Saitoh et al., J Otol Rhinol 2015, S1:1
http://dx.doi.org/10.4172/2324-8785.S1-010
Case Report
Journal of Otology &
Rhinology
A SCITECHNOL JOURNAL
Endoscopic Marsupialization of
Adult Nasolacrimal Sac Mucocele:
Reports of Two Cases
the anterior orbit that expanded into the nasolacrimal sac (Figure 1).
Successful endoscopic marsupialization of the mucocele was
performed. The anterior wall of the mucocele was located at the
lacrimal fossa. First, using a sickle knife, a mucosal flap was fashioned,
which was dissected and raised laterally.
Tatsuya Saitoh, Junko Murata and Katsuhisa Ikeda*
Department of Otorhinolaryngology, Juntendo University Faculty of Medicine,
Tokyo, Japan
*Corresponding
author: Dr. Katsuhisa Ikeda, MD, 2-1-1 Hongo, Bunkyo-ku,
Tokyo 113-8421, Japan, Tel: +81-3-5802-1094; Fax: +81-3-5689-0547; E-mail:
[email protected]
Rec date: Nov 17, 2014 Acc date: Feb 25, 2015 Pub date: March 06, 2015
Abstract
Background:
Adult
nasolacrimal
sac
mucocele,
dacryocystocele, is a rare complication of chronic dacryocysitis.
Study design and methods: Case report
Case presentation: We report two adult cases in which
epiphora and a bluish cystic mass was located inferior to
medial canthus. Nasolacrimal sac mucocele in both cases was
successfully cured by endoscopic marsupialization.
Figure 1: Computed tomographic scan images in case 1. Axial view
(A) shows a cystic dilatation of the left lacrimal sac (an arrow).
Coronal view (B) shows a low-density mass (arrow) on the inferior
medial side of the anterior orbit, which expands into the
nasolacrimal sac.
Conclusions: The successful outcomes were obtained by
endoscopic marsupialization of the nasolacrimal sac mucocele.
Keywords: Adult nasolacrimal sac mucocele; Bluish cystic mass;
Endoscopic marsupialization
Abbreviations:
CT: Computed tomography
Introduction
Dacryocytocele, nasolacrimal sac mucocele, is defined as a
distended lacrimal sac with bluish cystic swelling at and below the
medial canthal area accompanied by epiphora. This sac is initially
filled with mucoid material and often becomes secondarily infected.
Most of the case reports are concerned with congenital onset [1-4].
However, adult nasolacrimal sac mucocele is an uncommon mass
arising in the medial canthal region of the orbit [5-8]. Furthermore,
endoscopic approaches to treating the mucocele have rarely been
reported [5]. We present two cases of adult nasolacrimal sac mucocele
treated by endoscopic marsupialization.
Case Presentation
Case 1 was 21-year-old female. Seven years before, she had
experienced left epiphora. A lacrimal sac mass was pointed out by an
ophthalmologist. Stent replacement was performed, but failed in
dispelling the nasolacrimal sac mucocele. Next, the patient was
referred to our clinic. Computed tomographic (CT) scan revealed a
cystic dilatation of the left lacrimal sac on the inferior medial side of
Figure 2: Photograph of the face in case 2. There is a bluish cystic
mass (arrows) below the right medial canthus in the front (A) and
lateral (B) views.
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Citation:
Saitoh T, Murata J, Ikeda K (2015) Endoscopic Marsupialization of Adult Nasolacrimal Sac Mucocele: Reports of Two Cases. J Otol Rhinol S1:1.
doi:http://dx.doi.org/10.4172/2324-8785.S1-010
[1,4]. Several therapeutic modalities have been proposed for the
management of congenital dacryocele such as massage and warm
compress, or immediate probing and irrigation [8,9]. Complicated
congenital dacryocele accompanying infection, recurrent episodes and
respiratory difficulty are indications for surgical intervention such as
by marsupialization [2].
Figure 3: Computed tomographic scan images in case 2. Axial view
(A) shows a cystic dilatation of right lacrimal sac (an arrow).
Coronal view (B) shows a low-density mass (an arrow) on the
inferior medial side of the anterior orbit, which expands into the
nasolacrimal sac.
Then, the bony wall of the exposed mucocele was removed using a
high-speed diamond burr or cutting forceps and the content of the
mucocele was suctioned. The bony cut surface was covered with a
mucosal flap. No recurrence was observed after the 36 months followup.
Case 2 was a 30-year-old male who complained of a mass that had
devoped in the medial canthal region 2 months before (Figure 2). CT
scan demonstrated a cystic dilatation of the right lacrimal sac on the
inferior medial side of the anterior orbit, which expanded into the
nasolacrimal sac (Figure 3). The patient had a past history of StevensJohnson syndrome, which is thought to cause distension of the
lacrimal sac through distal nasolacrimal duct obstruction and
functional proximal obstruction at the junction of the common
canaliculus sac. Although nasolacrimal stent replacement was difficult
to perform, endoscopic marsupialization was successfully performed.
No recurrence was recognized postoperatively for 24 months.
Discussion
Adult nasolacrimal sac mucocele is an uncommon mass arising in
the medial canthal region of the orbit. Adult dacryocystocele has the
same clinical characteristics as congenital dacryocele, including bluish
medial canthal swelling, epiphora, purulent conjunctival discharge and
facial cellulites. However, there are differences in natural history,
mechanism, and treatment for the mucocele formation.
The mechanism of congenital dacryocele is thought to be distension
of the lacrimal sac resulting from distal nasolacrimal duct obstruction
and functional proximal obstruction at the junction of the common
canaliculus and sac [2]. Another postulated mechanism includes
kinking of the common canaliculus due to a distended lacrimal sac
and malfunction of the valve of Rosenmuller, the entrance of the
common canaliculus into the lacrimal sac, secondary to edema and
inflammation [3]. In children, nasolacrimal sac mucocele is presumed
to be related to failed canalization of the valve of Hasner, which might
result from secondary occlusion, possibly following local inflammation
Volume S1 • Issue 1 • S1-010
Adult nasolacrimal sac mucocele is related to acquired nasolacrimal
duct obstruction. In the presence of chronic distal obstruction of the
nasolacrimal duct, reflux inhibition is established by several
mechanisms. The mucosal swelling resulting from chronic
inflammation in the area of the valve of Rosenmuller may prevent
reflux drainage from the sac, and lateral swelling of the sac displaces
the canaliculi and may cause further compression or closure of the
internal common punctum. With time or in the presence of infection,
the proximal exit becomes sealed and an encysted dacryocystocele is
formed [7]. Adult nasolacrimal sac mucocele has the complication of
chronic dacryocystitis. Therefore, surgical intervention is
recommended. In our experience, successful outcomes were obtained
by endoscopic marsupialization of the mucocele in cases of treatment
failure by nasolacrimal stent replacement.
Conclusions
Adult nasolacrimal sac mucocele is an uncommon mass resulting
from a complication of chronic dacryocystitis. Successful outcomes
were obtained by endoscopic marsupialization in cases of treatment
failure by nasolacrimal stent replacement.
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