Endoscopic Management of Pediatric Nasolacrimal Obstruction

Simple Congenital Nasolacrimal Duct Obstruction

Spontaneous resolution of CNLDO is seen in 85% to 96% of children by 1 year of age, so conservative management is recommended with lid hygiene, topical antibiotic drops, and a hydrostatic massage known as a Crigler massage. Digital pressure is applied on the common canaliculus with firm downward pressure onto the lacrimal sac to increase hydrostatic pressure, leading to the rupture of the membranous obstruction. There is no definitive consensus on the timing of intervention for children with persistent CNLDO, and probing and irrigation with the patient under general anesthesia is often delayed until 12 months of age and has a success rate of 55% to 95%. Nasolacrimal duct probing is a reliable primary management of CNLDO; however, this blind procedure mainly depends on the surgeon’s knowledge of anatomy and feel of metal-on-metal contact, or proprioceptive intuition, to determine the location and severity of the obstruction and to confirm the passage of the probe through the inferior meatus. Metal-on-metal contact may traumatize the nasal mucosa surrounding the delicate valve of Hasner. The leading factors implicated in the failure of probing include improper technique, anatomic variations, complex NLDO, inferior turbinate impaction or hypertrophy, or associated nasal pathology. Even with positive metal-on-metal touch, false passages can be created, especially in cases of “buried probe” with the nasolacrimal duct extends into the nose down the submucosa for several millimeters or even to the floor without opening into the meatus, or the duct may end in the medial wall of the maxillary sinus blindly. Adjunctive use of the nasal endoscope has revealed a high incidence of false passage creation with this technique; thus nasal endoscopy is now increasingly used with nasolacrimal duct probing to improve the unexplained variable success rate, anatomic anomalies causing difficulty in probe advancement, and difficulty in accurately identifying the variants of CNLDO. In cases of obstruction caused by collapse of the inferior turbinate onto the nasolacrimal duct ostium, medialization, or fracturing, of the turbinate is also required in addition to probing to improve the outflow tract.

The success rate for the first nasolacrimal probing after 13 months of age is 54.7%. Many recommend probing before 13 months of age, as it is theorized that the risk of infection and scarring increases if probing is postponed. Conversely, other studies on conservative treatment have shown that the timing of probing can be postponed while still achieving a safe, satisfactory outcome with comparable success rates until the child reaches the age of 36 months. Additional factors associated with decreased success are severity of symptoms, bilateral symptoms, canalicular stenosis, atony of the lacrimal sac, and nonmembranous obstruction of the nasolacrimal duct (NLD). Repeat probing with intubation of a silicone stent and sometimes balloon catheter dilation are reserved for cases of failure. When the obstruction is refractory to such measures, or in those children with a more proximal NLDO, dacryocystorhinostomy (DCR) is needed. DCRs have been reported in children as young as 12 to 18 months without disturbance of bone growth; it is recommended that this procedure be deferred until the patient is 2 to 5 years old.

Complex Congenital Nasolacrimal Duct Obstruction

Complex CNLDO can results from other causes of obstruction, including bony obstruction, craniofacial deformities such as congenital facial cleft syndrome, cyclopia, and cryptophthalmos. As clefting can causes abnormalities of the soft tissues and bony structures, Tessier cleft types 2, 3, 4 are located in the lower medial canthal and nasolacrimal area and can lead to abnormalities of the nasolacrimal drainage system. Preoperative imaging with computed tomography scanning can be advantageous for surgical planning. The open cleft may preclude the need for endoscopic visualization.

Dacryocele/Dacryocystocele, and Dacryocystitis

Dacryocele typically appears as a bluish cystic mass just below the medial canthal tendon at birth or, as tear production increases, within the first few weeks of life ( Fig. 16.3 ). Epidemiologically, dacryoceles have a female predominance with a possible genetic predilection and occur more frequently in Caucasians than other racial groups. They may be unilateral or bilateral, although bilateral symptomatic presentation is infrequent.

Dacryoceles result from a concomitant upper functional obstruction at the valve of Rosenmüller and a lower anatomic obstruction of the valve of Hasner. The upper functional obstruction occurs at the junction of the common canaliculus and lacrimal sac with a proximal valve-like or trapdoor-like blockage. The distal membranous obstruction results from redundant membranous tissue or imperforation of the nasolacrimal duct with the nasal cavity. The nasolacrimal duct system then becomes distended with an accumulation of tears, mucoid material, and debris to cause the gray-blue cystic swelling at the medial canthus. Affected children are at risk of secondary infection. Dacryocystitis and preseptal cellulitis may develop within days or weeks and require intravenous antibiotics to prevent sepsis ( Fig. 16.4 ). Extension of the dacryocele intranasally may form a cyst below the inferior turbinate and cause nasal congestion. A large cyst can cause respiratory distress during feeding and sleeping, and is potentially life-threatening from airway compromise because neonates are nasal breathers.

In the absence of complicating factors such as infection or airway compromise, initial treatment includes warm compresses, hydrostatic digital massage, and topical antibiotics. In-office digital massage to reduce the cyst can expedite the resolution of a dacryocele. Transcutaneous needle or incisional aspiration is not recommended because of the risk of lacrimocutaneous fistula formation and does not address the underlying etiology. Endoscopic- assisted nasolacrimal probing and irrigation are successful mostly for the treatment of a congenital dacryocele. Direct visualization under endoscopic guidance assists with the removal of redundant mucosa from the lateral wall of the inferior meatus as well as marsupialization and excision of the medial wall of an intranasal cyst. Intubation with silicone stents may also be performed to minimize the postoperative scarring.