Facial Pain answer

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Facial pain usually comes from a tooth, sinuses, tmj, lymph nodes, and less commonly ears.  The remaining structure is the parotid.  Very rarely, facial pain is due to a bony skull lesion.


The patient’s pain is where her parotid is.  To verify the dx, you can (1) do a CT, (2) try to push pus out of Stensen’s duct [I never see this, largely because most parotitis is not purulent], or (3) do nothing.  I usually scan if I feel a lump (mass/abscess).

The dx of common childhood contagious disease nowadays is so complicated, requiring blood tests, imaging, etc.  There was a measles case in the nejm that got a ridiculous amount of tests (http://www.nejm.org/doi/full/10.1056/NEJMcps1413402).  In the old days, your doctor probably said, “oh you have measles, mumps, etc.” and sent you home with a lollipop.

Most parotitis I see are viral, but not mumps.  I have not had a mumps outbreak in my area despite occasional spikes in cases of parotitis and other salivary gland infections.  Most patients get better with ibuprofen, though there is a temptation to throw abx at the patient.  I usually send these patients for ent follow-up.  Most pcps have no idea what to do with parotitis nowadays.

On this patient’s scan, the L parotid is obviously enlarged, despite the lack of swelling on exam.  I do iv contrast in case there’s an abscess.  She was sent home with ibuprofen and got better after a few days.


    • siuf

      I was caught in between here.

      She had no swelling at all, which made me unsure, which led to the CT. She had also been in the ED for >12 hr when I got sign-out on her, which also made me want to scan her.

      The week prior, I scanned an older woman because she was swollen, but there was a hard mass on exam. I scanned her because I thought it might be cancer, and it turned out to be a small abscess which got better on abx.

      Otherwise, if it’s a young person and it’s obviously the parotid, I don’t scan them. I would ask about immunizations (which I would never do otherwise) and maybe send some titers.

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