Abstract
Purpose
The aim of the study was to present a consecutive series of neonatal dacryocele with endonasal cyst diagnosed and treated in our institution and to compare our management regimen and outcome with those reported in the literature.
Methods
The study was conducted at a university-affiliated teaching hospital. Study population included 5 infants, ages 1 day to 1 month, with either noninfected or infected neonatal dacryocele with endonasal cyst. Management included antibiotic treatment (topical and/or systemic) and local lacrimal massage. When conservative treatment failed, endoscopic identification and incision of the endonasal cyst with subsequent lacrimal duct irrigation with fluorescein and antibiotics were carried out in the office. Main outcome measures included resolution of symptoms and recurrence rate.
Results
Between the years 2003 and 2007, 5 infants were diagnosed and treated. All had unilateral dacryocele with endonasal cyst. Female-to-male ratio was 4:1. Age ranged from 1 day to 1 month old. Three had dacryocystitis (60%) before treatment. None had symptoms of airway obstruction. One patient was successfully treated conservatively with firm massage by the ophthalmologist resulting in rupture of the endonasal cyst and did not require further treatment. Four patients were treated with a combined ophthalmology/otolaryngology surgical procedure. All patients were treated in an office setting without general anesthesia. One patient underwent computed tomographic imaging before treatment to confirm the diagnosis. Follow-up ranged from 1 month to 50 months with an average of 23 months. Complete resolution was observed in all patients without recurrence and without complications.
Conclusions
We report on the successful surgical treatment of neonatal dacryocele with endonasal cyst in an office setting without the use of general anesthesia, using endoscopic incision of the cyst and irrigation alone. The high success rate of this relatively benign office procedure encourages its use and further supports the approach of early surgical intervention, thus, helping to avoid infectious complications that can be severe at this age.
1
Introduction
Simple nasolacrimal duct obstruction (NLDO) in the neonate is usually diagnosed and treated by an ophthalmologist. In the minority of cases, there is NLDO with an endonasal cyst requiring diagnosis and treatment by a joint team of an otolaryngologist and an ophthalmologist. This pathology that has been termed neonatal dacryocele with endonasal cyst is thought to be caused by congenital blockage of both the proximal nasolacrimal duct valve (Rosenmuller valve) and the distal nasolacrimal duct valve (Hasner valve) .
In simple neonatal NLDO, only one of the valves is blocked, namely Hasner valve, causing free backflow of tears and debris in the form of epiphora. In the case of dacryocele with endonasal cyst, both ends of the nasolacrimal duct are blocked, causing fluid accumulation in the duct, thus, distending the system with the resulting distal end of the duct protruding as a cyst into the inferior meatus . The proximal end presents classically in such cases as a blue cystic canthal mass. The goal of treatment is to restore patency of the nasolacrimal duct, preferably before the ensuing infection .
The accepted management of neonatal dacryocele with endonasal cyst includes hospitalization, antibiotic treatment, and surgical intervention performed under general anesthesia in an operating suite. In this study, we report the results of treatment of cases of neonatal dacryocele as an office procedure under topical anesthetic.
2
Methods
This is a retrospective review of 5 neonates diagnosed with congenital dacryocele with endonasal cyst treated in the years 2003 to 2007 in our medical center. We review the sex, management, definitive treatment, incidence of associated infections, and outcome.
In all cases, initial diagnosis was made by an ophthalmologist (HL) who then referred to an otolaryngologist (YB). An initial trial of conservative treatment including antibiotics, warm compresses, and manual pressure to the medial canthal cyst was used. In one case, of the only male in our series, the endonasal cyst ruptured under the local pressure applied by the ophthalmologist, and no further treatment was necessary. In all the other 4 cases, a joint office procedure of the ophthalmologist and otolaryngologist was preformed. Topical cocaine 5% (1–2 mL) on a Merocel (compressed cellulose sponge) wick was applied to the affected nostril to achieve both local anesthetic and vasoconstrictive effect. The endonasal cyst was then identified endoscopically in the inferior meatus. Incision of the cyst using a myringotomy knife was preformed with subsequent fluorescein irrigation of the nasolacrimal system by the ophthalmologist until visualized in the nasal cavity, thus, confirming patency. Probing of the nasolacrimal duct was not performed. No marsupialization or mucosal reduction was preformed. All patients completed a course of topical and systemic antibiotics.
2
Methods
This is a retrospective review of 5 neonates diagnosed with congenital dacryocele with endonasal cyst treated in the years 2003 to 2007 in our medical center. We review the sex, management, definitive treatment, incidence of associated infections, and outcome.
In all cases, initial diagnosis was made by an ophthalmologist (HL) who then referred to an otolaryngologist (YB). An initial trial of conservative treatment including antibiotics, warm compresses, and manual pressure to the medial canthal cyst was used. In one case, of the only male in our series, the endonasal cyst ruptured under the local pressure applied by the ophthalmologist, and no further treatment was necessary. In all the other 4 cases, a joint office procedure of the ophthalmologist and otolaryngologist was preformed. Topical cocaine 5% (1–2 mL) on a Merocel (compressed cellulose sponge) wick was applied to the affected nostril to achieve both local anesthetic and vasoconstrictive effect. The endonasal cyst was then identified endoscopically in the inferior meatus. Incision of the cyst using a myringotomy knife was preformed with subsequent fluorescein irrigation of the nasolacrimal system by the ophthalmologist until visualized in the nasal cavity, thus, confirming patency. Probing of the nasolacrimal duct was not performed. No marsupialization or mucosal reduction was preformed. All patients completed a course of topical and systemic antibiotics.
3
Results
Five consecutive neonates between the years 2003 to 2007 were identified with neonatal dacryocele with endonasal cyst. Four of them were females and 1 was male. All cases were unilateral, and none presented with breathing difficulty. Age distribution at treatment was between 3 days and 1 month with an average of 18 days. In one case, a computed tomography was performed to rule out other pathologic conditions and to confirm the diagnosis. In all the other cases, the diagnosis was made clinically without need for imaging. In 3 cases, the definitive treatment was given after dacryocystitis had begun; in the 2 others, diagnosis and treatment were begun before the onset of infection. In all 5 cases, conservative nonsurgical treatment was begun at the time of diagnosis, which included warm compresses and application of firm digital pressure, in an attempt to cause rupture of the endonasal cyst, thus, opening the Hasner valve and producing distal patency of the duct. In one case, in the only male in this series, this treatment was successful, and no further treatment was necessary. In the remaining 4 of 5 cases, a combined ophthalmology/otolaryngology procedure was performed in an office setting. All patients completed a course of systemic antibiotics (2 with first-generation cephalosporin-[cephalexin], 2 with amoxicillin + clauvulanic acid, and 1 with a combination of ampicillin and gentamycin) and topical antibiotics, usually an aminoglycoside. Follow-up ranged from 1 to 50 months (average, 23 months). Complete resolution was observed in all patients, and there were no recurrences or sequelae ( Table 1 ).
