What is the approach to managing face swelling in an adult patient with no significant past medical history?

Approach to Face Swelling in Adults

Begin by immediately assessing for life-threatening conditions: check airway patency and breathing, look for signs of anaphylaxis (respiratory compromise, systemic symptoms), and examine for orbital signs (periorbital edema, proptosis, diplopia, impaired eye movement, decreased visual acuity) that indicate potential intracranial complications requiring urgent intervention. 1

Immediate Life-Threatening Assessment

Anaphylaxis Protocol

• Administer intramuscular epinephrine 0.3 mg in the lateral thigh immediately if anaphylaxis is suspected (acute onset facial/mucosal swelling plus respiratory compromise), as delayed epinephrine is associated with increased mortality 1
• Do not delay epinephrine for IV access or antihistamines 1
• Observe for biphasic reactions requiring repeat dosing 1

Airway Compromise Evaluation

• Assess for stridor, dyspnea, difficulty swallowing, or sensation of throat closing 1
• If airway is compromised, follow anaphylaxis protocol regardless of other findings 1

Systematic Clinical Evaluation

History: Key Questions to Ask

• Timing: Acute onset (hours) suggests anaphylaxis or infection; subacute (days) suggests complicated sinusitis or cellulitis 2
• Associated symptoms: Fever, erythema, warmth, tenderness indicate infection; respiratory symptoms suggest anaphylaxis 2
• Recent exposures: Insect sting, new medications, dental procedures, trauma 1, 2
• Location specificity: Unilateral vs bilateral, localized vs diffuse 3

Physical Examination: Critical Findings

Infection Signs (require urgent evaluation):

• Fever with facial erythema and warmth indicates cellulitis or complicated sinusitis 1
• Orbital signs (periorbital edema, proptosis, diplopia, impaired eye movement, decreased visual acuity) are red flags requiring urgent CT with IV contrast and immediate otolaryngology/ophthalmology consultation 1, 2
• Severe frontal headache or cranial nerve palsies suggest intracranial extension 1, 2
• Crepitus on palpation indicates subcutaneous emphysema (rare but important differential after dental procedures) 4

Angioedema Characteristics:

• Non-inflammatory swelling (no erythema, warmth, or tenderness) 1
• Allergic angioedema responds to antihistamines and corticosteroids 1
• Hereditary angioedema does NOT respond to epinephrine/antihistamines and requires C1-inhibitor concentrate or icatibant 1

Diagnostic Algorithm

Step 1: Rule Out Emergencies

1. If respiratory compromise present → Epinephrine 0.3 mg IM immediately 1
2. If orbital signs present (periorbital edema, proptosis, diplopia, impaired eye movement, decreased visual acuity) → Urgent CT maxillofacial with IV contrast, broad-spectrum IV antibiotics (vancomycin plus piperacillin-tazobactam or carbapenem), urgent otolaryngology and ophthalmology consultation 1
3. If severe pain disproportionate to exam, rapid progression, systemic toxicity, or crepitus → Consider necrotizing fasciitis; urgent surgical exploration required 1

Step 2: Assess for Infection

Complicated Acute Bacterial Sinusitis:

• Purulent nasal discharge, facial pain, and facial swelling with erythema overlying affected sinus 5, 1
• Red flags requiring urgent CT with IV contrast: periorbital edema, impaired eye movement, proptosis, diplopia, severe frontal headache, decreased visual acuity 5, 1
• CT with contrast has 87% diagnostic accuracy for intracranial complications 1
• Management: Broad-spectrum IV antibiotics plus urgent specialist consultation 1

Cellulitis/Erysipelas:

• Well-demarcated erythema with warmth and tenderness 1
• Treatment: Antibiotics targeting streptococci and staphylococci 1

Step 3: Consider Non-Infectious Causes

Insect Sting Reactions:

• Large local reactions: extensive erythema and swelling persisting for days at sting site 1
• Treatment: Oral antihistamines, cold compresses, short course oral corticosteroids for severe cases 1
• Do NOT give antibiotics for insect sting local reactions 1

Angioedema:

• If responds to antihistamines/corticosteroids → Allergic angioedema 1
• If does NOT respond to antihistamines/epinephrine → Consider hereditary angioedema; requires C1-inhibitor concentrate or icatibant 1

Giant Cell Arteritis (in patients >50 years):

• New-onset headache, tender/cord-like temporal artery, polymyalgia rheumatica symptoms 6
• Requires immediate high-dose corticosteroids and temporal artery biopsy to prevent blindness 6

Imaging Strategy

CT with IV Contrast (urgent indications):

• Orbital signs present 1, 2
• Suspected complicated sinusitis with severe headache or cranial nerve palsies 1, 2
• Suspected deep space infection or abscess 2

Do NOT obtain imaging for:

• Uncomplicated acute rhinosinusitis (clinical diagnosis) 5, 2
• Simple insect sting reactions 2
• Clear allergic angioedema responding to treatment 2

Plain radiographs should NOT be used 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 (fever, erythema, warmth, tenderness) 1
• Do not delay imaging when orbital signs are present (periorbital edema, proptosis, diplopia, impaired eye movement, decreased visual acuity) 1
• Do not give antibiotics for insect sting local reactions 1
• Do not use antihistamines/steroids alone for hereditary angioedema (requires specific C1-inhibitor therapy) 1
• Do not discharge patients with anaphylaxis without observation period due to risk of biphasic reactions 1
• Do not miss subcutaneous emphysema after dental procedures (palpate for crepitus on second examination if swelling persists) 4