What are the diagnosis and treatment options for a patient presenting with face swelling?

Facial Swelling: Diagnosis and Treatment

Immediate Life-Threatening Assessment

When a patient presents with facial swelling, the first priority is to immediately rule out anaphylaxis by assessing for respiratory symptoms (dyspnea, wheeze, throat closing sensation) or systemic involvement (hypotension, altered consciousness). If anaphylaxis is suspected, activate emergency services and administer intramuscular epinephrine 0.3 mg in the lateral thigh immediately—delayed epinephrine is associated with increased mortality 1.

Anaphylaxis Diagnostic Criteria

• Acute onset facial/mucosal swelling PLUS respiratory compromise (dyspnea, wheeze, stridor) 1
• Associated anxiety represents the sensation of impending doom, not a separate diagnosis 1
• Do not delay epinephrine for IV access or antihistamines 1
• Observe for biphasic reactions requiring repeat dosing 1

Differential Diagnosis Framework

Acute Swelling with Inflammation (Hours to Days)

For acute facial swelling with fever, erythema, or tenderness, the primary considerations are infectious causes requiring urgent imaging and antibiotics.

Complicated Acute Bacterial Sinusitis

• Facial swelling with erythema overlying the affected sinus indicates potential complications 2
• Red flags requiring urgent CT maxillofacial with IV contrast: periorbital edema, impaired eye movement, proptosis, diplopia, severe frontal headache, or decreased visual acuity 2, 3
• CT with contrast has 87% diagnostic accuracy for intracranial complications 3
• Immediate management: Broad-spectrum IV antibiotics (amoxicillin-clavulanate 1.5-3g IV every 6 hours) plus urgent otolaryngology and ophthalmology consultation 3

Skin and Soft Tissue Infections

• Erysipelas/cellulitis: Well-demarcated erythema with warmth and tenderness 4
• Necrotizing fasciitis warning signs: Severe pain disproportionate to exam, rapid progression, systemic toxicity, crepitus 4
• For suspected necrotizing infection: Urgent surgical exploration plus vancomycin PLUS piperacillin-tazobactam or carbapenem 4
• MRI is preferred for pyomyositis diagnosis, though CT and ultrasound are useful 4

Bite Wounds (Animal or Human)

• Preemptive antibiotics indicated for: Face/hand injuries, immunocompromised patients, wounds >12-24 hours old, or injuries penetrating periosteum 4
• Amoxicillin-clavulanate covers both aerobic and anaerobic organisms 4
• Facial wounds should receive copious irrigation, cautious debridement, and preemptive antibiotics even if primary closure is performed 4

Insect Sting Reactions

Large Local Reactions

• Extensive erythema and swelling persisting for days at sting site 4
• Treatment: Oral antihistamines, cold compresses, short course of oral corticosteroids for severe cases 4
• Antibiotics are NOT indicated—swelling is allergic inflammation, not infection 4

Systemic Reactions

• Cutaneous systemic reactions (urticaria/angioedema distant from sting site) may be treated with antihistamines and observation 4
• Any respiratory or cardiovascular symptoms require epinephrine as for anaphylaxis 4

Angioedema (Non-Inflammatory Swelling)

Isolated facial swelling without erythema, warmth, or systemic symptoms suggests angioedema—distinguish between mast cell-mediated (allergic) and bradykinin-mediated (hereditary or ACE inhibitor-induced). 5

• Allergic angioedema: Responds to antihistamines, corticosteroids, epinephrine 4
• Hereditary angioedema: Does NOT respond to epinephrine/antihistamines; requires C1-inhibitor concentrate or icatibant 4
• ACE inhibitor-induced: Discontinue medication; may require airway management 5

Drug Reactions

DRESS syndrome (Drug Reaction with Eosinophilia and Systemic Symptoms) presents with facial swelling, fever, rash, and eosinophilia—requires immediate drug discontinuation. 5

Diagnostic Approach Algorithm

1. Assess airway and breathing: If compromised → anaphylaxis protocol with epinephrine 1

2. Check for infection signs: Fever, erythema, warmth, tenderness

   • Present → Consider sinusitis, cellulitis, abscess
   • Orbital signs present → Urgent CT with contrast 2, 3
   • Severe pain/systemic toxicity → Consider necrotizing infection, urgent surgical consultation 4

3. Recent exposure history:

   • Insect sting → Large local reaction vs systemic reaction 4
   • Bite wound → Preemptive antibiotics if face/hand involved 4
   • New medication → Drug reaction or angioedema 5

4. Isolated swelling without inflammation:

   • Consider angioedema (hereditary vs acquired) 5
   • Review medication list for ACE inhibitors 5

Common Pitfalls

• Do not assume allergic reaction without assessing for infection—facial cellulitis and sinusitis complications require antibiotics, not just antihistamines 2, 3
• Do not delay imaging when orbital signs are present—subperiosteal abscess requires urgent surgical drainage 3
• Do not give antibiotics for insect sting local reactions—the swelling is inflammatory, not infectious 4
• Do not use antihistamines/steroids alone for hereditary angioedema—these patients require specific C1-inhibitor replacement 4
• Do not discharge patients with anaphylaxis without observation period—biphasic reactions can occur 1