How should I evaluate and manage a patient with unilateral facial swelling?

Evaluation and Management of Unilateral Facial Swelling

Begin by immediately excluding life-threatening causes: assess airway patency, check for angioedema (especially if the patient takes ACE inhibitors), and rule out acute infection requiring urgent intervention. 1, 2

Immediate Assessment Priorities

Airway and Life-Threatening Conditions

• Evaluate for angioedema without urticaria by examining for lip, tongue, or periorbital swelling developing over hours without pruritus—this can be fatal if airway involvement occurs. 2
• Measure serum C4 immediately if angioedema is suspected to screen for hereditary or acquired C1 inhibitor deficiency. 2
• If the patient takes ACE inhibitors, consider drug-induced angioedema and discontinue the medication immediately. 2
• In immunocompromised patients with fever, facial pain, and unilateral swelling, suspect invasive fungal rhinosinusitis—this requires urgent tissue biopsy as early diagnosis is critical for prognosis. 1

Trauma Evaluation

• If there is any history of facial trauma with tenderness over the frontal bone or other facial structures, obtain high-resolution CT of the facial bones to evaluate for fractures. 3
• The frontal bone can withstand up to 1,000 kg of force, so fractures indicate high-energy trauma and may involve the posterior table with potential intracranial complications. 3

Systematic Clinical Evaluation

History: Key Elements to Elicit

• Onset timing: Acute onset (<72 hours) suggests infection, trauma, or allergic reaction; gradual onset over days to weeks suggests neoplasm or chronic inflammatory process. 1, 4
• Associated symptoms:
  • Fever, pain, visual changes, facial numbness, or motor weakness raise suspicion for serious infection or invasive disease. 1
  • Hoarseness, otalgia, dysphagia, or weight loss increase suspicion for head and neck malignancy. 3
  • Jaw or ear pain with facial droop suggests Bell's palsy or Ramsay Hunt syndrome. 4, 5
• Medication history: Specifically ask about ACE inhibitors, which can cause angioedema. 2
• Risk factors: Age >40 years, tobacco use, alcohol abuse, immunosuppression, or multiple sexual partners increase risk for head and neck squamous cell carcinoma. 3
• Geographic exposure: In Lyme-endemic regions, up to 25% of facial paralysis cases are due to Lyme disease. 4

Physical Examination: Specific Findings to Document

Inspection:

• Assess for erythema, warmth, or tenderness suggesting infection or inflammation. 1
• Look for vesicular rash in the ear canal (Ramsay Hunt syndrome). 4, 5
• Examine the scalp, face, and oral cavity for ulcerations, pigmented lesions, or masses. 3
• Check for facial asymmetry, proptosis, or lagophthalmos. 1

Palpation:

• Determine if the mass is firm (malignancy), tender (infection), or fluctuant (abscess). 3
• Palpate cervical lymph nodes—nontender nodes are more suspicious for malignancy than tender nodes. 3
• Perform bimanual palpation of submandibular and parotid glands to assess for salivary gland disorders. 2
• Measure the size with calipers if possible—masses >1.5 cm are more concerning for malignancy. 3

Neurologic examination:

• Critical distinction: If facial weakness includes the forehead, this indicates peripheral (lower motor neuron) facial nerve involvement; if the forehead is spared, this suggests central (stroke) pathology. 4
• Test all cranial nerves—additional deficits (diplopia, dysphagia, dizziness) suggest brainstem pathology. 4
• Assess tongue mobility and perform indirect laryngoscopy if available. 3

Nasal endoscopy (when indicated):

• Inspect for necrotic tissue, particularly of the middle turbinate, which is a hallmark of invasive fungal rhinosinusitis. 1

Differential Diagnosis by Clinical Pattern

Acute Swelling with Facial Weakness

• Bell's palsy: Acute onset (<72 hours) of unilateral facial paralysis including forehead, often with jaw/ear pain, hyperacusis, or reduced taste. 4
• Ramsay Hunt syndrome: Facial paralysis with vesicular ear rash; has poorer prognosis than Bell's palsy. 4, 5
• Lyme disease: Consider in endemic areas, especially if bilateral facial weakness. 4

Acute Swelling with Infection Signs

• Odontogenic infection: Most common cause of facial swelling in dental patients; assess for dental source. 6
• Bacterial sinusitis: Unilateral facial pain, swelling, and fever. 1
• Invasive fungal rhinosinusitis: In immunocompromised patients (50-65% incidence), presents with facial pain, unilateral swelling, nasal obstruction, and fever. 1
• Parinaud oculoglandular syndrome: Unilateral granulomatous conjunctivitis with ipsilateral lymphadenopathy, fever, and eyelid swelling; most commonly from cat-scratch disease or tularemia. 1

Gradual Progressive Swelling

• Neoplasm: Gradual progression over days to weeks suggests tumor (parotid tumor, schwannoma, meningioma, cholesteatoma, or perineural spread). 4
• Multiple myeloma: Rare but can present as unilateral facial swelling. 7
• Salivary gland disorders: Intermittent swelling before eating with tender glands. 2

Swelling with Systemic Features

• Nephrotic syndrome: Periorbital edema worse in the morning. 2
• Cushing's syndrome: Moon facies with central obesity and striae. 2
• Sarcoidosis: Can cause granulomatous inflammation of facial structures. 4

Imaging Strategy

When to Image and What to Order

For suspected trauma:

• High-resolution temporal bone CT with thin sections to evaluate facial bone integrity and fractures. 3
• Contrast may be added if infection or tumor is suspected. 3

For facial nerve palsy or suspected neoplasm:

• MRI brain with contrast is first-line to assess the facial nerve pathway from brainstem to peripheral branches. 3, 4
• Add high-resolution temporal bone CT to characterize bony canal involvement. 3, 4
• Do NOT use routine non-contrast CT head or CTA head alone—these are insufficient for facial nerve evaluation. 4

For suspected invasive fungal disease:

• MRI with contrast is superior to CT (86% sensitivity vs. 69%) and shows loss of contrast enhancement in affected tissues. 1
• Radiologic findings are typically unilateral. 1

For neck mass evaluation:

• CT or MRI to characterize extent and soft tissue involvement. 8

Laboratory Testing (Selective)

For suspected angioedema:

• Serum C4 level immediately; if low, confirm with quantitative and functional C1 inhibitor assays. 2

For suspected invasive fungal disease:

• Serum PCR and/or galactomannan testing (negative predictive value 100% when both negative, positive predictive value 88% when both positive). 1
• Blood cultures. 1

For suspected Lyme disease:

• Lyme serology only in endemic areas with appropriate exposure history. 4

For chronic urticaria with swelling:

• Complete blood count, ESR, and thyroid autoantibodies if not responding to H1 antihistamines. 2

For suspected nephrotic syndrome:

• Urinalysis with protein quantification and serum albumin. 2

Tissue Diagnosis When Indicated

• Immediate biopsy is required for suspected invasive fungal rhinosinusitis in immunocompromised patients—demonstrating hyphal forms within sinus mucosa, submucosa, vessels, or bone is diagnostic. 1
• Intra-operative frozen section can rapidly confirm invasive fungal disease. 1
• Nasal-sinus biopsy is indicated to determine if a lesion is neoplastic or to identify granulomatous inflammation when diagnosis is unclear. 1

Treatment Approach

Immediate Interventions

For Bell's palsy:

• Start oral corticosteroids within 72 hours (prednisolone 50 mg daily for 10 days or prednisone 60 mg daily for 5 days with 5-day taper)—evidence shows 83% recovery at 3 months versus 63.6% with placebo. 4

For Ramsay Hunt syndrome:

• Combine antiviral therapy with corticosteroids. 4

For Lyme disease-related facial palsy:

• Parenteral ceftriaxone for 14-21 days; steroids may be added after antimicrobial therapy. 4

For infection-related facial palsy:

• Do NOT give steroids alone; treat the underlying infection first. 4

For invasive fungal rhinosinusitis:

• Do not delay biopsy in immunocompromised patients—early tissue diagnosis is critical. 1

For ACE inhibitor-induced angioedema:

• Immediately discontinue the medication. 2

Red Flags Requiring Urgent Specialist Referral

• Bilateral facial weakness is never idiopathic—evaluate for Lyme disease, sarcoidosis, or Guillain-Barré syndrome. 4
• Additional neurologic signs (dizziness, dysphagia, diplopia) suggest brainstem pathology and require urgent imaging. 4
• Facial swelling with redness accompanying palsy is atypical for Bell's palsy and mandates investigation for infectious causes. 4
• Persistent or progressive symptoms beyond 2-4 months warrant imaging even if initial impression was Bell's palsy. 4
• Visual changes or eye pain with facial swelling require urgent ophthalmologic evaluation. 1
• Immunocompromised patient with fever and unilateral facial pain—suspect invasive fungal disease and obtain urgent ENT consultation. 1

Common Pitfalls to Avoid

• Assuming all acute facial weakness is Bell's palsy—approximately 30% have identifiable alternative etiologies requiring different management. 4
• Missing ACE inhibitor-induced angioedema by not obtaining complete medication history, which can progress to airway compromise. 2
• Failing to check C4 levels in patients with isolated facial swelling without urticaria, delaying diagnosis of potentially fatal hereditary angioedema. 2
• Routinely imaging typical Bell's palsy presentations—reserve MRI for atypical features such as recurrence, persistence >2-4 months, bilateral involvement, or facial swelling/redness. 4
• Overlooking potential ocular involvement, which may lead to vision-threatening complications. 1
• Delaying biopsy in immunocompromised patients with suspected invasive fungal rhinosinusitis—early tissue diagnosis is critical for prognosis. 1