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Summary Table

Domain	Details
Risk Factors	Children (viral), young adults with systemic inflammatory disease, women with autoimmune conditions (Sjogren, sarcoidosis), immunocompromised patients
Etiology	Acute: viral (EBV, mumps, adenovirus) or bacterial (Staphylococcus aureus, Streptococcus, Neisseria gonorrhoeae). Chronic: sarcoidosis, Sjogren syndrome, IgG4-related disease, granulomatosis with polyangiitis, lymphoproliferative disorders
Patient Presentation	Unilateral upper eyelid swelling, pain, and tearing. The swelling is concentrated over the lateral aspect of the upper lid
Classic Physical Exam	S-shaped ptosis (lateral upper lid droop creating a reverse S-curve of the lid margin), tender palpable mass in the superotemporal orbit, injection over the lateral conjunctiva, globe displaced inferomedially
Key Diagnostic Results	CT orbit with contrast showing enlarged lacrimal gland with enhancement. Biopsy for chronic/atypical cases showing granulomatous inflammation (sarcoid) or lymphocytic infiltration with fibrosis (IgG4-related disease)
Management	Acute viral: supportive care (warm compresses, NSAIDs). Acute bacterial: systemic antibiotics (amoxicillin-clavulanate or IV antibiotics if severe). Chronic: treat underlying cause (corticosteroids for sarcoidosis, rituximab for IgG4-related disease)
Keywords	"S-shaped ptosis," "superotemporal swelling," "lacrimal gland enlargement," "lateral upper eyelid mass"

1. Pathophysiology

The lacrimal gland sits in the lacrimal fossa of the frontal bone, within the superotemporal orbit. It is divided by the lateral horn of the levator aponeurosis into an orbital lobe (deeper, larger) and a palpebral lobe (superficial, smaller). When this gland becomes inflamed, the swelling produces a characteristic mass effect in the lateral upper lid area.

In acute dacryoadenitis, the mechanism is straightforward infectious inflammation. Viral agents such as EBV, mumps, or adenovirus cause direct glandular infection and reactive lymphoid hyperplasia within the gland. Bacterial dacryoadenitis results from hematogenous seeding or direct extension, most commonly from Staphylococcus aureus or Neisseria gonorrhoeae in sexually active young adults. The gland becomes edematous, infiltrated by neutrophils, and can progress to abscess formation if untreated.

In chronic dacryoadenitis, the pathophysiology reflects the underlying systemic disease. In sarcoidosis, non-caseating granulomas infiltrate the gland. In IgG4-related disease, dense lymphoplasmacytic infiltration with storiform fibrosis replaces normal glandular tissue, leading to a firm, painless enlargement. The reason this distinction matters is that chronic lacrimal gland enlargement on exam should immediately trigger a workup for systemic disease rather than simply prescribing antibiotics.

The S-shaped ptosis is the hallmark physical finding and is directly explained by anatomy. The inflamed gland pushes the lateral portion of the upper lid downward, while the medial lid remains in its normal position. This creates an S-curve when tracing the lid margin from medial to lateral. This is the single most tested physical finding for dacryoadenitis on vignette-based questions.

2. Classification and Clinical Manifestation

Dacryoadenitis Classification

Type	Onset	Pain	Laterality	Common Causes	Key Features
Acute Viral	Rapid (days)	Moderate	Often bilateral in children	EBV, mumps, adenovirus	Associated with URI symptoms, parotitis, or pharyngitis; self-limited
Acute Bacterial	Rapid (days)	Severe	Unilateral	S. aureus, Streptococcus, N. gonorrhoeae	Marked erythema, purulent discharge, fever, abscess risk
Chronic Granulomatous	Insidious (weeks to months)	Mild or painless	Can be bilateral	Sarcoidosis, granulomatosis with polyangiitis	Firm, non-tender mass; look for systemic signs (hilar lymphadenopathy, skin lesions)
Chronic Lymphoproliferative / IgG4	Insidious	Painless	Often bilateral	IgG4-related disease, lymphoma, Sjogren	Bilateral painless lacrimal gland enlargement; elevated serum IgG4; other organ involvement (pancreas, submandibular glands)

Dacryoadenitis vs. Dacryocystitis

This is one of the most commonly confused pairs in ophthalmology questions. Both involve lacrimal structures, but they affect entirely different anatomical locations and present with swelling in different quadrants of the periorbital area.

Feature	Dacryoadenitis	Dacryocystitis
Structure affected	Lacrimal gland (produces tears)	Lacrimal sac (drains tears)
Anatomical location	Superotemporal orbit (lateral upper lid)	Inferomedial to the medial canthus (beside the nose)
Swelling location	Lateral upper eyelid	Medial canthal area, below the medial canthal tendon
Classic sign	S-shaped ptosis	Painful swelling medial to the eye; reflux of purulent material on pressure over the lacrimal sac (positive regurgitation test)
Underlying problem	Gland inflammation (infectious or systemic)	Nasolacrimal duct obstruction leading to stasis and secondary infection
Common organisms	S. aureus, viral agents	S. aureus, Streptococcus pneumoniae, H. influenzae (children)
Age distribution	Children (viral), young adults (bacterial/autoimmune)	Bimodal: neonates (congenital nasolacrimal duct obstruction) and adults over 40 (acquired obstruction, female predominance)
Tearing pattern	Tearing from irritation	Epiphora (overflow tearing from blocked drainage) is a hallmark and often precedes infection
Risk of complications	Abscess, chronic inflammation, dry eye (gland destruction)	Preseptal or orbital cellulitis, lacrimal sac mucocele/abscess, fistula formation
Definitive surgical intervention	Biopsy (for chronic cases to rule out malignancy/sarcoid)	Dacryocystorhinostomy (DCR) to bypass the obstructed duct

The key discriminator for vignettes is the location of the swelling. Lateral upper lid points to dacryoadenitis. Medial canthal swelling with epiphora and purulent reflux points to dacryocystitis. Test-writers rely on anatomical localization as the primary way to distinguish these two.

3. Diagnostic Workup

Test	Purpose	When to Order
Clinical examination	Localize swelling, assess S-shaped ptosis, check globe position	Always; this is the first step
CT orbit with contrast	Evaluate gland size, detect abscess, rule out mass lesion	Acute cases not responding to treatment, or any chronic/painless enlargement
Blood work (CBC, ESR, CRP)	Assess for systemic inflammation	Acute bacterial (leukocytosis), or suspected systemic disease
Serum IgG4 levels	Screen for IgG4-related disease	Bilateral painless lacrimal gland enlargement
Serum ACE, chest X-ray	Screen for sarcoidosis	Chronic granulomatous dacryoadenitis with bilateral hilar lymphadenopathy
Lacrimal gland biopsy	Gold standard for chronic dacryoadenitis	Chronic enlargement not responding to therapy, suspicion for lymphoma or granulomatous disease

The workup is guided by whether the presentation is acute or chronic.

For acute dacryoadenitis, clinical diagnosis is usually sufficient. The combination of rapid-onset lateral upper lid swelling, pain, and S-shaped ptosis in a young patient with viral prodrome is often enough to make the diagnosis without imaging. If the patient has high fever, marked erythema, or the swelling is worsening despite oral antibiotics, CT orbit with contrast is indicated to assess for abscess formation or extension into the orbit.

For chronic dacryoadenitis, the workup must be more aggressive because the differential includes malignancy (lymphoma) and systemic inflammatory disease. A painless, firm lacrimal gland mass that has been present for weeks requires imaging followed by biopsy. The biopsy is the most accurate test and is necessary to distinguish between sarcoidosis (non-caseating granulomas), IgG4-related disease (storiform fibrosis, IgG4-positive plasma cells with an IgG4:IgG ratio greater than 40%), and lymphoma (monoclonal lymphocytic proliferation).

A commonly tested pearl: if a vignette describes bilateral painless lacrimal gland enlargement with submandibular gland swelling and elevated serum IgG4, the answer is IgG4-related disease (formerly called Mikulicz disease). If bilateral lacrimal enlargement appears alongside bilateral hilar lymphadenopathy and erythema nodosum, think sarcoidosis (Heerfordt syndrome if parotid glands and facial nerve palsy are involved).

4. Management and Treatment

Scenario	Treatment	Details
Acute viral	Supportive care	Warm compresses, oral NSAIDs (ibuprofen 400 mg TID), artificial tears. Self-limited over 4 to 6 weeks
Acute bacterial (mild)	Oral antibiotics	Amoxicillin-clavulanate 875/125 mg BID for 10 to 14 days, or doxycycline 100 mg BID if penicillin-allergic
Acute bacterial (severe / abscess)	IV antibiotics with or without drainage	IV ampicillin-sulbactam 3 g every 6 hours, or IV ceftriaxone 1 g daily. Incision and drainage if abscess is present on CT
Gonococcal dacryoadenitis	IM ceftriaxone + oral azithromycin	Ceftriaxone 500 mg IM single dose plus azithromycin 1 g orally once (treat concurrent chlamydia)
Chronic (sarcoidosis)	Systemic corticosteroids	Oral prednisone 1 mg/kg/day, taper over 6 to 8 weeks. Steroid-sparing agents (methotrexate) for relapsing disease
Chronic (IgG4-related)	Corticosteroids, then rituximab	Prednisone 0.6 mg/kg/day for 2 to 4 weeks with gradual taper. Rituximab for steroid-refractory or relapsing cases
Chronic (lymphoma)	Oncology referral	Radiation, chemotherapy, or observation depending on subtype and staging

In acute management, the next best step depends on severity. A well-appearing patient with mild unilateral swelling and no fever can be started on oral antibiotics with close follow-up in 48 to 72 hours. If there is no improvement, imaging is warranted. A toxic-appearing patient with proptosis, restricted extraocular motility, or vision changes needs urgent CT to rule out orbital abscess or cellulitis, followed by IV antibiotics.

For chronic management, the principle is to treat the underlying systemic disease, not the gland in isolation. Corticosteroids are the first-line therapy for both sarcoidosis and IgG4-related dacryoadenitis, but the long-term trajectories differ. Sarcoidosis may require prolonged immunosuppression with steroid-sparing agents such as methotrexate or mycophenolate. IgG4-related disease has a high relapse rate after steroid taper, and rituximab has emerged as the treatment of choice for refractory cases.

A critical contraindication to remember: do not use corticosteroids empirically for a lacrimal gland mass without biopsy first. Steroids can temporarily shrink a lymphoma, masking the diagnosis and delaying appropriate treatment. This is a commonly tested management pitfall.

5. Differential Diagnosis and Distractors

Differential Diagnosis	Why It Is Similar	Key Discriminator
Dacryocystitis	Both cause periorbital swelling and pain	Location: dacryocystitis causes swelling at the medial canthus with epiphora and purulent reflux, not the lateral upper lid
Preseptal cellulitis	Both cause lid swelling and erythema	Preseptal cellulitis causes diffuse lid edema without a focal superotemporal mass or S-shaped ptosis; no globe displacement
Orbital cellulitis	Both can cause proptosis and pain	Orbital cellulitis causes proptosis with restricted and painful extraocular movements and vision changes; dacryoadenitis displaces the globe inferomedially but usually preserves motility
Dermoid cyst	Both present as a superotemporal mass	Dermoid cysts are painless, present since childhood, slow-growing, and non-tender; no inflammatory signs
Lacrimal gland pleomorphic adenoma	Both cause lacrimal fossa mass	Pleomorphic adenoma is painless, slow-growing, and causes bony remodeling of the lacrimal fossa (fossa expansion on CT without destruction)
Lacrimal gland adenoid cystic carcinoma	Both cause lacrimal gland enlargement with pain	Adenoid cystic carcinoma is painful (perineural invasion) but shows bony destruction on CT rather than smooth remodeling; rapid progression

6. Traps and High-Yield Pearls

The most common way students get dacryoadenitis questions wrong is by confusing the anatomical location with dacryocystitis. When a vignette describes periorbital swelling, students often default to the more familiar diagnosis of dacryocystitis without paying attention to whether the swelling is lateral (lacrimal gland) or medial (lacrimal sac). The test-writer is checking whether you can localize the pathology based on where the swelling sits.

The second trap involves chronic presentations. A painless, bilateral lacrimal gland enlargement is not "just chronic dacryoadenitis" but demands a systemic workup. The vignette may bury clues to sarcoidosis (dry cough, skin nodules, elevated ACE) or IgG4-related disease (autoimmune pancreatitis, submandibular gland swelling) in the stem. Students who focus only on the eye miss the systemic diagnosis entirely.

The third and arguably most dangerous trap is empirically treating a lacrimal gland mass with steroids before obtaining a biopsy. This is a management sequencing question. The correct next step for any chronic lacrimal gland mass is biopsy first, then targeted treatment. Giving steroids without histology risks shrinking a lymphoma and losing the diagnostic window.

Finally, remember the anatomical mnemonic: the lacrimal gland is lateral (both start with "L"), while the lacrimal sac is near the nose (medial). This simple association resolves the majority of localization questions on the exam.

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