abscess of the lacrimal gland, or by an external incision into a dacryops. <Callout type="important" title="Important">Always seek medical advice before attempting any self-treatment.</Callout> THE LYMPHATIC GLANDS When we first glance over the face we note whether there is any swelling in front of the tragus, where the preauricular gland is situated, and this region may be palpated with the finger to learn whether this gland can be felt. If it is enlarged so that we can feel it we note whether it is small or large, hard, elastic, or soft, tender or insensitive, the seat of inflammation or not. Most of the lymph channels from about the eye pass through this gland, which arrests infectious organisms brought in the lymph current, in an attempt to prevent a general infection of the organism, and the nature of the adenopathy, when present, depends to a great degree on their nature, number, and virulence. The gland may be slightly swollen and tender, large and suppurating, or hard and insensitive. As a rule the swelling is not very marked, but it accompanies many acute infections of the lids and conjunctiva. The more severe the parent inflammation the greater usually is the swelling of the gland, so it is apt to be greatest in such infections as anthrax, vaccine ulcers, and hordeola of the lids, and streptococcal diseases of the conjunctiva, but this is by no means always the case. On the contrary it may be absent in a case of violent conjunctivitis of a nature in which it usually is present, like gonorrheal ophthalmia, or present where ordinarily absent, as in phlyctenular conjunctivitis. When the swelling is considerable a similar condition can be detected, as a rule, in the cervical glands, but when it is slight the gland seems to have been able to arrest the organisms. The adenopathy caused by a chancre of the lid or conjunctiva is hard, indolent, insensitive, never suppurates, but extends slowly to all of the neighboring glands. That present in tuberculosis of the lids or conjunctiva may be indolent, but usually ends in sup- puration; it seldom occurs in connection with lupus. Small ulcers of the conjunctiva of indefinite origin may induce a well marked adenopathy. <Callout type="risk" title="Risk">Be cautious when interpreting symptoms as they can vary widely.</Callout> That of Parinaud’s conjunctivitis is strongly marked and lasts for months after the conjunctiva is well; sometimes the glands suppurate, sometimes they do not. The slow, hard swelling associated with cancer occurs late in the course of the disease, as a rule, and indicates the involvement of the glands. Occasionally an affection of the preauricular gland with no explanatory lesion about the eye suggests that an infection has entered through the conjunctiva without producing trouble there; this has been noticed in glanders. The submaxillary lymphatic gland is apt to be affected in the same manner by lesions situated about the inner canthus, as it is located in the course of a part of the lymphatics that come from the inner portions of the lids and the adjoining tissues. THE ACCESSORY SINUSES No account of the symptoms presented by the eye would be com- plete without mention of those met with in cases of inflammation of the accessory sinuses, although none are of themselves diag- nostic. Certain groups render a diagnosis highly probable, but they have to be supplemented by rhinological examinations, trans- illuminations, roentgenographs, and sometimes exploratory pro- cedures. A sudden onset of cedema of the upper lid, perhaps with ptosis, accompanied by pain and fever, in a patient who gives a history of severe pain at the root of the nose, or in the brow, on catching cold, is very suggestive of empyema of the frontal sinus. If the oedema is confined mostly to the inner third of the lid, and is associated with severe neuralgic pain, imperfect motility of the eyeball, diplo- pia and lacrimation, we think of the anterior ethmoidal cells as the more probable site of the inflammation. If to these symptoms are added an exophthalmos downward and outward, or outward and a little downward, we feel pretty sure that pus is to be found in one of these two localities. But the symptoms may not be so characteristic, and other pathological conditions than pus in these sinuses may give rise to similar ocular symptoms. A slowly pro- gressive exophthalmos downward and outward with no signs of inflammation is very apt to be due to a tumor that has distended the walls of the frontal sinus, or has entered the orbit from that cavity, though it may be caused by a mucocele, an encephalocele, or ‘a tumor springing from the tissues in the upper, inner, front part of the orbit. If a hard painless tumor is felt in this situation and the brow is pressed forward, we may have to deal with an ivory osteoma of the sinus that arises at the junction of the frontal and ethmoid bones, distends the walls of the sinus in every direction, and sends offshoots into the neighboring cavities, including the orbit. A similarly progressive exophthalmos outward and a little downward suggests a mucocele or tumor of the anterior ethmoidal cells. When a patient has a persistent oedema of the lower lid asso- ciated with a swelling of the cheek that is not especially marked along the side of the nose, and pain in the side of the face, either constant or periodic, we think of an empyema of the antrum. Our suspicions are strengthened if there is a chemosis of the conjunctiva, dilatation of the retinal veins with some cedema of the papilla, and still more if to these symptoms is added an exophthalmos upward, or upward and outward. Such an exophthalmos without an in- flammatory cedema of the lid might indicate a new growth in the antrum. An orbital cellulitis of unknown origin always demands a thor- ough investigation of the accessory sinuses, for purulent sinusitis is a very common cause. An orbital cellulitis may be set up very quickly by a sinusitis when the agents are extremely virulent, but ordinarily the history will indicate that the sinusitis is not recent, rather that it has existed a long time. If the inflammation exists anteriorly the patient probably has had symptoms which were refer- able to the frontal sinus, the anterior ethmoidal cells, or the antrum of Highmore; if it is in the posterior sinuses he may have an im- pairment of vision with fundus changes that are insufficient to ex- plain it, or unaccountable themselves. We may find a tender point within the orbit from which the globe is displaced when the inflam- mation is anterior, or a direct protrusion of the eyeball when it is posterior; the former when the infection of the retrobulbar tissue is preceded by an osteitis and periostitis of the wall of the orbit be- tween it and the sinus, the latter when such an osteitis is too far back to allow the swelling of a periostitis to impinge on the surface of the eyeball, and the globe itself is crowded forward by the displacement of the retrobulbar tissues. DeSchweinitz has called attention to a recurrent or fugitive cedema of the lids, with or without reddening of the skin, that may vary from a slight to a marked swelling, and comes and goes at intervals, the attacks associated with intense headache, while there may be no trouble or discomfort during the intervals, and to a fugitive ecchymosis of the lids, also attended by pain during the THE ACCESSORY SINUSES 61 attacks, both of which he has found in connection with inflamma- tion in the frontal sinus and the anterior ethmoidal cells. Probably in these cases the pus drains away through the natural channels, and the attacks are caused by temporary occlusions of the latter. The same surgeon has observed a fugitive episcleral congestion to be sometimes indicative of sinus trouble, and has seen a distinct cedema of the corneal epithelium in a few of the more violent cases. A most serious condition confronts us when a patient complains of a rapid deterioration of the vision of one eye for which we can discover no adequate reason, and this one symptom is enough to call for a rigid and thorough investigation of the posterior eth- moidal cells and of the sphenoidal sinus. It is not enough that no pus can be seen to exude from the openings of these cavities, or that a roentgenograph is negative, these cavities should be skill- fully catheterized and the absence of pus demonstrated beyond a doubt, for not only the sight of the eye, but the life of the patient may be threatened. We learn little from an ophthalmoscopic ex- amination in these cases. Rarely the retinal vessels are occluded; more often we find a papilloedema, an optic neuritis, or a neuro- retinitis; still more often we can make out nothing more than a slight blurring of the margins of the disk, or a diminution in the size of the retinal vessels, and in many cases even these slight signs are wanting. We gain more from a study of the field of vision, particularly if we find an enlarged blind spot, or a scotoma, for either of these may be accounted for by a posterior sinusitis. Such a scotoma usually is central, may be relative for color at first, later absolute for color and relative for white, and may be of any shape, round, oval, or triangular, but it may be paracentral, ring shaped, or hemianopic. In other words, a scotoma exactly like one found in retinal troubles, lesions of the chiasm, and toxic amblyopia, some- times occurs in connection with empyema of the sphenoidal sinus. An additional symptom sometimes present is that movements of the eyeball cause pain. When a thorough examination of the ac- cessory sinuses has demonstrated the absence of inflammation in any one of them, we must bear in mind that an abscess in the zygo- matic fossa is a possible cause, though probably it is such only in very rare cases.
Key Takeaways
- Palpate lymph nodes for swelling and tenderness to diagnose infections or inflammation
- Monitor for signs of pus in accessory sinuses, which can indicate serious conditions like empyema
- Use a thorough examination including rhinological tests and imaging to confirm diagnoses
Practical Tips
- Regularly check your lymph nodes for any unusual changes that could indicate an infection or inflammation.
- If you experience sudden swelling in the eyelids, especially with fever or pain, seek medical attention immediately as it may be a sign of empyema.
- Use imaging techniques like roentgenographs to confirm diagnoses when symptoms are unclear.
Warnings & Risks
- Do not attempt self-treatment for eye infections; always consult a healthcare professional.
- Be cautious interpreting symptoms, as they can vary widely and may indicate different conditions.
- Avoid delaying medical attention if you experience rapid vision loss, as it could be life-threatening.
Modern Application
While the techniques described in this chapter are historical, the principles of diagnosing ocular symptoms through physical examination and imaging remain relevant. Modern technology has improved diagnostic tools but the importance of thorough examinations and prompt treatment remains critical for survival and health.
Frequently Asked Questions
Q: How can I tell if my lymph nodes around the eye are swollen due to an infection?
Swollen lymph nodes in this area, especially if they are tender or accompanied by fever, could indicate an infection. Palpate gently with your fingers and consult a healthcare professional for further evaluation.
Q: What should I do if I notice sudden swelling in my eyelid?
Seek medical attention immediately as it may be a sign of empyema, which requires prompt treatment to prevent complications.
Q: Can you explain the difference between an abscess and pus in the sinuses?
An abscess is a localized collection of pus caused by infection. Pus in the sinuses refers to inflammation and accumulation of pus within the sinus cavities, which can cause swelling and other symptoms. Both conditions require medical attention.