Chronic lacrimal sacculitis – can be treated surgically by rhinologists Keywords: tear overflow, nasal endoscopic lacrimal sac stoma, chronic lacrimal sacculitis Tips: Chronic lacrimal sacculitis is a common ophthalmological disease, the main symptom is tear overflow, which used to be mostly treated by ophthalmology. With the development of nasal endoscopic surgery, transnasal dacryocystostomy has become an important surgical method for the treatment of lacrimal obstructive diseases, and the technique is becoming more and more mature with positive results. The patient, a 52-year-old female, had a history of recurrent lacrimation and pus in the left eye with localized swelling and pain for 6 months in 2010, with severe conjunctival congestion, no generalized fever, no blurred vision, diplopia and decreased visual acuity, and no significant discomfort in the right eye. 2 years ago, she had a history of nasal surgery. The patient had been treated intermittently in the ophthalmology clinic, including ocular spotting, lacrimal flushing and probing, and oral antibiotics, but the symptoms always recurred. The ophthalmologist considered it as left nasolacrimal duct obstruction and chronic purulent dacryocystitis and suggested to seek surgical treatment from a rhinologist as soon as possible. The patient visited me with some questions. Patient: Dr. Yuan, what kind of disease is dacryocystitis and is it harmful to me? Doctor: Chronic dacryocystitis (chronic dacryocystitis) is the most common disease of the lacrimal sac, often due to obstruction of the nasolacrimal duct. Nasolacrimal duct obstruction can be secondary to trachoma, chronic rhinitis and sinusitis, nasal septum curvature, facial trauma or nasal surgery. When the nasolacrimal duct is obstructed, tears accumulate in the tear sac and cannot be drained into the nasal cavity. Bacteria within the tears multiply in the tear sac and infect the mucosa, producing mucus or purulent secretions, the most common pathogenic bacteria are pneumococcus, streptococcus and staphylococcus. The nasolacrimal ducts of women are more susceptible to dacryocystitis because they are more elongated than those of men. Chronic lacrimal dacryocystitis can be divided into several types: catarrhal lacrimal dacryocystitis, mucous cysts and chronic purulent lacrimal dacryocystitis. After the disease, most complain of tear overflow, eye discharge increases, squeeze the affected eye inner canthus with mucous or purulent discharge from the tear dots, can be accompanied by tear caruncle, semilunar valve and inner canthus conjunctival congestion. Sometimes a hemispherical elevation of the inner canthus skin may be formed, which is hard to touch and a large amount of mucus discharge may be released after squeezing. If the eye is traumatized or if internal eye surgery is performed, septic infection can easily occur and bacterial corneal ulcers or septic endophthalmitis can occur. Chronic dacryocystitis can also have recurrent acute attacks, which are characterized by localized skin redness, hardness, and significant pressure pain, and inflammation that can extend to the eyelids, nasal roots, and cheeks, sometimes forming localized fistulas and, in severe cases, systemic symptoms such as chills and fever. This is why ophthalmologists often refer to chronic dacryocystitis as a “ticking time bomb next to the eye”. Figure 1: Chronic dacryocystitis Patient: I had a nasal endoscopic surgery two years ago for a left nasal sinus invagination papilloma, and a year ago my left eye started to tear, and in the last six months it started to flow mucus and pus repeatedly. Doctor: trauma and nasal surgery is can cause damage and obstruction of the nasolacrimal duct, blocking the normal drainage channels of tears, it can cause chronic dacryocystitis, because bacteria multiply in the tear sac repeated infection, serious will form chronic purulent dacryocystitis, a potential threat to the eye. Based on the patient’s past surgical history, it may be related to surgery. Nasal sinus invagination papilloma is a benign tumor that is locally aggressive and prone to recurrence with malignant tendency, and it is found in the region of the middle nasal tract and maxillary sinus opening, and is closely related to the nasolacrimal duct, which is sometimes damaged or sacrificed for complete removal of the tumor. Through nasal endoscopy and sinus CT examination, it was confirmed that the patient’s middle and lower nasolacrimal ducts were resected and atretic, thus forming a chronic lacrimal sac. Figure 2: Adhesion of the left middle turbinate stump to the lateral wall of the nasal cavity Figure 3 shows the absence of the left nasolacrimal duct Patient: Lacrimal sacculitis is an ophthalmologic disease, why should I seek surgery with a rhinologist? Is the success rate of surgery high? Doctor: If chronic dacryocystitis cannot be cured by conservative treatment or lacrimal duct flushing and probing, especially if chronic septic lesions are formed, surgery is needed to reconstruct the drainage tract as soon as possible to prevent ocular complications. The most commonly used surgical procedure is nasal lacrimal sac ostomy. The relationship between the lacrimal duct and the nasal cavity can be illustrated: the lacrimal duct includes the lacrimal dots, the lacrimal ducts, the common lacrimal duct, the lacrimal sac and the nasolacrimal duct. The lacrimal sac is located in the lacrimal fossa between the anterior and posterior lacrimal crests and consists of the frontal process of the maxilla and the lacrimal bone. The posterior medial side of the lacrimal sac is bounded by the lacrimal bone and adjacent to the nasal mound airspace and anterior septum, and the lacrimal sac is about 12-15 mm long and 4-7 mm wide, with a blind end at the upper end, 3-5 mm above the medial canthus, and a gradually narrowing lower end that migrates to the nasolacrimal duct. The nasolacrimal duct continues down the lacrimal sac and opens at the tip of the inferior nasal canal, with a total length of 15-20 mm and a diameter of 3-7 mm. Figure 4: Diagram of lacrimal duct anatomy In the past, ophthalmologists mostly used the traditional external nasal method: i.e., external skin incision for lacrimal sac nasal anastomosis treatment, but the external nasal method would leave facial scarring after surgery. With the increasing maturity of nasal endoscopic surgery, ENT surgeons can perform this procedure via the intranasal approach. Endonasal endoscopic lacrimal sac rhinoplasty was first reported by Mc Donogh and Meiring in 1989. This procedure has the following advantages: (1) the medial wall of the lacrimal sac is separated from the anterior chamber of the middle nasal canal by only one layer of bone plate, which makes the intranasal approach the most convenient; (2) the procedure does not require incision of skin, muscle, medial canthal ligament and damage to internal blood vessels, etc., with little intraoperative bleeding and mild postoperative reaction; (3) there are no incisions and scars on the face, which meets the increasing requirements of people for cosmetology and is easily accepted by patients. The success rate of the surgery is relatively high. This surgery has been carried out in our department for more than ten years, and the surgical technique has been very mature. Prognosis: The patient was admitted to the hospital and underwent nasal endoscopic nasal lacrimostomy by a rhinologist, and was discharged 3 days after the operation with anti-inflammatory and lacrimal flushing. The lacrimal flushing was reviewed regularly on an outpatient basis, and the lacrimal cavity was epithelialized and the stoma was patent one month after the operation, and the patient continued to be followed up for one year without recurrence and was cured. The patient was very satisfied and grateful to the ophthalmologist for choosing a good treatment for her. Figure 5: One year postoperative nasal endoscopy, showing a patent stoma Physician’s tip: Nasal endoscopic nasal lacrimal sac anastomosis for chronic dacryocystitis is an ideal surgical procedure for the treatment of chronic dacryocystitis, with minimal tissue damage, no need to cut the medial canthal ligament, little damage to the lacrimal sac and preservation of the lacrimal sac’s pump function, allowing tears to drain in an almost physiological manner, few complications, no scarring on the face, and better long-term results. It is an ideal procedure for the treatment of chronic dacryocystitis and is worthy of clinical application. However, the procedure should be screened and performed by a rhinologist with this endoscopic surgical technique. The success rate of the procedure is reduced if the patient also has lacrimal duct stenosis or a history of previous (laser) surgery.