Adult dacryocystocele

Abstracts

The dacryocystocele represents a dilated lacrimal sac and is often considered as having a congenital etiology. However, dacryocystocele is a rare disease in adults. The clinical feature is characterized by a painless bulge in the medial region of the orbit, below the medial canthal ligament. The lacrimal excretion test, endoscopy, computerized tomography and magnetic resonance image are used to make the diagnosis of dacryocystocele. Similar to pediatric patients, endoscopic marsupialization of the cyst with nasal stenting seems to be the appropriate therapy. In some cases the treatment consists of external dacryocystorhinostomy.

Orbit; Nasolacrimal duct obstruction; Dacryocystocele; Dacryocystorhinostomy

A dacriocistocele representa um saco lacrimal dilatado e é frequentemente considerada como tendo uma etiologia congênita. No entanto, dacriocistocele é uma doença rara em adultos. A característica clínica se caracteriza por um abaulamento indolor na região medial da órbita, inferior ao ligamento cantal medial. O teste de excreção lacrimal, endoscopia, tomografia computadorizada e ressonância magnética são utilizados para fazer o diagnóstico de dacriocistocele. Semelhante a pacientes pediátricos, marsupialização endoscópica do cisto nasal e a colocação de stent parece ser a terapêutica adequada. Em alguns casos o tratamento consiste na dacriocistorrinostomia externa

INTRODUCTION

Dacryocystocele is characterised by a dilated lacrimal sac and is often regarded as a congenital condition. However, it is a rare disease in adults. It presents as a painless bulge in the medial region of the orbit below the medial ligament. Its mechanism involves an acquired obstruction at the level of Krause’s valve and obstruction proximal to the common canaliculus, at the level of Rosenmuller’s valve.^(1-3)

In a patient with nasal obstruction, the differential diagnosis includes masses such as haemangioma, glioma, encephalocele, and dermoid cyst, as well as congenital bone anomalies such as choanal atresia.^(4,5)

The tear secretion test, endoscopy, computed tomography, and magnetic resonance imaging can be used to diagnose the condition.

Dacryocystocele in adults should be considered as an obstruction of the nasolacrimal duct, and intranasal examination should be performed before external dacryocystorhinostomy.⁽⁶-⁸⁾ Similar to paediatric patients, endoscopic marsupialization of the nasal cyst with stent placement seems to be the appropriate therapeutic approach. Some cases can be treated with external dacryocystorhinostomy.^(9-11)

CASE REPORT

A white, 42-year-old woman presented with epiphora in the right eye and progressive ipsilateral nasal congestion starting 4 months earlier. She had no history of epistaxis, facial fracture, or sinus and nasal disorders. Ophthalmic examination found a soft mass in the medial region of the right orbit (Figure 1). Biomicroscopy showed no hyperaemia in the bulbar conjunctiva and no anterior chamber reaction. The Milder test was intensely positive. Catheterisation found a soft stop after introducing the Bowman probe 9 mm into the canaliculus. The Jones 1 test was negative. Examination of the left eye was normal, including eyelid position. Right anterior rhinoscopy found no mass below the inferior turbinate.The patient was prescribed prophylactic antibiotic therapy and cold packs, and the dacryocystocele resolved after 2 weeks, progressing to chronic dacryocystitis. The patient will undergo external dacryocystorhinostomy.

Figure 1
Frontal and lateral images of right dacryocystocele

DISCUSSION

Dacryocystocele in the medial orbital region is a relatively rare condition, but congenital dacryocystocele has been recognised as an individual disease since 1933⁽¹²⁾. Congenital dacryocystocele is found almost exclusively in paediatric patients⁽¹³⁾, and it has a specific natural history, clinical features, disease mechanism, and treatment. Lacrimal sac dilation occurs because of distal nasolacrimal duct obstruction and functional obstruction of the common canaliculus. In cases of nasolacrimal duct obstruction, secretions can accumulate in the lacrimal sac, culminating in its dilation and obstructing the common canaliculus. Another mechanism proposed for dacryocystocele involves folds in the common canaliculus due to a dilated lacrimal sac and Rosenmuller’s valve malfunction secondary to oedema and inflammation.⁽¹³⁾ Children with dacryocystocele are treated with antibiotics, massage, and cold compresses, and if medical treatment is ineffective, probing and irrigation of the lacrimal pathway associated with intranasal endoscopic marsupialisation of the cyst are then indicated.⁽¹⁴⁾

There are a few reports of dacryocystocele in adults⁽¹⁵⁾. Its clinical picture includes painless bulging of the medial region of the orbit below the medial ligament. The lacrimal secretion test, endoscopy, computed tomography, and magnetic resonance imaging can be used to diagnose the condition.⁽¹⁶⁾ The disease mechanism of dacryocystocele is similar in adults and children, but the nasolacrimal duct obstruction in adults is acquired. A complication of dacryocystocele is chronic dacryocystitis.⁽¹⁷⁾

Treatment involves placement of a nasolacrimal stent or dacryocystorhinostomy.^(18,19)

It may be necessary to differentiate dacryocystocele from a tumour of the lacrimal sac.^(20,21)Adult dacryocystocele can be adequately diagnosed through studies such as ultrasound imaging, computed tomography, and magnetic resonance imaging. Computed tomography has become the most important method for locating and characterising an orbital mass. CT can determine the correct anatomical diagnosis by showing the dacryocystocele in the lacrimal sac and is also helpful in differentiating dacryocystocele from other masses that can affect the medial canthus in adults. An orbital tumour in the medial orbital region such as haemangioma, neurofibroma, lymphangioma, or rhabdomyosarcoma can be seen on CT as a solid mass.

• Work conducted at the Lacrimal Pathways Unit, Federal University of São Paulo (UNIFESP), São Paulo/SP, Brazil.

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Publication Dates

• Publication in this collection
  Sep-Oct 2014

History

• Received
  11 Nov 2011
• Accepted
  03 Sept 2012