Evaluation and treatment of failed nasolacrimal duct probing in Down syndrome

Abstract

To elucidate the mechanisms underlying failed nasolacrimal duct (NLD) probing in children with Down syndrome (DS) utilizing computed tomography (CT) scans and histopathology of nasal mucosa. The medical records of children with DS and NLD obstruction confirmed by dye disappearance testing who failed NLD surgery were retrospectively reviewed. Dimensions of the bony NLD and presence of postductal mucosal obstruction were obtained from CT scans. Histopathology of the nasal mucosa was performed in a subset of patients. Subsequent treatment was topical or intranasal corticosteroids or submucosal corticosteroids alone or combined with surgical reduction of the inferior turbinate. A total of 9 subjects (age range, 8-10 years) and 43 age-matched controls were included. Both groups demonstrated a logarithmic increase in NLD and maxilla dimensions with increasing age; however, the transverse diameter of the NLD was consistently 1-2 mm smaller in children with DS ≤5 years age (n = 4) than in age-matched controls. The transverse diameter in DS children overlapped that of controls after 5 years age. Histopathology revealed abnormal lymphoplasmacytic inflammation of the mucosa in 4 of 5 biopsies of DS patients, consistent with chronic infection, allergic disease, or immune dysregulation. The postductal obstruction was successfully treated with topical or intranasal corticosteroids or by surgical reduction of the inferior turbinate submucosa with corticosteroid injection. Before 5 years of age, NLD obstruction in children with DS was associated with reduced dimensions of the NLD and hypertrophic nasal mucosa. In DS children older than 5 years of age, the dimensions of the NLD are normal and postductal obstruction due to hypertrophic nasal mucosa should be considered.