Symptomatic bilateral nasolacrimal duct cysts in a newborn. (Rhinoscopic Clinic).

A full-term baby boy born during an uncomplicated cesarean section was noted to have moderate respiratory distress soon after delivery. He was tachypneic and noted to be using accessory muscles of respiration. He had intercostal retractions and was breathing abnormally through his mouth and pursed lips, although his oxygen saturation level did not fall below 99%. His respiratory distress increased with feeding, and he was feeding poorly. His arterial blood gas level was normal.

Over the course of the next day, the patient was noted to have a bilateral purulent ocular discharge, which grew Hemophilus influenzae and alpha-hemolytic streptococci on culture. When his respiratory distress worsened, an oral airway tube was placed, and his breathing difficulty resolved immediately.

Flexible nasal endoscopy revealed that the choanae were patent bilaterally, but cystic swelling was noted under both inferior turbinates. The cysts appeared to displace the turbinates medially, leading to a near-complete bilateral nasal obstruction. The patient was taken to the operating room, where rigid nasal endoscopy confirmed the bilateral nasolacrimal duct cysts (figure 1). Both cysts were endoscopically marsupialized, and the inferior turbinates were outfractured. Following the procedure, a marked improvement was seen in the patency of the nasal airway (figure 2). The patient did well postoperatively, and his respiratory distress resolved completely. He was discharged home several days later, and he has not exhibited any further symptoms.

Congenital obstruction of the nasolacrimal drainage system is common, but symptomatic cases are rare. Nevertheless, this condition must be included in the differential diagnosis of any infant with nasal obstruction. The incidence of nasolacrimal drainage system obstruction in newborns is approximately 30%, but epiphora occurs in only 6%. (1) The most common site of obstruction is the most distal part of the duct near its exit into the nose. (2) Symptoms of congenital nasolacrimal duct obstruction can be present at birth, but they usually appear a few weeks later as tear production matures. The obstruction can be bilateral, but it is usually unilateral. (3)

Congenital dacryocystocele is an uncommon variant of nasolacrimal duct obstruction. It is also known as congenital mucocele, amniotocele, or amniocele. Congenital dacryocystocele is characterized by a bluish-gray cystic swelling just below the medial canthus, which is caused by distention of the nasolacrimal sac. If conservative measures (e.g., cyst massage) are not successful, probing of the duct is often effective.

An even less-common anomaly is cystic dilation of the lower end of the nasolacrimal duct with intranasal extension. In such cases, the bluish-gray cyst arises beneath the inferior turbinate. A large nasolacrimal duct cyst can fill the nasal cavity and lead to nasal obstruction. The cyst might also displace the inferior turbinate medially toward the nasal septum. Because infants are preferential nose breathers, this displacement can cause significant respiratory distress, manifested as cyanosis, labored breathing, and poor feeding. (4) These symptoms usually diminish with crying, and they can be temporarily relieved by inserting an oral airway tube to bypass the obstruction.

The treatment of choice for a symptomatic nasolacrimal duct cyst is endoscopic marsupialization or resection, which is usually curative. Outfracturing of a medially displaced inferior turbinate might further improve the patency of the nasal airway.

References

(1.) Berkowitz RG, Grundfast KM, Fitz C. Nasal obstruction of the newborn revisited: Clinical and subclinical manifestations of congenital nasolacrimal duct obstruction presenting as a nasal mass. Otolaryngol Head Neck Surg 1990;103:468-71.

(2.) Calhoun JH. Problems of the lacrimal system in children. Pediatr Clin North Am 1987;34:1457-65.

(3.) Wagner RS. Management of congenital nasolacrimal duct obstruction. Pediatr Ann 2001;30:48l-8.

(4.) Mazzara CA, Respler DS, Jahn AF. Neonatal respiratory distress: Sequela of bilateral nasolacrimal duct obstruction. Int J Pediatr Otorhinolaryngol l993;25:209-l6.

From the Division of Otolaryngology-Head and Neck Surgery, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, and the Department of Otolaryngology-Head and Neck Surgery, Hackensack (N.J.) University Medical Center.