Dacryocele

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Disease Entity

Disease

Dacryocele is also known as a dacryocystocele. It is formed when a distal blockage of the lacrimal sac causes distention of the sac that also kinks and closes off the entrance to the common canaliculus.  This prevents decompression by retrograde discharge of the accumulated secretions. They can occasionally be bilateral.[1]

Etiology

The mucocele forms within the lacrimal sac or within the nasal cavity as a result of a congenital nasolacrimal duct obstruction (NLDO). The mucous secrete by the lacrimal sac goblet cells or amniotic fluid is then trapped in the nasolacrimal sac. The trapping of the fluid causes distention of the sac, which can close off the entrance from the common canaliculus.[2]

Risk Factors

Nasolacrimal duct obstruction


Diagnosis

History

Patients are usually newborn infants who present with a bluish swelling just below and nasal to the medial canthus. They also have a NLDO, and can have a history of mucopurulent discharge or mattering of lashes, most notable after awakening. If untreated it can progress to dacryocystitis. [1][2][3][4]

Physical Examination

Exam reveals a bluish, cystic mass that is located below the medial canthal tendon in the area of the nasolacrimal sac. The medial canthus can be displaced superiorly. Gentle pressure over the mass can produce mucopurulent discharge from the eyelid puncta. The nasal mucosa may become distended as well. This can extend inferiorly under the inferior turbinate, and is visualized during endoscopic nasal examination.  [1][2][3][4]

Signs

A cystic mass present inferior to the medial canthus with a bluish discoloration of the overlying skin. Mucopurulent discharge on digital palpation.  [1][2][3][4]

Symptoms

Airway obstruction can occur in severe cases or if bilateral. [1][2][3][4]

Clinical Diagnosis

Diagnosis is made with clinical examination. It can be helpful to perform digital massage to attempt expression of fluid from the area. Nasal examination may also be needed. [1][2][3][4]

Diagnostic Procedures

It is a clinical diagnosis, however due to frequent association with endonasal cysts an endoscopic nasal examination is warranted for these patients. A computed tomography scan or magnetic resonance imaging will show a large cystic mass extending from the lacrimal system into the inferior meatus (figure 2). Ultrasonography can also be used in the detection of a dacryocele. B-scan will reveal a hollow round cavity with an ostium connected with the nasolacrimal duct, and the A-scan will reveal the high reflecting walls and very low internal reflectivity. [5]

Laboratory Tests

No laboratory tests are necessary

Differential diagnosis

The differential diagnosis includes hemangioma, dermoid cyst, encephalocele, rhabdomyosarcoma, and other solid tumors of the lacrimal system, including pylomatrixoma[1]. Imaging including CT and MRI scans can help differentiate a dacryocele from the others that are listed below with some differentiating clinical characteristics: 

Hemangioma - has irregular borders and inhomogeneous consistency, will not be present at birth, will increase in size with head down position, and is less firm when compared to a dacryocele.

Dermoid cyst- well delineated, mobile, skin colored cyst located above the medial canthal tendon

Encephalocele- located above the medial canthal tendon

Rhabdomyosarcoma- rapidly progressing mass, not present at birth


Management

General Treatment

Because the dacryocele is initially sterile, it may respond to conservative management with prophylactic topical antibiotics and digital massage. Definitive treatment requires treatment of the NLDO once the initial inflammation has resolved. The timing of this is controversial [3][4], but is usually performed within the first few weeks of life to reduce the risk of infection and increase the chances of successful probing. [3]

Medical Therapy

Medical therapy consists of prophylactic topical antibiotics.

Medical Follow Up

Patients must be followed to ensure an infection doesn’t develop. Once the initial inflammation has resolved, definitive treatment is indicated.

Surgery

Definitive treatment consists of eliminating the NLDO by probing, which can be undertaken once the initial inflammation has resolved. Please see Nasolacrimal Duct Obstruction for details. Commonly, there is an associated nasal mucocele present, which should be marsupialized to improve drainage into the nose. If this is not performed simple probing will not resolve the condition.[3] Decompression of an infected dacryocele with a skin incision should not be performed as this may cause a fistulous tract. [1]

Surgical Follow Up

See NLDO

Complications

If the dacryocele does not resolve with conservative management, infection may develop within the first few weeks of life. This is managed with systemic antibiotics. If improvement does not occur, probing of the nasolacrimal system as well as marsupialization of the nasal mucocele are needed to decompress the sac and allow the externalization of the contents [1][3].

Prognosis

The prognosis is excellent


References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Basic Clinical and Science Course. Pediatric Ophthalmology and Strabismus. 2011-12. Section 6 pg 204-205.
  2. 2.0 2.1 2.2 2.3 2.4 2.5 Basic Clinical and Science Course. Orbit, Eyelids, and Lacrimal System. 2011-12. Section 7 pg 272.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Becker BB. The treatment of congenital dacryocystocele. Am J Ophthalmology. 2006; 142(5):835- 838.
  4. 4.0 4.1 4.2 4.3 4.4 4.5 Yen, KG; Yen, MT. “Initial Management of the Tearing Infant.” EyeNet July 2004. http://www.aao.org/publications/eyenet/200407/pearls.cfm?RenderForPrint=1&
  5. Cavazza, S, et al. “Congenital Dacryocystocele: Diagnosis and Treatment. “ Acta Otorhinolaryngol Ital. 2008 December; 28(6): 298–301.


Original article contributed by: Michael D. Greenwood, MD, A. Paula Grigorian, MD
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