A case of endonasal balloon-assisted dacryoplasty after failure of endonasal dacryocystorhinostomy

Asymptomatic stones in the lacrimal canaliculus

Key Clinical Message

Asymptomatic lacrimal canaliculus stones causing many stones without symptoms are rare. The patient recovered well within a week after dacryolith removal. This diagnosis is prevalent in this age group. However, asymptomatic nasolacrimal obstruction should be considered.

Abstract

Dacryoliths, also known as symptomatic stones, are frequently observed in the lacrimal drainage system. These stones manifest through symptoms such as conjunctivitis, discharge, and epiphora. Nevertheless, the occurrence of numerous stones in the lacrimal canaliculus, in the absence of apparent symptoms, is uncommon. In this study, we present a case with the presence of several stones within the inferior lacrimal canaliculus. A female patient, aged 74, appeared with bilateral senile cataracts and was scheduled for cataract surgery. During a standard ocular examination, it was observed that the tear meniscus height in the left eye had a greater magnitude compared with the right eye. Canaliculitis with dacryolith was verified using a series of diagnostic procedures, including physical inspection, fluorescent dye disappearance test, palpation, 50 Mhz ultrasound biomicroscope scan, and irrigation of the lacrimal canaliculi. Upon surgical investigation, the canaliculus obstruction was confirmed, characterized by the existence of many tiny dacryolith formations inside the inferior canalicular system. Following the surgical excision of the dacryoliths, the patient experienced a full remission within a week. While it is common for individuals in this age range to receive this diagnosis, it is important to consider silent nasolacrimal blockage as a potential alternative diagnosis. It is important to note that the presence of dacryoliths in the lacrimal drainage system might manifest independently of conjunctivitis. No discernible risk indicators were found in relation to the aforementioned patient.

Multidisciplinary approach to lacrimal system diseases

Pathologies of the lacrimal drainage system range from benign to malignant lesions. However, independently of the etiological origin, the most common presenting symptom is represented by epiphora due to the dysfunction of the lacrimal system. Different diagnostic tools are now available, but for the most the first diagnostic approach is characterized by an ophthalmological visit, associated with nasal endoscopy, usually performed by an otolaryngologist. Frequently the diagnostic work-up is completed with a radiological exam (e.g. maxilla-facial CT or dacryocystography), whose role is still to be determined. Once a diagnosis has been made, different treatments are available in relation to the type of the disease, and commonly need close cooperation between an ENT and ophthalmic surgeon given the close anatomical structures involved. Taking into account all these aspects, the aim of this review is to highlight how a multidisciplinary approach to lacrimal pathologies is mandatory from diagnosis to treatment in order to offer the best clinical approach.

Long-term results of a balloon-assisted endoscopic approach in failed dacryocystorhinostomies

Purpose

Endoscopic endonasal balloon-assisted dacryoplasty is a minimally invasive surgical approach that can be applied after failure of dacryocystorhinostomy with recurrence of distal acquired lacrimal obstruction.

Methods

At the Department of Otolaryngology, San Raffaele Hospital, Milan (Italy), from December 2016 to October 2020, 14 patients underwent trans-nasal balloon-assisted dacryoplasty after a failed dacryocystorhinostomy (both external and endoscopic endonasal). The routinary pre-operative work-up included multidisciplinary study of the lacrimal disease, which consisted in primary ophthalmological and otorhinolaryngological visits associated with nasal endoscopy, in which a radiological exam was added if needed. The surgical approach includes pneumatic enlargement of the stenotic rhinostomy, created during the primary dacryocystorhinostomy, using a high-pressure trans-nasal balloon catheter. Anatomical success was considered when the ostium was patent upon irrigation, while functional success was considered as resolution of epiphora or free lacrimal flow on functional test.

Results

Among 14 patients included and after a mean follow-up of 19.5 months (range 13–51 months), anatomic success was achieved in 100% of patients and functional success was achieved in the 85.7% (12/14). Operative time ranged from 9 to 28 min (mean 18 min) and no complications were reported.

Conclusion

Trans-nasal balloon-assisted dacryoplasty is a mini-invasive surgical approach to treat failed dacryocystorhinostomies with reliable and stable outcomes in the long term. The absence of post-surgical complications, high success rate and short operative time are the main features of this innovative procedure.