(BMJ)—A healthy 53-year-old man presented with a swollen eyelid after blowing his nose. He was in a scooter accident earlier but initially had no problems. Exam: Visual acuity WNL; extraocular movement intact; edema of left lower lid, with small hematoma and crepitus; multiple small vesiculae on temporal bulbar conjunctiva. What’s the dx?
Subconjunctival emphysema
Amelanotic conjunctival neoplasm
Orbital compartment syndrome
Subcutaneous crepitation due to infection
You are correct. A CT scan showed fractures of the orbita, maxillary sinus, and frontal bone, with subcutaneous and orbital emphysema and without retrobulbar hemorrhage or entrapment of the eye muscles. Slit lamp exam confirmed subconjunctival emphysema without other ocular damage.

Although chemosis is a common cause of conjunctival swelling, it appears more homogeneous and is usually accompanied by sx such as itching and foreign body sensation. An amelanotic neoplasm has slower onset and prominent conjunctival vascularization. This patient lacked hx of infectious disease or surgery. Furthermore, crepitation due to infection appears slowly.

No intervention was required except for a prohibition to blow the nose and a follow-up visit after 1 week, at which time no abnormalities were found.

Emergency Medicine Journal 2022;39:9-29
(BMJ)—An otherwise healthy 53-year-old man presented with sudden-onset L-sided facial droop with a 4-day hx of bilateral facial swelling. No hx of trauma or recent travel. Exam: L facial palsy including forehead. Dx confirmed by blood tests. What’s the dx?
Ischemic stroke
Bell palsy
Lyme disease
Parotid abscess
You are correct. The patient was initially diagnosed with parotid abscess, but it didn’t improve with antibiotics. This prompted a full vasculitis screen, which showed a raised PR3-ANCA and identified a dx of ANCA-associated vasculitis.

Bilateral facial swelling with facial nerve palsy should raise suspicion of a systemic cause, such as a vasculitis. DDx includes TB, HIV, and Lyme disease. Investigation should include a full vasculitis screen, CXR and CT of the head and neck. Bell palsy is a dx of exclusion and only considered after other causes of unilateral facial nerve palsy have been ruled out. Stroke is an upper motor neuron palsy and spares the forehead. Bilateral parotid abscess is rare and facial nerve involvement with a parotid abscess often indicates a parotid tumor, which is predominantly unilateral.

Following a course of high-dose steroids, this patient’s facial nerve palsy and swellings resolved over 2 weeks.

Emergency Medicine Journal 2021;38:779-802