The role of routine nasolacrimal sac biopsy during endoscopic dacryocystorhinostomy

Abstract

Objectives/Hypothesis Most patients who undergo endoscopic dacryocystorhinostomy (DCR) have a diagnosis of idiopathic nasolacrimal duct obstruction. The purpose of this study was to examine the impact of routine biopsy of the lacrimal sac performed at time of DCR on subsequent patient diagnosis and treatment. Study Design Retrospective review. Methods The histopathology of nasolacrimal specimens (n = 769), obtained from 654 consecutive patients undergoing endoscopic DCR by a single surgeon over a 30‐year period, were reviewed. Specific focus included the identification of unanticipated pathologic findings as they related to pertinent patient demographics, clinical presentation, radiologic findings, and intraoperative observations. Results The study population was 69.6% female, with an average age of 56.1 ± 18.2 years. Pathological findings of tissue from the nasolacrimal sac, which was routinely sampled in all cases, showed inflammation (n = 566 [73.6%]), normal histology (n = 147 [19.1%]), granulomas (n = 8 [1.0%]), and neoplastic process (n = 7 [0.9%]). Patient history, preoperative CT scan, and/or intraoperative findings alerted the surgeon to the possibility of an unusual diagnosis in 12 of the 15 patients. An unsuspected neoplastic or granulomatous cause of lacrimal obstruction was identified on intraoperative biopsy in three patients (0.46%). Conclusions Although neoplastic and granulomatous diseases are relatively rare causes of lacrimal obstruction necessitating DCR surgery, they may be identified by through patient evaluation in most cases and by routine intraoperative biopsy of the lacrimal sac in all cases. Level of Evidence 4 Laryngoscope, 130:584–589, 2020

The predictive value of nasolacrimal sac biopsy in endoscopic dacryocystorhinostomy

“…Only one case had neoplasm (2%) in our study which coincides with the previous literatures that reported 0%–2.3% [ [ 2 , 6 , 7 , [26] , [27] , [28] , [29] ]]. However, the unexpected rate of neoplasms and granulomatous pathology in Banks et al [ 21 ] series was only 0.46% (n = 3 of 728 lacrimal sac specimens). They added that the patient's history, endoscopic assessment, CT imaging and intraoperative results were not indicative of neoplastic or granulomatous inflammation in all three unexpected instances.…”

“…The high resolution of nasal endoscopes enables for outstanding visualization of the interior sac through endoscopic DCR that can provide clinicians with valuable knowledge on lacrimal pathology that has gone undetected [ 21 ].…”

“…In Banks et al [ 21 ], their neoplastic cohort had an average age of >70 years, while granulomatous disease patients had an average age of <45 years. The granulomatous cohort's age range was 31–63 years, which corresponded to the well-known bimodal sarcoidosis distribution [ 23 , 24 ].…”

Nasolacrimal Duct Obstruction: An Unusual Presentation of Sarcoidosis

“…5,6 Merkonidis et al reported that only 1% of DCR patients were found to have sarcoidosis on pathologic examination; Banks et al reviewed histopathology of the lacrimal sac after 769 consecutive endoscopic DCRs and found only 10 cases of sarcoidosis. 5,6 Avisar et al in 2012 had 12 cases of sarcoidosis with NLD that required endoscopic DCR; 11 of these patients were already diagnosed with sarcoid prior to their operations. 7 Literature review of sarcoidosis-related NLD reveals that most cases are unilateral on presentation; however, Banks et al found that 3/10 patients with sarcoidosis presented bilaterally.…”

Epithelial–Myoepithelial Carcinoma of the Lacrimal Sac and Literature Review of the Lacrimal System

“…A recently published retrospective review by Banks et al found that an unsuspected neoplastic or granulomatous cause of lacrimal obstruction was identified on intraoperative biopsy in only 0.46% of cases, compared with 0% to 2.3% reported in the literature. 14 The senior authors only perform biopsies if there is a visible mass or thickened lacrimal sac flaps.…”