Differential Diagnosis for Facial and Eye Burning in a Patient with Hypothyroidism
The most critical consideration in this patient is thyroid eye disease (thyroid ophthalmopathy), which can occur with hypothyroidism, particularly Hashimoto's thyroiditis, and presents with periorbital and conjunctival symptoms including burning sensations. 1
Primary Thyroid-Related Considerations
Thyroid Eye Disease (Thyroid Ophthalmopathy)
- Can occur with hyperthyroidism, normal thyroid function, OR hypothyroidism (including Hashimoto's thyroiditis) 1
- Presents bilaterally but may be asymmetric with edema and erythema of periorbital tissues and conjunctivae 1
- Thyroid ophthalmopathy may precede or follow thyroid dysfunction by many years 1
- Risk factors include family history of thyroid disorders and cigarette smoking exposure 1
- Can progress to exposure keratopathy, which would cause burning sensations 1
Important Clinical Pitfall: Many clinicians mistakenly believe thyroid eye disease only occurs with hyperthyroidism, but it is explicitly associated with under-functioning thyroid states like Hashimoto's thyroiditis 1
Ocular Surface Disorders
Keratoconjunctivitis Sicca (Dry Eye Syndrome)
- Presents with burning sensation of eyes and can be bilateral 1
- Associated with autoimmune conditions, which commonly coexist with Hashimoto's thyroiditis 1
- Look for conjunctival injection and signs of dryness on examination 1
Allergic or Atopic Conjunctivitis
- Can present with burning and bilateral symptoms 1
- May be associated with cicatrizing changes in chronic cases 1
Neuropathic Pain Syndromes
Burning Mouth Syndrome (BMS)
- Characterized by burning of oral mucosa and can extend to facial areas 1
- Predominantly affects peri- and post-menopausal women 1
- Oral mucosa appears normal on examination 1
- Represents a disorder of peripheral nerve fibers with central brain changes 1
- Quality: burning, stinging, itchy, sore sensation that is continuous 1
Post-Traumatic Trigeminal Neuropathic Pain
- Continuous burning or tingling in trigeminal distribution 1
- Requires history of dental procedure or facial trauma within 3-6 months 1
- May have allodynia or other sensory changes on examination 1
Atypical Odontalgia/Persistent Dentoalveolar Pain
- Localized burning or aching sensation that can radiate to facial areas 1
- Continuous, mild to moderate severity 1
- May have hyperesthesia in affected area 1
Systemic/Autoimmune Causes
Vasculitis (Sarcoidosis, Granulomatosis)
- Can present with conjunctivitis and burning sensations unilaterally or bilaterally 1
- Often involves multiple organ systems including lungs, lymph nodes, kidneys 1
- Look for conjunctival nodules or granulomas on examination 1
Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis
- Presents with bulbar conjunctival injection and burning 1
- Associated with systemic medications (sulfonamides, barbiturates, phenytoin) 1
- Can be unilateral or bilateral 1
Key Examination Findings to Assess
- Periorbital edema and erythema suggest thyroid eye disease 1
- Upper eyelid retraction is specific for thyroid ophthalmopathy 1
- Proptosis indicates thyroid eye disease 1
- Conjunctival injection suggests inflammatory or autoimmune etiology 1
- Light touch-evoked pain (allodynia) indicates neuropathic pain 1
- Normal-appearing mucosa with burning suggests BMS or neuropathic pain 1
Diagnostic Approach
Confirm thyroid status: Verify TSH and free T4 levels, as hypothyroidism symptoms are non-specific and overlap with many conditions 2, 3
Check for autoimmune thyroid disease: Anti-TPO antibodies identify Hashimoto's thyroiditis, which increases risk for thyroid eye disease 4, 2
Ophthalmologic examination: Essential to evaluate for thyroid eye disease, dry eye, or other ocular surface disorders 1
No imaging indicated for hypothyroidism workup: Thyroid ultrasound, CT, or MRI are not indicated unless evaluating for thyroid eye disease complications 1, 4
Consider qualitative sensory testing if neuropathic pain is suspected based on allodynia or hyperalgesia 1