Synonyms: Nasolacrimal duct cyst, Amnioticocele, Amniocele.
Dacrycystocele is a cystic lesion involving the tear out flow tract due
to obstruction distal to the level of lacrimal sac. The common site of
obstruction being at the level of nasal end of naso lacrimal duct (i.e.
at the level of inferior turbinate).
1. Failure of complete canalization of the nasolacrimal duct.
The nasolacrimal drainage system starts to develop during the third
month of intrauterine life. It is initially seen as a cord of
epithelium between the maxillary and fronto nasal processes. This cord
of epithelium becomes canalized uniformly throughout its length.
Communication with the inferior meatus occur by the 6th month of
2. Persistence of the membranous barrier at the level of Hasner's valve.
Pathology: For congenital dacryocystocele to occur two things is a must:
1. Imperforate naso lacrimal duct distally and
2. Valve like obstruction at the junction of common canaliculus and lacrimal sac proximally.
a result of this obstruction fluid starts to accumulate within the
nasolacrimal duct system distending it proximally. Distension of sac
compresses the canalicular system further causing a functional trap
door like block. This functional obstruction can be confirmed by using
lacrimal sac probe. No anatomical barrier can be demonstrated when an
attempt is made to probe the nasolacrimal system.
1. Common in female infants
2. Common in whites
These features suggest a genetic predisposition.
dacryocystocele can be unilateral / bilateral. These are cystic
lesions, present at birth. This could infact become apparent during the
first few weeks of life when the tear secretion increases.
infants present with a bluish colored cystic mass in the medial canthal
region. Compression of this cyst with fingers usually fails to result
in the reflux of tears through the lacrimal puncta.
Figure showing a baby with dacryocystoceleInfants with
congenital dacryocystocele are at risk for secondary infection of the
eye / orbit. This is due to the absence of the well defined facial
layer that separates the lacrimal sac from the orbit. This is normally
present in older children and adults.
A combination of acute
dacryocystitis, peri orbital cellulitis / orbital cellulitis in
neonatal age group should raise suspicion of presence of congenital
Congenital dacryocystocele always has a nasal
component. A cystic mass over the inferior meatus. Since infants are
obligate nasal breathers, bilateral naso lacrimal cysts can cause life
threatening airway obstruction, i.e. something similar to choanal
All children with congenital dacryocystocele should have a
complete nasal examination done with a nasal endoscope. This cyst
should be differentiated from nasal dermoid cysts, nasal gliomas etc.
Nasal mass in these patients are soft and compressible when palpated with a nasal probe.
CT scan / MRI scanning: will help in differentiating these lesions from nasal dermoids / meningoencephaloceles.Management:
Depends on whether the dacryocystocele is a complicated or an
uncomplicated one. Uncomplicated dacryocystoceles can be managed
conservatively. Surgery is indicated if it is complicated with acute /
chronic dacryocystitis. If the external medial canthal cyst is large it
can cause corneal astigmatism with the impending risk of amblyopia. If
the intranasal component causes respiratory obstruction then surgery is
a must to save the patient.Role of topical antibiotics: Topical antibiotics can be used to prevent secondary conjunctivitis.
Warm compresses, lacrimal massage, probing of lacrimal duct can be performed to facilitate drainage of tears.Role of probing:
Probing should be attempted only when other conservative procedures
fail. For probing to be effective it should relive both the functional
proximal obstruction and the complete or incomplete distal obstruction.Surgery:1.
Endoscopic marsupialization of nasal component of Dacryocystocele.
After this decompression procedure the proximal one way valve of
Rosenmuller should be able to function normally.