Healthy boy with sore on left lower eyelid

What’s your diagnosis?

A healthy 5-year-old boy, whose only problem had been mild-to-moderate seborrheic dermatitis, is taken to his provider with the complaint of a sore on his left lower eyelid.

James H. Brien, DO, FAAP

There is no history of injury, and the sore was first noted about 1 week earlier, at which time it was much smaller. After 4 or 5 days, it had gotten larger and appeared to drain some slightly blood-tinged material, possibly caused by the child picking at it.

The child’s provider noted the chronic seborrheic dermatitis and a discrete, inflamed lesion on the outer part of the left lower eyelid as shown in Figure 1, which appears to have a central scab. The rest of his eye exam was normal.

Figure 1. A 4-year-old with a sore on the left lower eye lid. Image: James H. Brien, DO

What’s Your Diagnosis?

A. Hordeolum

B. Parinaud syndrome

C. Pott puffy tumor

D. Pyogenic granuloma

Answer and discussion

The answer is A, hordeolum. The term hordeolum is from the Latin for barley corn, which apparently describes the appearance of the lesion at an early stage of development. The term stye is a 17th century word, derived from Old English. When it occurs on the external surface of the lid, it may be due to obstruction of the follicle of an eyelash, but most likely it is caused by an obstructed meibomian gland. The oily substance associated with seborrhea can be a contributing factor, therefore more likely to occur in children with seborrheic dermatitis. In either case, bacteria — usually Staphylococcus aureus — becomes entrapped, resulting in abscess formation, giving it the typical appearance.

Treatment depends on the appearance at the time of diagnosis. In a case such as this, with drainage, it may be prudent to use warm compresses a few times per day, along with an anti-staph antibiotic. If the stye is in the early stages, warm compresses may be all it takes to resolve the problem. (Important note: Be sure to check the temperature of the compress before applying it to the face of the child, especially if using a microwave to heat it). As noted, although styes are common, a child with seborrheic dermatitis is more likely to develop a stye due to the excess oil production.

Parinaud syndrome, also known as oculoglandular syndrome, describes the combination of an inflammatory condition of the eye with involvement of an ipsilateral lymph node, usually preauricular. Henri Parinaud, a French ophthalmologist, described three adults with this condition in 1889. It was subsequently found that a variety of infectious agents may result in this condition. Today, cat scratch disease (CSD) is the most common cause, typically resulting in a discrete granuloma within the conjunctiva of the upper eyelid, along with a swollen, possibly suppurative ipsilateral preauricular lymph node, as shown in Figures 2 and 3, a patient with CSD, as seen in the March 1992 column. Since France is the “world capital of cats,” it may be possible that Dr. Parinaud was seeing CSD, but we will never know. Even though CSD was initially called “cat scratch fever,” most cases have no associated fever. Another major cause of oculoglandular syndrome is tularemia, which would likely be seen in a sicker patient with fever and other local and systemic findings, such as oral ulcers, inflammation of tonsils and signs of lung involvement, and is often life-threatening. Therefore, the absence of fever in a patient with oculoglandular syndrome would more likely be CSD.

Figure 2. A 10-year-old male with oculoglandular syndrome of Parinaud, status-post needle drainage of suppurative material from the preauricular node. Image: James H. Brien, DO

Figure 3. A 10-year-old male with oculoglandular syndrome of Parinaud, showing the granuloma under the upper lid. Image: James H. Brien, DO

Pott puffy tumor is a condition described in 1760 by Sir Percivall Pott, an 18th century English surgeon. It is a complication of frontal sinusitis that spreads via the venous system to involve the frontal bone (osteomyelitis), with painful swelling of the forehead (Figure 4, shown in the November 2001 column), and may progress to intracranial spread, as shown in another patient (Figure 5, imaging showing spread of infection through the frontal bone to the forehead — the puffy tumor — and intracranially with an abscess). Treatment of Pott puffy tumor almost always requires surgical drainage and debridement by an otolaryngologist, and possibly a neurosurgeon, with material sent for cultures. Broad-spectrum IV antimicrobial agents should be initiated. Most experts recommend a combination of vancomycin, a third-generation cephalosporin, and metronidazole, pending aerobic and anaerobic culture results. The duration of therapy is usually 6 to 8 weeks. Debridement of devitalized frontal bone may be necessary (Figure 6, showing a discrete area of dead frontal bone as noted by the arrow to be debrided, courtesy of Lewis Hutchinson, MD).

Figure 4. Adolescent with Pott puffy tumor. Image: James H. Brien, DO

Figure 5. Imaging of a patient with Pott puffy tumor, showing soft tissue swelling, frontal sinus and intracranial abscess. Image: James H. Brien, DO

Figure 6. Showing intraoperative appearance of the damage to the frontal bone over the frontal sinus due to Pott puffy tumor prior to debridement of the dark, dead area. Image: Courtesy of Lewis Hutchinson, MD

A pyogenic granuloma of the upper eyelid is seen in Figure 7. The painless lesion began several weeks earlier, with no discharge or visual impairment, but has been slowly increasing in size. These lesions may be sessile, as in Figure 7, or pedunculated. The name is a misnomer in that they are not caused by an infection but rather an abnormal growth of vessels along with granulation tissue. A pyogenic granuloma such as this should be managed by an ophthalmologist.

Figure 7. Pyogenic granuloma of the upper eyelid. Image: James H. Brien, DO

Columnist comments

The practice of naming a disease after the one who discovered or described it (an eponym) is a centuries-old practice that has become controversial in modern times but is generally accepted. Somewhere along the way, eponyms turned into possessive eponyms. Pott disease, or tuberculosis of the spine, became Pott’s disease. Pott puffy tumor, noted above, became Pott’s puffy tumor. Parinaud syndrome became Parinaud’s syndrome. Crohn disease became Crohn’s disease, etc. I am not sure when I started ranting on this, but here I go again.

I do not claim to be a linguist or grammarian; that is not my background. However, as a medical writer of well over 400 columns over the last 36 years — which have included discussing conditions with eponyms — I have become somewhat obsessed with this issue of possessive eponyms. I do not think any of the three physicians mentioned above had ownership or actually had “their” described diseases. Language does change for various reasons over time, including generational differences, which is a polite way of saying that us “old goats” do not like change. However, the basics, such as anything possessive or not possessive, should not change — and yet, it has, and does, even at some of the highest levels of academia. OK, my rant is over — again.

I invite anyone to write me with a counterargument, and I will be happy to include it in an upcoming column.

Lastly, please remember to get your influenza, COVID-19 and respiratory syncytial virus immunizations. It is never too late. I wish you all a safe and joyful holiday season and a Happy New Year.