Distinguishing Periorbital Ecchymosis (Raccoon Eyes) from Allergic Discoloration
Allergic shiners are symmetrical, blue-grey discolorations below the orbits caused by venous stasis from chronic nasal congestion, while true periorbital ecchymosis (raccoon eyes) involves blood extravasation into periorbital tissues with tarsal sparing and is associated with trauma or serious systemic disease. 1, 2
Key Distinguishing Features
Allergic Shiners (Allergic Blue Discoloration)
Location and Appearance:
- Symmetrical blue-grey discoloration primarily below the orbit, most apparent in the infraorbital region 1
- Appear as dark infraorbital swollen semicircles 1
- No tarsal sparing pattern 1
- Asymptomatic and chronic in nature 1
Associated Clinical Features:
- Present with nasal congestion as the primary driver 1
- Accompanied by pale or bluish nasal mucosa, clear rhinorrhea, and watery eyes 1, 3
- Itching of nose, eyes, and palate 1
- Frequent throat clearing and sneezing 1, 3
- May see nasal crease from constant nose rubbing 1
- Often present in 60% of atopic patients but can occur in 38% of nonatopic individuals 1
- Tend to fade with increasing age 1
Temporal Pattern:
- Chronic, persistent finding that correlates with nasal obstruction 1
- Seasonal or perennial pattern matching allergen exposure 1, 3
- No acute onset or progression 1
True Periorbital Ecchymosis (Raccoon Eyes)
Location and Appearance:
- Blood extravasation into periorbital skin and subcutaneous tissues around both upper and lower eyelids 2, 4
- Classic "raccoon eyes" show tarsal sparing due to the orbital septum limiting spread beyond the tarsal plate 2
- Actual bruising with color evolution (red-purple initially, then yellow-green) 2, 5
- Can spread beyond tarsal plate with direct trauma or non-traumatic medical conditions 2
Associated Clinical Features:
- History of head trauma, basal skull fracture, or facial fractures 4, 5
- May present with Battle's sign, hemotympanum, CSF rhinorrhea/otorrhea 4
- Cranial nerve injury is the most common associated finding (seen in 10 of 36 trauma patients) 4
- Can indicate serious systemic disease: multiple myeloma, AL amyloidosis, neuroblastoma 6, 5
- May follow procedures like kidney biopsy in amyloidosis patients 6
- In neonates, can result from birth trauma with subgaleal hematoma 7
Temporal Pattern:
- Acute onset following trauma or procedure 2, 4
- Progressive color changes over days to weeks 5
- Resolves completely (unlike chronic allergic shiners) 7
Clinical Approach to Differentiation
History Assessment:
- Recent trauma, falls, or procedures? → Consider true ecchymosis 4, 6
- Chronic nasal symptoms, seasonal pattern, family history of atopy? → Consider allergic shiners 1
- Vomiting, coughing, or Valsalva maneuvers? → Can cause periorbital ecchymosis 2
Physical Examination:
- Check for tarsal sparing (suggests basal skull fracture if present) 2
- Examine nasal mucosa: pale/boggy suggests allergy; red/swollen suggests infection 1
- Look for clear watery discharge (allergic) versus purulent discharge (infectious) 1
- Assess for conjunctival findings: watery discharge and swollen conjunctivae suggest allergy 1
- Palpate for skull tenderness, check cranial nerves if trauma suspected 4
Critical Red Flags for True Ecchymosis:
- Unilateral presentation initially (allergic shiners are always bilateral) 1, 4
- Acute onset without chronic nasal symptoms 4
- Associated neurological symptoms 4
- History of bleeding disorders or systemic disease 6, 5
- Absence of other allergic features (itching, sneezing, clear rhinorrhea) 1, 3
Common Pitfalls
Do not assume bilateral periorbital discoloration is always benign allergic shiners - serious conditions like amyloidosis can present with bilateral periorbital purpura without other ecchymosis 6. If there is no history of chronic nasal congestion or other allergic symptoms, investigate further 1, 6.
Do not rely solely on symmetry - while allergic shiners are symmetrical, bilateral periorbital ecchymosis from basal skull fractures or systemic disease can also be symmetrical 2, 6.
In children with periorbital discoloration and no clear allergic history, consider neuroblastoma - this is a critical differential that requires urgent evaluation 7.