Left Nasolacrimal Duct Research Articles

Incidental detection of acquired unilateral nasolacrimal duct obstruction on I-131 whole body scan following I-131 therapy for thyroid cancer: a case report

BackgroundRadioactive iodine 131 (I-131) is used in the treatment of differentiated thyroid cancer after thyroidectomy; however, its accumulation in non-thyroidal regions may give false positive results on iodine whole body scan (WBS). Only a few cases of radioiodine uptake in the orbital region in patients with thyroid cancer have been reported, which could be due to metastasis or false positive causes resulting from contamination or inflammatory etiology.Case presentationWe describe a case of 49-year-old male with history of papillary thyroid carcinoma. The follow-up I-131 whole body scan showed a focus of increased radiotracer uptake in the region of left orbit. Correlative single photon emission computed tomography (SPECT-CT) showed that uptake was due to stenosis of the left nasolacrimal duct causing obstructive symptoms on left side. Dacryoscintigraphy also demonstrated significant obstruction of left nasolacrimal system.ConclusionsThe nasolacrimal duct obstruction is a rare adverse event after I-131 therapy that can result in an accumulation of radioiodine on whole body scan, mimicking metastasis. The use of additional spot views and SPECT-CT images along with thyroglobulin levels can help physicians in clarifying the situation in these uncertain cases.

Idiopathic acquired dacryocystocele in an adult: case report of a rare entity

BackgroundIdiopathic acquired dacryocystocele in adults is a rare disorder of the lacrimal drainage pathway. Only 20 cases have been reported in the literature. It presents with a triad of epiphora, medial canthal swelling, and recurrent dacryocystitis. Patients presenting without recurrent dacryocystitis is quite uncommon. This presentation can be confused with secondary nasolacrimal duct obstruction and other non-inflammatory pathologies. Dacryocystorhinostomy with stenting is the treatment employed in most reported cases.Case presentationA 24-year-old male presented with epiphora and medial canthal swelling for 3 years. Examination revealed features of left nasolacrimal duct obstruction. Imaging was suggestive of a cystic, homogenous, non-enhancing lesion in the left lacrimal sac region without bone destruction. Findings were suggestive of dacryocystocele. Patient underwent endoscopic dacryocystorhinostomy without stenting. Postoperatively, the swelling and epiphora resolved. Patient is symptom-free on follow-up.ConclusionIdiopathic dacryocystocele must be considered in evaluation of a medial canthal mass with epiphora without dacryocystitis. Conservative treatment is ineffective. Endoscopic dacryocystorhinostomy is safe and effective.

ENDOSCOPIC ENDONASAL DACRYOCYSTORHINOSTOMY: EXPERIENCE OF HUNDRED CASES

Objective: To determine the success rate of Endonasal Endoscopic Dacryocystorhinostomy (Endo-DCR) in cases of chronic dacryocystitis secondary to primary acquired nasolacrimal duct obstruction (NLDO).
 Study Design: Quasi-experimental study.
 Place and Duration of Study: Department of Oculoplastic Surgery, Armed Forces Institute of Ophthalmology Rawalpindi, from Sep 2018 to Nov 2019.
 Methodology: Endo-DCR under General Anaesthesia was performed on 100 patients of primary acquired nasolacrimal duct obstruction causing chronic dacryocystitis. Post-operatively these patients were checked on first post-op day, then on one week and finally four months after surgery. We removed silicone tubes of all the patients four months after surgery. To ensure patency of lacrimal passage, we did syringing and irrigation of lacrimal system of all cases, at conclusion of the study. We chose absence of epiphora and patent lacrimal system on syringing as indicators of successful procedure.
 Results: Hundred patients (males 37; females 63) were recruited for this study. Mean age of our sample population was 51.1 ± 29 years. Right nasolacrimal duct obstruction cases were 56 whereas left nasolacrimal duct obstruction cases were 44. Subjective improvement i.e., absence of epiphora was found in 90% patients. We got successful irrigation of lacrimal passages (objective improvement) in 94% of patients.
 Conclusion: Endo-DCR yields comparable results to external Dacryocystorhinostomy (Ex DCR). It offers additional benefits of esthetically better outcome, lesser complication rate and short surgery and patient recovery time.

Osteoma of maxillary sinus: A rare cause of epiphora

Osteomas are fibro-osseous lesions of the nose and paranasal sinuses. We report a case of a 14-year-old girl who presented with complaints of left-sided epiphora along with intermittent mucoid discharge for 6 months. Based on the clinical diagnosis of left nasolacrimal duct obstruction, radiological investigations were done which reported as an osteoma of the left maxillary sinus, compressing the nasolacrimal duct. The patient underwent conventional dacryocystorhinostomy and the tumor was removed. To the best of our knowledge, acquired nasolacrimal duct obstruction due to an osteoma of maxillary sinus is a rare presentation and has been reported only in few literatures.

Primary lacrimal sac diffuse large B-cell lymphoma in a child

We report the case of a 13-year-old boy who presented with a 2-month history of left eyelid swelling, ecchymosis, and epiphora. Magnetic resonance imaging revealed a lobulated lesion in the region of the left lacrimal sac extending to the left nasolacrimal duct. Biopsy revealed diffuse large B-cell lymphoma of the lacrimal sac. Chemotherapy was initiated, consisting of rituximab, methotrexate, cytarabine, doxorubicin, cyclophosphamide, and vincristine. The lesion resolved within weeks of treatment, and the patient remained disease free at 1year. Primary orbital lymphoma is rare in children; primary diffuse large B-cell lymphoma of the lacrimal sac in a child has not been reported previously.

Vomer Agenesis as a Rare Cause of Hypernasality

Hypernasality which is a rare symptom commonly occurs as a consequence of velopharyngeal insufficiency (VPI). VPI usually manifested as nasal air emission and hypernasal resonance during speech. The cause can be divided into congenital, neuromuscular disorder, and surgical complication. Congenital cause of VPI includes cleft palate, nasal septum malformation such as vomer agenesis, submucous cleft palate, and velar dysplasia, while neuromuscular VPI can be due to cerebral palsy or cerebrovascular accident. The surgical cause of VPI could be due to adenoidectomy and scarring of the velum post palatoplasty in cleft palate repair. We present a 17-year-old man who was diagnosed with congenital left nasolacrimal duct obstruction referred to us for left endoscopic dacryocystorhinostomy in which during nasoendoscopic examination revealed the absence of vomer.

Lacrimal Sac Smooth Muscle Tumor of Uncertain Malignant Potential

A 13-year-old male presented with recurrent left nasolacrimal duct obstruction following endoscopic dacryocystorhinostomy 4 years prior at an outside institution. The past medical history was significant for stage IV neuroblastoma, diagnosed at age 2, requiring surgical resection, induction chemotherapy, autologous bone marrow transplantation and radiation, currently in remission. Preoperative CT scan demonstrated a 2 cm ovoid mass centered in the left lacrimal fossa, consistent with dacryocystocele; however, a solid tumor could not be ruled out. Subsequent surgical exploration of the lacrimal sac revealed a friable, solid mass filling the lacrimal sac, and extending into the duct. The mass was grossly resected with preservation of the lacrimal drainage system and placement of indwelling silicone stents. Histopathology confirmed the diagnosis of smooth muscle tumor of uncertain malignant potential. The patient remained free of epiphora and showed no clinical or radiographic evidence of recurrence at 6 months of follow up.

A rare case of lacrimal sac diverticulum associated with rhinosporidiosis

A 13-year-old female presented with gradually increasing painless swelling of the left lower eyelid for 2 years with no history of watering, ocular trauma, or sinus infection. The swelling (10 mm × 5 mm) was soft, nontender, and free from the skin. The left nasolacrimal duct was patent on syringing. There was regurgitation of serosanguinous fluid from lower puncta on firm pressure over the swelling. Computed tomography scan showed a soft tissue-enhancing mass near the left medial canthus. Dacryocystography revealed diverticulum of the left lacrimal sac. The diverticulum was excised leaving the sac behind. Histopathological examination of the excised mass was found to be infected with rhinosporidiosis. A fistula developed postoperatively discharging spores. Dacryocystectomy with fistulectomy and electrocauterization of the area was done. No recurrence was seen till 12 months follow-up. After PubMed search, we have found only one such case report. We would like to discuss the clinical presentation and management of this rare case.

Rhinofacial Entomophthoromycosis Presenting as a Oronasal Tumor

Abstract Entomophoromycosis is a rare mycotic infection affecting the subcutaneous tissue and nasal mucosa. Entomophthorales are seen in immunocompetent individuals. We present the case of a 22-year-old man who presented with nasal obstruction, unilateral watering from eye, and oral mass. On examination, the patient had an oronasal mass completely filling the left nasal cavity and extending into the left oropharynx. He also had left nasolacrimal duct obstruction. The mass was excised by a combined endoscopic and transoral microscopic approach along with endoscopic dacryocystorhinostomy. Postoperative biopsy was entomophthoromycosis. The patient was put on itraconazole and is on follow-up. This case is unique because of its atypical presentation. We also discuss the nuances regarding its optimal management as per the available literature and how we successfully managed the case.

Educational report: A case of lacrimal sac rhinosporidiosis

ABSTRACTThis article reports a presentation of lacrimal sac rhinosporidiosis and informs the reader of this uncommon but important diagnosis. A 36-year-old man from Pakistan presented with a 3-month history of swelling at the nasal aspect of the left lower lid. This was associated with occasional crepitus and slight localised discomfort, but no epiphora. There was a palpable fullness near the left medial canthus associated with telecanthus but a normal sac washout and normal eye examination otherwise. Previous medical history included an ipsilateral nasal polypectomy and inferior meatal antrostomy around 10 years previously, whilst living in Pakistan. Various imaging modalities were useful in identifying a soft tissue mass within the left nasolacrimal duct. Following excision biopsy, histological examination confirmed the presence of rhinosporidiosis, likely caused by the organism Rhinosporidium seeberi. Rhinosporidiosis should be considered as a potential cause in any case of lacrimal sac pathology. Imaging studies may be helpful in measuring the extent of disease, although histological examination is required to confirm the diagnosis. Although rare, the complications of rhinosporidiosis can be potentially blinding or fatal. As discussed in this case, the presence of telecanthus may represent a lacrimal system tumour, either malignant or benign, and should always prompt further investigation.

Inferior Canaliculi Punctal Granuloma of the Lacrimal System: A Case Report

Pyogenic granuloma of the eyes usually occurs after ocular surgery or inflammation related to the eyes, itself. This lesion is commonly related to procedures associated with chalazia, strabismus, or even enucleation. However, the incidence of pyogenic granuloma that arises directly from the lower canaliculi of the nasolacrimal system is rare and not being extensively reported. We report a case of an elderly lady who presented with pyogenic granuloma post EDCR with silicone stenting for left nasolacrimal duct obstruction. She presented with persistent left eye epiphora following procedure. The unusual site for pyogenic granuloma and it occurrence after EDCR raise the possibility that the condition is related to previous procedure and the material being used.

Diode laser photoablation to correct distal nasolacrimal duct atresia in an adult horse

An 8-year-old Hanoverian mare was presented for chronic mucopurulent discharge in the left eye, which was responsive to topical antibiotic therapy. The nasolacrimal orifice was absent in the left nasal meatum, and anterograde irrigation of left nasolacrimal duct was not possible. Dacryocystorhinography was performed and revealed about 4-6 cm of distal nasolacrimal duct atresia. A novel technique was attempted with the horse under standing sedation using an urinary catheter and a 980 nm diode laser with a 600 μm diameter flexible bare quartz fiber. A nasolacrimal orifice was successfully created by ablating the nasal mucosa directly over the tip of the urinary catheter, and patency was maintained with a soft catheter sutured in place for 4 weeks. At 3 months re-evaluation, the left nasolacrimal duct was patent and functional. This case report describes a successful novel surgical technique used to correct congenital distal nasolacrimal duct atresia in an adult horse under standing sedation. Advantages over conventional surgical techniques are shorter operating time and limited hemorrhage.

New TASER injuries: lacrimal canaliculus laceration and ethmoid bone fracture

The TASER is a non-lethal conducted electrical weapon intended to incapacitate a person. The growing use of the TASER has resulted in an increased risk of injuries, including those to the face. We report a case of lacrimal canaliculus laceration and ethmoid bone fracture caused by an extra penetration (XP) TASER X26 dart. A 35-year-old was subdued with a TASER head shot; the probe was discharged into the left medial canthus without causing any ocular lesions. A computed tomography scan revealed the probe to be embedded in the left nasolacrimal duct and showed a displaced ethmoid fracture. The barbed dart had sectioned the inferior lacrimal canaliculus without electrifying the lesion. This case expands the knowledge of injuries that may occur as a result of the use of this device and the management of peri-ocular TASER injuries.

Dacryocystorhinostomy Precipitating Keratoconjunctivitis Sicca in Aplasia of Lacrimal and Major Salivary Glands (ALSG)

We report a 16-month-old girl referred for bilateral epiphora and sticky eyes since birth. Examination revealed a refluxible left lacrimal sac mucocele, agenesis of the left lower punctum, and agenesis of both puncta on the right side. Complete bony obstruction was noted on probing of the left nasolacrimal duct. At 4 years of age, she underwent left external dacryocystorhinostomy (DCR) with silicone intubation because of chronic dacryocystitis. Her epiphora and stickiness improved significantly in the first postoperative year, but she subsequently developed dryness of the left eye, dry mouth, and dental caries. CT and MRI scans revealed the absence of the lacrimal and salivary glands. The clinical signs and symptoms improved with plugging the left upper punctum and topical lubricants. Aplasia of the lacrimal and salivary glands may present with symptoms of congenital lacrimal obstruction, and failure to make an early diagnosis will result in inappropriate lacrimal surgery and dry eye.

Sinonasal Myxoma in an Infant

Myxomas of the maxillofacial region are neoplastic entities of mesenchymal origin most often associated with odontogenic origin; sinonasal myxoma is rare, located in the nasolabial region and originating from the sinonasal tract. The aim of the current study was to report a well-documented case of sinonasal myxoma in a 12-month-old boy, initially presenting with obliteration of his left nasolacrimal duct. A soft-tissue mass of the nasobuccal groove, firmly attached to the underlying bone, was revealed. After biopsy where benign fibroblastic elements were found, the tumor was removed surgically in wide margins, whereas great care was taken to reconstruct the involved adjacent anatomic structures and preserve facial aesthetics. Histopathologic findings were compatible with an extragnathic, nonodontogenic sinonasal myxoma originating from the nasolacrimal duct. The clinical significance of the case presented was its rather rare location and origin. Three and a half years postoperatively, functional and aesthetic results were satisfactory with no sign of recurrence. To the authors' knowledge, this is the second youngest reported case in the literature.

Use of an image-guided navigation system for insertion of a Lester-Jones tube in a patient with disturbed orbito-nasal anatomy

Image-guided navigation systems are increasingly used in orbito-facial surgery where advanced pre-operative image manipulation and intra-operative localisation have proved invaluable. We describe the novel use of one such system for Lester-Jones tube placement to the contralateral nasal space in a 54-year-old man with left nasolacrimal duct obstruction following left rhinectomy, hemi-maxillextomy, radiotherapy and reconstruction for a left sinonasal squamous cell carcinoma. Reconstruction included a vascularised iliac crest graft, titanium mesh implant and polyaryletheretherketone (PEEK) maxillo-orbital implant. Pre-operative image analysis was used to determine the required tube length to extend to the right nasal space. Passive optical tracking facilitated intra-operative localisation of suitable entry and exit sites for the tube to avoid the orbital implants and achieve drainage into the contralateral nasal cavity. Free drainage and good positioning of the tube was confirmed by nasal endoscopy. This case supports a role for image-guided navigation in complex lacrimal surgery, particularly in cases with distorted anatomy.

Thalassemia major in a child with Dubowitz syndrome

To the Editor: Dubowitz syndrome (DS) is an autosomal recessive disorder of growth retardation, microcephaly, mental retardation, and eczema 1 with a variable phenotypic spectrum. It also involves the skin, eyes, teeth, musculoskeletal, urogenital, cardiovascular, and immune systems 1. The diagnosis is based on the characteristic phenotypic features. Although, various hematological [aplastic anemia 2 acute lymphocytic leukemia 3] and malignant disorders [lymphoma 4, neuroblastoma 5, embryonal rhabdomyosarcoma 6] are associated, hemoglobinopathies has never been reported with DS. A 3½ month male was the first born to healthy unrelated parents at term gestation. The antenatal period was uneventful. At birth the child had a weight of 3 kilogram (kg) (z-score −0.73), Occipitofrontal circumference (OFC) was 36 centimeter (cm) (z-score 1.21) and the length was 50 cm (z-score 0.06). At 3 1/2 months the weight was 3.5 kg (z-score −4.62), length 55 cm (z-score −3.17) and OFC 39 cm (z-score −1.30). There was no significant family history. The child had a high sloping forehead, sparse eyebrows, hypertelorism, telecanthus, blephropimosis, left sided ptosis, left nasolacrimal duct blockage, flat and broad nasal bridge (Figure 1A), low set posteriorly angulated ears, high arched palate, left hand simian crease, clinodactyly, bilateral partial cut syndactyly of second/third toes with overlapping crowded toes (Figure 1B). The systemic examination including joints, skin, and genitalia were normal. The diagnosis of DS was considered on the basis of the phenotypic features. Thyroid function tests, lipid profile, karyotype, and FISH analysis were within normal limits. Five millimeter osteum secundum ASD was detected on echocardiography. Chromosomal breakage studies did not show any spontaneous or induced breaks. At 5 months of age there was increasing pallor and hepatosplenomegaly. The hemoglobin was 5.5 g peripheral smear showed microcytic hypochromic anemia, teardrop cells and nucleated RBC's. MCV was 57 fl. Hemoglobin electrophoresis by HPLC (high performance liquid chromatography) was suggestive of TM (HbF = 78%; HbA2 = 3%; HbA = 19%). Both parents were found to have thalassemia trait with presence of 619 bp deletion in the father and IVS 1–5 in the mother. The child was a compound heterozygote with both the mutations. Clinical photographs of the child. A: Facial appearance. Note sparse eyebrows, hypertelorism, blephropimosis, left sided ptosis, flat and broad nasal bridge. B: Feet of the child with cutaneous partial syndactyly of the second and third toes with crowded overlapping toes. Our patient had typical findings of DS. Absence of eczema and cryptorchidism does not rule out DS since this is seen in only 60% and 18% cases, respectively 1. There is no laboratory confirmatory test for DS. Neither the gene location nor the pathogenesis is yet known. Chromosomal breakage (spontaneous or after clastogenic stress) 7 and defects in cholesterol biosynthetic pathway or transport have also been reported 8. Sister chromatid exchanges have been shown to be normal 1. Whether this represents a chance association in a family with high carrier rate of thalassemia or is an associated gene defect is unclear.

Visualization of nasolacrimal drainage system after radioiodine therapy in patients with thyroid cancer

The objective of this study was to report three cases with an accumulation of (131)I in the nasolacrimal duct after radioiodine therapy for papillary thyroid cancer. A whole-body scan was taken 3 days after the administration of 3.7 GBq of (131)I. Single-photon emission computed tomography (SPECT)/CT images were added when the location of a focal tracer uptake was undetermined on whole-body scans. In case 1, a 62-year-old woman complained of epiphora of the left eye after nine radioiodine therapies with a cumulative dose of 31.08 GBq. The left nasolacrimal duct was visualized at her tenth treatment with (131)I. In case 2, a series of three radioiodine therapies had been given to a 73-year-old woman with a cumulative dose of 11.1 GBq. The accumulation of (131)I was noted in the left nasolacrimal duct at her fourth treatment. She complained of epiphora of the left eye. In case 3, bilateral nasolacrimal ducts were visualized at the second radioiodine therapy in a 75-year-old woman. The patient had received 3.7 GBq of (131)I at the first therapy. She did not complain of epiphora. It is possible that radiation from (131)I that is secreted in tears and/or actively accumulated in the nasolacrimal duct may induce nasolacrimal duct obstruction. (131)I in tears would be responsible for the visualization of nasolacrimal duct in the first two cases. (131)I actively accumulated in the nasolacrimal duct might have been visualized in the third case. In summary, (131)I is excreted in tears and is actively accumulated in the nasolacrimal duct. Obstruction of the lacrimal drainage system could occur after high-dose radioiodine therapy.

Reactive Lymphoid Hyperplasia of the Nasolacrimal Duct Presenting as Bloody Epiphora

A 90-year-old man reported a 1-year history of tearing and irritation in the left eye. Ophthalmic examination was significant for bloody mucopurulent material expressed from the left nasolacrimal duct. The patient underwent external dacryocystorhinostomy with excision of a soft-tissue mass. Initial histopathologic examination of the specimen revealed an atypical lymphoid infiltrate. Subsequent immunohistochemistry suggested that the mass was reactive lymphoid hyperplasia. Lymphoid hyperplasia should be considered in the differential diagnosis of bloody epiphora, in addition to primary malignancy of the nasolacrimal duct, hematologic abnormalities, coagulopathies, vascular tumors, and giant papillary conjunctivitis.

Characteristics of lacrimo-auriculo-dento-digital (LADD) syndrome: Case report of a family and literature review

We describe a family with lacrimo-auriculo-dento-digital syndrome (LADD). A 13-year-old boy had cup-shaped ears, deafness, unilateral choanal atresia, bilateral nasolacrimal duct obstruction, xerostomia, alacrima due to congenital absence of lacrimal glands, agenesis of salivary glands, chronic dacryocystitis, keratoconjunctivitis sicca, ptosis, nail dysplasia of the thumb, shortness of fifth toe, temporal bone abnormality and epilepsy. His younger sister had shortened middle phalanx of fifth digits. His middle sister had hypodontia, shortened distal phalanx of fifth digit, agenesis of salivary glands, mild hearing loss and exotropia. His older sister had left nasolacrimal duct obstruction and aplasia of both parotid glands. The oldest sister had hypodontia and divergent excess exotropia. His mother had hypodontia. These findings are consistent with LADD syndrome. An autosomal dominant pattern of inheritance with variable expressivity has been demonstrated. Renal and uro-genital anomalies have been noted variably.