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Dacryoadenitis and Dacryocystitis

Patient with dacryoadenitis will present as → a 32-year-old woman presents to the emergency department with a 2-day history of pain, redness, and swelling in the outer corner of her right eye. She denies any vision changes, discharge, or trauma. She has no significant past medical history and is not on any medications. On physical examination, you note localized erythema and swelling over the lateral aspect of her right upper eyelid. Her visual acuity is normal, and there is no proptosis.


Patient with dacryocystitis will present as →  a 58-year-old woman presents to the emergency department with a 3-day history of increasing pain, redness, and swelling in the inner corner of her left eye. She also reports some purulent discharge from the same eye. She denies any vision changes or trauma. On physical examination, you note localized erythema, warmth, and swelling over the medial canthal area of her left eye. Her visual acuity is normal.

Dacryoadenitis is inflammation of lacrimal (tear-producing) glands usually caused by bacteria or a virus that initiates the inflammation (supratemporal)

  • s/sx: unilateral severe pain, swelling, redness, tearing, drainage
  • Acute dacryoadenitis is most commonly due to viral or bacterial infection. Common causes include mumps, Epstein-Barr virus, staphylococcus, and gonococcus.
  • Chronic dacryoadenitis is most often due to noninfectious inflammatory disorders. Examples include sarcoidosis, thyroid eye disease, and orbital pseudotumor.
"On the boards you may be able to differentiate between the two based on the location: dacryocystitis will be medial. Remember, medial = Center = dacroCystitis. vs. dacryoAdenitis, which is up, up, and Away. Also, it's important to note that dacryocystitis affects the duct, and dacryoadenitis affects the gland."

Dacryocystitis is an infectious obstruction of the nasolacrimal duct (inferomedial region)

  • Dacryocystitis will be medial (remember "c" for central)
  • There will be an overflow of tears because the nasolacrimal duct is obstructed, and there is nowhere for the fluid to exit
  • Often caused by a stone, debris, or dacryostenosis (would be seen in small children) = congenital malformation or failure of duct to open
  • Dacryoadenitis may lead to dacryocystitis and periorbital cellulitis if untreated – redness to the nasal side of the lower lid
Left side Dacryocystitis woman 80 years

Left-sided dacryocystitis

The diagnosis of dacryocystitis and dacryoadenitis based on clinical observation

  • In cases of chronic dacryoadenitis/dacryocystitis, a CT or MRI of the orbits may be warranted
  • In acute cases of dacryocystitis, a tear duct massage can be performed to express material for culture and gram stain
  • In patients who appear to be acutely toxic or those who present with visual changes, imaging, and bloodwork should be considered
Dacryocystitis2017

A case of dacryocystitis

Dacryoadenitis 

  • If the cause of dacryoadenitis is a viral condition such as mumps, simple rest and warm compresses may be all that is needed
  • For other causes, the treatment is specific to the causative disease

Dacryocystitis

  • Acute dacryocystitis (< 3 months) is treated with systemic antibiotics
  • Chronic dacryocystitis (> 3 months) typically presents with fewer inflammatory signs and requires surgical therapy for the underlying cause

Image by Lecturio

Question 1

A 7-month-old female is brought to your clinic by her mother, who is concerned about persistent swelling at the nasal corner of the child's left eye. The mother reports that the swelling has been present for several weeks and occasionally becomes red and inflamed. If this condition is left untreated, which of the following complications is most likely to develop?

A
Hyphema
Hint:
This refers to the presence of blood in the anterior chamber of the eye, typically resulting from trauma or eye surgery, not related to nasolacrimal duct obstruction.
B
Papilledema
Hint:
This is swelling of the optic disc due to increased intracranial pressure and is not a complication associated with nasolacrimal duct obstruction.
C
Pterygium
Hint:
A pterygium is a benign growth on the conjunctiva that can encroach onto the cornea, usually related to UV light exposure, not nasolacrimal duct issues.
D
Dacryocystitis
E
Orbital Cellulitis
Hint:
While severe untreated eye infections can potentially lead to orbital cellulitis, it is less likely in this scenario without evidence of a more significant or spreading infection.
Question 1 Explanation: 
The described symptoms are suggestive of a nasolacrimal duct obstruction, which is common in infants and can lead to the accumulation of fluid in the lacrimal sac (known as dacryocystocele). If left untreated, this can progress to dacryocystitis, an infection of the lacrimal sac. Dacryocystitis is characterized by pain, redness, and swelling in the area of the lacrimal sac, typically at the nasal corner of the eye.
Question 2
Which of the following most accurately differentiates Dacryoadenitis from Dacryocystitis?
A
Location of swelling: Dacryoadenitis - lateral canthus, Dacryocystitis - medial canthus.
B
Discharge: Dacryoadenitis - mucopurulent, Dacryocystitis - purulent.
Hint:
While both can have purulent discharge, it's not a reliable differentiator.
C
Tenderness: Dacryoadenitis - absent, Dacryocystitis - present upon lacrimal sac palpation.
Hint:
Both conditions can have tenderness, though lacrimal sac palpation in Dacryocystitis might be more pronounced.
D
Fever: Dacryoadenitis - common, Dacryocystitis - rare.
Hint:
Fever can be present in both, especially with infections.
E
Lacrimation: Dacryoadenitis - decreased, Dacryocystitis - increased.
Hint:
Dacryoadenitis typically presents with decreased tear production, while Dacryocystitis can have either increased or decreased tears depending on the cause and obstruction.
Question 2 Explanation: 
Dacryoadenitis affects the lacrimal gland, located in the upper outer eyelid (lateral canthus), causing swelling and tenderness in that area. Dacryocystitis affects the lacrimal sac, located in the inner corner of the eye (medial canthus), leading to swelling and tenderness near the bridge of the nose.
Question 3
A 40-year-old female with acute dacryocystitis is experiencing worsening symptoms despite oral antibiotic therapy. She now presents with fever and increased swelling and tenderness of the lacrimal sac area. What is the most appropriate next step in management?
A
Intravenous antibiotics
B
Warm compresses and continued oral antibiotics
Hint:
Appropriate for mild cases but not for worsening symptoms.
C
Dacryocystorhinostomy
Hint:
A surgical procedure indicated for chronic dacryocystitis or obstruction, not acute infection.
D
Topical corticosteroids
Hint:
Not indicated in acute infections and can potentially worsen the condition.
E
Incision and drainage of the lacrimal sac
Hint:
Typically reserved for abscess formation or severe cases not responding to intravenous antibiotics.
Question 3 Explanation: 
In cases of acute dacryocystitis that do not respond to oral antibiotics and present with systemic symptoms like fever, the next step is intravenous antibiotics. This approach is necessary to manage the infection more aggressively and prevent complications such as orbital cellulitis.
Question 4
A 40-year-old female with acute dacryocystitis is experiencing worsening symptoms despite oral antibiotic therapy. She now presents with fever and increased swelling and tenderness of the lacrimal sac area. What is the most appropriate next step in management?
A
Intravenous antibiotics
B
Warm compresses and continued oral antibiotics
Hint:
Appropriate for mild cases but not for worsening symptoms.
C
Dacryocystorhinostomy
Hint:
A surgical procedure indicated for chronic dacryocystitis or obstruction, not acute infection.
D
Topical corticosteroids
Hint:
Not indicated in acute infections and can potentially worsen the condition.
E
Incision and drainage of the lacrimal sac
Hint:
Typically reserved for abscess formation or severe cases not responding to intravenous antibiotics.
Question 4 Explanation: 
In cases of acute dacryocystitis that do not respond to oral antibiotics and present with systemic symptoms like fever, the next step is intravenous antibiotics. This approach is necessary to manage the infection more aggressively and prevent complications such as orbital cellulitis.
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References: Merck Manual · UpToDate

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