Dacryocystitis

Dacryocystitis is the inflammation of the nasolacrimal sac related to impairment in the lacrimal drainage system and superimposed infection. 

Epidemiology

Dacryocystitis has a bimodal distribution: neonates due to congenital abnormalities and, when acquired, usually affect individuals older than 40 years of age. 

Clinical presentation

Dacryocystitis is typically characterised by epiphora, erythema, and oedema in the region of the medial epicanthus and lacrimal puncta as the result of an infection of the nasolacrimal sac. There is often mucopurulent discharge from the puncta and associated conjunctivitis.

Pathology

Obstruction or stricture of the nasolacrimal drainage is an underlying factor. 

Most cases in infants represent congenital abnormalities, such as incomplete canalisation or atresia of the nasolacrimal duct, dacryocele,  and facial clefts. Whereas in adults it is usually the result of an acquired abnormality, including:

• inflammation / infection
  • rhinitis / sinusitis
  • paranasal sinus mucocele
  • nasal septal abscess
  • enlarged adenoids
• anatomic variation
  • enlarged turbinates 
  • nasal septal deviation
• tumour
  • sinonasal carcinoma
  • nasolacrimal duct carcinoma
• iatrogenic / trauma
• foreign bodies

The microbiology of dacryocystitis mimics normal conjunctival flora in most instances.

In chronic dacryocystitis, there can be superinfection with fungal species.

Radiographic features

The typical imaging finding is a well-circumscribed round lesion that is centred at the lacrimal fossa, and that demonstrates peripheral enhancement.

Treatment and prognosis

Treatment of acute dacryocystitis typically involves treatment with antibiotics in the acute phase, which may or may not be followed by an external dacryocystorhinostomy or other interventional procedure.

Chronic dacryocystitis typically requires surgery or an interventional procedure.

Complications 

• abscess formation
• fistula formation
• orbital cellulitis

Differential diagnosis

Differentials on imaging include:

• pseudodacryocystitis
  • anterior ethmoidal cells sinusitis 
  • ethmoidal bone erosion 
• conjunctivitis 
  • can co-exist with dacryocystitis
• pre-septal orbital cellulits
  • can co-exist with dacryocystitis