International Journal of Pediatric Otorhinolaryngology 78 (2014) 139–141
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Case Report
Dacryocystectomy: An uncommon indication – A case report Christie M. Varghese, Ajoy M. Varghese, Kamran A. Syed *, Roshna R. Paul Department of ENT, Christian Medical College, Vellore, India
A R T I C L E I N F O
A B S T R A C T
Article history: Received 5 August 2013 Received in revised form 21 October 2013 Accepted 29 October 2013 Available online 7 November 2013
Post traumatic nasolacrimal drainage obstruction is an uncommon presentation of naso-orbito-ethmoid fracture. Dacryocystorhinostomy (DCR) with or without silicon intubation is the universally accepted treatment modality. Here we report a case of recurrent lacrimal sac abscess due to post traumatic nasolacrimal drainage obstruction following naso-orbito-ethmoid fracture. The patient had previously undergone incision and drainage thrice and twice failed DCR. In the background of extensive nasal synechiae and twice failed DCR, dacryocystectomy was performed. Post operatively patient has improved and is symptom free for past 14 months. This is the first report of a successful dacryocystectomy for a post traumatic dacryocystitis. ß 2013 Elsevier Ireland Ltd. All rights reserved.
Keywords: Naso-orbito-ethmoid fracture Post-traumatic nasolacrimal drainage obstruction Dacryocystectomy
1. Introduction Traumatic dacryocystitis is an infrequent complication of nasoorbito-ethmoid (NOE) fractures, secondary to obstruction of the naso-lacrimal drainage pathway [1]. Dacryocystorhinostomy (DCR) is the preferred line of treatment in recurrent lacrimal abscess with successful outcomes reported by various authors ranging from 88% to 96% [1,2]. However the presence of extensive nasal synechiae can make the problem very complex and difficult to manage. In such cases, a DCR is likely to fail. We present our management of a patient who had post traumatic NOE fracture dacrocysitis with extensive nasal synechiae and twice failed DCR. 2. Case report A nine-year-old girl was referred to us with history of road traffic accident 2 years back with NOE and anterior skull base fractures with CSF rhinorrhoea. She had history of swelling below the right medial canthus. She had no history of any visual disturbance. She complained about minimal tearing from the right eye. She was diagnosed with recurrent lacrimal sac abscess on the right side and had undergone incision & drainage thrice followed by endoscopic DCR twice. On examination, a telecanthus and saddle nose deformity was evident and a swelling below the right medial canthus with
* Corresponding author at: Department of ENT, Christian Medical College, Vellore, Tamil Nadu 632 004, India. Tel.: +91 984 356 7893/416 228 2798; fax: +91 416 223 2035. E-mail address:
[email protected] (K.A. Syed). 0165-5876/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijporl.2013.10.046
scarring from previous incision was visible (Fig. 1). Anterior rhinoscopy revealed extensive nasal synechiae bilaterally. Computerized tomography of paranasal sinus revealed healed NOE fracture. In view of twice failed previous DCR, child was referred to Department of Pediatric ENT. Since the patient had extensive nasal synechiae with external nasal deformity, a dacryocystectomy (DCT) was preferred over a revision DCR. Intra-operatively, a scarred and thickened sac with pus was noted. The lacrimal sac was excised in-to (Fig. 2). Post operatively, the patient is on follow up for the past 14 months and is asymptomatic but for minimal tearing on the operated side.
3. Discussion Road traffic accidents are the commonest cause of NOE fractures [3]. Any trauma to the mid-face severe enough to cause fracture of the nose will often be associated with NOE fracture [3]. Traumatic nasolacrimal duct injury is a common finding and can be seen in up to 20% of patients with NOE fractures [4]. Becelli et al. have reported a higher incidence of post traumatic epiphora (46%), of which a fraction is temporary and usually resolves conservatively with only 30% remaining symptomatic beyond 5 months. [5] Telecanthus invariable accompanies NOE fractures and is the most common injury. [1,4] It is a clear indication of underlying bony communition and dislocation of bony fragments. The fracture can be an open or a closed fracture. The nasolacrimal drainage obstruction may be due to external compression by a displaced bony fragment or due to soft tissue and mucosal swelling. Obstruction is usually at the level of the bony nasolacrimal canal as the upper pathway is protected by the medial canthus [6]. Open
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C.M. Varghese et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 139–141
Fig. 1. Depressed nasal bridge with telecanthus – front and lateral view (a and b).
Fig. 2. Lacrimal sac (a)intra operative picture (b)specimen.
reduction and fixation provides ideal situation where displaced bony fragments can be reduced and fixed. Other causes of post traumatic epiphora include lid deformities like ectropion, entropion and detachment of medial canthal ligament. In such cases, correction of deformity or repositioning of canthal ligament respectively can restore the lacrimal drainage system [7]. DCR is the accepted modality of treatment for NOE fractures with nasolacrimal duct obstruction [1,2]. In the present era of endoscopic DCR, the role of DCT is limited to lacrimal sac malignancies and rarely in patients with Wegener’s granulomatosis, ocular cicatral pemphigoid, systemic lupus erythematosis, Crohn’s disease and in elderly [8–10]. In 1974 Woolhouse described DCT where the infected lacrimal sac was excised [11]. However the eye continued to water as the lacrimal passages were destroyed. Mukherjee et al. performed only a DCR in majority of their patients with post traumatic nasolacrimal duct obstruction and concluded that external DCR with or without intubation with silicone stent can be beneficial [1]. Rizvi et al. opine that external DCR with silicone intubation is the most effective modality in these cases [2]. In addition Ali et al. state application of Mitomicin C along with external DCR with silicone intubation give superior
results [12]. Gruss et al. emphasized on identification of nasolacrimal sac during open reduction of fracture and discouraged probing and intubation except in case of a laceration [13]. An untreated dacryocystitis can lead to recurrent conjunctivitis, lacrimal sac abscess to more serious and rare complications like post septal cellulitis, cavernous sinus thrombosis and death. [14] 4. Conclusion Recurrent lacrimal abscess is an infrequent presentation following naso-orbito-ethmoid fracture. It is treated by an external DCR with or without silicon intubation. In the present case, the child had extensive nasal synechiae and had twice failed DCR. In patients with extensive nasal synechiae following NOE complex fractures and failed conservative DCR, radical therapy of dacryocystectomy appears to be safe and effective. References [1] B. Mukherjee, M. Dhobekar, Traumatic nasolacrimal duct obstruction: clinical profile, management, and outcome, Eur. J. Ophthalmol. 23 (2013) 615–622. [2] S.A.R. Rizvi, S.C. Sharma, S. Tripathy, S. Sharma, Management of traumatic dacryocystitis and failed dacryocystorhinostomy using silicone lacrimal intuba-
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