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Lacrimal Gland Mass/Chronic Dacryoadenitis

URGENT — Adnexa

Symptoms

progressive swelling of the outer one-third of the upper eyelid

pain (highly suggestive of malignancy or acute infection)

double vision due to mass effect on extraocular muscles

inferomedial globe displacement ("down and in")

v1/v2 numbness (forehead/temple) suggests perineural invasion by carcinoma

Clinical Findings

Clinical signs

  • s-shaped upper eyelid deformity: classic for lacrimal gland enlargement
  • "down and in" proptosis (inferomedial displacement)
  • "salmon patch" subconjunctival extension suggests lymphoma (malt)

Imaging discriminators (CT/MRI)

  • pleomorphic adenoma: painless, >1 year history, fossa remodeling without erosion
  • adenoid cystic carcinoma (acc): painful, subacute growth, frank bony erosion
  • bilateral enlargement: suspect igg4-rd, sarcoidosis, or sjögren syndrome
  • lymphoma: lesion typically "molds" to the globe and conforms to orbital anatomy

Etiology

Epithelial tumors

  • pleomorphic adenoma: benign mixed tumor; most common epithelial tumor
  • adenoid cystic carcinoma (acc): most common malignant epithelial histology

Inflammatory / systemic

  • sarcoidosis: often bilateral and painless; may have lung or skin signs
  • igg4-related dacryoadenitis: increasingly recognized systemic inflammatory cause
  • idiopathic orbital inflammation (ioi): usually more acute and painful

Other

  • lymphoma: often indolent; malt is the most common subtype
  • dacryops: simple lacrimal gland ductal cyst

Red Flags

pain or rapid growth (strongly suggests adenoid cystic carcinoma)

bony erosion on ct (indicator of malignancy)

v1/v2 numbness (sign of perineural invasion into the forehead or temple)

bilateral involvement (mandates systemic workup for igg4, sarcoid, or lymphoma)

Investigations

Imaging

  • orbital ct (thin-cut): best to evaluate for bony remodeling vs. frank erosion
  • chest ct: to screen for sarcoidosis or primary systemic malignancy

Laboratory

  • ace, lysozyme, and chest imaging for sarcoidosis
  • serum igg4 levels, c-anca/p-anca, and cbc with differential

Biopsy protocol

  • STRICT RULE: do NOT perform incisional biopsy on suspected pleomorphic adenoma (seeds tumor and risks malignancy); excise en bloc
  • biopsy with flow cytometry is indicated for suspected lymphoma or inflammatory disease

Treatment

Benign epithelial

  • pleomorphic adenoma: complete surgical en bloc excision (capsule must remain intact)

Malignant epithelial

  • acc: radical surgical resection often with involved bone + adjunctive radiation

Inflammatory / systemic

  • sarcoidosis and igg4-rd: systemic corticosteroids or steroid-sparing agents
  • lymphoma: localized radiation or systemic chemotherapy depending on subtype

Clinical Pearl

A pleomorphic adenoma of the lacrimal gland must be excised en bloc — incisional biopsy seeds tumor into orbit and virtually guarantees recurrence with malignant transformation risk.

Differential Diagnosis

  • sarcoidosis
  • orbital lymphoma
  • pleomorphic adenoma
  • adenoid cystic carcinoma
  • acute bacterial dacryoadenitis

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