Proptosis/Exophthalmos
Proptosis is a finding that usually signals significant pathology. Regardless of duration of symptoms, a rapid evaluation is necessary to discover and treat malignancy or conditions that will result in visual loss.
Differential Diagnosis
- Orbital cellulitis is associated with ethmoid sinusitis, presents with rapid onset of fever, EOM restriction, periorbital edema
- Malignancy
–Rhabdomyosarcoma: Most common primary pediatric orbital malignancy, average age 5–7, proptosis is presenting sign, may develop acutely
–Neuroblastoma: One of most common childhood cancers, most frequent source of orbital metastasis, associated with opsoclonus (rapid multidirectional eye movements), periorbital ecchymoses, 40% bilateral
–Acute leukemia: Most common childhood malignancy, may cause proptosis, ecchymosis, and lid edema
- Benign tumors
–Capillary hemangioma: Most common benign pediatric orbital tumor, females > males, presents in infancy, slowly progressive, increases in size with crying, associated with skin hemangioma, thrombocytopenic purpura
–Lymphangioma: Second most common benign pediatric orbital tumor consists of lymph-filled channels, may hemorrhage after minor trauma or URI (chocolate cyst)
- Neurofibromatosis type 1 (NF1)
–Optic gliomas: Slowly progressive, associated with decreased vision, optic disc atrophy, and swelling
–Orbital and periorbital plexiform neurofibromas; associated with sphenoid bone defects, may be pulsatile
- Hyperthyroidism
–Graves disease is the cause of hyperthyroidism most commonly associated with proptosis/exophthalmos
–Proptosis may be unilateral or bilateral, and lid retraction is common
-
Trauma
–Fracture of orbital bones and hemorrhage into the orbital space may cause proptosis, pain, and EOM impairment
-
Orbital dermoid cyst
–Rupture of cyst causes an inflammatory reaction
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Craniosynostosis (e.g., Apert, Crouzon)
Workup and Diagnosis
- History
–Onset, duration, progression, pain
–Other ocular symptoms such as vision loss, diploplia
–Systemic symptoms such as fever, fatigue
–Associated symptoms such as skin rash, birthmarks
(e.g., café au lait spots in NF1), tremors, palpitations
–History of trauma
–Past medical history of CA, thyroid disease,
neurocutaneous disorders
- Physical exam
–Temperature, vital signs, growth parameters
–Doppler studies to evaluate orbital blood flow
–Check vision and visual fields
–Evaluate pupil function and EOM movement (pain,
diplopia, restriction)
–Palpate orbital rim for mass
–Funduscopic exam including optic nerve and retinal
appearance
–Physical examination for skin findings, abdominal mass, hepatomegaly, neurological exam
-
Labs
–TSH, T3, T4
–CBC, ESR, LDH, blood cultures
-
Studies
–CT or MRI to look for masses
–Doppler studies to evaluate orbital blood flow
-
Biopsy if diagnosis uncertain
Treatment
-
Ophthalmology consultation is always warranted
-
Daily vision testing and optic nerve function evaluation
-
Lubrication for exposure
-
Cellulitis: Inpatient admission, drainage of abscess, IV antibiotics, close observation for visual detrioration
-
Systemic steroids for thyroid disease, capillary hemangioma
-
Orbital decompression if optic nerve compression
-
Surgical removal of tumors if appropriate
-
Irradiation (Graves disease, lymphoid tumors, lacrimal gland tumors)
Book Source Details
- Book Title: In A Page: Pediatric Signs and Symptoms
- Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
- Year of Publication: 2007
- Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Goiter
Read excerpts from these other book chapters related to Goiter:
Medical Books Excerpts
- Thyroid Nodule
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Goiter
- "The 5-Minute Pediatric Consult" (2008)
- [ read ]
Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.
More About Causes of Goiter
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More About This Book:
Title: In A Page: Pediatric Signs and Symptoms
Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 1-4051-0427-9
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» Next page: Salivary Gland Enlargement (In A Page: Pediatric Signs and Symptoms)
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