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Arch Ophthalmol. 2003;121:1065-1066.

Nasolacrimal duct mucoceles (NLDMs) are encountered almost exclusively in the pediatric population.^1-3 Recognition of a mucocele associated with nasolacrimal duct obstruction is important, as its presence dictates alternate management. In this report, we describe an unusual occurrence and the management of an NLDM found in conjunction with lacrimal drainage obstruction in an adult, emphasizing the need for thorough evaluation of the nasal passage in not only pediatric but also adult patients.

Report of a Case
A 51-year-old white woman was evaluated for right eye epiphora and progressive ipsilateral nasal congestion of 3 years' duration. She denied epistaxis, facial fracture, malignancy, and known sinus or nasal diseases. Ophthalmic examination findings were only notable for an increased right eye tear lake. Findings from the remainder of the right eye examination and the entire left eye examination were unremarkable, including normal eyelid position and structure, with all puncta patent, and no palpable lacrimal sac distention or mass. Dye disappearance was markedly delayed on the right eye; nasolacrimal duct obstruction was confirmed with irrigation. Intranasal examination revealed a mass located below the inferior turbinate. Computed tomography demonstrated a fluid-filled cyst and ipsilateral nasolacrimal duct dilation (Figure 1). There was no radiographic evidence of sinus disease.

View larger version (81K): [in this window] [in a new window] Figure 1. Computed tomography demonstrating a right inferior meatus cystic mass.

Endoscopically, a smooth, nodular, light pink mass was found below the inferior turbinate (Figure 2). Following marsupialization with mucosal wall resection, the lacrimal drainage system irrigated freely, and a bicanalicular stent was placed. Histologically, the excised tissue consisted of chronically inflamed ciliated columnar epithelium with goblet cells and submucosal fibrosis consistent with a mucocele. Postoperatively, she was treated with an oral antibiotic (cephalexin hydrochloride), nasal decongestant (oxymetazoline), and a topical antibiotic/steroid drops (tobramycin/dexamethasone). The stent was removed after 3 months, and she remains asymptomatic 1 year postoperatively.

View larger version (66K): [in this window] [in a new window] Figure 2. Endoscopic view of right nasolacrimal duct mucocele (arrow).

Comment
We describe an adult patient with an NLDM, managed with marsupialization and stent placement, thus avoiding a more involved dacryocystorhinostomy. Inferior meatus masses, which secondarily cause nasolacrimal duct obstruction, are infrequently encountered.⁴ The occurrence of NLDMs, which results from—as opposed to causes—lacrimal drainage obstruction, is vanishingly rare. In an adult patient, an NLDM extending beneath the inferior turbinate has not previously been encountered in our practices, and we are unaware of any published reports.

In children, NLDMs are presumed to relate to failed canalization of the valve of Hasner and, in this case, might have resulted from secondary occlusion, possibly following local inflammation.^1-3 Although early treatment of NLDMs in infants has been advocated to prevent complications, including infection and airway obstruction, there is no consensus on optimal therapy. Several treatment modalities have been proposed for the management of NLDMs in children and usually involve nasolacrimal probing and intranasal mucocele marsupialization with mucosal wall resection.^1-3 Resolution has also been described with conservative management, including nasal decongestants and observation.^1-3 The adult patient described in this report was successfully treated with endoscopic mucocele marsupialization with partial mucosal wall resection and stent placement.

As emphasized by this case, despite its rarity, a mucocele should be considered in adult patients with nasolacrimal duct obstruction, and an intranasal examination should be performed prior to dacryocystorhinostomy. Similar to pediatric patients, mucocele marsupialization with stent placement seems to be appropriate therapy.

AUTHOR INFORMATION
The authors have no relevant financial interest in this article.

Chee-Chew Yip, MMed(Ophth), FRCSEd
Cincinnati, Ohio

Timothy J. McCulley, MD
Irvine, Calif

Robert C. Kersten, MD; Adam T. Bowen, MD; Suhail Alam, MD; Dwight R. Kulwin, MD
Cincinnati

Corresponding author: Timothy J. McCulley, MD, Department of Ophthalmology, University of California College of Medicine, 118 Med Surge I, Irvine, CA 92697-4375 (e-mail: tmcculle{at}uci.edu).

REFERENCES
1. Yee SW, Seibert RW, Bower CM, Glasier CM. Congenital nasolacrimal duct mucocele: a cause of respiratory distress. Int J Pediatr Otorhinolaryngol. 1994;29:151-158. PUBMED 2. Meyer JR, Quint DJ, Holmes JM, Wiatrak BJ. Infected congenital mucocele of the nasolacrimal duct. AJNR Am J Neuroradiol. 1993;14:1008-1010. ABSTRACT 3. Edmond JC, Keech RV. Congenital nasolacrimal sac mucocele associated with respiratory distress. J Pediatr Ophthalmol Strabismus. 1991;28:287-289. PUBMED 4. Baron EM, Kersten RC, Kulwin DR. Rhabdomyosarcoma manifesting as acquired nasolacrimal duct obstruction. Am J Ophthalmol. 1993;115:239-242. ISI | PUBMED

SECTION EDITOR: W. RICHARD GREEN, MD

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