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Facial/periorbital swelling

Medicine > Infection

Differential Diagnosis Schema 🧠

Allergic Reactions

  • Angioedema: Sudden onset of painless swelling, often triggered by allergens, ACE inhibitors, or idiopathic causes.
  • Allergic Conjunctivitis: Periorbital swelling with itching, redness, and watery eyes, typically associated with allergens.
  • Anaphylaxis: Rapid onset of swelling with associated symptoms like urticaria, hypotension, and airway compromise.

Infective Causes

  • Cellulitis (Preseptal/Periorbital): Unilateral, tender swelling, often with erythema, fever, and a history of local trauma or infection.
  • Orbital Cellulitis: More severe, with pain on eye movement, visual disturbances, proptosis, and systemic signs.
  • Sinusitis: Swelling around the eyes, associated with nasal congestion, headache, and purulent nasal discharge.
  • Herpes Zoster Ophthalmicus: Periorbital swelling with a painful vesicular rash following the trigeminal nerve distribution.
  • Conjunctivitis: Swelling with redness and discharge from the eyes, may be bacterial, viral, or allergic in origin.

Renal and Cardiac Causes

  • Nephrotic Syndrome: Generalised oedema, often starting in the periorbital area, associated with proteinuria, hypoalbuminemia, and hyperlipidemia.
  • Congestive Heart Failure: Dependent oedema that can extend to the periorbital region, often worse in the morning, with associated symptoms of heart failure.
  • Renal Failure: Generalised oedema including facial swelling, may be associated with symptoms of uraemia and oliguria.

Endocrine Causes

  • Hypothyroidism: Generalised puffiness, particularly around the eyes, often with other symptoms like weight gain, fatigue, and dry skin.
  • Cushing’s Syndrome: Facial swelling (moon face), with other features like central obesity, hypertension, and skin changes.
  • Hypopituitarism: Can cause generalised oedema including facial swelling, often with symptoms of adrenal insufficiency or hypothyroidism.

Other Causes

  • Trauma: Localised swelling due to direct injury, may include bruising or haematoma formation.
  • Superior Vena Cava Obstruction: Facial and neck swelling, often with visible collateral veins and dyspnea.
  • Dermatomyositis: Periorbital oedema with a heliotrope rash, often associated with muscle weakness.
  • Venous Thrombosis: Thrombosis of the cavernous sinus or internal jugular vein causing periorbital swelling, pain, and proptosis.

Key Points in History 🥼

Onset and Duration

  • Sudden onset: Suggests acute allergic reactions (e.g., angioedema, anaphylaxis) or trauma.
  • Gradual onset: More indicative of chronic conditions like hypothyroidism, nephrotic syndrome, or congestive heart failure.
  • Recurrent swelling: Consider hereditary angioedema or recurrent allergic reactions.

Associated Symptoms

  • Pain: Suggests infective causes (e.g., cellulitis, sinusitis) or trauma.
  • Rash: Vesicular rash suggests herpes zoster; erythema with warmth suggests cellulitis.
  • Itching: Common in allergic causes, particularly allergic conjunctivitis or angioedema.
  • Fever: Indicative of infection such as cellulitis or sinusitis.
  • Systemic Symptoms: Dyspnoea and orthopnoea in heart failure; fatigue, cold intolerance in hypothyroidism.
  • Neurological Symptoms: Consider cavernous sinus thrombosis or orbital cellulitis if there is visual disturbance or pain on eye movement.

Background

  • Past Medical History: Previous episodes of swelling, chronic conditions like heart failure, renal disease, or hypothyroidism.
  • Drug History: ACE inhibitors associated with angioedema; immunosuppressants increasing the risk of infections.
  • Family History: Hereditary angioedema or other genetic conditions predisposing to swelling.
  • Social History: Recent travel (consider infectious causes), occupation (exposure to allergens or irritants), alcohol use.

Possible Investigations 🌡️

Blood Tests

  • Full Blood Count: To assess for infection or haematological causes of symptoms.
  • Urea and Electrolytes: Assess renal function, especially in suspected nephrotic syndrome or renal failure.
  • Thyroid Function Tests: To evaluate for hypothyroidism in cases of chronic swelling.
  • C-Reactive Protein/ESR: Elevated in inflammatory or infective conditions.
  • Serum Albumin: Low in nephrotic syndrome and chronic liver disease, contributing to oedema.
  • Complement Levels (C4): Low in hereditary angioedema.

Imaging

  • Ultrasound: To assess for deep vein thrombosis in cases of suspected venous thrombosis.
  • CT Head/Sinuses: Useful in evaluating sinusitis, orbital cellulitis, or facial trauma.
  • MRI Orbit: Indicated if there is suspicion of orbital cellulitis or cavernous sinus thrombosis.
  • Echocardiogram: To assess for heart failure in patients with suspected cardiac cause of swelling.
  • Chest X-ray: May reveal signs of heart failure or superior vena cava obstruction.

Special Tests

  • Skin Prick Testing: For identification of specific allergens in cases of suspected allergic reactions.
  • Serum Tryptase: Elevated in anaphylaxis and can help confirm the diagnosis.
  • Direct Immunofluorescence: Useful in diagnosing conditions like dermatomyositis.
  • Angiography: Consider if there is a suspicion of vascular causes such as superior vena cava obstruction.

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Infection