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-52-year-old woman -History of diabetes
-Complaints of unilateral right-sided facial swelling that began 3 days ago. 
-Area is considerably painful. It hurts when she opens her mouth, chews food or swallows. 
-She describes an abnormal foul taste in her mouth which she noticed just before the pain started.
-Says she’s had a fever but has not taken her temperature.
 
For the Dx and a full discussion, continue NEXT.
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A 52-year-old woman with a past medical history of diabetes comes to your ED with the complaint of right-sided facial swelling for three days. She states the area is painful and hurts when she opens her mouth, chews or swallows. She recalls a subjective fever but has not taken her temperature.

Her temperature is 102.4 F and HR is 107 but vitals are otherwise unremarkable. Upon physical examination, the patient looks uncomfortable with a large degree of swelling over her right face/neck as pictured. It is exquisitely tender, warm and mildly erythematous. You attempt to palpate the parotid but there is a substantial amount of edema making the gland borders indistinct. The patient does not have stridor but there are a few tender posterior cervical lymph nodes. The rest of the physical is grossly unremarkable.

Discussion: Working through the possible causes of facial swelling, from worst to best case scenario.

Ludwig’s angina is an infection of the submandibular space. This disease can displace the swollen tongue posteriorly, potentially occluding the airway. The patient may complain of pain or drooling and will often be leaning forward in the “sniffing position” to maximize the airway patency. The best place to look to confirm this diagnosis is under the tongue in the floor of the mouth. It will appear raised up and approach the level of the occlusive surface of the teeth. Our patient’s swelling is confined to the lateral face making this diagnosis unlikely.

Angioedema is another scary entity causing swelling of the face and throat. It can be either medication induced or hereditary. This patient is not on any medication that would induce angioedema such as an ACE inhibitor and this has never happened to her or any member of her family. Again, our patient’s swelling is all lateral to the teeth so we can rest easy that our patient is unlikely to have either of these diagnoses. It can not be overstated that early airway control is of utmost importance for both of these scary afflictions due to the fact that it may not be possible once massive swelling occurs. 

With the most life threatening entities out of the way, we can begin to actually diagnose our patient.

A parapharyngeal space infection can look like this and can also be life threatening due to airway impingement and their ability to infect the carotid sheath. The patient will complain of dyspnea in addition to neck pain. They may look toxic with medial swelling of the pharyngeal wall and swelling below the angle of the mandible. Again, evaluate and secure their airway if necessary. A CT with IV contrast is the study of choice for delineating exactly where the infection is located and IV antibiotics are almost always required.

Nodal swelling. Other structures to consider that may be causing symptoms in this region are the submandibular nodes and salivary glands. Nodal swelling can be reactive with an infectious origin or due to cancer, more specifically, a lymphoma or metastases from a salivary gland neoplasm. A lymphoma with systemic symptoms might produce fevers such as seen in our patient; however, most lymphomas are not fluctuant or warm and do not develop so rapidly. Salivary gland neoplasms themselves may also cause similar swelling in this region. They are typically slowly enlarging, painless masses and may also resemble some aspects of our patient’s case. However, our patient has rapid onset of a painful mass going against these diagnoses. A facial/neck CT would again be helpful to identify the origin of such a tumor. Metastasis from other neoplasms can rarely manifest in this area but these cases are very rare.

Parotitis, another disease that presents with facial swelling, trismus and fever, is inflammation of the parotid gland itself and can be caused by either infectious or auto-immune triggers. Two of the more chronic causes of parotitis are Mikulicz disease and Sjögren’s syndrome. The prior entity initiates inflammation of all of the salivary and lacrimal glands. Sjogren’s syndrome is an auto-immune disease that presents with dry eyes and mouth with bilateral parotid enlargement. Neither of these syndromes typically presents with unilateral involvement and both are slowly forming and thus unlikely.

One of the more common causes of parotid swelling and inflammation is Mumps virus infection. It typically presents in an unvaccinated individual with bilateral swollen/tender parotids without warmth or erythema. Fever is occasionally seen. The swelling usually lasts 5-10 days and resolves with supportive treatment. Other viruses that can cause parotitis include influenza, parainfluenza, echovirus, coxsackie and HIV.

In bacterial parotitis, patients often present similarly to this case and may have had salivary duct stones or risk factors such as diabetes, alcohol abuse or immunosuppressive states that allow ascending infection through Wharton’s duct. The most common organism recovered from bacterial parotitis is S. aureus, but many cases are polymicrobial.

Our patient had basic labs which demonstrated a WBC of 15K with left shift. The renal function was normal so a contrast CT of the face/neck was performed. This found a suppurative process within the parotid gland confirming our suspicion of such an infection. Antibiotics given for 14 days is usually curative. However, if not caught in time, bacterial parotitis can organize into a parotid abscess. In addition to IV antibiotics, the abscess must be incised and drained to ensure resolution.

Our patient had many symptoms consistent with a parotid abscess. Sometimes the fluctuance associated with an abscess might not be felt due to the thick fascia over the gland so a high index of suspicion is necessary to make this diagnosis. Progression of parotiditis can lead to massive facial parapharyngeal space swelling, respiratory obstruction, septicemia and even osteomyelitis of the adjacent facial bones so the diagnosis must be reached promptly to avoid morbidity or mortality.
 

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