What is the appropriate management for an adult patient with no significant medical history presenting with cheek swelling?

Management of Cheek Swelling in Adults

For an adult presenting with cheek swelling, immediately assess for signs of bacterial infection (warmth, erythema, tenderness, fever) or malignancy risk factors (firm/fixed mass, size >1.5 cm, duration ≥2 weeks), as these determine whether urgent intervention, imaging, or observation is appropriate. 1, 2

Initial Risk Stratification

High-Risk Features Requiring Urgent Evaluation

Assess for infectious signs first:

• Warmth, erythema of overlying skin, localized tenderness to palpation 1
• Fever, tachycardia, systemic symptoms 1
• Trismus (limited jaw opening), difficulty swallowing, or diffuse swelling extending beyond the cheek 2
• Recent dental pain, carious teeth, or dental procedures suggesting odontogenic source 2

Assess for malignancy risk factors:

• Mass present ≥2 weeks without significant fluctuation or uncertain duration 1
• Firm or fixed consistency, size >1.5 cm, or ulceration of overlying skin 1
• Age >40 years, tobacco use, alcohol abuse, or immunocompromised status 3
• Associated numbness (particularly concerning for neoplastic nerve infiltration) 3

Management Algorithm Based on Risk Assessment

If Signs of Bacterial Infection Present

Determine if odontogenic source:

• Examine for dental pain, carious teeth, purulent drainage, or recent dental work 2
• Palpate for maxillary dental tenderness or percussion tenderness of upper teeth 1

Obtain imaging for severe infections:

• Order maxillofacial CT scan with contrast if fever, lymphadenopathy, trismus, cellulitis extending beyond jaw, or diffuse swelling present 2
• CT identifies fluid collections, deep space involvement, and extent of infection 2

Treatment approach:

• Surgical drainage or tooth extraction is mandatory for dental abscess—antibiotics alone will fail 2
• Prescribe amoxicillin 500 mg every 8-12 hours for 5-7 days after drainage for acute dentoalveolar abscess 2, 4
• Use amoxicillin-clavulanic acid if no response to amoxicillin or suspected resistant organisms 2
• Refer immediately to oral surgery for diffuse swelling, trismus, systemic involvement, or infections extending to cervicofacial tissues 2

Critical pitfall: Antibiotics provide no benefit over drainage alone for localized abscesses and should never be used as monotherapy for dental abscess 2

If Suspected Sinusitis

Diagnostic criteria for acute bacterial rhinosinusitis:

• Purulent nasal discharge PLUS nasal obstruction OR facial pain-pressure-fullness 1
• Symptoms persisting ≥10 days without improvement OR worsening within 10 days after initial improvement 1
• Fever, maxillary dental pain, or percussion tenderness of upper teeth may be present 1

Management:

• Facial swelling from sinusitis is extremely rare and should prompt search for coexisting conditions (postsurgical/posttraumatic antral wall defect, fungal disease, neoplasm, or dental infection) 5
• If sinusitis confirmed without complications, treat with amoxicillin or amoxicillin-clavulanic acid 1, 4

If No Infectious Signs BUT High-Risk for Malignancy

Do not prescribe antibiotics—most adult neck/facial masses are neoplastic, not infectious 1

Perform targeted physical examination:

• Visualize mucosa of larynx, base of tongue, and pharynx (may require referral to otolaryngology) 1
• Palpate for fixation to adjacent tissues, firm consistency, lymphadenopathy 1

Obtain imaging before any biopsy:

• MRI of face and neck with and without IV contrast is preferred to exclude intracranial extension or malignancy 6
• CT maxillofacial with IV contrast is alternative if MRI unavailable 6
• Never perform open biopsy before imaging in high-risk patients—this can seed tumor cells and worsen outcomes 6

Proceed to fine-needle aspiration (FNA):

• Perform FNA instead of open biopsy when diagnosis remains uncertain after imaging 1
• Continue evaluation even if FNA shows cystic mass—do not assume benign 1

If no diagnosis after FNA and imaging:

• Obtain additional ancillary tests based on history and physical examination 1
• Recommend examination of upper aerodigestive tract under anesthesia before considering open biopsy 1

If Low-Risk (No Infectious Signs, No Malignancy Risk Factors)

Advise patient of criteria triggering need for additional evaluation:

• Development of firm/fixed consistency, rapid growth, size >1.5 cm 1
• Persistence ≥2 weeks, development of systemic symptoms, or ulceration 1

Document follow-up plan:

• Reassess within 2 weeks to confirm resolution or establish final diagnosis 1, 3
• If no improvement at 2 weeks, reconsider diagnosis or refer to specialist 3

Special Considerations

Numbness with swelling is particularly concerning:

• This combination may indicate neoplastic infiltration of infraorbital nerve and requires immediate specialist referral 3
• Do not delay malignancy workup in patients with numbness, firm texture, reduced mobility, or duration >2 weeks 3

Antibiotic trial only if infectious etiology suspected:

• If prescribing antibiotics for presumed infection, reassess within 2 weeks 1
• If mass has not completely resolved, pursue malignancy workup—partial resolution may represent infection in underlying malignancy 1