Nasolacrimal duct obstruction and dacryocystocele associated with a concha bullosa mucocele

Infected Concha Bullosa Mucocele: A Case Report

Concha bullosa (CB) is a common sinonasal anatomic variant. The obstruction of a CB, though rare, might result in mucocele that may be misdiagnosed. In this report, we present a case of a 32-year-old female with a one-year history of unilateral nasal obstruction, headache, facial pain, foul nasal discharge, and hyposmia, initially misdiagnosed as a neoplasm. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a right middle CB infection with a mucocele. Laboratory cultures yielded Pseudomonas aeruginosa. Endoscopic sinus surgical mass excision was performed, and treatment with oral cefuroxime was administered. The patient recovered fully. A CB mucocele, though rare, should be considered in the differential diagnosis of an intranasal mass.

Concha bullosa mucocele: A case series and review of the literature

Background:

Concha bullosa mucocele is a rare diagnosis that presents as a nasal mass. It impinges on surrounding structures and can easily be mistaken for a neoplasm.

Objective:

The objective of this study was to shed light on this rare entity and report its diagnostic features and treatment outcomes.

Methods:

A case series conducted in a tertiary health care center. Demographic data, clinical presentation, imaging, cultures, and treatments were recorded. Operative video illustration and key images were obtained. A review of the literature was also performed.

Results:

A total of five cases were reviewed, four of which were concha bullosa mucoceles and one was a mucopyocele. Three of the patients had some form of previous nasal trauma. Headache and nasal obstruction were the most common symptoms with a nasal mass finding on physical examination. Computed tomography was used in all the patients, and magnetic resonance imaging was used in four of the five patients. Four patients had coexistent chronic rhinosinusitis, and three had positive bacterial cultures. All these patients were treated endoscopically either with middle turbinate marsupialization or subtotal resection. No recurrence has been noted thus far.

Conclusion:

Concha bullosa mucocele is a rare diagnosis. Imaging characteristics are helpful in considering the diagnosis, although surgical intervention is often necessary to confirm the diagnosis and treat concha bullosa mucocele.

Bilateral dacryocystoceles in a pregnant woman

The authors describe, for the first time, bilateral, sequential large dacryocystoceles during pregnancy and review the literature for this presentation. A 26-year-old, 15-week pregnant woman presented with OD epiphora, diplopia, and pain in the setting of an inferomedial orbital mass. Surgical exploration and histopathology were consistent with a dacryocystocele, and a dacryocystorhinostomy was curative. She returned at 34-week gestation, with an identical presentation on the left side. Review of the literature reveals that dacryocystoceles occasionally present in adults; however, bilateral involvement may be unusual. Bilateral dacryocystoceles have not been previously reported in a pregnant woman.

Cone-Beam Computed Tomography (CBCT) dacryocystography for imaging of the nasolacrimal duct system

PURPOSE

To evaluate the usefulness and safety of cone-beam computed tomography (CBCT) dacryocystography in detecting lesions, identifying coexisting soft-tissue changes and determining treatment options in patients with epiphora.

PATIENTS AND METHODS

Unilateral digital subtraction dacryocystography and CBCT dacryocystography were carried out on 45 patients. Stenoses and occlusions were identified and coexisting changes such as septal deviation and dacryoliths were noted. The diameter of the bony lacrimal duct of affected and unaffected side was measured and related to the clinically evident epiphora. An attempt was made to base the subsequent therapeutic planning on the CBCT dacryocystographic findings. Additionally, the radiation dose levels for CBCT dacryocystography in comparison to those of multislice computed tomography (MSCT) were evaluated in a standardized head-neck Rando-Alderson phantom.

RESULTS

Nasolacrimal duct obstructions were present in 37/45 patients, 18 with a stenosis and 19 with an occlusion in parts of the lacrimal outflow system. The minimal bony diameter of the side with epiphora was significantly decreased compared to the unaffected side. Coexisting soft-tissue changes did not correlate significantly with the clinical sign of epiphora. Eight patients showed no underlying reason for the epiphora and were treated conservatively. A total of eleven patients received interventional therapy for their stenosis and 23 patients had to be treated surgically. A further three patients received medical treatment for infection, before surgery and interventional therapy, respectively, were carried out. Dose levels for CBCT imaging remained far below those of MSCT.

CONCLUSION

CBCT dacryocystography is a safe and time-efficient modality for assessing the nasolacrimal duct system in patients with epiphora. CBCT dacryocystography provides detailed images of the nasolacrimal drainage system, surrounding soft tissue, and bony structures in one diagnostic tour. It allows clear measurement of the bony nasolacrimal duct and displays information beyond that of the drainage lumen, improving the planning of therapeutic interventional and surgical procedures.

Large concha bullosa mucopyocele replacing the anterior ethmoid sinuses and contiguous with the frontal sinus

Concha bullosa, a pneumatized middle turbinate, is a common anatomic variant found in the paranasal sinuses. When a concha bullosa becomes obstructed, it can form a mucocele and, eventually, a mucopyocele if it becomes secondarily infected. This is a rare phenomenon; only 9 concha bullosa mucopyoceles have been previously reported in the English-language literature. We present the case of a large concha bullosa mucopyocele in a pediatric patient in which the concha bullosa replaced the anterior ethmoid sinuses and was contiguous with the frontal sinus.

Surgical treatment of obstruction of the nasolacrimal ducts in patients with anatomical endonasal variants

The presence of anatomical endonasal variants (concha bullosa, nasal septal deviation, or hypertrophic turbinates) may cause more complications in patients with epiphora who have external dacryocystorhinostomy (DCR). The purpose of this study was to assess the results of surgical placement of a stent in 28 patients. They were randomised into two groups and had either DCR or placement of a Song's polyurethane stent. They were followed up for 18 months. Twenty-six patients had a good result. The success rate was 13/14 for those who had DCR and 13/14 for those who had a stent. Operating time was significantly less for placing a stent (mean (SD) 15 (2) minutes) compared with 40 (3) minutes for DCR (p <0.01). Placement of a polyurethane stent is an effective and short procedure for nasolacrimal obstruction, which is suitable for patients with unusual intranasal conditions.

Bilateral congenital dacryocystocoeles with concurrent intranasal mucocoeles causing respiratory distress in a neonate

Congenital dacryocystocoeles are uncommon, presenting as a fluctuant bluish mass inferior to the medial canthus. Even more rarely, these dacryocystocoeles are complicated by intranasal extension. We present a case of a newborn infant with bilateral dacryocystocoeles with intranasal extension (intranasal mucocoeles) causing respiratory distress and feeding difficulties. Prompt surgical correction was performed, with the mucocoeles being de-roofed, leading to the resolution of the dacryocystocoeles. The aetiology, clinical features, and therapeutic options are discussed.

Blind canalicular marsupialization in complete punctal absence as part of a systematic approach for classification and treatment of lacrimal system obstructions

The procedure of choice for epiphora caused by bipunctal and canalicular obstruction is conjunctivodacryocystorhinostomy. Despite its high success rate, it may result in multiple complications, such as extrusion, migration, and secondary obstruction. The author describes a simple alternative procedure to conjunctivodacryocystorhinostomy for patients with epiphora caused by bipunctal and proximal canaliculus complete occlusion and a systematic approach to treat lacrimal system obstructions. Ten instances of bipunctal and proximal canaliculus absence in five consecutive patients, caused in four patients by ocular surface disorders (topical drug toxicity, herpetic keratoconjunctivitis, and trachoma), were treated by blunt dissection of the presumed lower punctal site under a surgical microscope. The punctal site was determined by several landmarks, the peaked medial lid margin, a dimple at that site, or an area of relative avascularity. The canaliculus was exposed and expanded to create a pocket. After the procedure, the lacrimal drainage system was found patent in nine of the 10 procedures. After one additional procedure, irrigation of the lacrimal drainage system revealed a nasolacrimal duct obstruction that was treated with dacryocystorhinostomy and silicone tube insertion. After these procedures, an objective resolution of the epiphora was noted in all patients. Epiphora resulting from lack of punctal and proximal canaliculus caused by ocular surface diseases may be treated with blind exposure and marsupialization of the proximal canaliculus instead of conjunctivodacryocystorhinostomy. If, in addition, the nasolacrimal duct is obstructed, a dacryocystorhinostomy may be performed. If this proposed procedure fails, the patient can still undergo conjunctivodacryocystorhinostomy or other procedures. The procedure may be part of a systematic approach to treat lacrimal drainage obstructions that is based on an association between the location and the cause of the obstruction.

MRI of childhood dacryocystocele

We report an unusual presentation of a dacryocystocele in a 3-day-old child, with clinical and novel MRI findings. The literature contains extensive CT documentation, but descriptions of the MRI appearances of dacryocystoceles are lacking. Although CT is the standard initial imaging modality, MRI can be helpful if there are questions as to the content of the lesion or a need for further anatomical characterization.

Diseases of the lacrimal drainage system

We will refer to lacrimal system pathologies involving the outflow pathways, as well as to the recent advances in the management of canalicular and lacrimonasal duct anomalies, including modifications to dacrycystorhinostomy technique, treatment for congenital obstructions, and lacrimal intubations. Special emphasis will be placed on the usefulness of nasal and canalicular endoscopy for the examination and treatment of congenital obstructions and endonasal pathologies, as an aid for intubations and lacrimal surgery, as well as on reasons for failed procedures.