Facial and Periocular Swelling: Diagnostic Challenge

Eyelid swelling is a relatively nonspecific sign with widespread aetiologies, and as such can pose a diagnostic challenge. The differential diagnosis includes congenital, hereditary, infectious, inflammatory, infiltrative, and idiopathic conditions, many of which have key distinguishing features. As with most pathologies, the key to diagnosis often lies in the history. This should include information on laterality, episodes, triggers, alleviators, presence of pain, itching or skin erythema, systemic symptom of inflammation, family history, medication, known allergies, previous surgery or trauma. Oedema may occur due to inflammation and increased vascular permability, or “cold oedema”, due to increased hydrostatic pressure, reduced oncotic pressure, or reduced lymphatic drainage. Investigations include blood tests (including inflammatory and tumour markers), ultrasound, imaging (CT and MRI) and biopsy for tissue diagnosis. Treatment may be straightforward in the case of discrete lesions, infections, infiltrative conditions and a number of inflammatory causes (such as thyroid-associated orbitopathy and dacryoadenitis). However, a number of disorders can be difficult to treat (such as blepharochalasis and angioedema), and multiple therapeutic interventions, including systemic anti-inflammatory therapy, surgical debulking, and corticosteroid injection are typically employed, albeit with variable efficacy. A multi-disciplinary approach to management is often advisable in chronic conditions which are unresponsive to treatment (e.g angioedema, lymphoedema and orofacial granulomatosis).