What is the appropriate workup for an adult patient with no significant past medical history presenting with facial swelling?

Workup for Facial Swelling in Adults

Begin by immediately assessing for life-threatening causes: check airway patency and breathing, examine for signs of anaphylaxis (respiratory compromise, systemic symptoms), and evaluate for severe infection with orbital involvement or deep space infection requiring urgent intervention. 1

Immediate Assessment and Red Flags

First, rule out anaphylaxis. Look for acute-onset facial/mucosal swelling combined with respiratory compromise (stridor, wheezing, dyspnea), hypotension, or gastrointestinal symptoms. If present, administer intramuscular epinephrine 0.3 mg in the lateral thigh immediately—do not delay for IV access or antihistamines. 1

Second, assess for complicated infections requiring urgent imaging and intervention:

• Orbital signs: periorbital edema, proptosis, diplopia, impaired eye movement, or decreased visual acuity indicate potential orbital cellulitis or abscess 2, 1
• Severe sinusitis complications: facial swelling with erythema overlying sinuses, severe frontal headache, or cranial nerve palsies 2
• Necrotizing infection: severe pain disproportionate to exam findings, rapid progression, systemic toxicity, or crepitus 1

If any orbital signs or severe infection indicators are present, obtain urgent CT maxillofacial with IV contrast (87% diagnostic accuracy for intracranial complications), initiate broad-spectrum IV antibiotics, and consult otolaryngology and ophthalmology emergently. 1

Systematic History

Obtain specific details about:

• Timing: acute onset (hours) suggests anaphylaxis or infection; subacute (days) suggests sinusitis or cellulitis; chronic suggests malignancy or systemic disease 1, 3
• Associated symptoms: fever, erythema, warmth, tenderness (infection); respiratory symptoms (anaphylaxis); hoarseness, otalgia, dysphagia (malignancy); night sweats, weight loss (lymphoma) 2, 1
• Recent exposures: insect sting, new medications (especially ACE inhibitors, NSAIDs causing angioedema), dental procedures, trauma 1, 3, 4
• Medication review: ACE inhibitors and NSAIDs can cause non-inflammatory angioedema; even supplements like melatonin have been reported to cause facial swelling 5, 3
• Risk factors for malignancy: age >40 years, tobacco use, alcohol abuse, immunosuppression, history of head/neck cancer or skin cancer 2

Physical Examination

Perform a targeted examination focusing on:

Facial inspection:

• Assess for erythema, warmth, tenderness (suggests infection) versus non-inflammatory swelling (suggests angioedema) 1, 3
• Examine scalp and face for ulcerations or pigmented lesions (melanoma or other cutaneous malignancy) 2
• Check for unilateral versus bilateral distribution 3

Oral cavity and oropharynx (remove dentures first):

• Inspect for dental caries, gingival swelling, floor of mouth masses, tongue mobility 2
• Palpate floor of mouth and tongue for masses 2
• Examine tonsils for asymmetry or masses 2

Sinus examination:

• Palpate over maxillary and frontal sinuses for tenderness 2
• Facial swelling with overlying erythema and tenderness suggests complicated sinusitis 2, 1

Orbital examination:

• Assess extraocular movements, visual acuity, proptosis 2, 1

Neck examination:

• Palpate for lymphadenopathy, thyroid masses, or other neck masses 2
• Assess for dilated neck veins or prominent venous pattern (superior vena cava syndrome from lung cancer) 2

Neurologic examination:

• Test all cranial nerves to exclude other causes of facial paralysis or nerve involvement 2

Diagnostic Algorithm Based on Clinical Presentation

Acute Swelling WITH Inflammation (Erythema, Warmth, Tenderness, ± Fever)

Sinusitis with complications:

• If purulent nasal discharge >10 days, facial pain, and facial swelling with erythema over sinuses, consider acute bacterial sinusitis 2, 1
• Obtain CT with IV contrast if: orbital signs present, severe headache, cranial nerve palsies, or high fever 2, 1
• Do NOT obtain routine imaging for uncomplicated sinusitis 2

Cellulitis/abscess:

• Well-demarcated erythema with warmth and tenderness suggests cellulitis 1
• If severe pain disproportionate to exam, rapid progression, or crepitus: suspect necrotizing fasciitis and obtain urgent surgical consultation plus vancomycin and piperacillin-tazobactam or carbapenem 1

Odontogenic infection:

• Dental pain, caries, or recent dental procedure with facial swelling requires dental consultation 1

Acute Swelling WITHOUT Inflammation (Non-Erythematous, Non-Tender)

Angioedema:

• Allergic angioedema: responds to antihistamines, corticosteroids, and epinephrine if severe 1
• ACE inhibitor or NSAID-induced: review medications; these cause bradykinin-mediated angioedema that does NOT respond to antihistamines/epinephrine 1, 3
• Hereditary angioedema: does NOT respond to epinephrine or antihistamines; requires C1-inhibitor concentrate or icatibant 1

Insect sting large local reaction:

• History of sting with extensive swelling persisting for days 1
• Treat with oral antihistamines, cold compresses, short course oral corticosteroids for severe cases 1
• Do NOT give antibiotics for uncomplicated local reactions 1

Chronic or Progressive Swelling

Malignancy concerns (if age >40, tobacco/alcohol use, weight loss, night sweats, hoarseness, dysphagia, otalgia):

• Examine for neck masses, intraoral masses, tonsil asymmetry 2
• Superior vena cava syndrome from lung cancer presents with facial edema, plethora, dilated neck veins, and prominent chest venous pattern 2
• Consider CT neck with contrast and referral to otolaryngology for endoscopy 2

Systemic diseases:

• Multiple myeloma can rarely present with facial swelling; consider if other systemic symptoms present 6
• Granulomatosis with polyangiitis or Churg-Strauss vasculitis may present with chronic rhinosinusitis and facial swelling 2

Imaging Strategy

Do NOT obtain imaging for:

• Uncomplicated acute rhinosinusitis (clinical diagnosis) 2
• Uncomplicated insect sting reactions 1
• Clear allergic angioedema responding to treatment 1

Obtain CT with IV contrast urgently for:

• Orbital signs (periorbital edema, proptosis, diplopia, vision changes) 2, 1
• Suspected complicated sinusitis with severe headache or cranial nerve findings 2, 1
• Suspected deep space infection or abscess 1
• Suspected malignancy with neck mass or concerning symptoms 2

Plain radiographs are NOT recommended due to high false-positive and false-negative rates for sinusitis. 2

Common Pitfalls to Avoid

• Do NOT assume allergic reaction without assessing for infection, especially if erythema, warmth, or fever present 1
• Do NOT delay imaging when orbital signs are present—this represents a true emergency requiring urgent intervention 2, 1
• Do NOT give antibiotics for insect sting local reactions unless there is clear secondary infection 1
• Do NOT use antihistamines or steroids alone for hereditary angioedema or ACE inhibitor-induced angioedema—these do not respond to standard allergic treatments 1
• Do NOT discharge patients with anaphylaxis without observation period due to risk of biphasic reactions 1
• Do NOT forget medication review—ACE inhibitors, NSAIDs, and even supplements can cause facial swelling 1, 5, 3
• Do NOT miss malignancy in high-risk patients—progressive unilateral swelling with hoarseness, dysphagia, or weight loss requires endoscopic evaluation 2