One Approach to Facial Swelling: Tooth or Fiction

Abstract

Facial swelling is a common problem in the pediatric population with a variety of causes, ranging from congenital to acquired diseases. A fundamental understanding of typical clinical presentation helps in narrowing this broad differential. A 35-month-old, previously healthy, African American boy presented with 2 weeks of intermittent nightly leg pain and 1 week of unilateral, progressive nontender facial swelling. He had severe, achy right leg pain relieved by ibuprofen, which was diagnosed as a sprain at an outside emergency center 2 days before admission. The patient had developed mild, nontender right facial swelling 1 week before admission and had started amoxicillin for a suspected tooth abscess (Fig 1). He developed a fever of 38.7°C 2 days before admission. Because the patient failed to improve with outpatient management, he was admitted for further evaluation. FIGURE 1 Patient at initial presentation with predominantly right facial swelling. On admission, the patient appeared well nourished with mild fever of 38.1°C, pulse rate of 108 beats per minute, and blood pressure of 107/64 mm Hg. His physical examination showed enlarged tonsils with no exudates and 1-cm, firm, nonerythematous soft tissue swelling overlying the right maxilla with no evidence of dental caries or decay. No cervical, axillary, or inguinal lymph nodes were palpated. There were no other signs of constitutional symptoms such as weight loss, night sweats, diarrhea, nausea, or vomiting. What should be included in an initial differential diagnosis of a patient who presents with facial swelling, and when is imaging indicated? Cases of facial swelling can be divided into 4 groups: acute swelling with inflammation, nonprogressive swelling, slowly progressive swelling, and rapidly progressive swelling.1 The most common form of facial swelling is acute swelling with inflammation, which typically is caused by lymphadenitis, sinusitis, or a tooth infection. Children who have severe systemic symptoms, concern for …