#54 – Dacryocystitis



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Definition

  • Infection of the lacrimal sac usually due to obstruction of the nasolacrimal systems

Anatomy

The lacrimal apparatus is responsible for tear production and drainage of the eye and consists of 3 main structures:

  • Lacrimal gland
    • Serous gland located in the superiorlateral corner of the orbit in the lacrimal fossa
    • Responsible for tear secretion onto the globe
  • Lacrimal canaliculi
    • Drainage ducts located in the medial corner of the eye and drain into the nasolacrimal duct
  • Nasolacrimal duct
    • Drains into the inferior nasal meatus of the nasal cavity

Pathophysiology

  • The most common cause of dacryocystitis is obstruction of the nasolacrimal duct
  • Adults
    • Chronic inflammation leading to fibrosis/stenosis of the duct
    • Most commonly in postmenopausal women
  • Infants/Children
    • Persistent membrane covering the Valve of Hasner
      • Occurs in up to 90% of newborns
        • Becomes patent by the end of the first month of life in 90%

Microbiology

  • Pediatric
    • Streptococcus pneumoniae
    • Staphylococcus species
    • Haemophilus influenza
    • Entrobacteriaceae species
  • Adults
    • Staphylococcus aureus
    • Staphylococcus epidermidius
    • Pseudomonas aeruginosa
    • Propionibacterium species

Clinical Findings

  • The main clinical finding is tearing and discharge
  • Acute
    • Inflammation, pain, swelling, and tenderness beneath the medial canthal tendon around the lacrimal sac
      • Purulence can be expressed through the lacrimal puncta with direct pressure on the lacrimal sac
  • Chronic
    • Tearing and matting of the eyelashes is most common
    • Mucoid material can be expressed occasionally

Diagnostic Studies

  • Although this is clearly a clinical diagnosis and the majority do not need further studies, you can do a bedside test called “Dye Disappearance Test”
    • Apply a drop of topical anesthetic
    • Place a drop of fluorescein stained saline in the inferior cul-de-sac of each of the patient’s eyes
    • Wipe away excess tears from eyelids
    • Observe patient for 5 minutes with careful instructions that the eye should not be rubbed and cheeks should not be wiped
    • After 5 minutes inspect eye, nose, and cheek
      • All of the fluorescein should have drained into the nose within 5 minutes if there is no obstruction
      • If any fluorescein remains in eye or drained down the cheek, then the test is positive

Treatment

  • Most cases respond to appropriate systemic antibiotic therapy
    • Culture expressed purulence to aid in antibiotic selection
    • Acute (7-10 days of therapy)
      • Mild cases – Clindamycin
      • Severe – Vancomycin + 3rd generation cephalosporin
  • For infants:
    • External digital massage of the lacrimal sac is first line
      • Increases the hydrostatic pressure to force open the obstructed membrane
  • Nasolacrimal probing is indicated in acute cases and cases persisting for > 6 months
    • Some cases require balloon dilation, silicone stent placement, or inferior turbinate fracture
  • For adults:
    • Chronic topical antibiotic drops can help keep patent, but this is only symptomatic relief
      • Fluoroquinolones – moxifloxacin, ciprofloxacin, ofloxacin
      • Aminoglycoside – tobramycin, gentamicin
    • Dacryocystorhinostomy is required to prevent recurrence
      • Permanent fistula formed between lacrimal sac and the nose

The Cottage Physician (1893)



References

  1. Duncan JL, Parikh NB, Seitzman GD, Riordan-Eva P. Disorders of the Lids & Lacrimal Apparatus. In: Papadakis MA, McPhee SJ, Rabow MW. eds. Current Medical Diagnosis and Treatment 2020. New York, NY: McGraw-Hill
  2. Orbit. In: Morton DA, Foreman K, Albertine KH. eds. The Big Picture: Gross Anatomy, 2e New York, NY: McGraw-Hill;
  3. Vagefi M. Lids & Lacrimal Apparatus. In: Riordan-Eva P, Augsburger JJ. eds. Vaughan & Asbury’s General Ophthalmology, 19e New York, NY: McGraw-Hill
  4. Horton JC. Disorders of the Eye. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison’s Principles of Internal Medicine, 20e New York, NY: McGraw-Hill
  5. Hoffmann J, Lipsett S. Acute Dacryocystitis. The New England journal of medicine. 2018; 379(5):474. [pubmed]
  6. Campolattaro BN, Lueder GT, Tychsen L. Spectrum of pediatric dacryocystitis: medical and surgical management of 54 cases. Journal of pediatric ophthalmology and strabismus. ; 34(3):143-53; quiz 186-7. [pubmed]
  7. Qian Y, Traboulsi EI. Lacrimal sac compression, not massage. Journal of pediatric ophthalmology and strabismus. ; 46(4):252. [pubmed]
  8. Örge FH, Boente CS. The lacrimal system. Pediatric clinics of North America. 2014; 61(3):529-39. [pubmed]

Ep-PAINE-nym



Le Fort Fractures

Other Known Aliasestransfacial fracture of the midface

DefinitionThese fractures involve the maxillary bone and are graded based on their direction and involvement of surrounding structures. The key distinguishing feature of this type of fracture is separation of the pterygoid plates from the maxillary sinuses.

Clinical Significance Continuity of the pterygoid plates is essential for midface structural stability and any disruption requires surgical fixation. There are three types of Le Fort fractures:

  1. Type I – Horizontal fracture – involves the lateral bony margin of the nasal opening
  2. Type II – Pyramidal fracture – involves the inferior orbital rim
  3. Type III – Transverse fracture – involves the zygomatic arch, vomer, and across the orbital floor and walls

HistoryNamed after René Le Fort (1869-1951), who was a French surgeon and received his medical doctorate at the age of 21 while serving in the French military. He taught and practice in Lille, France for the majority of his career. He served his country numerous times when called to serve as a military physician, as well as coming out of retirement during World War II to teach at the University of Lille to replace colleagues called to the war effort. He published the findings of his eponymous conditions in 1901 in a treatise entitled “Étude expérimentale sur les fractures de la mâchoire supérieure”, where he described his experiments of dropping cannon balls from varying directions and heights on the faces of cadavers to describe the predictable injury patterns


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Gartshore L. A brief account of the life of René Le Fort. The British journal of oral & maxillofacial surgery. 2010; 48(3):173-5. [pubmed]
  7. Patterson R. The Le Fort fractures: René Le Fort and his work in anatomical pathology. Canadian journal of surgery. Journal canadien de chirurgie. 1991; 34(2):183-4. [pubmed]
  8. Le Fort R. Étude expérimentale sur les fractures de la machoire supérieure. Revue de chirurgie, Paris 1901; 23: 208-27; 360-79; 479-507

PAINE #PANCE Pearl – HEENT



Question

One of the visual disturbances that can be seen with carotid atherosclerosis is transient, painless, monocular vision loss.

  • What is this condition called?
  • Why does it occur?

Answer

  1. Transient monocular vision loss is called amaurosis fugax
    • Amaurosis is Latin for darkening/dark/obscure
    • Fugux is Latin for fleeting
  2. The most common cause of amaurosis fugax is ischemia from carotid artery atherosclerotic microemboli. The ophthalmic artery is the first branch off the internal carotid artery and gives rise to the central retinal artery, as well as the anterior and posterior ciliary arteries.
    1. Other causes include retinal vein occlusion, giant cell arteritis, optic neuropathy, papilledema, and retinal vasospasm

Ep-PAINE-nym



Lemierre Syndrome

Other Known Aliasesseptic phlebitis

Definitioninfectious thrombophlebitis of the internal jugular vein.

Clinical Significance Often this starts out as a simple oropharyngeal infection, but if it goes untreated, it can quickly spread to the deep spaces of the neck and infiltrate the carotid sheath. Septic emboli can travel the body and cause severe bacterial complications, resulting in a mortality of up to 15%. The common pathogen for this condition is Fusobacterium necrophorum.

HistoryNamed after André-Alfred Lemierre (1875-1956), who was a French bacteriologist and received his medical doctorate in 1904. He became Médicine de Hôpitaux (hospitalist) in 1912 and later worked at the famed Hôspital Bischat. He was promoted to professor of microbiology in 1926 due to his work on septicemia, typhus, and GI/GU infections. It was in 1936 when he published a case series in The Lancet describing his eponyomous disease.


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. EM Docs. Lemierre’s Syndrome. http://www.emdocs.net/em-in-5-lemierres-syndrome/
  7. Lemierre AA. On certain septicaemias due to anaerobic organisms. Lancet. 1936;227(5874):701-703. [link]

Ep-PAINE-nym



Roth’s Spots

Other know aliasesLitten’s spots

Definitionexudative, edematous hemorrhagic lesions of the retina with pale, white centers that can be composed of coagulated fibrin, platelets, infectious organisms, or neoplastic cells

Clinical Significanceone of the classic physical examination findings in bacterial endocarditis seen on fundoscopy. Further research and analysis has shown these can be present in leukemia, diabetes, and hypertensive retinopathy

Historynamed after Mortiz Roth (1839-1914), who was a Swiss pathologist and recieved his medical doctorate from University of Basel in 1864. He practiced all around Switzerland before returning to Basel as professor extraordinary of pathology in 1872, when he published his now eponymous findings in an article entitled “Uber Netzhauteffecstionen bei wundfiebren [Retinal Manifestations of wound fever]”. Dr. Roth, though, never described the classic appearance of the retinal red spot with a white center. Dr. Moritz Litten described this finding 6 years later and would coin the term we still use today.


References

  • Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  • Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  • Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  • Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  • Up To Date. www.uptodate.com
  • Roth Spots – StatPearls. [article]
  • Roth M. Uber Netzhauteffecstionen bei wundfiebren [Retinal manifestations of wound fever]. Deutsch A Chir. 1872;1:471–84.
  • Litten M. Ueber akute maligne endocarditis
  • und die dabei vorkommenden retinal veranderungen.
  • Charite-Ann 1878;3:135.

Ep-PAINE-nym



Dix-Hallpike Manuever

Other known aliasesNylen-Barany test

DefinitionStarting supine, the patient’s head is rotated to one side and then quickly lowered to supine with the neck extended over the exam table.  Patient is observed for nystagmus for 30 seconds and then returned to supine and observed for another 30 seconds.  This is then repeated for the other side.

Clinical SignificanceThe Dix-Hallpike maneuver is the diagnostic maneuver to induce vertigo and nystagmus in patients with benign paroxysmal positional vertigo by relocating canaliths to the posterior semicircular canals.

HistoryNamed after Margaret Ruth Dix (1902-1991), a British neuro-otologist, and Charles Skinner Hallpike (1900-1979), an English otologist.  Dr. Dix earned her medical doctorate in 1937 from the Royal Free Hospital School of Medicine and Dr. Hallpike earned his from the University of London in 1926.  Dr. Dix was training to become a surgeon when she was injured during the World War II air raids of London and suffered facial and ocular injuries which forced her to change her medical career path.  It was during this time she was hired by Dr. Hallpike to pursue the field of neuro-otology.  Their work resulted in a landmark series in the Proceedings of the Royal Society of Medicine and Annals of Otology, Rhinology, and Laryngology.  It was this series in 1952 where one of the papers describing their eponymous finding  entitled “The Pathology, Symptomatology, and Diagnosis of Certain Common Disorders of the Vestibular System” was published.


References

  • Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  • Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  • Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  • Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  • Up To Date. www.uptodate.com
  • DIX MR, HALLPIKE CS. The pathology symptomatology and diagnosis of certain common disorders of the vestibular system. Proceedings of the Royal Society of Medicine. 1952; 45(6):341-54. [pubmed]
  • Margaret Ruth Dix – Royal College of Surgeons [link]

#45 – Preseptal vs Orbital Cellulitis



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Definitions

  • Orbital Septum
    • Membranous structure that extends from orbit to the tarsal plate and is the anterior boundary of the orbital compartment
  • Preseptal Cellulitis
    • Infection of the soft tissues ANTERIOR to the orbital septum
  • Orbital Cellulitis
    • Infections of the soft tissues POSTERIOR to the orbital septum

Numbers

  • Preseptal cellulitis is much more common than orbital (>90%)
  • Both conditions are more common in children than adults

Pathogenesis

  • Preseptal
    • Usually due to superficial dermatologic infections (though the data has wide variability in reported causes)
  • Orbital
    • Bacterial rhinosinusitis
      • Due to perforations in the lamina papyracea
    • Other causes:
      • Ophthalmologic surgery
      • Dacrocystitis
      • Orbital trauma
      • Dental infections

Microbiology

  • Preseptal
    • Staphylococcus aureus (skin causes)
      • Increasing incidence of MRSA
    • Streptococcus pneumoniae (sinus/nasopharynx causes)
  • Orbital
    • Same as preseptal, but include:
      • Fungal (mucormycosis and Aspergillus spp.)

Signs and Symptoms

  • Both present with unilateral eyepain, erythema, and edema, but:
  • Preseptal
    • No pain with eye movement
    • Sclera is white
Preseptal Cellulitis (sclera is white and quiet)

    • Orbital
      • Painful eye movement
      • Vision changes (acuity, diplopia)
      • Proptosis
      • Sclera injection and chemosis
      • Decreased pupillary response
Orbital cellulitis (notice sclera is red and angry with chemosis)

Complications

  • Complications of preseptal cellulitis are rare, but orbital cellulitis can lead to:
    • Vision loss (3-11%)
    • Subperiosteal abscess
    • Orbital abscess
    • Cavernous sinus thrombosis

Diagnostic Studies

  • CBC with differential may be helpful in risk stratification or atypical presentation
  • Preseptal
    • None! –> Clinical diagnosis
  • Orbital
    • Indications for CT scan
      • Inability to assess vision or deteriorating vision
      • Double vision
      • Inability to examine due to age
      • Proptosis
      • Restricted, limited, and/or painfuleye movement
      • Edema extending beyond eyelid margin
      • Lack of improvement in 24 hours on antibiotics
      • Cyclical fevers
      • Signs of CNS involvement
      • ANC > 10,000 cell/microL
a. proptosis, b. soft tissue inflammation, c. choroidal detachment, d. retrobulbar inflammation, e. optic nerve sheet enhancement
medial orbital subperiosteal abscess with left sided ethmoid sinusitis
  • Blood cultures are not routinely recommended but should be entertained in ill appearing children prior to antibiotic administration

Treatment

  • Preseptal
    • Outpatient
      • > 1 year old and no signs of systemic toxicity
      • Treatment duration typically 5-7days, but treatment should continue until eyelid erythema and swelling have resolved
    • Inpatient
      • < 1 year old, children who can’t cooperate with exam, toxic appearance, or outpatient treatment failing to improve in 24-48 hours
      • Follow orbital cellulitis treatment
  • Orbital
    • Medical
      • Staphylococcal coverage
        • Vancomycin
      • Streptococcal coverage
        • Ceftriaxone
        • Cefotaxime
      • Anaerobic coverage
        • Metronidazole
      • Improvement should occur within24-48 hours
      • Transition to oral therapy when:
        • Afebrile and periorbital signs are resolving
        • Typically 3-5 days
        • Follow culture data (if obtained) or follow outpatient preseptal cellulitis regimen
      • Treat for a total of 2-3 weeks
    • Surgical indications
      • Radiographically identified abscess
        • Typically > 10mm, though small abscesses respond to antibiotics well
      • Intracranial extension
      • Failure to respond to antibiotic treatment
      • Threat to vision


References

  1. Hauser A, Fogarasi S. Periorbital and orbital cellulitis. Pediatrics in review. 2010; 31(6):242-9. [pubmed]
  2. Botting AM, McIntosh D, Mahadevan M. Paediatric pre- and post-septal peri-orbital infections are different diseases. A retrospective review of 262 cases. International journal of pediatric otorhinolaryngology. 2008; 72(3):377-83. [pubmed]
  3. Horton JC. Disorders of the Eye. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison’s Principles of Internal Medicine, 20e New York, NY: McGraw-Hill; http://accessmedicine.mhmedical.com/content.aspx?bookid=2129&sectionid=192011900
  4. Chaudhry IA, Shamsi FA, Elzaridi E, Al-Rashed W, Al-Amri A, Arat YO. Inpatient preseptal cellulitis: experience from a tertiary eye care centre. The British journal of ophthalmology. 2008; 92(10):1337-41. [pubmed]
  5. Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. The New England journal of medicine. 2006; 355(7):666-74. [pubmed]
  6. Brook I, Frazier EH. Microbiology of subperiosteal orbital abscess and associated maxillary sinusitis. The Laryngoscope. 1996; 106(8):1010-3. [pubmed]
  7. Erickson BP, Lee WW. Orbital Cellulitis and Subperiosteal Abscess: A 5-year Outcomes Analysis. Orbit (Amsterdam, Netherlands). 2015; 34(3):115-20. [pubmed]
  8. Howe L, Jones NS. Guidelines for the management of periorbital cellulitis/abscess. Clinical otolaryngology and allied sciences. 2004; 29(6):725-8. [pubmed]
  9. Rudloe TF, Harper MB, Prabhu SP, Rahbar R, Vanderveen D, Kimia AA. Acute periorbital infections: who needs emergent imaging? Pediatrics. 2010; 125(4):e719-26. [pubmed]
  10. Tanna N, Preciado DA, Clary MS, Choi SS. Surgical treatment of subperiosteal orbital abscess. Archives of otolaryngology–head & neck surgery. 2008; 134(7):764-7. [pubmed]
  11. Greenberg MF, Pollard ZF. Medical treatment of pediatric subperiosteal orbital abscess secondary to sinusitis. Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology and Strabismus. 1998; 2(6):351-5. [pubmed]

PAINE #PANCE Pearl – HEENT



Question

Benign paroxysmal positional vertigo (BPPV) can be quite a debilitating condition for patient it effects.  What are the two maneuvers that are used at the bedside for this condition and how do they differ?


Answer

The two maneuvers used clinically in the evaluation and treatment of BPPV are:

  • Dix-Hallpike Maneuver (diagnosis)
    • This is used to diagnosis BPPV and is performed by having the patient starting sitting upright.  The head is then turned to one side and the patient is rapidly lowered to the supine position with their extended over the examination table.  The provider then watches for nystagmus or vertigo symptoms.  If this side is negative, then the maneuver is repeated on the other side.
Dix-Hallpike
  • Epley Maneuver (treatment)
    • This is used to treat active vertigo in BPPV by attempting to relocate the canalith back into the utricle by using a series of repositioning techniques.
Epley

References

  • Shim DB, Ko KM, Kim JH, Lee WS, Song MH. Can the affected semicircular canal be predicted by the initial provoking position in benign paroxysmal positional vertigo? The Laryngoscope. 2013; 123(9):2259-63. [pubmed]
  • Furman JM, Cass SP. Benign paroxysmal positional vertigo. The New England journal of medicine. 1999; 341(21):1590-6. [pubmed]
  • Woodworth BA, Gillespie MB, Lambert PR. The canalith repositioning procedure for benign positional vertigo: a meta-analysis. The Laryngoscope. 2004; 114(7):1143-6. [pubmed]
  • White J, Savvides P, Cherian N, Oas J. Canalith repositioning for benign paroxysmal positional vertigo. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology. 2005; 26(4):704-10. [pubmed]

Ep-PAINE-nym



Epley Manuever

Other known aliasescanalith repositioning manuever

Definitionseries of positions and manual manipulations used to reposition free-floating otoconia in the semicircular canals of the inner ear

Clinical SignificanceThe Epley maneuver is used to treat benign paroxysmal positional vertigo (BPPV) by relocating the otoconia back to the utricle where they can no longer stimulate the cupula of the semicircular canal and cause vertigo. 

HistoryNamed after John Epley, an American otolaryngologist from Portland, OR, who received his medical degree from the Oregon Health Sciences University and fellowship from Stanford Medical Center.  He pioneered the “canalith theory” of vestibular disease and published his eponymous maneuver in 1980 in the article entitled “New Dimensions of Benign Paroxysmal Positional Vertigo”.  Dr. Epley is still in practice today.


References

  • Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  • Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  • Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  • Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  • Up To Date. www.uptodate.com
  • Epley JM. New dimensions of benign paroxysmal positional vertigo. Otolaryngology and head and neck surgery. 1980;88(5):599-605. [pubmed]