EXOPHTHALMOS

EXOPHTHALMOS: Excerpt from Differential Diagnosis in Primary Care

The mnemonic VINDICATE is a useful and quick way to recall the causes of exophthalmos (for enophthalmos, see the section on ptosis, page 369). V—Vascular disorders include a carotid–cavernous fistula and cavernous sinus thrombosis. I—Inflammatory diseases recall orbital cellulitis, osteomyelitis, and sinusitis. N—Neoplasms suggest hemangiomas, lymphangiomas, sarcomas, metastatic carcinomas, and nervous system tumors such as sphenoid ridge meningiomas. D—Deficiency diseases suggest the retroorbital hemorrhages of scurvy. Degenerative diseases suggest the apparent exophthalmos of facial palsy associated with progressive muscular atrophy and dystrophy in many forms. I—Intoxication suggests the exophthalmos that develops or progresses on treatment in hyperthyroidism. Idiopathic diseases such as Paget disease and fibrous dysplasia of the skull must also be considered. C—Congenital brings to mind hydrocephalus, Hand–Schüller–Christian disease, meningoceles, and cleidocranial dystosis, all of which cause exophthalmos. In this category, one should also include the genetic exophthalmos of blacks. A—Autoimmune disorders suggest Wegener granulomatosis. T—Trauma suggests orbital fractures and hematomas, which will cause proptosis in many cases. E—Endocrine disorders suggest that the most significant cause of exophthalmos is Graves disease.

If exophthalmos can be classified as a result of a mass, then the causes can be recalled by the methods applied to any mass. The mass may be air (orbital emphysema), fluid (orbital abscess), blood (e.g., hematomas from trauma, scurvy, hemophilia), a foreign substance (e.g., echinococcal cyst), or hypertrophy of one of the tissues around the orbit. The latter can be developed by a histologic analysis. Thus, fat may hypertrophy or multiply in Hand–Schüller–Christian disease and in exophthalmic goiter. Blood vessels may become hypertrophied in cavernous sinus thrombosis, carotid–cavernous fistulas, and aneurysms and will undergo hyperplasia in hemangiomas. Lymph tissue and connective tissue may form sarcomas or granulomas. Bone may swell with a periosteitis and may undergo hyperplasia in Paget disease, osteomas, metastatic carcinoma, and meningiomas. Nerve tissue may undergo hyperplasia in neurofibromatosis.

Approach to the Diagnosis

Because bilateral exophthalmos is usually due to hyperthyroidism, a thyroid profile must be done. The most useful in this profile are the total T₄ level by immunoassay, the free thyroxine index, and the radioiodine (RAI) uptake and scan. A total triiodothyronine (T₃) test by immunoassay should be done to exclude T₃ thyrotoxicosis. Because bilateral exophthalmos can occur without hyperthyroidism, testing for thyrotropin receptor antibody and peroxidase antibodies must be done if thyroid function tests are negative. With exophthalmos, chemosis, and ecchymosis, the patient should be hospitalized for a workup of cavernous sinus thrombosis and a neurologist consulted. When there is unilateral exophthalmos, ultrasonography and angiography will rule out carotid–cavernous fistula and a cystic lesion. A CT scan of the brain and orbits will rule out tumors and abscesses. It is wise to consult a neurologist, ophthalmologist, or endocrinologist to assist in this workup.

Pictures

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins MD, FACP
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

More About Goiter

• Back to disease: Goiter: Introduction
• Next Book Extract About Goiter: Goiter (The 5-Minute Pediatric Consult)
• More Book Extracts: All Online Books for Goiter

More Medical Textbooks Online about Goiter

Review other book chapters online related to Goiter:

Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins MD, FACP Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

 » Next page: Goiter (The 5-Minute Pediatric Consult)

Rate This Website

What do you think about the features of this website? Take our user survey and have your say:

Website User Survey

Medical Tools & Articles:

Next articles:

• Goiter (The 5-Minute Pediatric Consult)
• Surveys relating to Goiter
• Ask Question about Goiter

Tools & Services:

• Bookmark this page
• Symptom Search
• Symptom Checker
• Medical Dictionary
• Give your feedback

Medical Articles:

• Disease & Treatments Search
• Misdiagnosis Center
• Full list of interesting articles

Forums & Message Boards

• Ask or answer a question at the Boards:
• I cannot get a diagnosis. Please help.
• Tell us your medical story.
• Share your misdiagnosis story.
• What is the best treatment for my condition?
• See all the Boards.

Enter your search terms Submit search form
Search The Web Search wrongdiagnosis.com

Common Health Mistakes

Symptom
Checker

Search Specialists by State and City