What is the diagnosis and treatment for a patient with facial swelling, ear pain, and a persistent cough lasting more than a month, with a negative chest X-ray (CXR) and no other symptoms?

Diagnostic and Treatment Approach for Facial Swelling, Ear Pain, and Chronic Cough

This patient most likely has upper airway cough syndrome (UACS) from chronic rhinosinusitis, and should be treated empirically with a first-generation antihistamine plus decongestant while pursuing further evaluation for the facial swelling. 1, 2

Initial Diagnostic Considerations

The combination of facial swelling, ear pain, and chronic cough (>1 month) with negative chest X-ray points toward an upper airway process rather than pulmonary pathology. 2

Most Common Causes of Chronic Cough to Consider:

• Upper airway cough syndrome (UACS) - most common cause of chronic cough in adults, often from rhinosinusitis 1, 2
• Asthma - second most common, though less likely without dyspnea 2
• Gastroesophageal reflux disease (GERD) - third most common 2

The facial swelling and ear pain strongly suggest chronic rhinosinusitis as the underlying etiology driving the UACS. 1

Critical Red Flags to Assess Immediately

Examine carefully for complications requiring urgent intervention: 1

• Orbital involvement: diplopia, visual changes, proptosis, periorbital edema/erythema
• Intracranial extension: altered mental status, severe headache, neurologic deficits
• Facial cellulitis: erythema and warmth over involved sinus

If any of these are present, obtain urgent CT imaging and specialist consultation. 1

Physical Examination Findings to Document

• Nasal examination: Look for mucosal erythema, purulent secretions, nasal polyps (polyps in adults suggest aspirin sensitivity/asthma; in children suggest cystic fibrosis) 1
• Sinus tenderness: Palpate over maxillary and frontal sinuses 1
• Ear examination: Check for middle ear effusion indicating eustachian tube dysfunction 1
• Pharynx: Look for purulent postnasal drainage, pharyngeal erythema, lymphoid hyperplasia 1
• Chest auscultation: Rule out asthma component 1

Empiric Treatment Approach

For UACS from presumed chronic rhinosinusitis, initiate: 1, 2

• First-generation antihistamine (e.g., diphenhydramine or chlorpheniramine) plus decongestant 2
• Consider intranasal corticosteroids to reduce mucosal edema 1

Antibiotic considerations: 1

• If bacterial sinusitis is suspected (purulent nasal discharge, facial pain, symptoms >10 days), start amoxicillin for 3-5 days 1
• If no improvement after 3-5 days, switch to high-dose amoxicillin-clavulanate or cefuroxime axetil 1
• Continue antibiotics for 7 days after symptom resolution (typically 10-14 day course total) 1
• However, if this appears to be postinfectious cough without active bacterial infection, antibiotics have no role 1

When Imaging is Indicated

Plain radiographs are generally not necessary for acute sinusitis diagnosis and have significant false-positive/false-negative rates. 1

Consider CT imaging if: 1

• Severe symptoms not responding to initial therapy
• Concern for complications (orbital/intracranial involvement)
• Recurrent episodes requiring documentation of anatomic abnormalities
• Facial swelling that is rapidly progressive or associated with neurologic symptoms 3

Advanced Imaging for Persistent Cough

If cough persists beyond 8 weeks despite appropriate empiric treatment for UACS, asthma, and GERD: 1

• High-resolution CT (HRCT) chest is recommended to evaluate for bronchiectasis, which accounts for up to 8% of chronic cough cases 1
• HRCT is the reference standard for detecting bronchiectasis, which chest X-ray misses with poor sensitivity 1

Alternative Diagnoses to Consider

If facial swelling is unilateral and slowly progressive: 4, 5, 3

• Consider neoplastic processes (though less likely without constitutional symptoms)
• CT or MRI can assess soft tissue and osseous involvement 4, 5

If cough has paroxysmal quality with post-tussive vomiting or inspiratory whoop: 1

• Consider pertussis (Bordetella pertussis infection)
• Obtain nasopharyngeal culture for definitive diagnosis 1
• If confirmed, treat with macrolide antibiotic and isolate for 5 days 1

Follow-Up Timeline

• Reassess in 3-5 days if antibiotics started - switch agents if no improvement 1
• Reassess in 4-6 weeks to evaluate overall response to UACS treatment 6
• If symptoms persist >8 weeks, reclassify as chronic cough and consider HRCT chest 1

Common Pitfalls to Avoid

• Do not assume all chronic cough is pulmonary - UACS is the most common cause and requires upper airway-directed therapy 2
• Do not give antibiotics for postinfectious cough unless bacterial sinusitis or pertussis is specifically suspected 1
• Do not delay evaluation of facial swelling with red flag features (orbital signs, neurologic changes) - these require urgent imaging and specialist involvement 1
• Do not stop at normal chest X-ray if cough persists >8 weeks - proceed to HRCT to evaluate for bronchiectasis 1