Dacryocele

Article initiated by:

A. Paula Grigorian, MD, Michael D. Greenwood, MD

All authors and contributors:

Michael D. Greenwood, MD, Shubhra Goel, MD, Matthew Zhang, S. Grace Prakalapakorn, MD, MPH, Michael T Yen, MD, Carla J. Osigian, MD, Preeti Thyparampil, MD, Marcus M. Marcet, MD, Cat Nguyen Burkat, MD FACS

Assigned editor:

Carla J. Osigian, MD, Preeti Thyparampil, MD

Review:

Assigned status Up to Date

 by Carla J. Osigian, MD on January 3, 2023.

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Contributing Editors:	add

Dacryocele

ICD-10

[1]10.5

Disease Entity

ICD10: Q10.5

Disease

Dacryocele causing upward slanting/displacement of the palpebral fissure nasally (photo from eye rounds.org)

Dacryocele is also known as a dacryocystocele, amniotocele, amniocele, or mucocele. It is formed when a distal blockage (usually membranous) of the lacrimal sac causes distention of the sac, which also kinks and closes off the entrance to the common canaliculus. This restricts retrograde discharge of the accumulated secretions and prevents decompression of the sac. Dacryoceles may present in 3% of infants with NLDO and are most commonly unilateral, but can be bilateral in up to 30% of patients.

Etiology

A dacryocele forms within the lacrimal sac +/- nasal cavity as a result of a congenital nasolacrimal duct obstruction (NLDO). The mucus secreted by the lacrimal sac goblet cells or amniotic fluid becomes trapped in the nasolacrimal sac secondary to a distal blockage. The trapping of the fluid then causes distention of the sac, which can close off the entrance from the common canaliculus, preventing decompression of the sac.

Risk Factors

Nasolacrimal duct obstruction

Diagnosis

History

Patients are usually infants who present at birth or within the first few days of life with a bluish swelling just below and nasal to the medial canthus. They also have a NLDO and may have mucopurulent discharge or mattering of lashes, most notable after awakening. If untreated it can progress to dacryocystitis.

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. In some cases, the nasal mucosa may become distended and extend into the nasal cavity. This cystic extension may be visualized during endoscopic nasal examination under the inferior turbinate. The nasal cavity should always be evaluated to assess for an intranasal cyst extension that may cause airway obstruction.

Signs

A cystic mass present inferior to the medial canthus with a bluish discoloration of the overlying skin. Mucopurulent discharge or mattering of lashes, most notable after awakening. Mucopurulent discharge on digital palpation.

Symptoms

Mucopurulent discharge or mattering of lashes, most notable after awakening. Historically, it has been stated that infants are obligate nasal breathers. However, further studies have demonstrated that infants can breathe through their mouths if necessary, although nasal-breathing is highly preferred as it allows them to feed at the same time. In severe cases with large intranasal cysts or bilateral obstructions, infants may present with respiratory symptoms of airway obstruction ranging from breathing difficulty when feeding to acute respiratory distress.

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 is warranted to evaluate for an intranasal cyst extension that may affect breathing.

Diagnostic Procedures

It is a clinical diagnosis, however due to frequent association with endonasal cysts, an endoscopic nasal examination is often warranted. A computed tomography scan or magnetic resonance imaging will show a large cystic mass extending from the lacrimal system into the inferior meatus. 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.

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. 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

Early treatment is warranted to prevent possible complications. 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, but is usually performed within the first few weeks of life to reduce the risk of infection and increase the chances of successful probing.

Medical Therapy

Medical therapy consists of prophylactic topical antibiotics and digital massage to decompress the dacryocystocele.

Medical Follow Up

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

Surgery

If a dacryocele does not resolve within the first 2 weeks of life, surgical intervention is often necessary. 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 (See NLDO ). 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. Decompression of an infected dacryocele with a skin incision should not be performed as this may cause a fistulous tract.

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. In acute dacryocystitis, the skin over the lacrimal sac becomes erythematous and pressure over the sac may produce purulent discharge. Infections require management 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. Infants with acute respiratory distress require immediate surgical management.

Prognosis

The prognosis is excellent