Abstract
This is a rare case of a patient who developed a relapse of dacryocystitis and maxillary sinusitis although previous dacryocystectomy. We decided to perform an external dacryocystorhinostomy to remove the scar and the residual part of the lacrimal sac combined with endoscopic sinus surgery (ESS) to solve the symptoms.
Keywords: Dacryocystitis, Dacryocystectomy, Dacryocystorhinostomy
Introduction
Dacryocystitis is an infection of the nasolacrimal sac presenting with epiphora and swelling of the lacrimal sac [1]. In 1724, Woolhouse described the use of external dacryocystectomy to treat inflammation for the first time [2]. Nowadays, the most common surgical technique used to treat dacryocystitis is external dacryocystorhinostomy (DCR) or endoscopically-assisted dacryocystorhinostomy (endoDCR). Despite this evolution of surgical technique there are some surgeons who continue to perform dacryocystectomy.
Case Report
A 51-year-old woman referred to our department reporting epiphora of the left eye associated with pain, redness, and swelling of the lacrimal sac region. One year before, she underwent dacryocystectomy on the same side, due to chronic dacryocystitis, which unfortunately recurred a few days after surgery.
Magnetic resonance imaging (MRI) of the maxillofacial region showed a thickening of the lacrimal sac region of the left eye which was isointense on T1 sequences. Dilation of a residual portion of the lacrimal sac was still present and was associated with circumscribed inflammation of ethmoidal cells in the anterior ethmoidal labyrinth, as well as sinusitis of the left maxillary and frontal sinuses.
A CT scan confirmed left maxillary sinusitis, with thickening of the mucosa, sclerosis, and hyperostosis of the sinus walls (Fig. 1). Mucosal and bone alterations to the anterior cells of the left ethmoidal labyrinth were present. Additionally, there was focal post-surgical dehiscence at the left lacrimal fossa.
Fig. 1.
Preoperative CT Scan examination Coronal (a) and axial (b) section
Due to the persistent epiphora and the relapse of dacryocystitis due to incomplete removal of the lacrimal sac, we decided to perform an external dacryocystorhinostomy to remove the scar and the residual part of the lacrimal sac, combined with endoscopic sinus surgery (ESS) to resolve these symptoms.
Surgical Procedure
Surgery was performed under general anesthesia. A skin incision was made to remove the previous scar in the medial canthus, and to expose the affected area of the inflammatory process. A surgical revision of the sac was performed, and a mucosal flap was harvested. A bicanalicular intubation with a silicon tube was also performed.
Next, endonasal endoscopy started after applying cotton wool soaked in a combined solution of vasoconstrictor and lidocaine. Inflammatory tissue was found in the left nasal cavity, between the lateral wall and the middle turbinate. The tissue extended up to the anterior ethmoid causing obliteration of the natural ostium of the maxilla. Inflammatory tissue was removed, then anterior ethmoidectomy and maxillary sinus revision was performed. A cartilage spur on the left side was removed. An inverted V-shaped mucous incision was made in the axilla of the middle turbinate, a mucous flap was prepared, and the lacrimal bone was exposed. A dacryocystorhinostomy was performed with rotating instruments, intracanalicular stents were placed, and control of lacrimal drainage patency was verified endoscopically. Control of hemostasis was obtained. A nasal splint was placed, and a Merocel swab was lodged in the left nasal cavity (Fig. 2).
Fig. 2.
View from skin incision in the medial canthus to expose the affected area of the inflammatory process (A). Bi-canalicular intubation with a silicon tube (B). Surgical revision of the sac removing inflammatory tissue (C). A dacryocystorhinostomy using rotating instruments was performed (D). The intracanalicular stent placement (E). The control of lacrimal drainage patency (F)
Post-operative treatment consisted of oral antibiotics (amoxicillin + clavulanate) and corticosteroids for 1 week. Locally, a course of antibiotics and steroid eye drops were administered for 7 days. Regular nasal washes were recommended for one month after surgery.
The patient underwent regular endoscopic follow-up to evaluate the maxillary sinus and the patency of the lacrimal pathway. The silicon stent was removed 20 days after the procedure. Post-operative CT scan was performed and confirmed the patency of dacryocystorhinostomy (Fig. 3). At one-year follow-up, there was no evidence of epiphora and dacryocystitis (Fig. 4).
Fig. 3.
Postoperative CT Scan examination Coronal (a) and axial (b) section
Fig. 4.
Pre (A) and post surgical 1 year follow-up (B) clinical pictures of patient
Discussion
The therapeutic approach of chronic dacryocystitis varies according to the patient's age and clinical condition [3]. Generally, in adults, dacryocystorinhostomy (DCR) represents the gold standard treatment in terms of functional outcome, in the treatment of nasolacrimal duct obstruction [4]. However, dacryocystorinhostomy is not preferred in elderly patients with important comorbidities, in these patients dacryocystectomy (DCT) could be a valid option [5].
The dacryocistorinhostomy can be performed by external or endonasal approaches. The external approach dacryocystorhinostomy (DCR), was first described by Addeo Toti in 1904, and was later modified by Dupuy-Dutemps and Bourguet [6]. The endonasal DCR (endoDCR) was first introduced by Caldwell in 1893, who used an endonasal electric burr to remove the bone, once a metal probe had been passed through the canaliculus and into the lacrimal sac [7]. Even if external dacryocystorhinostomy is the currently accepted technique, it has some disadvantages, including facial scarring and increased tearing which results from disruption of the medial canthal anatomy and orbicular muscles of the eye.
The reported success rate of endoDCR in the literature, ranges from 60 to 99%; DCR from 80 to 95%; and DCT around 80% [8, 9].
In our patient, a dacryocystectomy had been already performed and a scar was already present, thus we decided not only to perform an endoDCR, but to use an additional external surgical approach which provided a wider view of the affected area for removal of the hypertrophic scar and exploring the residual part of the lacrimal sac. The aims of the endoscopy were principally to perform the rhinostomy, to verify the patency of the lacrimal pathway, and to treat the maxillary sinusitis.
Alternatives included performing the procedure only via the traditional external approach, which lacks endoscopic confirmation of a complete procedure. However, if the procedure is performed only endoscopically, the hypertrophic scar remains. Sinusitis could be treated independently, but this would not resolve the epiphora. Our treatment seemed more complete because it eliminated the hypertrophic scar, included an endoscopic check, and treated the sinusitis, all in a one-stage procedure. For this reason, we decided to perform the surgery under general anesthesia [10].
As far as we know, there are no other cases described in the literature of patients treated with a dacryocystorhinostomy after dacryocystectomy by performing this apparently novel combined approach. We decided on this approach because the patient’s symptoms were highly suggestive of the persistence of a residual portion of the lacrimal sac, which was confirmed by imaging.
Owing to the young age of the patient, our goal was to resolve the epiphora and associated sinusitis in a one-stage procedure. One year after surgery, she is stable. We therefore suggest this approach in select cases, such as relapse of dacryocystitis after dacryocystectomy.
Funding
The authors did not receive support from any organization for the submitted work.
Declarations
Conflict of interest
The authors have no conflicts of interest to declare that are relevant to the content of this article.
Consent to Participate
Verbal informed consent was obtained prior to the interview.
Consent to Publish
Patient signed informed consent regarding publishing his data and photographs.
Informed Consent
Verbal informed consent was obtained prior to the interview. Patient signed informed consent regarding publishing his data and photographs.
Footnotes
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