Adnexal & Oncology

Question 1

What is adnexal?

Answer 1

Adnexal means appendages, medically it refers to orbit, eyelids and lacrimal system

Question 2

What are the categories of Adnexal tumours? [2]

Answer 2

Eyelid

Orbital (including lacrimal)

Question 3

What are the common types of benign eyelid tumours? [3]

Answer 3

Squamous cell Papilloma

Basal Cell Papilloma

Question 4

What are the common types of malignant eyelid tumours? [4]

Answer 4

90-95% Basal Cell Carcinoma (Split into nodular, ulcerative & Infiltrative)

2-5% are squamous cell carcinoma

1-2% are sebaceous Gland Carcinoma

Malignant Melanoma

Question 5

How we ddx between different benign eyelid tumours? [3]

Answer 5

Squamous cell papillomas may be pedunculated or sessile & have a raspberry texture

Basal Cell Papillomas are greasy, brown, flat and oval/round

Melanocytic Naevus are asymmetrical, irreuglar bordered, variegated in colour and growing.

Question 6

How do we ddx between different types of malignant eyelid tumour? BCC, SCC, sebaceous gland ca

Answer 6

Basal cell carcinomas are non-pigmented & elevated with a pearly, rolled irregular border and telangectasia. Can be nodular, ulcerative or infiltrative

Squamous cell carcinoma is a scaly surface over thick plaque, growing in weeks rather than months and arises from pre-existing actinic keratosis (rough scaly patch from sun damage)

Sebaceous gland Carcinomas are yellowish due to lipid content and cause blepharitis and recurrent chalazion

Question 7

What are blepharitis and chalazion?

Answer 7

Blepharitis - Inflammation around the edge of the eyelids

Chalazion is a swelling in the Meibomian glands due to blockage from inflammation

Question 8

What structures can be involved in an orbital tumour? [3]

Answer 8

Lacrimal gland

Extrinsic Eye Muscles

Nerves, Blood Vessels

Question 9

What are the common types of orbital tumours?

Benign [3]

Malignant [5]

Answer 9

Benign:

• Capillary, Cavernous Hemangioma
• Pleomorphic Adenoma
• Optic Nerve Glioma

Malignant:

• Lymphoma
• Rhabdomyosarcoma
• Lacrimal Gland Carcinoma
• Osteosarcoma, Liposarcoma
• Primary Melanoma

Question 10

Blepharitis

Ax

Presentation [3]

Mx [4]

Answer 10

Lid margin inflammation

Ax: staph, seborrheic dermatitis, rosacea

Sy/Si:

• bilateral grittiness
• redness, crusting, sticking in the morning with scales on lashes
• may also have assoc. conjunctivitis or keratitis

Mx:

Diluted baby shampoo, hot compresses, massage

Topical abx

Artificial tears

Lid hygiene

Question 11

Styes

Types [2]

Mx

Answer 11

Hordeolum externum: staph infection or abscess in lash follicle that may also involve glands of Mall (sweat) and Zeis (sebaceous), pointing outwards

Hordeolum internum: abscess of Meibomian gland, points inwards

Mx: hot compress for 5-10 min several times a day

Question 12

Chalazion

Ax

Presentation [2]

Mx [2]

Answer 12

Ax: chronic inflammation of Mebomium gland

Presentation:

• Painless (unless recurrently inflamed or infected
• Granular mass

Mx:

• surgical incision and curettage, intra-lesion steroid injection

Question 13

Dermatitis

Ax [2] Mx [2]

Answer 13

Ax: cosmetics, eye drops

Mx:

• Avoidance
• Topical steroids

Question 14

Ophthalmic shingles

Ep, Ax, pathophysiology [2], risk factors [3]

Answer 14

Ep:>50y/o

Ax:re-activation of varicella zoster virus

Px:after chickenpox, VZV lies dormant in sensory ganglia until becomes reactivated and spreads across dermatome

RF:increasing age, immunocompromised, trauma to affected area

Question 15

Ophthalmic shingles

Presentation [3]

Mx and timing [2]

Answer 15

Sy/Si:

• vesicular rash in ophthalmic division of CN V
• pain and systemically unwell
• nasociliary branch involvement (nose tip = Hutchinson’s sign)

Mx:

• oral ACICLOVIR (more effective if given before vesicles crust reduces incidence of post-herpetic neuralgia and uveitis complications)

Question 16

Eyelid malposition

Ax

Classification and ddx [2]

Mx

Answer 16

Ax: degeneration of lid fascial attachments and their muscles

Entropion: lashes turned inwards causing rubbing and irritation of cornea (assoc. lid laxity and inferior retractor weakness)

Ectropion: lower lid eversion causes eye watering (misalignment of drainage punctum) and irritation, especially if muscles lax secondary to CN VII palsy

Mx: surgical correction

Question 17

Diacrodenitis

Define

Acute causes [2]

Chronic causes [4]

Answer 17

Define: lacrimal gland inflammation

Acute: mumps, glandular fever

Chronic: inflammation (may be granulomatous) due to sarcoidosis, leukaemia, lymphoma, TB or amyloidosis

Question 18

Cannaliculitis

Ax [2]

Presentation [2]

Mx

Answer 18

Ax: canaliculi inflammation secondary to herpes or actinomyces

Sy/Si: stenosis and watering (epiphora)

Mx: ACICLOVIR

Question 19

Dacrocystitis

deFINE

Ax

Acute causes [1] and presentation [3]

Chronic causes [2] and presentation [3]

Answer 19

Define: acute or chronic inflammation of lacrimal sac

Ax: secondary to sac or nasolacrimal duct obstruction

• Acute causes - periorbital cellulitis
  
  • suppurative with pain, tenderness and swelling; associated with periorbital cellulitis
• Chronic causes - atresia or occlusion of nasolacrimal duct
  
  • epiphora +/- regurgitating pus spontaneously or after injury, mucocele (thinning and swelling of sac)

Question 20

Dacrocystitis Mx Acute vs Chronic

Answer 20

Acute:hot compresses, abx +/- surgical drainage

Chronic:dacrocytsorhinostomy (if canaliculi patient)

Question 21

Dry eyes

Causes [8]

Ix

Mx [2]

Answer 21

Ax:

• mebomitis
• conjunctival keratinisation
• trachoma
• burns
• Sjogren’s
• CN VII palsy
• debilitating disease
• vitamin A deficiency

Investigation: Schirmer’s test

Mx: artificial tears, punctal plugs