What is the cause of a puffy face and swollen glands in a patient, and how should it be treated?

Differential Diagnosis and Management of Puffy Face with Swollen Glands

The most critical first step is to determine whether this represents mumps, Sjögren's syndrome, medication-induced sialadenosis, or giant cell arteritis, as each requires distinctly different management and has different implications for morbidity and mortality.

Immediate Assessment Priority

Life-Threatening Conditions to Rule Out First

• Giant cell arteritis (temporal arteritis) must be excluded immediately in patients over 50 years old, as delay in treatment can result in irreversible blindness 1
• Check for jaw claudication (pain with chewing), new-onset headache, visual changes, or temporal artery tenderness 2, 1
• If suspected, immediately order ESR and C-reactive protein; if elevated, initiate high-dose corticosteroids (minimum 40 mg prednisone daily) within 2 weeks and arrange temporal artery biopsy 2, 1

Infectious Causes

• Mumps presents with swelling of one or more salivary glands (typically parotid) and is a systemic illness 3
• The virus is isolated from saliva 7 days before through 8 days after onset of swelling, making patients highly contagious 3
• Up to one-third of mumps cases do not cause salivary gland swelling, presenting instead as respiratory tract infection 3
• Complications include orchitis after puberty, viral meningitis (10% of cases), and rarely permanent hearing loss, myocarditis, or pancreatitis 3
• All suspected mumps cases must be reported immediately with laboratory confirmation through serologic testing or viral detection 3

Autoimmune Causes

• Sjögren's syndrome commonly presents with parotid and/or submandibular gland swelling along with sicca symptoms 3
• Ask specifically about dry mouth requiring liquids to swallow dry foods, frequent water sipping, burning mouth sensation, angular cheilitis, frequent dental cavities (especially gumline), and gum inflammation 3
• Inquire about dry, irritated eyes, foreign body sensation, light sensitivity, and frequent use of eye drops 3
• Associated symptoms include extreme fatigue, arthralgias, myalgias, peripheral neuropathy, and Raynaud's phenomenon 3
• If Sjögren's is suspected, order serologic testing (anti-SSA/Ro, anti-SSB/La antibodies) and arrange rheumatology consultation 3

Medication-Induced Causes

Catecholamine-Induced Sialadenosis

• Excessive use of inhaled beta-adrenergic agonists (such as epinephrine inhalers) can cause recurrent facial swelling in the preauricular area extending to the angle of the jaw 4
• This represents catecholamine-induced sialadenosis, a rare but important adverse drug reaction 4
• Episodes completely resolve when the offending inhaler is discontinued 4
• Obtain detailed medication history, specifically asking about frequency of inhaled bronchodilator use (abuse pattern: 10-20 times daily) 4

Other Medication Culprits

• Immunotherapy-related hypophysitis can present with facial puffiness due to hormonal deficiencies, particularly in patients on immune checkpoint inhibitors 3
• Check thyroid function (TSH, FT4), morning cortisol, and consider pituitary imaging if on immunotherapy 3
• ACE inhibitors can cause angioedema and should be permanently discontinued if this develops 5

Diagnostic Algorithm

Step 1: Age and Temporal Features

• If age >50 years with new-onset symptoms: Immediately evaluate for giant cell arteritis with ESR/CRP and temporal artery examination 2, 1
• If acute onset (<7 days): Consider mumps (especially if unvaccinated or single-dose vaccine), bacterial parotitis, or allergic reaction 3
• If chronic/recurrent: Consider Sjögren's syndrome, medication-induced causes, or sarcoidosis 3, 4

Step 2: Distribution Pattern

• Bilateral parotid swelling: Mumps, Sjögren's syndrome, sarcoidosis 3
• Unilateral swelling: Bacterial parotitis, abscess, neoplasm 6, 7
• Preauricular to angle of jaw: Catecholamine-induced sialadenosis 4

Step 3: Associated Symptoms

• Fever, systemic illness: Mumps, bacterial infection, Pott's puffy tumor (if frontal swelling with sinusitis) 3, 8
• Dry eyes/mouth: Sjögren's syndrome 3
• Jaw claudication, headache: Giant cell arteritis 2, 1
• Occurs after meals: Consider food-related angioedema or medication-induced sialadenosis 4

Treatment Based on Diagnosis

For Mumps

• Supportive care only; no specific antiviral treatment 3
• Isolate patient to prevent transmission 3
• Immunization of exposed contacts who lack documentation of two MMR doses 3
• Monitor for complications (orchitis, meningitis, hearing loss) 3

For Sjögren's Syndrome

• Rheumatology referral for definitive diagnosis and management 3
• Symptomatic treatment with secretagogues, humidification, and artificial tears 3
• Smoking cessation is mandatory 3

For Medication-Induced Sialadenosis

• Discontinue offending medication (inhaled catecholamines) 4
• Symptoms resolve completely with cessation 4
• Provide alternative asthma management strategies 4

For Giant Cell Arteritis

• Immediate high-dose corticosteroids (≥40 mg prednisone daily) before biopsy results 2, 1
• Temporal artery biopsy within 2 weeks of starting steroids 2, 1
• Consider low-dose aspirin therapy 1

Critical Pitfalls to Avoid

• Never delay treatment for giant cell arteritis while awaiting biopsy results in patients over 50 with suggestive symptoms, as blindness can occur rapidly 2, 1
• Do not assume facial swelling is simply angioedema without considering systemic causes like mumps, Sjögren's, or temporal arteritis 1, 6
• Do not prescribe epinephrine, antihistamines, or corticosteroids for mumps, as these are ineffective for bradykinin-mediated or viral-mediated swelling 3
• Do not miss medication-induced causes by failing to obtain detailed medication history, particularly regarding inhaled bronchodilator abuse 4
• Do not overlook sinister causes like multiple myeloma or Pott's puffy tumor in patients with progressive or atypical presentations 7, 8