with diabetes: Consider invasive fungal infection if immunosuppressed or high blood glucose 3

Specific Treatment Recommendations

For Confirmed Bacterial Infection

Amoxicillin-clavulanate 875 mg/125 mg every 12 hours for serious infections in adults 6

• Adjust dose in severe renal impairment (GFR <30 mL/min) 6
• Take with full glass of water to avoid esophageal irritation 6

Alternative for severe infections or penicillin allergy: Clindamycin 300-450 mg every 6 hours 7

• Critical warning: Discontinue if significant diarrhea occurs (C. difficile risk) 7
• Take with full glass of water to avoid esophageal irritation 7

For Non-Infectious Causes

Treatment depends on definitive diagnosis after imaging and/or biopsy 1, 2, 4