Acute bacterial vs chronic granulomatous obstruction of eyelid sebaceous glands — warm compresses are mainstay.
Also known as: hordeolum, stye, external hordeolum, internal hordeolum, chalazion, meibomian cyst
Overview
Hordeolum is an acute, painful, suppurative infection of an eyelid sebaceous gland — external when arising from glands of Zeis or Moll along the lash line (classic stye), internal when arising from a meibomian gland in the tarsal plate. Chalazion is a chronic, sterile, granulomatous inflammation from a retained meibomian gland secretion — typically painless and rubbery.
Epidemiology
Common at all ages; peak incidence in adults 30-50. Recurrence is frequent, especially with rosacea or chronic blepharitis. Children with poor lid hygiene are also affected.
Try two board-style Hordeolum (Stye) and Chalazion questions
Real questions from the FirstPassPA bank, with the full explanation. Pick an answer — no signup, no email.
Question 1EENTMedium
A 42-year-old woman presents with a painless lump on her upper eyelid that has been slowly enlarging over the past 4 weeks. She initially noticed mild tenderness and redness that resolved after a week, leaving a firm nodule. She denies vision changes, discharge, or fever. On examination there is a 6 mm rubbery, nontender nodule in the mid-tarsal portion of the right upper lid, away from the lid margin. The overlying skin moves freely, and eversion reveals a focal area of conjunctival injection over the lesion. Visual acuity and pupils are normal. Which of the following is the most likely diagnosis?
AHordeolum
BChalazion
CBasal cell carcinoma
DPreseptal cellulitis
Reveal answer & full explanation
Correct answer: B — Chalazion
AHordeolum
BChalazion✓
CBasal cell carcinoma
DPreseptal cellulitis
Why Chalazion is correct
A chalazion is a sterile lipogranulomatous inflammation of a meibomian gland caused by obstruction of the gland's duct
The classic presentation is a painless, firm, rubbery nodule in the mid-tarsal plate that develops over weeks following resolution of an acute inflammatory phase, exactly as described here
The focal conjunctival injection seen on lid eversion reflects the deep meibomian origin
Why the others are wrong
Hordeolum — a stye is an acute, painful, erythematous, often pointing abscess at the lid margin involving a Zeis/Moll gland (external) or meibomian gland (internal); the painless, chronic, mid-tarsal location here argues against it (confused-with acute lid abscess)
Basal cell carcinoma — typically a pearly, telangiectatic papule with central ulceration along the lid margin in older sun-exposed patients, not a rubbery sub-tarsal nodule (anchoring on a lid lump)
Preseptal cellulitis — produces diffuse lid erythema, warmth, and edema rather than a discrete nodule, and is usually painful and tender (confused-with active infection)
Question 2EENTEasy
A 22-year-old woman presents with a 2-day history of a painful, red bump on her right upper eyelid. She reports tenderness, warmth, and mild swelling of the lid. She wears eye makeup daily and recently slept in her mascara. On examination there is a 4 mm erythematous, tender pustule pointing at the lid margin near the base of a single eyelash. The surrounding lid is mildly edematous without diffuse cellulitis. Visual acuity, extraocular movements, and pupillary responses are normal. Which of the following is the most likely diagnosis?
ADacryocystitis
BOrbital cellulitis
CExternal hordeolum
DChalazion
Reveal answer & full explanation
Correct answer: C — External hordeolum
ADacryocystitis
BOrbital cellulitis
CExternal hordeolum✓
DChalazion
Why External hordeolum is correct
An external hordeolum (stye) is an acute pyogenic infection of a gland of Zeis or Moll at the eyelash follicle, most commonly caused by Staphylococcus aureus.
The hallmark is an acutely painful, tender, erythematous pustule pointing at the lid margin adjacent to a lash — exactly as described (4 mm erythematous tender pustule at the lid margin near the base of a single eyelash).
Risk factors present: daily eye makeup use and sleeping in mascara; other risk factors include blepharitis and rosacea.
Why the others are wrong
Dacryocystitis — is infection of the lacrimal sac, presenting with pain, swelling, and erythema below the medial canthus over the lacrimal sac, often with purulent reflux from the puncta, not a lid-margin pustule (confused-with lacrimal infection).
Orbital cellulitis — involves postseptal structures with proptosis, restricted or painful extraocular movements, decreased vision, and an afferent pupillary defect, none present here (anchoring on lid swelling).
Chalazion — is a chronic, painless, rubbery mid-tarsal nodule from sterile meibomian gland obstruction; the acute pain, lid-margin location, and pustular appearance argue against it (confused-with chronic lid nodule).
🔒 Free preview limit reached
Keep reading — start your free trial
You've read your 2 free diagnosis previews. Create your free account to unlock the full Hordeolum (Stye) and Chalazion outline — plus all 514 diagnoses, 6,500+ board-style questions, flashcards, and an AI tutor. Your 7-day free trial includes everything, and there's no credit card required.
Poor eyelid hygiene; rubbing eyes; eye makeup that occludes lid margin
Contact lens wear with inadequate hygiene
Prior hordeolum or chalazion
Pathophysiology
Hordeolum: obstruction of a sebaceous gland leads to bacterial superinfection — usually Staphylococcus aureus — producing focal abscess. External hordeolum points anteriorly through the skin; internal hordeolum points through the conjunctival surface. Chalazion: lipogranulomatous reaction to meibomian gland secretions that have leaked into surrounding tarsal tissue after duct obstruction; no organism, no acute infection.
Clinical presentation
Symptoms
Hordeolum: acute onset tender, red, warm eyelid bump over hours to days
Foreign body sensation if lesion abrades cornea
Mild tearing; usually no decrease in vision
Chalazion: gradual painless lid nodule, often weeks; may follow a resolved hordeolum
Signs / physical exam
External hordeolum: tender pustule along lash line, points externally
Internal hordeolum: tender focal swelling on tarsal plate, points to conjunctival side on lid eversion
Chalazion: firm, rubbery, NON-tender nodule within the tarsus; overlying skin normal
Surrounding lid erythema or diffuse edema if secondary infection
Look for blepharitis and meibomian gland dysfunction
Classic findings
Tender, well-localized lid pustule (hordeolum) vs painless rubbery tarsal nodule (chalazion).
Differential diagnosis
Preseptal cellulitis — Diffuse lid erythema/edema without focal lesion, fever; oral antibiotics, exclude orbital involvement
Orbital cellulitis — Proptosis, painful EOM, decreased vision, fever; CT orbits; IV antibiotics; surgical drainage if abscess
Sebaceous gland carcinoma — Recurrent or persistent chalazion-like lesion in elderly, often upper lid; biopsy any chalazion that does not resolve or recurs in same site
Basal cell carcinoma of lid margin — Pearly nodule with telangiectasias, lash loss; biopsy
Pyogenic granuloma — Rapidly growing red friable papule, often following chalazion incision; excision
Molluscum contagiosum of lid — Umbilicated dome-shaped papules; can cause follicular conjunctivitis
Dacryocystitis — Tender swelling at medial canthus over lacrimal sac with mucopurulent reflux; systemic antibiotics
Diagnostic workup
Labs
Clinical diagnosis — no labs routinely required
Culture of expressed pus if recurrent, antibiotic failure, or atypical (MRSA suspicion)
Biopsy any recurrent chalazion in the same location, especially in patients >50, to exclude sebaceous gland carcinoma
Imaging
Imaging not indicated unless orbital cellulitis or atypical mass suspected (then CT orbits with contrast)
Diagnostic algorithm
Feature
Hordeolum (Stye)
Chalazion
Onset
Acute (days)
Subacute to chronic (weeks)
Pain
Tender, warm
Painless
Etiology
Bacterial (S. aureus)
Sterile granulomatous reaction
Gland involved
Zeis/Moll (external) or meibomian (internal)
Meibomian
Location
Lash line or tarsal
Within tarsal plate
First-line treatment
Warm compresses, lid hygiene
Warm compresses, lid hygiene
Procedure
Rarely needed; I&D if abscess
I&D or intralesional steroid if >4-6 wk
Hordeolum vs chalazion — distinguishing features and management.
Treatment
First-line
Warm compresses 10-15 minutes 4 times daily — mainstay of therapy for both hordeolum and chalazion
Eyelid hygiene: gentle lid scrubs with diluted baby shampoo or commercial lid wipes
Light digital massage of nodule after warm compress to promote drainage
Avoid eye makeup and contact lenses until resolved
Second-line / adjunct
Topical ocular antibiotic — erythromycin ointment, polymyxin/trimethoprim, or bacitracin ointment — applied to lid margin if drainage occurs or surrounding cellulitis; not needed for uncomplicated lesions
Oral antibiotics — dicloxacillin, cephalexin, or doxycycline — for surrounding preseptal cellulitis, large abscess, or systemic symptoms; add MRSA coverage (trimethoprim-sulfamethoxazole, doxycycline, clindamycin) where prevalent
Oral doxycycline 100 mg BID × 6-12 weeks or low-dose maintenance for recurrent chalazia with rosacea/MGD
Incision and curettage from conjunctival surface by ophthalmology for chalazion persisting >4-6 weeks or causing astigmatism/ptosis
Intralesional corticosteroid injection (triamcinolone 5-10 mg/mL) — alternative to I&D for small to moderate chalazia; risk of depigmentation in dark skin
Ophthalmology referral for recurrent same-site lesions, persistent >6 weeks, lash loss, or suspicion of malignancy
Complications
Preseptal or orbital cellulitis if secondary spread
Cosmetic deformity, lid notching, lash loss after I&D
Induced astigmatism from large chalazion pressing on cornea
Recurrence — especially with untreated blepharitis or rosacea
Missed sebaceous gland carcinoma in 'recurrent chalazion'
PANCE pearls
Hordeolum is acute, painful, and bacterial; chalazion is chronic, painless, and granulomatous — they are NOT a spectrum, although a hordeolum can evolve into a chalazion after acute phase resolves.
Warm compresses 4×/day is the highest-yield intervention; topical antibiotics add little for the typical uncomplicated stye.
Never squeeze or incise externally — promotes scarring; if drainage is needed, transconjunctival I&D by ophthalmology.
Any chalazion that recurs in the same location should be biopsied to exclude sebaceous gland carcinoma — the great masquerader of the eyelid.
Treat underlying blepharitis, meibomian gland dysfunction, and ocular rosacea to prevent recurrence — long-term doxycycline is a recognized option.
References
AAO 2018 — American Academy of Ophthalmology. Blepharitis Preferred Practice Pattern. Ophthalmology 2019;126(1):P56-P93
AAO EyeWiki — American Academy of Ophthalmology. Hordeolum and Chalazion (EyeWiki, accessed 2026)
Cochrane 2017 — Lindsley K et al. Interventions for acute internal hordeolum. Cochrane Database Syst Rev 2017;1:CD007742
Practice EENT questions on FirstPassPA
Turn this outline into retention. 6,500+ board-style questions with an AI tutor that explains every answer — free to start, no card required.
Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA or PAEA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants; End of Rotation™ is a program of the Physician Assistant Education Association.