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Treatment of Congenital Nasolacrimal Duct Cyst: the Role of Endoscopic

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Treatment of Congenital Nasolacrimal Duct Cyst: the Role of Endoscopic ACTA OTORHINOLARYNGOLOGICA ITALICA 2020;40:377-382; doi: 10.14639/0392-100X-N0759 Rhinology Treatment of congenital nasolacrimal duct cyst: the role of endoscopic marsupialisation Il trattamento delle cisti congenite del dotto nasolacrimale: il ruolo della marsupializzazione endoscopica Vittorio Rampinelli1, Marco Ferrari1,2, Silvia Zorzi1, Marco Berlucchi3 1 Unit of Otorhinolaryngology-Head and Neck Surgery, University of Brescia, ASST Spedali Civili of Brescia, Italy; 2 Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences; University of Padua, Italy; 3 Unit of Pediatric Otorhinolaryngology, ASST Spedali Civili of Brescia, Italy SUMMARY Objective. Congenital nasolacrimal duct cyst (NLDC) is a rare disorder, which can present with ophthalmological and nasal signs and symptoms. The authors analyse their personal experience to identify diagnostic criteria for NLDC, which were treated by endoscopic transnasal procedure. Methods. Clinical records of patients with a diagnosis of NLDC were retrospectively re- viewed. All patients underwent rhinoscopy and ophthalmologist evaluation before surgery, whereas imaging was performed in selected cases. All neonates underwent transnasal endo- scopic marsupialisation after failure of conservative medical therapy. Results. Five patients were included in the study. One patient presented bilateral NLDC. In Received: March 23, 2020 3 cases, CT scan of the sinus was carried out. A total of 6 marsupialisation procedures were Accepted: May 21, 2020 performed and a bi-canalicular lacrimal stent was positioned in 1 case. Complete remission of symptoms was observed in all cases. Correspondence Conclusions. Nasal endoscopy is mandatory to diagnose NLDCs, and, in some cases, it can Vittorio Rampinelli be complemented by radiological procedures. When symptoms persist after systemic and Unit of Otorhinolaryngology-Head and Neck topical therapy, nasal endoscopic marsupialisation is the treatment of choice. This surgical Surgery, Department of Medical and Surgical procedure is effective, safe and can be repeated if needed. Specialties, Radiological Sciences, and Public Health, University of Brescia, ASST Spedali Civili KEY WORDS: nasolacrimal duct, children, nasal surgical procedures, minimally invasive di Brescia, 25121 Brescia, Italy surgical procedures Tel. +39 030 3995319. Fax +39 030 3995212 E-mail: [email protected] RIASSUNTO Obiettivo. La cisti congenita del dotto nasolacrimale (CDNL) è una condizione rara, che Funding None. si manifesta con segni e sintomi oftalmologici e nasali. Gli autori analizzano la propria esperienza al fine di identificare criteri diagnostici per la CDNL, trattata con procedura endoscopica transnasale (ET). Conflict of interest The Authors declare no conflict of interest. Metodi. È stata eseguita un’analisi retrospettiva dei dati clinici dei pazienti affetti da CDNL. I pazienti sono stati sottoposti ad endoscopia nasale (EN) e valutazione oculistica prima dell’intervento, l’imaging è stato eseguito in casi selezionati. Tutti i neonati sono How to cite this article: Rampinelli V, Ferrari M, stati sottoposti a marsupializzazione ET dopo fallimento di terapia medica. Zorzi S, et al. Treatment of congenital nasolacri- Risultati. Cinque pazienti sono stati inclusi nello studio. Un paziente ha presentato CDNL mal duct cyst: the role of endoscopic marsupiali- bilaterale. In 3 casi, è stata eseguita TC del massiccio facciale. Sono state eseguite 6 pro- sation. Acta Otorhinolaryngol Ital 2020;40:377- cedure di marsupializzazione; uno stent lacrimale bi-canalicolare è stato posizionato in 1 382. https://doi.org/10.14639/0392-100X-N0759 caso. La remissione completa dei sintomi è avvenuta in tutti i casi. © Società Italiana di Otorinolaringoiatria Conclusioni. L’EN è chiave per la diagnosi di CDNL e può essere integrata con procedure e Chirurgia Cervico-Facciale radiologiche. Quando i sintomi persistono dopo terapia sistemica e topica, la marsupia- lizzazione ET rappresenta il trattamento di scelta. Questa procedura chirurgica è efficace, OPEN ACCESS sicura e può essere se necessario ripetuta. This is an open access article distributed in accordance with PAROLE CHIAVE: dotto nasolacrimale, pediatrico, procedure chirurgiche nasali, the CC-BY-NC-ND (Creative Commons Attribution-Non- procedure chirurgiche mininvasive Commercial-NoDerivatives 4.0 International) license. The article can be used by giving appropriate credit and mentio- ning the license, but only for non-commercial purposes and only in the original version. For further information: https:// creativecommons.org/licenses/by-nc-nd/4.0/deed.en 377 V. Rampinelli et al. Introduction Pediatric Otorhinolaryngology, Spedali Civili of Brescia, Brescia - Italy, from January 2010 to January 2019 were Congenital nasolacrimal duct (NLD) obstruction is a com- retrospectively reviewed. mon disorder. Cassady reported incomplete canalisation of Informed consent was systematically acquired at time of NLD in more than 70% of newborns 1, with Hasner’s valve hospitalisation. Ethical approval was not required due to being the most frequent site of stenosis 2,3. The majority of the retrospective nature of the study and anonymisation of cases resolve spontaneously during the first weeks of life 4,5, all data. while persistent epiphora is observed in 6-20% of infants 5,6. All patients underwent preoperative flexible nasal endosco- Several malformations have been attributed to persistent py and ophthalmologist evaluation. Before January 2013, epiphora in young patients. The term “inferior mucocele” all patients underwent CT scan of sinuses to confirm diag- or “NLD cyst” (NLDC) refers to an unperforated Hasner’s nosis; thereafter, our diagnostic strategy changed, in order valve showing an inferior prolapse and therefore occupying to avoid redundant radiological exams. We utilised the fol- the inferior meatus and nasal cavity 7. NLDC associated lowing diagnostic criteria for NLDC: with dacryocystocele, which consists of a cystic enlarge- • nasal obstruction; ment of lacrimal sac 8, is reported in 0.1% of infants dur- • epiphora; ing the first year of life 5. The dacryocystocele may resolve • nasal endoscopy revealing a translucent, cystic lesion spontaneously, but frequently becomes infected and rapidly centered on the anterior portion of the inferior turbinate progresses to acute dacryocystitis, lacrimal sac empyema and obstructing the nasal fossa; and preseptal/orbital cellulitis 9. • no suspicion of orbital complications at ophthalmologist Diagnosis of NLDC is usually based on clinical symptoms, evaluation; endoscopic appearance and imaging. The typical clinical • no suspicion of another pathological condition (i.e., cho- presentation includes epiphora, history of relapsing dacryo- anal atresia, pyriform aperture stenosis, nasopharyngeal cystitis, and unilateral nasal obstruction. When the malfor- teratoma, and meningoencephalocele) at flexible nasal mation is bilateral, clinical presentation emulates adenoid endoscopy. hypertrophy, with different respiratory issues consisting of chronic snoring respiration, difficulties in sleeping and If all the above criteria were satisfied, a clinical diagno- feeding, and severe respiratory distress associated with sis was made and CT and/or magnetic resonance imaging cyanosis and/or intercostal retraction. At nasal endoscopic (MRI) were deemed unnecessary. All patients underwent evaluation, NLDC appears as a mucosal translucent protru- surgery after failure of conservative treatments (i.e., mas- sion stemming from the inferior meatus, in proximity to the sage of the medial cantus, antibiotic and steroid eye drops, area of Hasner’s valve. If associated with dacryocystocele, systemic antibiotic therapy) for at least 3 weeks. Signs of a blue swelling at the level of the ipsilateral medial cantus acute inflammation of the nasolacrimal duct system were is usually noticeable. CT scan of the sinuses confirms diag- considered a temporary contraindication to surgery, which nosis, above all when the nasal fossa is not clearly explor- was postponed after resolution of inflammation-related able and/or other associated conditions are suspected 10. symptoms. Management of NLDC includes conservative and non- conservative treatments. The former comprises massage of Surgical technique and postoperative management the lacrimal sac, topical antibiotics and steroids and sys- The surgical procedure was performed under general anaes- temic antibiotic therapy. The latter, which usually follows thesia. After mucosal decongestion with pledgets soaked an unsuccessful conservative strategy, consists of a surgical with adrenalin (1:100,000), a rigid nasal 0° endoscope 2.7 procedure, ranging from nasolacrimal probing to intrana- diameter, 11 cm long (Karl Storz, Tuttlingen, Germany) sal endoscopic marsupialisation 2. The aim of the present connected with high definition camera and xenon-175-watt single-institution study is to analyse clinical outcomes of cold light illumination source (HD 3 CCD camera, Karl children who underwent transnasal endoscopic marsupi- Storz, Tuttlingen, Germany) was placed intranasally to alisation of NLDC and to identify clinical and endoscopic identify and analyze the extent of NLDC. The NLDC was diagnostic criteria to diagnose congenital NLDC. marsupialised by removing the anteromedial wall of the cyst by cold sharp instruments that are commonly em- ployed for otosurgery. In one case, a microdebrider was Materials and methods used to perform partial marsupialisation
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