The treatment of congenital dacryocystocele

Otoscopy-assisted intranasal cyst marsupialization for congenital dacryocystocele

We describe 3 infants with congenital dacryocystocele resistant to conservative treatment who were treated with a novel, simple intranasal cyst marsupialization (ICM) technique. Otoscopy-guided ICM was performed by an otolaryngologist in the manner of otoscopic myringotomy for cases with nasal cyst distension. All 3 infants were treated successfully by a single surgical procedure under topical anesthesia in an office setting.

Probing versus primary nasal endoscopy for the treatment of congenital dacryocystoceles

PURPOSE

To compare outcomes and complications of three surgical techniques for the treatment of congenital dacryocystoceles: nasolacrimal probing and irrigation (P+I), P+I plus nasal endoscopy (NE) with intranasal cyst marsupialization, and primary NE with intranasal cyst marsupialization.

METHODS

The medical records of children ≤2 years of age at a single academic center with a diagnosis of dacryocystocele from 2012 to 2022 were retrospectively identified and reviewed. The primary outcome was resolution of the dacryocystocele (ie, elimination of the medial canthal mass and resolution of tearing or discharge) after a single procedure ("primary success"). Surgical techniques were compared using exact logistic regression.

RESULTS

Of 54 patients, 21 (39%) underwent P+I, 23 (43%) underwent P+I plus nasal endoscopy, and 10 (18%) underwent primary NE. Primary success was 76% for P+I and 100% for the other two cohorts. Most patients (89%) who underwent P+I received general anesthesia compared with none who underwent primary nasal endoscopy. Most complications were related to the use of general anesthesia, with a complication rate of 10% for P+I, 48% for P+I plus NE, and 0% for primary NE. Most P+I procedures required hospital admission compared to half of primary NE procedures.

CONCLUSIONS

In our study cohort, primary NE provided good outcomes and was associated with a lower complication rate than P+I with or without NE.

Management of Congenital Dacryocystocele: A Case Series and Literature Review

Congenital dacryocystocele presents with a distinct bluish swelling in the medial canthal region in neonates. The authors present four illustrative cases with differing courses and a literature review on dacryocystocele management to raise awareness of the importance of prompt diagnosis, initiation of conservative management, and appropriate referral for surgical assessment. [J Pediatr Ophthalmol Strabismus. 2023;60(3):e31-e34.].

Congenital Nasolacrimal Duct Obstruction Update Study (CUP Study): Paper 4-Infantile Acute Dacryocystitis (InAD)-Presentation, Management, and Outcomes

PURPOSE

To study the presentation, management, and outcomes of infantile acute dacryocystitis.

METHODS

Retrospective study of infants diagnosed with acute dacryocystitis over a period from June 2016 to December 2019. Data collected include demographics, clinical history, presenting features, management, complications, and outcomes. Treatment provided was intensive medical care followed by early probing under endoscopic guidance. Further interventions, where needed, were performed based on intraoperative findings during probing. Successful outcomes were defined as resolution of infection, subjective relief from epiphora, and anatomical patency determined by a normal fluorescein dye disappearance test.

RESULTS

Twenty-seven eyes of 27 infants were analyzed during the study period. The mean age of infants was 3.26 months, and males were more affected than females (male:female 15:12). The mean duration of symptoms was 4.66 weeks, with 96% (26/27) presenting with symptoms of redness, watering, discharge, and swelling. Preseptal cellulitis was seen in 74% (20/27) infants, lacrimal abscess in 67% (18/27) infants, and lacrimal fistula in 37% (10/27). Most infants had complex congenital nasolacrimal duct obstruction (62%, 13/27), of which 7 also had intranasal cysts. One infant successfully underwent endoscopic dacryocystorhinostomy. At a mean follow-up period of 7.95 months, successful outcomes were observed in 90.4% (19/21) infants. The 2 failed cases were complex congenital nasolacrimal duct obstruction with associated sac diverticula and are scheduled for an endoscopic dacryocystorhinostomy.

CONCLUSION

Infantile acute dacryocystitis is a distinct clinical entity. The outcomes of systemic antibiotics and early probing are excellent.

Management of Pediatric Acute Dacryocystitis

PURPOSE

To analyze the clinical presentation, course, and management in a large cohort of pediatric acute dacryocystitis subjects and to examine whether hospitalization and urgent surgical intervention are indeed mandatory.

METHODS

A retrospective analysis of all pediatric subjects diagnosed with dacryocystitis at the Children's Hospital of Philadelphia over a 12-year period (2009-2020).

RESULTS

One-hundred sixty-nine pediatric acute dacryocystitis patients were included in this study. Management included admission in 117 cases (69%). Sixty-eight patients (40%) were treated medically with no surgical intervention, 75 cases (44%) required urgent surgical intervention, and 26 additional cases (15%) required surgery due to persistent tearing symptoms after medical management. The urgent procedures included most commonly: 1) endonasal examination and microdebridement of intranasal cysts in 26 cases (35%); 2) probing and irrigation without examination and microdebridement, with or without stent intubation, in 30 cases (40%); and 3) dacryocystorhinostomy (13 endonasal and 4 external) in 17 cases (23%).

CONCLUSIONS

Management of pediatric acute dacryocystitis should be tailored individually for each case. Hospital admission and early surgical intervention are not mandatory, as 31% of cases resolved without admission, and 56% without early surgical intervention. Although a specific age cutoff is not plausible, hospital admission for younger patients is more commonly advocated. When surgical intervention is indicated, endonasal examination and microdebridement of any associated intranasal cyst and probing with possible stenting are the initial procedures of choice. Dacryocystorhinostomy is reserved for more complex obstructions. Although pediatric acute dacryocystitis is an infection with serious potential problems, when managed appropriately, complications are rare.

Outcomes of lacrimal probing surgery as the first option in the treatment of congenital dacryocystocele

PURPOSE

To determine the demographic and clinical characteristics of newborn patients who underwent lacrimal probing surgical intervention with or without the marsupialization of intranasal cysts as the primary management for dacryocystocele treatment.

METHODS

Data from the medical charts of 350 infants who underwent lacrimal probing surgery due to nasolacrimal duct obstruction were reviewed retrospectively. Ten newborn patients with a naive diagnosis of congenital dacryocystocele were included in the study. Congenital dacryocystocele diagnosis was based on a triad of swelling in the inner canthal region, a bluish appearance, and epiphora. Lacrimal probing surgery accompanied by nasal endoscopy was planned for all patients as the first treatment option.

RESULTS

The mean age of the patients was 24.90 ± 7.15 days, with a range of 6-85 days. A total of 10 patients were included, comprising seven females and three males. The mean postoperative follow-up period was 38.7 ± 24.41 months. Five patients had left, four patients had right, and one patient had bilateral dacryocystocele. Seven eyes of the six patients had uncomplicated dacryocystocele, while the remaining patients had dacryocystocele with complications of dacryocystitis and/or preseptal cellulitis. All patients had intranasal cysts. All patients underwent one session of lacrimal probing surgery under general anesthesia; all with successful outcomes. Four patients with additional dacryocystocele-associated complications underwent combined intranasal marsupialization of the cyst wall.

DISCUSSION

Lacrimal probing surgery ± intranasal marsupialization of the cyst wall as a first treatment option can be effective for both congenital dacryocystocele and/or congenital dacryocystocele plus associated complications and provide complete resolution of dacryocystocele-related symptoms.

Endoscopic marsupialization of nasolacrimal duct cysts under topical anaesthesia: 5 years of a single institute experience

OBJECTIVE

To present the outcomes of neonatal nasolacrimal duct cysts treated through endoscopic intranasal marsupialization under topical anaesthesia.

METHODS

A retrospective study of 19 infants diagnosed with congenital nasolacrimal duct cyst, with or without dacryocystocele, diagnosed and treated between March 2015 through March 2020. Data were extracted for descriptive purposes and included: birth weight, main presenting symptom, stertor or dyspnoea, unilateral or bilateral occurrence. Follow-up one month after intervention included recurrence of symptoms, physical examination and fibreoptic naso-endoscopy.

RESULTS

Nineteen infants with intranasal cyst were presented to our department at the age of 1 day. Four-teen infants had unilateral and 5 infants had bilateral intranasal cysts. There were 8 boys and 11 girls. Mean gestational age at birth was 39 weeks, mean birth weight was 3351 g. 42.1% of infants presented with dacryocystocele, 31.5% with stertor, and 26.3% with dyspnoea. 80% of infants with bilateral cysts presented with dyspnoea. Follow up ranged from 6 to 48 months, no recurrence of symptoms was reported.

CONCLUSION

Intranasal endoscopic marsupialization under topical anaesthesia is a successful, safe, low cost procedure for treating neonatal nasolacrimal duct cysts while avoiding general anaesthesia for infants.

Congenital Dacryocystocele: A Major Review

PURPOSE

To provide a systematic review of the literature on congenital dacryocystoceles (CDCs) and summarize their presentations, investigations, management, and outcomes.

METHODS

The authors performed a PubMed search of all articles published in English on CDCs. Data captured include demographics, clinical presentations, investigations, management modalities, complications, and outcomes. Fourteen major series (10 or more than 10 cases) and 89 isolated case reports/series on CDCs with a collective patient pool of 1,063 were studied in detail. Specific emphasis was laid on addressing the controversial issues including initial conservative versus surgical management and the role of endoscopic evaluation.

RESULTS

Numerous terminologies have been used to describe CDC. Congenital dacryocystoceles are rare variants of congenital nasolacrimal duct obstructions and comprise of 0.1% to 0.3% of all such cases. There is a female predilection (64.2%, 683/1,063) and the mean age at presentation is at 7 days of birth. Initial conservative treatment can be a viable option in the absence of an acute dacryocystitis or a respiratory distress. Endoscopy-assisted probing appears to have better outcomes as compared with the in-office probing. Congenital dacryocystoceles with acute dacryocystitis are preferably managed with intravenous antibiotics and an early probing under endoscopy guidance to avoid missing intranasal cysts. Marsupialization is the preferred technique in the management of intranasal cysts. Silicone intubation was rarely used and has no definitive indications. Dacryocystorhinostomy is very rarely needed in the management of CDC.

CONCLUSIONS

Congenital dacryocystocele is a commonly accepted term and its use should be advocated to enhance uniformity in reporting. Endoscopic evaluation of CDC is useful in the diagnosis and treatment of associated intranasal cysts and enhances the rates of successful outcomes.

The Role of Bacterial Etiology in the Tear Duct Infections Secondary to Congenital Nasolacrimal Duct Obstructions

PURPOSE

To define the microbiological features of dacryocystitis in childhood.

METHODS

Patients with dacryocystitis secondary to CNLDO between 2017 and 2019 in Izmir, Turkey were included in the study. Inclusion criteria of the study were: mucopurulent secretion, being under 4 years old and not having received prior antibiotic treatment. Samples from secretion were cultivated in sheep blood agar, eosin methylene blue, and chocolate agar. Reproduction was checked intermittently. Clinically significant growths were reported.

RESULTS

Seventy patients with dacryocystitis secondary to CNLDO were included in the study. Sixty percent of patients were female (n = 42) and 40% (n = 28) percent of patients were male. The average age of participants was 2.09 ± 0.68 (1-3) years old. Positive bacterial proliferation results were noted in 20 patients (28.6%). Eighty percent (n = 16) of culture-positive bacterias were gram-negative bacterias and 20% (4) were gram-positive bacterias. Twenty percent of culture-positive bacterias were aerobic and 80% were facultative bacterias. The most common bacteria seen in culture specimen was Haemophilus 40% (Haemophilus haemolyticus [20%] and Haemophilus influenzae [20%]).

CONCLUSIONS

Gram-negative organisms especially Haemophilus were most prevalent. These findings could be helpful for antibiotic selection.

Awake bedside nasal endoscopy for primary management of neonatal dacryocystoceles with intranasal cysts

OBJECTIVE

To present outcomes of neonatal dacryocystoceles treated through endoscopic intranasal cyst marsupialization (EICM) without general anesthesia and nasolacrimal duct (NLD) probing or irrigation.

METHODS

Records of eleven consecutive infants diagnosed with unilateral or bilateral congenital cysts associated with the nasolacrimal system between January 2016 and February 2019 at our institution were retrospectively reviewed.

RESULTS

Age at diagnosis ranged from 0 to 56 days, and 45.5% were male. 54.5% had dacryocystitis before surgical intervention. Patients were initially treated with a combination of massage and topical antibiotics; some received parenteral antibiotics if infected. Nearly all patients (90.9%) had one or more intranasal cysts. Of these patients, two underwent lacrimal probing and EICM in the operating room. One underwent EICM only in the operating room. Another patient initially failed bedside NLD probing and subsequently underwent bedside nasal endoscopy and awake EICM. The final six patients underwent EICM without general anesthesia or NLD probing. No complications were noted. Follow-up ranged from 7 to 906 days. Complete resolution was observed in all ten patients who underwent EICM, regardless of anesthesia.

CONCLUSIONS

Neonatal dacryocystoceles and/or intranasal cysts are successfully treated at the bedside through nasal endoscopy with simple awake endoscopic intranasal cyst marsupialization. Avoidance of general anesthesia and NLD probing or irrigation would greatly simplify and decrease the cost of dacryocystocele management.

Computed tomography for guidance in the diagnosis and surgical correction of recurrent pediatric acute dacryocystitis

IMPORTANCE

This is the first retrospective study of the effect of computed tomography (CT) in diagnosis and surgical correction of recurrent pediatric acute dacryocystitis (PAD).

OBJECTIVE

To explore the pathogenesis of recurrent PAD and the impact of CT in guidance of surgical planning.

METHODS

Medical histories, clinical manifestations, and CT results of 10 patients with recurrent PAD were reviewed. Etiologies and treatment effectiveness were recorded for all patients.

RESULTS

CT revealed that three patients had congenital dacryocystocele with lacrimal sac cyst, enlargement of the nasolacrimal canal, and intranasal cyst of affected sides. After regression of local inflammation, marsupialization was performed. CT showed that four patients had PAD secondary to congenital nasolacrimal canal dysplasia; these patients exhibited normal upper portions of the nasolacrimal canals, but had stenotic or atretic middle and terminal segments. After improvement of local inflammation, endonasal dacryocystorhinostomy was performed. Three patients had PAD secondary to congenital lacrimal sac diverticulum; after contrast injection, CT showed that the cysts at the lacrimal sac area were filled with contrast, and were connected to the normal lacrimal sac. After the topical infection was controlled, transcutaneous dacryocystorhinostomy was performed in combination with excision of the lacrimal sac diverticulum. No recurrence of PAD was detected at 6-month follow-up.

INTERPRETATION

Causes of PAD include congenital dacryocystocele, congenital lacrimal sac diverticulum, or congenital nasolacrimal canal dysplasia. Marsupialization with endoscope, endonasal dacryocystorhinostomy, and transcutaneous dacryocystorhinostomy constitute distinct surgeries for PAD treatment. CT provides an important diagnostic function and facilitates selection of specific surgical approaches for recurrent PAD.

Dacryoendoscopy-assisted nasal endoscopic marsupialization for congenital dacryocystocele

OBJECTIVE

To examine the surgical outcome of dacryoendoscopy-assisted nasal endoscopic marsupialization for congenital dacryocystocele.

METHODS

This is a retrospective, observational study that included 7 sides of 6 patients with congenital dacryocystocele. The surgical indication in 5 of the patients was acute dacryocystitis while one of the patients had no spontaneous resolution after long-term observation. Dacryoendoscopy was used for visualisation of the lacrimal cavity, direct probing of the obstruction at the common canaliculus, and localisation of a deflated intranasal cyst after an initial incision of the cyst. Surgical success was defined when the following postoperative conditions were satisfied: no epiphora, normal tear meniscus height, and complete clearance of the dye 5 min after instilling a drop of 2% fluorescein solution into the inferior conjunctional fornix.

RESULTS

Out of 6 patients, 2 patients were noted to have membranous common canalicular obstruction. Postoperative follow-up ranged from 11 days to 3 months. Surgical success was achieved in all patients without any complication.

CONCLUSIONS

Dacryoendoscopy-assisted nasal endoscopic marsupialization is an effective surgical management for congenital dacryocystocele.

Conservative management of congenital dacryocystocele: resolution and complications

OBJECTIVE

To investigate the clinical outcomes of initial conservative management in infants with congenital dacryocystocele.

DESIGN

Retrospective case series.

PARTICIPANTS

A total of 30 congenital dacryocystoceles of 28 Korean infants treated between January 2006 and December 2015.

METHODS

All patients were managed conservatively with lacrimal sac massage. Clinical courses and outcomes of the patients were retrospectively reviewed, and rates of resolution of dacryocystoceles and development of dacryocystitis were analyzed.

RESULTS

In 27 cases of dacryocystoceles without infection, spontaneous resolution was achieved without any complication in 20 of 27 (74.1%) cases after conservative treatment. The mean duration of treatment was 27.5 days. Lacrimal probing was needed in 5 (18.5%) dacryocystoceles that persisted despite lacrimal sac massage for more than 1 month. Infectious dacryocystitis developed in 2 of 27 (7.4%) cases. Three dacryocystoceles were infected at presentation. Overall, 5 dacryocystoceles were complicated with infection and those cases received prompt systemic antibiotics treatment. External incision and drainage of the lacrimal sac was needed in 3 dacryocystoceles, and all cases were finally resolved without any additional procedures.

CONCLUSIONS

In this case series, most of the uninfected dacryocystoceles could be successfully managed with conservative treatment alone. In cases with infection, systemic antibiotics were essential and external drainage was sometimes required, but these cases could be conservatively managed after the remission of infection.

Selection of surgical intervention for congenital dacryocystocele

PURPOSE:

To evaluate the surgical intervention and its effect on congenital dacryocystocele.

METHODS:

A total of 531 children with congenital dacryocystocele admitted to the Department of Ophthalmology of Beijing Children's Hospital, Shanghai Aier Eye Hospital, Nanjing Aier Eye Hospital, and the First Affiliated Hospital of Jinzhou Medical University between January 2007 and January 2017 were retrospectively analyzed.

RESULTS:

A total of 531 patients were followed up for 3-24 months, with an average of 13.3 months. No serious intraoperative complications (such as bleeding and tissue damage) and postoperative complications (bleeding, infection, and hole atresia) were found. We classified the outcomes into three categories based on the signs (overflowing tears and empyema) and objective routine follow-up by endoscopy. Cure indicated that mass, overflow of tears, and breathing difficulties disappeared, and 81.5% cases (433/531) were postoperatively cured. Improvement indicated disappearance of mass, overflow empyema, and the presence of residual tears (due to trocar and tears puncture), and 18.5% cases (98/531) were postoperatively improved. Unhealed indicated overflowing pus and tears, and 0% cases did not heal after surgery.

CONCLUSIONS:

Nasal endoscopic surgery is relatively safe, with high success rate for treatment of congenital dacryocystocele. Systematic training is required to promote the application of nasal endoscopy, so that more ophthalmologists can learn this technique.

The presentation, clinical features, complications, and treatment of congenital dacryocystocele

PurposeTo determine the incidence and presenting features of congenital dacryocystocele in the United Kingdom. To report on those cases complicated by dacryocystitis, respiratory compromise, and the treatment undertaken.MethodsA prospective observational study of cases of congenital dacryocystocele presenting in the United Kingdom between September 2014 and October 2015. Infants <3 months of age presenting with a cystic swelling in the medial canthal area were included. Cases were identified via the British Ophthalmology Surveillance Unit (BOSU) reporting system.ResultsA total of 49 cases were reported during the study period. This gives an incidence of 1 in 18 597 live births. There was a 71% response rate to the questionnaire. The average age at presentation was 16.94 days. Dacryocystoceles were unilateral in 91% of cases. Dacryocystitis was a complicating factor in 49% of patients and 17% had respiratory distress. Uncomplicated dacryocystocele responded well to conservative measures in 86%. Surgical intervention was required in 23% of patients. Those cases complicated by dacryocystitis (29%) and nasal obstruction (17%) were more likely to require surgical intervention compared to those with dacryocystocele alone (14%). Digital massage appears to reduce the likelihood of requiring surgical intervention. The mean time to resolution was 19 days.ConclusionsCongenital dacryocystocele is a rare presentation in the United Kingdom. Dacryocystitis and respiratory compromise commonly complicate a dacryocystocele. The use of digital massage as an early intervention is advocated and conservative measures may be sufficient in cases of uncomplicated dacryocystocele.

Severe Respiratory Distress in a Neonate due to Bilateral Dacryocystoceles

Nasal passage contributes up to 50% of total resistance in normal breathing especially in neonates who are obligatory nose breathers. Any further increase in airway resistance may lead to severe respiratory distress. Dacryocystoceles are a rare cause of nasal obstruction in neonates. We present the case of a full-term 3-day-old female infant with progressive respiratory distress due to bilateral dacryocystoceles.

[Palpebral malformations in children]

Palpebral malformations can be isolated or associated with a craniofacial disorder. Their assessment is based on clinical examination; additional investigations are mainly done to characterize craniofacial syndromes. In case of extrapalpebral lesions or complex craniofacial pathology, genetic testing must be performed. Some isolated malformations will only need a simple follow-up; others must have specific treatment, undertaken following a precise timing, taking into account child and anatomical structures' growth and the possible consequences of the malformation on the eye and child's sight (degree of urgency). When dealing with these malformations, there are two main risks to be taken into consideration: corneal irritation due to lagophtalmos and amblyopia owing to visual axis obstruction, anisometropia or strabismus.

Long-term outcomes of cruciate marsupialization of intra-nasal cysts in patients with congenital dacryocele

OBJECTIVES

To evaluate the long-term outcomes of cruciate marsupialization of intranasal cysts associated with congenital dacryocele.

METHODS

This is a retrospective review of 15 patients of dacryoceles with intranasal cysts who underwent cruciate marsupialization of the medial wall of the cyst. Post-operative follow up for a minimum of 9 months was an inclusion criterion for analysis. Data analyzed include demographics, clinical presentations, previous interventions, associated systemic abnormalities, clinical course following marsupialization and recurrences. Primary outcome measures were resolution of the dacryocele and symptomatic relief from epiphora.

RESULTS

The mean age at presentation was 1.6 months with a female preponderance (60%). History of prematurity (pre-term) was noted in 20% (3/15). Swelling in the lacrimal sac area (dacryocele) was the universal presentation. Five patients (33.3%) had a prior conservative treatment. Four patients (26.6%) had respiratory distress with feeding. Acute dacryocystitis was noted in 26.6% (4/15). At a mean follow up of 19.1 months, successful outcomes were achieved in 86.6%.

CONCLUSION

Cruciate marsupialization of intranasal cysts achieves good results in patients with congenital dacryocele, which are maintained over a long period of time. Early diagnosis and management may prevent acute dacryocystitis in these patients.

Rarely Seen Nasal Congenital Problems Causing Neonatal Upper Respiratory Obstruction: A Case Series

Since newborns are obligatory nasal breathers, upper respiratory tract problems may sometimes be life threatening. The most common pathology causing dyspnea and stridor in newborns is laryngomalacia. Nasal cavity pathologies that risk the neonatal airway are more rarely met. These anomalies may be seen either as solitary anomalies or as a part of a syndrome. While choanal atresia is one of the best-known nasal cavity anomalies, choanal stenosis, congenital nasal mid-line masses, congenital nasal pyriform aperture stenosis, and nasal tip anomalies are more rarely seen structural pathologies. Choanal atresia may be present either as an isolated congenital anomaly or as a part of CHARGE syndrome. Some rare chromosome anomalies may also cause significant problems during nasal respiration in newborns. With this study, we presented a case series of newborns with pathologies that affected nasal respiration. Although the diagnosis and treatment of choanal atresia and congenital dacryocystocele are well known, the information on the diagnosis and treatment of the other two uncommon cases are limited. With this study, we aimed to contribute to the literature by presenting our approach in six cases having congenital pathologies that cause nasal respiratory obstruction.

[Congenital dacryocystocele: Surgical treatment or routine follow-up?]

INTRODUCTION

Congenital dacryocystoceles are rare and often misunderstood pathologies. Their treatment varies and consists in simple follow-up, lacrimal catheterization or endoscopic surgical drainage, depending on medical teams. The aim of our study was to discuss the place of endoscopic drainage in the treatment of congenital dacryocystocele.

METHODS

We conducted a retrospective review on 18 cases of congenital dacryocystoceles taken in charge in a tertiary care center between 2009 and 2012.

RESULTS

Thirteen newborns, including five bilateral cases, were taken in charge. The average age was 14.6 days. Six newborns presented with an acute dacryocystitis at the time of diagnosis. No respiratory complications were observed. Spontaneous drainage of the dacryocystocele was observed in 38.8% of the cases, occurring at 22 days of life on average. Endonasal endoscopic drainage was performed in 66.6% of the cases. No recurrence or complication was observed after surgery. After spontaneous drainage, one recurrence was observed. The mean follow-up period of these patients was 8.8 months.

DISCUSSION

Spontaneous drainage is common. Conservative management may therefore be considered in absence of infection. In case of infection and/or persistence of dacryocystocele after 4 weeks of life, endonasal surgical drainage should be considered. Imaging of the facial structure should be performed before any surgical treatment.

Congenital dacryocele with large intranasal cyst: efficacy of cruciate marsupialization, adjunctive procedures, and outcomes

PURPOSE

To evaluate the safety and efficacy of a new technique of medial wall cruciate marsupialization of large intranasal cysts associated with dacryocele and to evaluate the outcomes.

METHODS

A prospective, interventional consecutive case series of 7 patients with large intranasal cysts were included in this study. All patients underwent endoscopic marsupialization by a single surgeon (MJA) using a new technique involving a medial wall cruciate incision. Patients were followed up for a minimum of 6 months and analyzed for the resolution of dacryocele and intranasal cysts and anatomical and functional success.

RESULTS

The mean age at presentation was 5.9 weeks with a female preponderance (71.4%). All patients presented with a subcutaneous swelling in lacrimal sac region. Acute dacryocystitis was noted in 42.8% (3/7). Associated lacrimal anomalies were noted in 28.5% (2/7), and associated respiratory distress was noted in 57.1% (4/7) of the patients. At a mean follow up of 10.8 months, anatomical patency and resolution of intranasal cyst were achieved in all cases, and functional success was noted in all except 1 patient.

CONCLUSIONS

Endoscopic evaluation of all dacryoceles is recommended. Medial wall cruciate marsupialization is a safe and effective modality in the management of large intranasal cysts. Early diagnosis and appropriate quick referral are likely to prevent acute dacryocystitis, progression of dacryocele, and may aid in better outcomes.

Urgent bilateral endoscopic marsupialization for respiratory distress due to bilateral dacryocystitis in a newborn

We describe an infant with respiratory distress due to bilateral dacryocystoceles and dacryocystitis who was successfully treated with urgent bilateral endoscopic marsupialization.

A male infant was brought to our outpatient department 7 days after birth, with red, acutely inflamed swellings near the medial canthal area of both eyes. From birth, there had been bluish swelling near the medial canthal area, and redness and swellings developed within 3 days. On physical examination, the child was afebrile but showed respiratory distress with coarse breathing sound. That day, the infant was admitted and treated with intravenous cefotaxime 150 mg. After withholding oral intake for appropriate preoperative fasting, urgent bilateral probing with endoscopy was done. On endoscopy, huge bilateral congenital dacryocystoceles were found. Because of its huge size, the inferior surface of the cyst was touching the nasal floor, which made probe unable to perforate the wall of dacryocystocele. Therefore, an endoscopy-assisted marsupialization of dacryocystoceles and bicanalicular silicone intubation were performed. Both swellings and erythema subsided within 48 hours postoperatively, and the patient was discharged after 72 hours from treatment.

Proximal drainage plus massage of lacrimal sac improves the symptoms of congenital dacryocystoceles

PURPOSE

To examine the effect of proximal drainage plus lacrimal sac massage in patients with congenital dacryocystoceles.

METHODS

A retrospective review of 77 patients was performed. Traditional massage was performed in the traditional treatment group (35 patients) first. Proximal lacrimal sac drainage plus massage of the lacrimal sac using a Bangerter lacrimal cannula (defined as modified massage) was performed in the modified group (42 patients). Probing was undertaken if the treatments failed in both groups. Success rates of decompression of lacrimal sac and recovery rate were observed. The χ2 test was used to compare the groups.

RESULTS

Success rates of decompression of lacrimal sac were 100% in the modified group and 31% in the traditional group. In the modified group, 34 patients with 37 dacryocystoceles (80%) recovered with the modified treatment within 14 days. However, in the traditional group, only 11 patients with 12 dacryocystoceles (30%) had resolution after conservative treatment. The recovery rate of the modified massage in the modified group was higher than that of massage alone in the traditional group (p&lt;0.001). As to the individuals receiving probing, 8 patients with 9 dacryocystoceles (100%) in the modified group were successful, while 18 patients with 21 dacryocystoceles (78%) in the traditional group had a satisfying effect.

CONCLUSIONS

Proximal drainage plus massage has the advantage of high efficiency and safety for the treatment of congenital dacryocystoceles.

Clinical, radiological, microbiological, and histopathological aspects of acquired dacryocystoceles

Purpose. The aim of this study is to investigate the etiology and the clinical, microbiological, histopathological, and radiological findings of acquired dacryocystoceles. Methods. In this retrospective study, we reviewed the clinical records of 10 eyes of 8 patients with dacryocystoceles who underwent external dacryocystorhinostomy (DCR) surgery. Etiology, presenting symptoms and radiological findings as well as microbiological and histopathological assessment results and outcome were analyzed. Results. The records of 8 patients with dacryocystoceles were included in this study. In the histopathological evaluations of the samples collected from the lacrimal sac wall, chronic inflammation was found in all biopsied samples and fibrosis was observed in two histopathological evaluations. Computerized tomography (CT) imaging showed fluid collection separated from adjacent tissues by a thin rim, corresponding to dacryocystoceles in the sac. In the microbiological culture examination of samples collected from the fluid within the cyst, no bacterial growth in 5 eyes, gram-negative bacillus growth in 3 eyes, and gram-positive cocci growth in 2 eyes were found. Conclusions. Acquired dacryocystoceles were observed extremely rarely and a definite pathogenic agent could not be identified in any of the cases, either microbiologically or histologically, whereas chronic inflammation was detected in all cases in our study.

Process of spontaneous resolution in the conservative management of congenital dacryocystocele

Purpose

To assess efficacy of the conservative management of patients with congenital dacryocystocele.

Materials and methods

This was a retrospective case series involving six sides of five infants with a dacryocystocele treated at Osaka Kaisei Hospital, Osaka, Japan. The conservative management protocol consisted of the application of warm compresses and massage over the mass, with the addition of antibiotics when dacryocystitis developed. Patient age at the time of resolution, presence of retrograde outflow of contents of dacryocystoceles from the puncta, and development of dacryocystitis were recorded.

Results

The dacryocystocele was unilateral in four patients and bilateral in one patient. A nasal cyst was present in four patients without respiratory distress. The median patient age at the time of the diagnosis was 7 days (range 2–10 days). Conservative management was selected in all patients, and the dacryocystocele was resolved in all patients at a median patient age of 14.5 days (range 11–105 days). Two sides developed dacryocystitis, which resolved in a few days with antibiotic treatment. In those two sides, rupture of the dacryocystoceles to the common canaliculus with retrograde discharge of the contents from the puncta before the dacryocystitis developed was noted. For the other four treated sides, no such discharge or development of dacryocystitis was observed.

Conclusion

The findings of this study show that a dacryocystocele has a good chance of resolving spontaneously with conservative management and careful observation, and that rupture of the dacryocystocele to the common canaliculus might be an important precursor of dacryocystitis.

A case of congenital heminasal hypoplasia with an intranasal cyst: an extremely rare occurrence

Various congenital nasal deformities can occur because of the complexities of the developmental process. These conditions range from partial deformities of the nose (such as isolated absence of the nasal bones, absence of columella, absence of the septal cartilage, and absence of vomeral bone) to complete absence of the nose. Congenital heminasal hypoplasia is an extremely rare defect of embryogenesis. We present a case of congenital heminasal hypoplasia with an associated dacryocystocele and intranasal cyst. The treatment of congenital dacryocystocele remains controversial. The majority of researchers recommend an initial treatment plan that does not include surgical intervention. Surgical reconstruction of the external nose and inner cavities can be delayed at least until the preschool years, when facial development is nearly complete.

Sonographic antenatal diagnosis of congenital dacryocystoceles

Congenital dacryocystoceles are a relatively rare variant of nasolacrimal duct obstruction, accounting for only 0.1% of infants with congenital nasolacrimal duct obstruction. We report a new case of bilateral congenital dacrocystoceles diagnosed in an otherwise uncomplicated fetal ultrasound examination during the 33rd week of pregnancy. The diagnosis was confirmed postnatally. The neonate, who did not present postpartum respiratory distress, was scheduled for endoscopic marsupialization-probing of the cystic structures. Parents must be well informed about the risk of respiratory distress, and facial appearance. Complete resolution is achieved after surgical intervention.

Associated signs, demographic characteristics, and management of dacryocystocele in 64 infants

PURPOSE

To describe the incidence of associated infection, respiratory compromise, apparent intranasal cyst, as well as sex, laterality, and age at presentation in 64 infants with dacryocystocele and to assess characteristics associated with successful interventions.

METHODS

A retrospective chart review of all patients with dacryocystocele seen at Children's Hospital Boston between 1996 and 2010 was performed. Inclusion criteria were accuracy of diagnosis, treatment, and follow-up at our institution. Interventions were divided into 3 categories: procedures that did not require general anesthesia; simple procedures requiring general anesthesia, such as nasolacrimal probing with or without stent or balloon dilation; and more complex procedures under general anesthesia, specifically, those aided by intranasal endoscopy.

RESULTS

Of the 90 identified patients, 64 met inclusion criteria. The majority of patients were female (63%) and had unilateral involvement (77%). More than one-half of all patients were successfully treated without anesthesia; however, patients presenting with infection were more likely to be treated with a simple procedure under general anesthesia. All patients treated endoscopically had intranasal cysts. Age, sex, and infection did not predict the use of intranasal endoscopy. Bilaterality of dacryocystocele was associated with the use of an endoscopic approach.

CONCLUSIONS

Many infants with dacryocystocoele can be successfully treated without general anesthesia. The incidence of occult intranasal cyst among those treated without endoscopy remains unknown. Patients who were treated under general anesthesia but without the use of nasal endoscopy were more likely to have an infected system, but the clinical significance of this association is not clear.

Congenital nasolacrimal duct cyst/dacryocystocele: An argument for a genetic basis

Embryogenesis of a congenital nasolacrimal duct (NLD) cyst is attributed to the failure of the Hasner membrane of the NLD system to cannulate. Prenatal diagnosis of congenital NLD cysts supports the argument for a developmental error, with a postnatal prevalence of 6%. The role of a genetic basis for this malformation has never been ascribed. We present a set of monozygotic twins with bilateral congenital NLD cysts as an argument for a genetic basis of this entity. A case report and literature review were performed. We present two cases of bilateral congenital NLD cysts occurring in a set of monozygotic twins. Patients were delivered at 37 weeks via cesarean section. The pregnancy was complicated by preterm labor at 33 weeks requiring administration of terbutaline and betamethasone. At presentation, twin A had bilateral eye discharge, erythema, and swelling medial to the medial canthi as well as nasal obstruction. Computed tomography (CT) showed classic bilateral cystic masses in the inferior meatus. The diagnosis of bilateral infected congenital dacryocystoceles was made. Twin B initially presented with only bilateral eye discharge and CT showed a dilated NLD system. Twin B subsequently developed early signs of bilateral dacryocystoceles the following day. Both patients underwent lacrimal probing and endoscopic marsupialization of the dacryocystoceles. Biopsies were consistent with dacryocystocele. Dacryocystocele is a common presentation of unresolved neonatal NLD obstruction. This case report in a set of identical twins is an argument for a genetic basis for the formation of this lesion.

Congenital dacryocystocele: is there a familial predisposition?

Congenital impatency of the nasolacrimal drainage system is relatively common. Dacryocystocele formation is an infrequent variant of such congenital nasolacrimal duct obstruction (NLDO). Congenital dacryocystocele typically manifests as a mass in the medial canthal region; alternatively the nasolacrimal expansion may present solely intranasally as a nasolacrimal duct cyst. Despite the relative frequency of congenital NLDO, there have been few reported familial cases. We report here two female siblings with congenital dacryocystocele, and review the etiology and potential inherited predisposition to this comparatively rare entity.