Management of Swollen Cheek in a 20-Month-Old
The most critical first step is to determine if this represents an acute infectious process requiring urgent intervention, particularly odontogenic infection, which is the most common cause of facial swelling in this age group and may require hospital admission for intravenous antibiotics and surgical drainage. 1
Immediate Assessment Priorities
Rule Out Life-Threatening Conditions
- Assess for signs of systemic toxicity: poor feeding, lethargy, fever >38.5°C, toxic appearance, which indicate need for immediate hospital admission 2, 1
- Evaluate airway patency: rapidly progressive swelling with respiratory distress requires emergency management 3
- Check for orbital involvement: periorbital cellulitis, proptosis, or vision changes necessitate urgent ophthalmology consultation and imaging 4
Determine the Etiology Based on Clinical Pattern
Acute swelling with inflammation (most common in this age):
- Odontogenic infection: Most frequent cause in pediatric patients; look for dental caries, recent dental trauma, or gingival swelling 1
- Lymphadenitis: Palpable lymph nodes, often submandibular or preauricular 3
- Sinusitis with facial extension: Extremely rare in toddlers but consider if maxillary fullness present 5
- Abscess formation: Fluctuance, erythema, warmth, and tenderness indicate need for surgical drainage 3, 1
Location-specific considerations:
- Preauricular swelling: Consider lymphadenitis or parotitis 2
- Infraorbital/cheek swelling: Odontogenic infection most likely, maxillary sinusitis rare 5, 1
- Periorbital swelling with tearing: Dacryocystitis or nasolacrimal duct obstruction with secondary infection 4
Management Algorithm
For Acute Infectious Swelling (Most Common Scenario)
Admission criteria (16% of cases require this): 1
- Systemic toxicity or poor neonatal reflexes
- Inability to maintain oral intake
- Rapidly progressive swelling
- Airway compromise
- Orbital involvement
- Failed outpatient management
Hospital management includes:
- Intravenous antibiotics
- Surgical drainage if abscess present
- Supportive care with hydration 1
Outpatient management (84% of cases): 1
- Immediate surgical management (extraction of offending tooth) with or without oral antibiotics if abscess is fluctuant and localized
- Oral antibiotics with delayed surgical management if significant cellulitis without drainable abscess; definitive dental treatment after resolution of acute infection
- Oral antibiotics alone only if the source has already been removed 1
Important Caveat
Delayed surgical management with antibiotics alone fails in 2% of cases, requiring subsequent admission 1. Therefore, close follow-up within 24-48 hours is mandatory for any child managed as an outpatient.
Imaging Considerations
Contrast-enhanced CT is the modality of choice when abscess requiring surgical drainage is suspected 3. However, imaging should not delay treatment in a toxic-appearing child.
Non-Infectious Causes (Less Likely at 20 Months)
If swelling is nonprogressive and present since birth, consider congenital anomalies (cephalocele, dermoid cyst) 3. If slowly progressive over weeks to months, consider vascular malformations, hemangiomas, or fibrous dysplasia 3. These require elective specialist referral, not urgent intervention.
Child Abuse Screening
For a 20-month-old with cheek swelling/bruising, skeletal survey is NOT routinely indicated unless there are additional concerning features: patterned bruising, history of abuse, additional unexplained injuries, or no history of trauma 6. A single bruise on the cheek in a mobile toddler with appropriate history does not mandate skeletal survey 6.
Dental Referral
All children with odontogenic infections require dental follow-up for definitive management of the causative tooth, even after acute infection resolves 1. Establish collaborative relationships with pediatric dentists for timely referral 6.