What are the possible causes and treatments for swelling and tenderness of the upper eyelid, particularly near the nasal area?

Upper Eyelid Swelling Near the Nose: Diagnosis and Management

For upper eyelid swelling with tenderness localized toward the nasal area, you must immediately rule out orbital cellulitis by assessing for proptosis, painful or impaired eye movements, decreased vision, fever, or systemic toxicity—if any are present, hospitalize immediately for IV antibiotics and urgent CT imaging. 1, 2

Immediate Red Flag Assessment

Before considering benign causes, evaluate for these emergency features:

• Proptosis (eye bulging forward) 1, 2
• Pain with eye movement or restricted extraocular movements 1, 2
• Decreased visual acuity 1, 2
• Severe headache or altered mental status 1
• Fever and systemic toxicity 1, 2

If ANY of these are present: Hospitalize immediately, obtain contrast-enhanced CT of orbits and sinuses, start IV antibiotics, and consult ophthalmology, otolaryngology, and infectious disease urgently. 1

Most Likely Diagnoses for Upper Nasal Eyelid Swelling

Preseptal Cellulitis (Infection Anterior to Orbital Septum)

Clinical features: Eyelid swelling, erythema, warmth, and tenderness WITHOUT proptosis or eye movement restriction. 1, 3

Predisposing factors: Upper respiratory infection (68% of cases), trauma to eyelids (20%), or sinusitis. 3 The nasal location suggests possible ethmoid sinusitis extension. 4

Treatment approach:

• Mild cases (eyelid <50% closed): High-dose amoxicillin-clavulanate with daily follow-up until definite improvement. 1, 2
• No improvement in 24-48 hours or progressive infection: Hospitalize for IV antibiotics. 1, 2
• Most common pathogens are Staphylococcus aureus, Streptococcus pneumoniae, and Staphylococcus epidermidis. 3

Acute Dacryocystitis (Lacrimal Sac Infection)

Clinical features: Erythema, swelling, warmth, and tenderness specifically over the lacrimal sac (medial canthus/nasal side of lower lid extending upward), often with profuse tearing. 5

Critical consideration: Must be identified and treated early to prevent complications including periorbital cellulitis, orbital cellulitis, meningitis, brain abscess, and sepsis. 5

Treatment: Systemic antibiotics; urgent ophthalmology referral if dacryocystocele present. 5

Hordeolum (Stye) - Upper Lid

Clinical features: Localized, tender, erythematous swelling of the eyelid margin or tarsal plate, may have visible pustule. 2

First-line treatment:

• Warm compresses for 5-10 minutes once or twice daily 1, 2
• Gentle eyelid cleansing with diluted baby shampoo or hypochlorous acid 0.01% after compresses 1
• Gentle massage to express gland contents 1

Second-line treatment: Topical antibiotic ointment (bacitracin or erythromycin) applied to lid margins once daily or at bedtime. 1, 2

Ethmoid Sinusitis with Periorbital Extension

Clinical features: Upper eyelid swelling (especially medial/nasal aspect), purulent nasal discharge, facial tenderness, symptoms persisting >10 days. 4

Key examination finding: Purulent exudates in the middle meatus are highly predictive of bacterial sinusitis, though absence doesn't exclude infection. 4

Critical pitfall: Ethmoid sinusitis is the most common source of orbital cellulitis due to thin lamina papyracea separating ethmoid sinus from orbit. 3, 6 The nasal location of your patient's swelling makes this particularly concerning.

Non-Infectious Causes to Consider

Floppy Eyelid Syndrome

Clinical features: Upper eyelid edema, easily everted upper lid, horizontal lid laxity, bilateral but often asymmetric. 4

Associated factors: Obesity, sleep apnea, thyroid disease (especially Hashimoto's). 4

Treatment: Temporary relief with nighttime eyelid taping or protective shield; definitive treatment requires surgical lid tightening and sleep apnea evaluation. 1

Giant Papillary Conjunctivitis (GPC)

Clinical features: Papillary hypertrophy of superior tarsal conjunctiva, mucoid discharge, associated with contact lens wear. 4

Treatment: Discontinue contact lens wear, switch to daily disposables, use preservative-free solutions, consider topical mast-cell stabilizers. 1

Medication-Induced Keratoconjunctivitis

Clinical features: Conjunctival injection, punctal edema, contact dermatitis of eyelids with erythema and scaling. 4

Common culprits: Topical glaucoma medications, NSAIDs, antibiotics, antivirals, or preservatives. 4

Treatment: Discontinue the offending medication. 1

Malignancy Warning Signs (Must Not Miss)

Sebaceous carcinoma can masquerade as chronic unilateral blepharoconjunctivitis resistant to standard therapy, presenting with a hard, non-mobile tarsal mass with yellowish discoloration. 4, 2

Biopsy indications:

• Unifocal recurrent lesions with asymmetry 2
• Resistance to therapy 2
• Focal lash loss 2
• Chronic unilateral presentation unresponsive to treatment 4, 2

Clinical Algorithm

Step 1: Assess for orbital cellulitis red flags (proptosis, painful eye movements, vision loss, fever). If present → immediate hospitalization. 1, 2

Step 2: If no red flags, examine for:

• Localized pustule/nodule → treat as hordeolum 1, 2
• Medial canthal swelling with tearing → consider dacryocystitis, urgent ophthalmology referral 5
• Diffuse lid swelling with URI symptoms → consider preseptal cellulitis from sinusitis 4, 3

Step 3: If treating preseptal cellulitis, ensure daily follow-up and hospitalize if no improvement in 24-48 hours. 1, 2

Step 4: For recurrent or chronic cases, evaluate for underlying conditions (blepharitis, contact lens wear, medication toxicity, malignancy). 1, 2

Critical Pitfalls to Avoid

• Never delay imaging or hospitalization if any orbital cellulitis signs are present—vision loss can occur rapidly from tension orbit. 7
• Never start steroids before ophthalmology exam in suspected infectious cases, as this may worsen infection or mask diagnosis. 1
• Never dismiss chronic unilateral cases as benign without considering biopsy for sebaceous carcinoma. 2
• Never assume sinusitis is benign in the setting of periorbital swelling—79% of orbital cellulitis cases are associated with sinusitis. 3
• Odontogenic sources can cause rapidly progressive orbital cellulitis leading to blindness; dental problems require careful attention. 7