What could be causing painful swelling on the right side of my face where the jaw meets the ear?

Painful Swelling at Jaw-Ear Junction: Differential Diagnosis and Management

The most likely diagnoses are salivary gland disorders (particularly parotitis or parotid stone), temporomandibular disorder (TMD), or acute otitis externa with periauricular extension—each requiring distinct management approaches based on specific clinical features.

Critical Initial Assessment

Immediately evaluate for these red flag features:

• Fever, systemic symptoms, or extension beyond the ear canal suggest infection requiring systemic antibiotics 1, 2
• Age >50 years with new-onset headache or visual changes raises concern for giant cell arteritis, which requires immediate high-dose corticosteroids to prevent blindness 3, 4
• Cartilage involvement with sparing of the earlobe indicates auricular perichondritis requiring urgent fluoroquinolone therapy to prevent permanent ear deformity 5
• Timing with meals (pain just before eating) is pathognomonic for salivary stone obstruction 3

Most Likely Diagnoses Based on Location

Salivary Gland Disorders (Most Common at Jaw-Ear Junction)

Salivary stones are most frequent in the submandibular gland and present with intermittent pain characteristically occurring just before eating 3. The pain location at the jaw-ear junction strongly suggests parotid gland involvement rather than submandibular.

Key diagnostic features:

• Intermittent swelling that worsens with eating 3
• Tenderness of the involved gland on bimanual palpation 3
• Slow or absent salivary flow from the duct 3
• Ultrasound imaging is the preferred initial diagnostic modality 3

Management approach:

• Refer to oral/maxillofacial surgery for definitive management 3
• Imaging with ultrasound to confirm stone location 3

Temporomandibular Disorders (TMD)

TMD is the commonest non-dental cause of facial pain, affecting 5-12% of the population with peak age 20-40 years 3. Pain typically radiates to the periauricular area, temple, or neck 1.

Diagnostic criteria:

• Tenderness with palpation of muscles of mastication 3
• Clicking or locking of the jaw joint 3
• Pain with prolonged chewing 3
• Associated headaches, fibromyalgia, or chronic widespread pain 3

Management priorities:

• Education and self-management are more beneficial long-term than splints 3
• Physiotherapy and cognitive behavioral therapy have evidence of effectiveness 3
• Hard full coverage stabilization splints worn at night may provide some efficacy 3
• Avoid splints that don't account for occlusion, as they can cause tooth movement and malocclusion 3

Acute Otitis Externa with Periauricular Extension

If swelling extends beyond the ear canal with tenderness on tragal pressure, this represents complicated otitis externa requiring systemic antibiotics 1, 2.

Critical management steps:

• Topical fluoroquinolones (ofloxacin 0.3% or ciprofloxacin 0.2%) PLUS systemic antibiotics are required for periauricular extension 2, 5
• Aural toilet with gentle suction to remove debris before administering drops 2
• Pain management with NSAIDs or acetaminophen; symptoms typically improve within 48-72 hours 1, 2

Common pitfall: Using topical therapy alone when infection extends beyond the ear canal is insufficient 2, 5.

Auricular Perichondritis

Perichondritis presents with painful swelling, warmth, and redness that characteristically spares the earlobe 5.

Immediate treatment required:

• Start fluoroquinolone antibiotics immediately (ciprofloxacin or levofloxacin) to cover Pseudomonas aeruginosa and Staphylococcus aureus 5
• Systemic antibiotics are mandatory; topical therapy alone is insufficient 5
• Delaying treatment leads to devastating focal cartilage necrosis and permanent ear deformities 5

Diagnostic Algorithm

Step 1: Assess timing and aggravating factors

• Pain just before eating → Salivary stone 3
• Pain with chewing/jaw movement → TMD 3
• Pain with tragal pressure → Otitis externa 1, 2

Step 2: Examine for specific features

• Earlobe spared with cartilage involvement → Perichondritis 5
• Tender temporal artery in patient >50 → Giant cell arteritis 3, 4
• Bimanual palpation reveals stone → Salivary obstruction 3

Step 3: Determine extent of infection

• Swelling beyond ear canal → Systemic antibiotics required 2, 5
• Confined to ear canal → Topical therapy sufficient 1, 2

Critical Pitfalls to Avoid

• Missing giant cell arteritis in patients >50 years, which can present as facial swelling and requires immediate corticosteroids 3, 4
• Confusing perichondritis with simple otitis externa, resulting in inadequate antibiotic coverage for Pseudomonas 5
• Failing to provide adequate analgesia in the first 24-48 hours when pain is most severe 1, 2
• Using topical therapy alone when infection extends beyond the ear canal 2, 5