What are the most common causes of prolonged isolated facial swelling in adults and children?

Most Common Causes of Isolated Facial Swelling for Greater Than One Week

For prolonged isolated facial swelling lasting more than one week, the most common causes differ by clinical presentation: slowly progressive swelling suggests benign tumors (hemangioma, lymphangioma, neurofibroma) or fibrous dysplasia; nonprogressive swelling indicates congenital anomalies (dermoid cysts, cephaloceles); while persistent swelling with inflammation points to chronic sinusitis, salivary gland disorders, or dental infections. 1

Clinical Classification Framework

Facial swelling persisting beyond one week should be categorized by temporal pattern and associated features to narrow the differential diagnosis 1:

Slowly Progressive Swelling (Most Common for >1 Week Duration)

• Vascular malformations and tumors including hemangiomas, lymphangiomas, and vascular malformations represent the most frequent cause of slowly progressive facial swelling in both pediatric and adult populations 1
• Neurofibromas present as gradually enlarging masses, particularly in patients with neurofibromatosis 1
• Fibrous dysplasia causes painless, slowly progressive bony expansion of facial bones 1
• Salivary gland tumors manifest as persistent swelling, with submandibular stones causing intermittent pain characteristically occurring just before eating 2

Nonprogressive Swelling

• Congenital anomalies including nasal dermoid cysts, epidermoid cysts, cephaloceles, and nasal gliomas present as stable midfacial swelling 1
• These lesions are typically present from birth but may not become clinically apparent until later 1

Persistent Inflammatory Swelling

• Chronic maxillary sinusitis causes prolonged facial swelling with tenderness overlying the affected sinus, though chronic forms are less likely to be painful than acute presentations 2
• Salivary gland disorders including chronic sialadenitis or duct obstruction produce intermittent or persistent swelling with bimanual palpation revealing stones or gland tenderness 2
• Dental infections from odontogenic sources can cause prolonged swelling if inadequately treated, with pain localizable to specific teeth 2

Critical Diagnostic Pitfalls

Do Not Miss These Serious Causes

Rapidly progressive swelling with cranial nerve deficits mandates immediate imaging to exclude rhabdomyosarcoma, Langerhans cell histiocytosis, Ewing sarcoma, osteogenic sarcoma, or metastatic neuroblastoma 1. These malignancies can initially present with seemingly benign swelling before neurologic symptoms develop.

Temporal arteritis (giant cell arteritis) in patients over 50 years presents with facial swelling accompanied by new-onset headaches, jaw claudication, or visual symptoms 3. This requires immediate high-dose corticosteroids before temporal artery biopsy to prevent blindness 3.

Angioedema (hereditary or acquired) causes episodic swelling lasting 24-72 hours per attack, progressively worsening over 24 hours then slowly remitting 2. Unlike allergic causes, it does not respond to antihistamines, corticosteroids, or epinephrine 2. Most patients begin experiencing symptoms in childhood with worsening around puberty 2.

Uncommon but Important Differentials

• Multiple myeloma can present as unilateral facial swelling from plasma cell infiltration of facial bones 4
• Cervicofacial subcutaneous emphysema following dental procedures causes acute swelling with crepitus on palpation, requiring CT imaging to exclude pneumothorax or mediastinitis 5
• Superior vena cava syndrome or upper extremity deep vein thrombosis can cause facial swelling from increased capillary hydrostatic pressure 2

Diagnostic Approach Algorithm

Step 1: Characterize the Temporal Pattern

• Acute onset (<48 hours): Consider infection, trauma, allergic reaction, or angioedema
• Subacute (days to 1 week): Consider sinusitis, dental abscess, or salivary obstruction
• Chronic (>1 week): Consider neoplasm, vascular malformation, or congenital anomaly 1

Step 2: Identify Associated Features

• Purulent nasal discharge in middle meatus: Chronic sinusitis 2
• Palpable cord or stone with eating-related pain: Salivary stone 2
• Dental tenderness or visible caries: Odontogenic infection 2
• Cranial nerve deficits: Malignancy requiring urgent imaging 1
• Crepitus on palpation: Subcutaneous emphysema 5

Step 3: Select Appropriate Imaging

Contrast-enhanced CT is the modality of choice for detecting abscesses requiring surgical drainage and evaluating acute inflammatory processes 1. It provides excellent visualization of sinuses, dental structures, and salivary glands 2.

MRI with contrast is preferred for evaluating soft tissue masses, vascular malformations, and when malignancy is suspected 1. MRI directly images the entire course of cranial nerves from brainstem through skull base 6.

Step 4: Consider Age-Specific Differentials

Pediatric patients: Congenital anomalies, vascular malformations, and lymphangiomas are more common 1. The presence of nasal polyps should raise concern for cystic fibrosis 2.

Adults over 50 years: Temporal arteritis becomes a critical consideration, especially with new headaches or visual symptoms 3. Malignancy risk increases with age 1.

Key Clinical Examination Findings

• Bimanual palpation of submandibular region identifies salivary stones with absent or slow salivary flow from the duct 2
• Nasal endoscopy after topical decongestants reveals purulent secretions in middle meatus (sinusitis) or identifies nasal polyps 2
• Dental examination with good lighting assesses for caries, gingival inflammation, or periapical abscesses 2
• Palpation for tenderness over maxillary or frontal sinuses suggests sinusitis, though absence does not exclude it 2