SAEM Clinical Images Series: Dangerous Eye Drainage

orbital abscess

A 32-year-old man with a history of traumatic globe rupture from a stab wound two months ago, status post repair, presented to the emergency department for worsening right eye pain and green malodorous drainage for the past three days. These symptoms started when he got a fleck of sawdust in the right eye about four days prior to presentation, which he was able to brush out with his finger. He described the pain as severe, throbbing, constant, and non-radiating. He had been unable to open the right eyelid for three days, both due to pain and from the thick sticky discharge that adhered his eyelids together. He reported that his vision had been normal before these symptoms started. On review of systems, he reported nausea that started on the day of presentation but otherwise denied any vision loss or pain in the other eye.

General: Nontoxic appearing but seemed quite uncomfortable.

Eye: On inspection, he had substantial right upper and lower eyelid swelling and erythema, with a green discharge dripping from the palpebral fissure. There was a well-healed scar on the bottom eyelid. The lateral canthus appeared inferiorly displaced. The patient was unable to open his right eye actively, and was unable to tolerate passive opening due to severe discomfort, despite pain medication.

White blood cell (WBC) count: 9.1 x 10^3 /uL with 80.4% neutrophils

Complete metabolic panel (CMP): Within normal limits

Procalcitonin:<0.05 ng/mL

Lactate: 1.4 mmol/L

Cultures from the eye revealed penicillin-sensitive Streptococcus pneumoniae.

Pain with extraocular movements should be present in orbital cellulitis due to inflammation of the structures deep within the orbit. Although not sensitive, proptosis, leukocytosis & fever, chemosis, or any visual impairment should raise concern for orbital cellulitis.

In this patient, displacement of the lateral canthus likely represents a mass effect from his orbital abscess. This abscess is seen lateral to the globe on imaging. On ultrasound, it appears as a heterogeneous isoechoic collection that abuts the right globe. A hyperechoic structure between the orbit and this collection with shadowing raises the possibility of a foreign body. Debris is also visible throughout the right globe and within the anterior chamber. On CT scan, the abscess is described as a rim-enhancing fluid collection that adheres to the lateral rectus muscle. The hyperdense foreign body is again seen on CT, as well as a small focus of air within the anterior chamber.

Take-Home Points

  • Orbital abscess is an uncommon but vision-threatening ocular emergency, which can come from traumatic injury to the globe (as with this case), sinus/nasal infections, or as a complication of dental procedures.
  • The most common organisms responsible for orbital abscesses are Streptococci species (including Strep. pneumoniae and Strep. pyogenes), Staphylococcus aureus (including methicillin-resistant Staph. Aureus), and Pseudomonas aeruginosa.
  • Surgical management is necessary in almost all cases of orbital abscess, with just under 50% of all patients achieving complete visual recovery.

  • Krohel GB, Krauss HR, Winnick J. Orbital abscess. Presentation, diagnosis, therapy, and sequelae. Ophthalmology. 1982 May;89(5):492-8. doi: 10.1016/s0161-6420(82)34763-6. PMID: 7099569.
  • Zawadzki T, Komisarek O, Pawłowski J, Wojtera B, Bilska-Stokłosa J, Osmola K. Orbital Abscess-Two Case Reports with Review. Indian J Otolaryngol Head Neck Surg. 2022;74(Suppl 2):1334-1343. doi:10.1007/s12070-021-02486-z

By |2023-10-22T20:48:41-07:00Oct 23, 2023|HEENT, Ophthalmology, SAEM Clinical Images|

SAEM Clinical Images Series: A Serious Pain in the Neck


An otherwise healthy 34-year-old male presented to the Emergency Department with two weeks of anterior neck pain. Symptoms began with several days of pain in his mandibular molars, progressing to pain and swelling in the neck. In the last several days, the patient developed warmth and redness in the chest wall associated with subjective fever and chills. Additionally, the patient reports difficulty swallowing solid foods secondary to odynophagia associated with intermittent globus sensation. He has no history of immunocompromise and denies any drug or alcohol use. Of note, he has not seen a dentist in many years.

Vitals: BP 115/80; HR 120; T 101°F; RR 16; O2 sat 97%

General: Well appearing in no acute distress

HEENT: Poor dentition, mild trismus. No gingival inflammation or swelling or induration to suggest abscess. The floor of the mouth is unremarkable.

Skin: The neck and upper chest demonstrate erythema and tenderness with an enlarged area of fluctuance on the superior aspect of the left breast (Figure 1).

White blood cell (WBC) count: 6.3 k/uL

Lactate: 1.6 mmol/L

Glucose: 95 mg/dL

Creatinine: 0.72 mg/dL

Lemierre Syndrome, also known as septic thrombophlebitis of the internal jugular vein, is a rare condition with an incidence of 3-15 cases per million people. This condition occurs when an oropharyngeal or odontogenic infection spreads locally from pharyngeal tissue to the internal jugular vein. The pathogens classically arise from normal oral flora, most commonly Fusobacterium necrophorum. The presentation may be associated with trismus and/or dysphagia. Subsequent complications, including localized abscess formation and bacteremia, stem from a combination of surrounding tissue invasion and systemic septic embolization.

Given the potential for regional lymphatic spread and septic embolization, patients may present with both local and systemic findings. Skin exam may reveal regionalized cellulitic or infectious changes overlying the neck or chest (Figure 1).

Respiratory signs and symptoms may suggest the presence of pulmonary septic emboli or mediastinitis.

Constitutional symptoms including fever, chills, and fatigue are common though nonspecific. The differential is broad and includes a number of infectious, lymphatic, endocrine, and neoplastic conditions.

It is essential for the clinician to consider the alternative diagnosis of Ludwig’s Angina through careful evaluation of the oral floor.

Given the potential for oropharyngeal and respiratory compromise, emergency clinicians must maintain a high index of suspicion for this condition. Diagnostics should include laboratory studies with blood cultures, as well as CT imaging of the neck and chest to evaluate for filling defects of the internal jugular vein.

When entertaining the diagnosis, early antibiosis is prudent. Treatment should include both an extended course of antibiotic therapy as well as surgical source control of abscesses. Given the propensity for thrombus development (Figure 2), anticoagulation may be considered, but its indication here remains controversial. Patients with Lemierre Syndrome will require surgical consultation and hospital admission.

Take-Home Points

  • Lemierre Syndrome is a septic thrombophlebitis of the internal jugular vein most commonly occurring via direct spread from the oral cavity. Distinction from Ludwig’s Angina is imperative.
  • Given the proximity to critical structures and the potential for systemic organ dysfunction from septic emboli, emergency physicians need to maintain a high clinical suspicion for this rare diagnosis.
  • Treatment includes parenteral antibiotics and prompt consultation of medical and surgical subspecialists to identify the infectious source as well as mitigate against systemic spread and/or thrombus propagation.
  • Kuppalli K, Livorsi D, Talati NJ, Osborn M. Lemierre’s syndrome due to Fusobacterium necrophorum. Lancet Infect Dis. 2012 Oct;12(10):808-15. doi: 10.1016/S1473-3099(12)70089-0. Epub 2012 May 25. PMID: 22633566.

SAEM Clinical Images Series: There’s a Stone Under My Tongue


A 44-year-old female presented to the emergency department with the complaint of a “stone under [her] tongue.” She reported that the “stone” had been present and painless for two years. The day prior, she began experiencing pain at this site while brushing her teeth. She squeezed the area in an attempt to expel it, but this action only increased her pain.

Vitals: BP 156/92; Pulse 80; Temp 98.4°F; Resp 14; SpO2 100%

General: Sitting on chair, no acute distress

HEENT: Localized swelling to the inferior lingual frenulum at Wharton’s duct with associated erythema. Partially visualized white calculus, palpable through the mucosal membrane.

Sialolith in Wharton’s Duct. There was visual and tactile evidence of a calculus under the patient’s tongue. It had slowly grown and was associated with increased pain and swelling while brushing her teeth.

The majority of sialoliths can be managed conservatively with hydration, moist heat application, massaging of the gland, milking the duct, and advising the patient to suck on tart candies to promote salivation. Larger, more superficial sialoliths may benefit from excision in the emergency department. In the case above, local anesthetic was injected, and manual expulsion was attempted but was unsuccessful. The emergency physician made a single 1 cm incision over the calculus and a 0.5 cm x 0.75 cm sialolith was removed with minimal bleeding. The patient was discharged on a course of amoxicillin-clavulanic acid.

Take-Home Points

  • Dehydration, trauma, anticholinergics, and diuretics predispose to the formation of sialoliths, with 80-90% arising from the submandibular glands. As with our patient, the most common presentation is a single calculus within Wharton’s duct causing pain and swelling during periods of increased salivation.
  • Conservative treatment is the mainstay of sialolith management. Larger, more superficial sialoliths may require excision. Imaging and specialist referral should be considered in cases concerning for tumor, abscess, or treatment failure.
  • Huoh KC, Eisele DW. Etiologic factors in sialolithiasis. Otolaryngol Head Neck Surg. 2011 Dec;145(6):935-9. doi: 10.1177/0194599811415489. Epub 2011 Jul 13. PMID: 21753035.

By |2023-08-27T21:38:49-07:00Aug 28, 2023|HEENT, SAEM Clinical Images|

SAEM Clinical Images Series: My Eye Looks Different


A 29 year-old-male with a past medical history of left eye enucleation secondary to a gunshot wound several years prior presents to the Emergency Department (ED) for blurry vision, redness, and concern for a deformity to his right eye. The patient states symptoms started 2-3 months ago and he initially thought symptoms were due to allergies and recalls rubbing his eye a lot. Over the past 3-4 days, he noticed an acute decline in his vision with what the patient describes as a “cloudy bump” appearing during that time. The patient normally does not wear contacts or corrective lenses but states his vision is very blurry and he is now having difficulty reading. He also reports photophobia and mild eye pain. Review of systems is negative for any fevers, headache, eye discharge, or any recent falls or trauma.

Vitals: BP 125/83; Pulse 70; Temp 97.6 F (36.4 C); Resp 17; SpO2 100%

Constitutional: No acute distress, lying in stretcher comfortably.

Head: No visible traumatic injuries. No peri-orbital edema or facial swelling.


  • OD: Edematous cone-shaped protrusion with central haziness. V-shaped deformity to lower lid margin noted on downward gaze. The patient reports no pain when performing extraocular movement testing which is intact and pupil is reactive to light. Visual fields intact. There is no fluorescein uptake upon Wood’s Lamp exam and IOP is 18. VisualAcuity OD 20/200.
  • OS: Eye prosthesis in place.

Nose: No foreign bodies.

Mouth/Throat: Oropharynx is clear and moist and mucous membranes are normal.

Neck: Normal range of motion.

Corneal hydrops secondary to keratoconus.

Keratoconus is a degenerative, multifactorial, non-inflammatory disorder of the cornea that causes bilateral thinning of the cornea and distorted vision. The corneal thinning leads to a structural weakness in the collagen fibers that causes the characteristic bulging, “cone-shaped” cornea. If the thinning is significant enough, a break in collagen fibers and Descemet’s membrane lead to sudden edema which appears as a corneal opacification. This complication is known as corneal hydrops and causes sudden eye pain and decreased visual acuity. Patients with keratoconus present in young adulthood with progressive blurry or distorted vision. Risk factors include connective tissue disorders and Down syndrome as well as a familial history of keratoconus. There is also a risk in patients with a history of eye rubbing as was the case with this patient. The initial treatment for keratoconus is corrective eyewear for refractive correction.

The clinical hallmark of keratoconus is the cone-like protrusion of the cornea. The bulging may eventually lead to “Munson’s sign”, a v-shaped indentation of the lower eyelid on downward gaze as the cornea bulges outward that is seen in advanced keratoconus.

Take-Home Points

  • Suspect keratoconus in patients with a history of constant eye rubbing, developmental delay (i.e. Down Syndrome), and in patients with connective tissue disorders.
  • Munson’s Sign is a v-shaped indentation of the lower eyelid on downward gaze as the cornea bulges outward.
  • Initial treatment of keratoconus is conservative management with prompt ophthalmology follow-up.

  • V. Mas Tur, C. MacGregor, R. Jayaswal, D. O’Brart, N. MaycockA review of keratoconus: Diagnosis, pathophysiology, and genetics Surv Ophthalmol, 62 (6) (2017), pp. 770-783
  • Gold J, Chauhan V, Rojanasthien S, Fitzgerald J. Munson’s Sign: An Obvious Finding to Explain Acute Vision Loss. Clin Pract Cases Emerg Med. 2019 Jul 8;3(3):312-313. doi: 10.5811/cpcem.2019.5.42793. PMID: 31403106; PMCID: PMC6682229.
  • Gialousakis, John P. “Management of Acute Corneal Hydrops in a Patient with Keratoconus: a Teaching Case Report.” The Journal of the Association of Schools and Colleges of Optometry, vol. 45, 2020.
  • Greenwald MF, Vislisel JM, Goins KM. Acute Corneal Hydrops. August 3, 2016; Available from:
  • Stack L, Sheedy C, Bales B. Corneeal Hydrops: A Complication of Keratoconus. Visual Diagnosis Ophthalmology. Published 2015 Dec 11. Available from:

By |2023-04-05T14:07:32-07:00Apr 17, 2023|HEENT, Ophthalmology, SAEM Clinical Images|

SAEM Clinical Images Series: Facial Swelling

facial swelling

A 5-year-old male with a history of recent frontal sinusitis associated with preseptal cellulitis requiring surgery presented with facial swelling. Swelling developed in the 24 hours prior to presentation without facial pain, nausea, or emesis. Denied facial trauma as well as any neurologic deficits, loss of consciousness, headaches, or fever/chills. At the time of his prior surgery, he presented with swelling localized to the left eye along with worsening pain, nausea, and emesis. After surgery, he was discharged in stable condition on antibiotics for 10 days. He has been in his usual state of health since that time.

Vitals: BP 93/59 (Sitting); HR 84; Temp 37.3 °C (99.1 °F) (Oral); Resp 12; Wt 20.6 kg (45 lb 6.6 oz)

General: Active, alert, normal development, and in no acute distress

HEENT: Swelling over the forehead and nasal bridge. Tenderness to palpation over the forehead. No erythema or overlying skin changes.

Nose: Normal appearance. No congestion or rhinorrhea.

Mouth/Throat: Mucous membranes are moist. Oropharynx is clear.

White blood cell (WBC) count: 8.9 x 10^3/uL

Hemoglobin: 11.5 g/dL

Platelets: 365 x 10^3/uL

ANC: 4.490 x 10^3/uL

ESR: 15 mm

CRP: <0.5 mg

In the initial management of this patient, CT imaging of the head with contrast should be used to characterize the lesion and evaluate for intracranial involvement. In our patient, the CT scan showed frontal bone osteomyelitis with possible extension into the subdural space. He was admitted on broad-spectrum antibiotics and surgical washout was performed the following day.

Pott’s Puffy Tumor is a rare but serious complication of sinusitis with potential intracranial involvement. Complications include orbital cellulitis, intracranial abscess, meningitis, and cavernous sinus thrombosis.

Take-Home Points

  • Pott’s Puffy Tumor is a rare potential complication of sinusitis. Early diagnosis and treatment are essential to reduce morbidity.
  • CT of the head with contrast is the initial imaging that should be obtained in the emergency department.

  • Blumfield E1, Misra M. Pott’s puffy tumor, intracranial, and orbital complications as the initial presentation of sinusitis in healthy adolescents, a case series. Emerg Radiol. 2011 Jun;18(3):203-10. PMID: 21380513.
  • Palabiyik FB1, Yazici Z, Cetin B, Celebi S, Hacimustafaoglu M. Pott Puffy Tumor in Children: A Rare Emergency Clinical Entity. J Craniofac Surg. 2016 May;27(3):e313-6. PMID: 27100642.

By |2022-12-08T22:22:41-08:00Dec 19, 2022|HEENT, Pediatrics, SAEM Clinical Images|

SAEM Clinical Images Series: My Eye is Swollen


A 56-year-old male presented to the Emergency Department with a chief complaint of painful eyelid swelling and itching upon waking up. He reported no history of trauma or fever. He had one similar episode in the past which was self-limiting. The patient denied vision loss, diplopia, pain with extraocular movement, and ophthalmoplegia.

Vitals: T 37.4°C; BP 129/73; HR 91; RR 16

General: A/O x 3; well nourished in NAD

HEENT:  Extraocular movements intact in both eyes. Pupils are equal, round, and reactive to light and accommodation bilaterally. Visual Acuity: OD 20/20, OS 20/25.

Left eye: Diffuse swelling and erythema to the left upper and medial lower eyelids with minimal purulent discharge from the lacrimal puncta. Tenderness localized to the medial canthal region.

Right eye: Normal.

Complete blood count (CBC): within normal limits

Comprehensive metabolic panel (CMP): within normal limits

Acute dacryocystitis. Dacryocystitis is defined by inflammation or infection of the nasolacrimal sac. Whether acute or chronic, acquired or congenital, inflammation is caused by obstruction of the nasolacrimal duct usually from infection, trauma, or a space-occupying lesion. The most common infectious organisms are Staphylococcus and beta-hemolytic streptococcus species. The classic clinical presentation is a sudden onset of swelling, erythema, and tenderness in the medial part of the orbit. Conjunctival injection and swelling around the entire orbit can suggest the development of preseptal cellulitis. Complications of dacryocystitis include orbital abscess, orbital cellulitis, vision loss, ophthalmoplegia, and eyelid necrosis. The differential diagnosis includes dacryoadenitis, lacrimal sac or sinonasal tumor, ethmoid sinusitis, and infected sebaceous or dermoid cyst.

Treatment for dacryocystitis depends on the severity and clinical manifestations of the disease. In mild cases, symptoms will resolve with the application of warm compresses, lacrimal sac massage (Crigler technique), and topical antibiotics if indicated. Severe cases may require oral or parenteral antibiotics and surgical decompression.

Take-Home Points

  • Dacryocystitis is inflammation of the medial nasolacrimal sac preceded by obstruction and may be acute or chronic, congenital or acquired.
  • Dacryocystitis exhibits a bimodal age distribution. The common congenital form is found in infancy, and in adulthood at age of 40 years older.
  • Dacryocystitis is occasionally mistaken for dacryoadenitis (inflammation of the nasolacrimal gland with superolateral eyelid edema). Far less common, dacryoadenitis is associated with systemic inflammatory conditions such as malignancy, Sjogren syndrome, sarcoidosis, Crohn’s disease, and other autoimmune diseases.
  • Proper recognition and prompt treatment may prevent serious complications including orbital cellulitis, vision loss, and sepsis.

  • Alsalamah AK, Alkatan HM, Al-Faky YH. Acute dacryocystitis complicated by orbital cellulitis and loss of vision: A case report and review of the literature. Int J Surg Case Rep. 2018;50:130-134. doi: 10.1016/j.ijscr.2018.07.045. Epub 2018 Aug 9. PMID: 30118963; PMCID: PMC6098209.
  • Carlisle RT, Digiovanni J. Differential Diagnosis of the Swollen Red Eyelid. Am Fam Physician. 2015 Jul 15;92(2):106-12. PMID: 26176369.

By |2022-09-11T10:08:30-07:00Sep 19, 2022|HEENT, SAEM Clinical Images|

SAEM Clinical Images Series: Unilateral Facial Pain


A 78-year-old male with a past medical history of Lewy body dementia, hypertension on bisoprolol, hypothyroidism, COPD, chronic lower extremity edema on furosemide, and overactive bladder on oxybutynin presented to the emergency department for evaluation of three days of progressively worsening left-sided neck and facial swelling. Associated symptoms included poor oral intake, a nonproductive cough, and one week of sore throat.

The black arrow represents the left parotid gland.

Vitals: Afebrile; normal room air saturation

HEENT: Firm, tender, warm and erythematous swelling over the left mandibular ramus that extended to the cheek, left neck, and spread caudally into the supraclavicular region and anterior chest. There were no identifiable hard masses or areas of fluctuance. Further inspection of the oral cavity revealed dry mucous membranes, poor dental hygiene without identifiable dental abscess, tonsils were normal size and equal bilaterally, and uvula was midline. Direct pressure externally over the area of concern revealed purulent discharge from Stenson’s duct.

White blood cell (WBC) count: 22.15

Comprehensive metabolic panel (CMP): Na 131; BUN 39; Cr 3.3

Lactic acid: 2.9

Acute suppurative parotitis (ASP) is a serious bacterial infection of the parotid gland that occurs in patients with diminished salivary flow, increased susceptibility to infection, and poor oral hygiene. Our patient had multiple risk factors for this disease which can include dehydration, advanced age, sialolithiasis, medications (diuretics, beta-blockers, antihistamines, phenothiazines, tricyclic antidepressants, anticholinergics), and certain disorders including diabetes, HIV, hypothyroidism, Sjogren’s syndrome. The most common organisms responsible for ASP are Staphylococcus aureus and oral flora anaerobes.

The most feared complications include supraglottitis, cervical necrotizing fasciitis, and other deep neck space infections which can be surgical emergencies and rarely cause impending airway obstruction. Further central and vascular complications include brain abscess, central venous thrombosis, and Lemierre’s syndrome

Take-Home Points

  • The role of bedside ultrasound in acute suppurative parotitis can help to rule out a superficial abscess or sialolithiasis. CT scan is beneficial in ruling out deep space infections as a complication from this disease process or other causes of head and neck swelling.
  • ASP-associated complications are rare but can lead to significant morbidity and mortality secondary to the parotid gland’s proximity to vital structures and ability to spread to adjacent deep spaces.
  • Emergency medicine physicians will manage acute suppurative parotitis and must be aware of the potential complications when determining safe disposition and appropriate treatment.

  • Markovich A, Ronen O. Factors predicting length of stay in patients hospitalized for acute parotitis. J Investig Med. 2021 Feb;69(2):388-392. doi: 10.1136/jim-2020-001506. Epub 2020 Oct 21. PMID: 33087427.

By |2022-09-11T10:03:16-07:00Sep 12, 2022|HEENT, SAEM Clinical Images|
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