Facial and Peri-orbital Swelling

Remit

 

Naturally, there are many conditions that can cause swelling in the face and so this page is a pointer to the commoner diseases that may present this way. Some of the diseases are covered elsewhere in your course of study and are put here only as a sign-post to further study.

 

Here is a list of the topics that this page introduces:

 

Pre-septal cellulitis

Acute Dacryocystitis

Angioedema

Parotitis

Dental disease

Ludwig’s Angina

Sinus tumour

Pre-septal cellulitis

 

This is an infection in the tissues around the eye and anterior to the septum of the orbit. The orbital septum is a membranous sheet that extends from the margins of the bony orbit and extends into the fibrous portion of the eye lids. There is a picture of it below. The infection is not within the orbit but is anterior to it.

 

It is primarily a paediatric disease.

 

The infection can come from a scratch in the skin, or an upper respiratory infection. The usual bacteria are Staph aureus, Strep pneumoniae, and H influenzae. Haemophilus vaccination has reduced the incidence of the disease.

 

Note: pre-septal cellulitis must be differentiated from orbital cellulitis. See your ophthalmology lecture notes for more on this.

 
 

Acute dacryocystitis

 

This is a bacterial infection of the nasolacrimal sac and is usually due to there being a blockage in the nasolacrimal duct. This leads to stasis of lachrymal fluid.

 

Infants and post-menopausal women are most affected.

 

Staph aureus and Strep pneumoniae are the commonest Gram +ves and Haemophilus influenzae is a common Gram -ve.

 

Symptoms and signs.

 

Pain, redness and swelling over the lachrymal sac – medial end of the lower eyelid. Swelling can extend around the orbit because of the lax tissue here. The infection may extend to cause a pre-septal cellulitis or conjunctivitis.

 

Pus may be seen on pressing the sac.

 

Treatment: oral or IV antibiotics is the usual acute management but incision of the sac may be necessary if a pyocoele has developed. Long-term management of nasolacrimal outflow may be needed to prevent recurrence.

 

Angio-oedema

 

This is a deep dermal or mucosal swelling. It is not usually serious but, rarely, is life-threatening if the swelling affects the airways.

 

Symptoms and signs: swelling in the face – especially around the eyes, lips and tongue, can affect feet and hands too. 

 

Causes: idiopathic, allergic, drug-induced (eg ACE inhibitors and angiotensin-2 receptor blockers, NSAIDs), hereditary.

 

Treatment: mild cases do not need management. Antihistamines are the usual choice for more problematic cases. Changing drugs can help. For more in depth management options look here. https://dermnetnz.org/topics/angioedema/

Angioedema in the eyelids of  child.

Parotitis

 

 

The parotid gland lies under the skin of the face anterior to the tragus. It is superficial to the masseter muscle and extends down into the upper neck behind the angle of the mandible. It drains into the buccal cavity via a duct that opens adjacent to the second upper molar tooth.

 

Infection within the gland causes swelling in the face and the adjacent soft tissues. The swelling may be tender and redness and heat over the gland may be present.

 

Bacterial parotitis.

 

The commonest cause is bacterial and arises in situations of poor dental health, dehydration, and debility. It is unilateral usually. Elderly post-op patients and those in intensive care or care homes are vulnerable to this infection. Anticholinergic medications are a risk factor too as they decrease salivary production.

 

Staphylococcus is the commonest infecting organism but mixed oral bacteria can contribute.

 

Viral parotitis.

 

Mumps is the commonest cause of this and causes a unilateral or bilateral swelling. There is swelling and pain and there may be headache as well as the symptoms of orchitis.

 

It is caused by a paramyxovirus. Vaccination against the virus has greatly reduced the incidence of the disease.

 

Isolation and supportive medications are all that are usually required. Occasionally, oral steroids will be beneficial in reducing pain swelling and the symptoms of orchitis.

 

Autoimmune / other.

 

Sjögren’s syndrome causes a chronic inflammation of the salivary glands and may present with an enlarged, tender parotid gland. 9:1 female male ratio.

 

Sarcoidosis affects salivary tissue in about 10% of cases. Swelling is bilateral, smooth and non-tender.

 

Stasis of salivary flow.

 

Stones and strictures can case stasis and infection within the gland. Stones are much more common in the submandibular gland, however. Stones can be seen on X-ray and USS is a valuable assessment tool.

 
Mumps parotitis. Note the swelling over the gland and nearby soft tissues.

Dental disease

 

Abscesses associated with dental disease may present as swellings in the face over the maxilla or mandible. Once the infection has broken through the bone and reaches the soft tissues the swelling becomes obvious externally. 

 

Dental caries, plaque, gingivitis and post-traumatic infection (including post dental surgery) are the leading causes.

These are polymicrobial infections that include Bacteroids, Fusobacterium, Actinomyces and others. 

 

About a third of abscesses have bacteria resistant to beta-lactam antibiotics.

Dental abscess associated with a lower 2nd molar
 
 

Ludwig’s angina

 

 

This is a neck space cellulitis involving the floor of the mouth. As such the swelling is mainly in the neck rather than on the face but the topic seems well placed here as it can extend into the lower face.

 

The cellulitis is in the submandibular space, sublingual, and submental spaces. It is bilateral, and of acute and rapid onset.

 

The commonest cause is from a dental infection (around 80% of cases) but oral ulcers and malignancy, oral trauma and mandibular gland infection can all cause it.

 

Causative organisms are as for dental abscesses above. 

 

Signs are of rapid onset and include elevation of the floor of the mouth, swelling under the chin and into the upper neck, and airway compromise.

 

Treatment

 

1. Airway management including endotracheal intubation

2. Early, aggressive antibiotic management

3. Incision and drainage of collections

4. Rehydration and nutritional support

Ludwig's angina showing swelling under the chin and upper neck
 

Sinus tumours

 

Given that this is a page on facial swelling, it would be improper to forget sinus tumours even though that, in the UK, they are very rare. For FY1 competence it is as well to know that they exist and cause a swelling in the face over the involved maxillary sinus. By the time the swelling appears in the face the tumour will usually be extensive and will be affecting the structures around it:

 

Eye – diplopia, epiphora, proptosis

Face – numbness and swelling of the middle third of the face, changes in the skin

Oral – loosening of the maxillary teeth, swelling and ulceration in the palate

Nose – unilateral blockage and serosanguinous discharge, foul smell

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