Unexpected pathologies in patients referred for endoscopic DCR

Abstract

The objective of this study is to describe a series of patients with different pathologies mimicking nasolacrimal duct obstruction (NLDO), diagnosed with the use of a computed tomography (CT) scan prior to a scheduled endoscopic dacryocystorhinostomy (DCR). This study is a retrospective report. We reviewed the medical records of 47 consecutive patients (57 sides) with long-standing epiphora between 2007 and 2012. All patients were referred to our tertiary Medical Center with a diagnosis of NLDO and were expected to undergo endoscopic dacryocystorhinostomy (DCR). They all underwent routine sinus CT scan prior to surgery. All scans, as well as the demographic and medical characteristics of these patients were reviewed. Of all 47 patients enrolled, in 4 patients (7 % of all sides), unexpected pathologies, other than nasolacrimal system distention, inflammation or infection were identified preoperatively. These included squamous cell carcinoma of the lacrimal sac and nasolacrimal duct, rhinoscleroma at Hasner's valve region, a compressing ethmoidal mucocele and a case of dacryocystocele. These unusual pathologies mandated a different management and surgical approach. In all four cases, a preoperative CT scan helped in identifying the pathology and in localizing the lacrimal apparatus in relation to the paranasal sinuses. Different nasal, paranasal and lacrimal pathologies may mimic primary acquired NLDO. A high index of suspicion, a thorough clinical evaluation and utilizing preoperative imaging may lead to an alteration of patient management and to a completely different surgical approach.

The role of routine nasolacrimal sac biopsy during endoscopic dacryocystorhinostomy

“…Although routine preoperative imaging for DCR has been debated in the literature, imaging remains preferable in complex cases, including cases with a history of concurrent sinonasal disease . Golan et al reviewed the clinical history and CT reports of 47 patients with a diagnosis of nasolacrimal duct obstruction prior to DCR surgery.…”

“…Although routine preoperative imaging for DCR has been debated in the literature, imaging remains preferable in complex cases, including cases with a history of concurrent sinonasal disease. 19,20 Golan et al reviewed the clinical history and CT reports of 47 patients with a diagnosis of nasolacrimal duct obstruction prior to DCR surgery. Preoperative CT imaging identified four patients (8%) with unexpected pathologies and recommended imaging in select cases to assist in diagnosis of unsuspected lesions of the lacrimal sac.…”

Avoiding dacryocystorhinostomy in cases of epiphora caused by inferior meatus obstruction

“…Seven out of eight (87%) patients in our series were referred for a computed tomography or magnetic resonance imaging (MRI) as part of their pre-operative evaluation. Although Golan et al [2] have shown the importance of imaging in NLDO patients, it is not routinely preformed in our clinic, and it is reserved for atypical cases, usually in young patients.…”

“…Secondary causes of NLDO are less common and diagnosis may require a more extensive workup. Correct diagnosis of the obstruction site and its nature is essential for choosing a treatment plan and a surgical approach [2]. Recent reports suggest that obstructions of Hasner's valve (inferior meatus, IM) are significantly more common in adults than previously appreciated [3][4][5][6].…”

Preoperative imaging should be performed prior to surgery in all cases of acquired nasolacrimal obstruction–Yes

“…1 It is possible that small tumours intrinsic to the lacrimal sac may not be evident on CT imaging; however, subtle changes such as bony erosion surrounding the nasolacrimal duct may be suggestive of the pathology. 2 When endoscopic DCR is planned, preoperative CT is required if use of a stereotactic image-guided system is anticipated. This three-dimensional navigation system provides intra-operative localization of anatomic structures using magnetic probes and will likely become the norm in the future for both clinical and medico-legal reasons as it can help prevent inadvertent entry into the orbit.…”