Use of a nasolacrimal stent to treat air regurgitation after dacryocystorhinostomy in a patient using a continuous positive airway pressure device

Abstract

The dacryocystorhinostomy procedure creates a direct passageway between the lacrimal sac and nasal cavity, bypassing any nasolacrimal duct obstruction. Use of a continuous positive airway pressure device after dacryocystorhinostomy can cause nasolacrimal air regurgitation. Here, we report a case of air regurgitation after dacryocystorhinostomy that was successfully treated with placement of a Mini Monoka device, a silicone stent used in nasolacrimal surgery to prevent closure of the passageway, in a patient using a continuous positive airway pressure machine. Following the procedure, the patient was able to resume use of her continuous positive airway pressure device.

Citation:

Srivatsan S, Mirza M, Imayama I, Setabutr P, Mahoney NR. Use of a nasolacrimal stent to treat air regurgitation after dacryocystorhinostomy in a patient using a continuous positive airway pressure device. J Clin Sleep Med. 2023;19(12):2123–2124.

INTRODUCTION

The nasolacrimal duct (NLD) drains tears from the lacrimal sac to the nasal cavity. NLD obstruction can cause epiphora, eye irritation, and mucous discharge. Dacryocystorhinostomy (DCR) treats NLD obstruction by creating a new passageway between the lacrimal sac and nasal cavity, bypassing the obstruction.¹

In patients using a continuous positive airway pressure (CPAP) device, a passage created between the lacrimal sac and nasal cavity can result in air regurgitation via the nasolacrimal system. We report a case of air regurgitation after DCR that was successfully treated via placement of a Mini Monoka device (Figure 1; FCI Ophthalmics, Pembroke, Massachusetts),² a silicone stent used in nasolacrimal surgery to prevent closure of the passageway, in a patient using a CPAP device for obstructive sleep apnea.

Figure 1. Mini Monoka stent dimensions.

REPORT OF CASE

A 71-year-old woman with a history of obstructive sleep apnea requiring CPAP returned to the clinic with concern for air coming out of her right eye 6 weeks after undergoing endoscopic DCR. The patient was diagnosed with severe obstructive sleep apnea at the age of 68 years and had been using a CPAP device set at 15 cm H2O since that time.

She had recently been diagnosed with bilateral NLD obstruction and had undergone endoscopic DCR with bicanalicular silastic intubation of the puncta of both eyes to prevent the newly created passageways from closing. The silicone stents were removed 6 weeks after the surgery as per protocol to allow for resumption of lacrimal drainage. Following removal of the stents she noticed air regurgitation from her right eye while using her CPAP device.

The air regurgitation persisted even after her mask was changed from a nasal pillow to an oronasal face mask. She also tried a total face mask but was not comfortable. The right lower eyelid punctum was identified as the site of regurgitation, confirmed by the Valsalva DCR bubble test.³ In this test, saline is placed in the patient’s medial canthus and the patient is asked to perform the Valsalva maneuver. If bubbles form, emanating from either punctum, this is considered demonstrative of air regurgitation. To block this persistent air leak, a Mini Monoka device was placed into the lumen of the right lower punctum (Figure 2). The procedure was performed in the clinic using surgical loupes to visualize the target anatomy. Topical proparacaine was instilled on the globe for anesthetic. The distal 30 mm of the Mini Monoka device was cut, leaving a total length of 10 mm from the cuff to the distal end. The stent was inserted into the right lower punctum using a pair of nontoothed forceps. Following placement of the device the air regurgitation resolved, and the patient was able to tolerate use of her CPAP machine with a nasal pillow mask.

Figure 2. Nasolacrimal anatomy (A) prior to dacryocystorhinostomy, (B) after dacryocystorhinostomy (arrow indicates air regurgitation), and (C) after Mini Monoka placement.

DISCUSSION

Our patient experienced nasolacrimal air regurgitation following removal of nasolacrimal stents after endoscopic DCR. Prior to removal of the nasolacrimal stents, the patient had been using her CPAP device without issue. The air regurgitation was corrected via placement of a Mini Monoka device in the outpatient setting. Air regurgitation into the eyes via the nasolacrimal system has previously been reported in patients using positive airway pressure devices. Air regurgitation is normally prevented in the native tear system through several small soft-tissue valves throughout the duct and in the lacrimal sac.⁴ After DCR, the NLD is bypassed and tears flow directly from the lacrimal sac into the nose. Thus, only lacrimal sac valves are able to prevent regurgitation. Trauma from surgical manipulation combined with positive pressure in the airway can result in retrograde airflow up the tear system. In 1 case report, computerized tomography scan demonstrated air in the nasolacrimal duct in a 14-month-old boy with neuromuscular disease who was using a noninvasive ventilation device.⁵ In another patient with a Jones tube, a glass tube used during conjunctival DCR, air regurgitation was observed and was treated by changing from an oronasal to a total face mask.⁶ Silicone stoppers can also be used to occlude the Jones tube for activities like scuba diving.

To our knowledge, this is the first case report to demonstrate improvement of air regurgitation after DCR via placement of a Mini Monoka. A Mini Monoka may stay in place indefinitely with follow-up approximately every 3 months, though it may need to be removed if a granuloma develops. With the stent in place tear drainage cannot occur; however, with only the lower punctum occluded, tears can still drain via the upper punctum. We believe that placement of a Mini Monoka may prevent ocular air regurgitation in patients using CPAP devices for the treatment of obstructive sleep apnea.

DISCLOSURE STATEMENT

All authors have seen and approved the manuscript for submission. Work for this study was performed at the University of Illinois at Chicago. Dr. Ikuyo Imayama has received a grant from the American Academy of Sleep Medicine Foundation. The authors report no conflicts of interest.

ABBREVIATIONS

CPAP

continuous positive airway pressure

DCR

dacryocystorhinostomy

NLD

nasolacrimal duct