Wagner: Today we will be discussing congenital dacryocystocele. You are asked to consult in the newborn nursery on a 1-day-old normal newborn with a firm bluish mass in the right lower eyelid and medial canthal area, which is displacing the lower eyelid superiorly. How would you proceed with your evaluation and what would be your differential diagnosis?
Kipp: I would look at the lesion to see if it looks inflamed or infected. You're describing a bluish lesion that, assuming the skin overlying it is not red and indurated, would give me less cause for alarm that I have to do anything urgently. I would also look at where this lesion is exactly in relation to the medial canthal tendon. If it is below it, I am more convinced that this is a dacryocystocele. If it is above it, it could be an encephalocele or hemangioma. I would press on it. If it feels firm, that is more evidence that it is a dacryocystocele. I will see if I can get any reflux by pressing on the mass. I will also have the parents do massaging for several days to see if it will resolve that way first.
Dumitrescu: I would press on the dacryocystocele (lacrimal sac) and look in the nose to see whether I could see the sac of the dacryocystocele. I also would want to know how the infant is feeding and breathing, because if it's bilateral and the infant has trouble breathing and feeding, the surgical treatment becomes an emergency.
Wagner: Would you try to massage digitally by applying pressure on the mass?
Dumitrescu: I would, with the idea that if I see the reflux in the lower punctum, it's more reassuring for being able to drain it.
de Beaufort: I agree with those approaches. I've also heard that if there is a unilateral dacryocystocele you should ask about how the infant feeds on that same side, because with gravity that can actually occlude half of the nasal passage. So I specifically ask about that.
Wagner: Would you say that this is a clinical diagnosis or would you recommend imaging?
de Beaufort: Unless I think there's anything outside of the normal clinical findings we'd expect, I wouldn't recommend imaging. We generally don't image as long as it's below the medial can- thus, not above, and appears to be a classic dacryocystocele.
Wagner: Have any of you ever had a case where you massaged the mass and it immediately reduced or expressed some of the contents to the nares?
Dumitrescu: I had a case where I was showing the parents how to do the massage with my finger and it was somewhat embarrassing when the infant started choking and something came out of the mouth.
Wagner: They can sometimes rupture or break that way. I guess the obstruction is overcome and it will drain out through the nose. Once you have examined this 1-day-old infant who is probably going to go home the next day, what would you tell the parents regarding follow-up?
Dumitrescu: I usually don't give the infant antibiotics preventatively. I don't think they work like that. I tell the parents that there's a high risk of this becoming infected and causing a serious emergency. I tell them the signs of that and to look for symptoms such as fevers, not feeding, and not sleeping. I usually ask them to send pictures to me for a couple of days before we see where it is going. They should follow-up in a week if it is fine or come back sooner if it's not.
de Beaufort: I generally advise the parents to massage the lesion with every feeding, which tends to be a pretty regular schedule. I usually prescribe something like polymyxin B sulfate and trimethoprim topical drops just to be on the safe side.
Wagner: I agree. I haven't encountered a case that I thought was true dacryocystitis. Sometimes you can get a nasal extension into the nasal cavity, and it can interfere with both feeding and ventilation. They're more likely to be a problem if the nasal extension is bilateral.
Kipp: I take the bilateral ones more seriously, almost like a dacryocystitis. Those are the ones I plan on probing more urgently. I used to try to probe these in the office. I now do these in the operating room with the help of an otolaryngologist because you're almost always going to find an intranasal cyst and I want the specialist to be able to marsupialize the cyst. So I will intervene surgically for dacryocystitis and bilateral dacryocystocele.
Wagner: How soon would you consider doing the procedure in a infant like this?
Kipp: If there is no obvious evidence that the infant is struggling with breathing or feeding, maybe in a week or so. But I don't wait too long. As with dacryocystitis, I will have the infant admitted to the hospital, start intravenous antibiotics, and probe the infant within a week.
de Beaufort: I think I am a little conservative in this regard. I follow the infant closely every 1 or 2 weeks and, assuming there's no sign of infection or respiratory compromise, I have gone up to 5 or 6 weeks until I probe.
Wagner: Have you ever tried to do a probing in your office?
de Beaufort: I tried once in the office and I don't believe I will ever try again.
Dumitrescu: I trained in Romania and administering anesthesia at a very young age was not encouraged, so we were doing probing in the office. I will never do it again.
Wagner: Why is that?
Dumitrescu: There are issues with the timing of it and needing extra people to restrain the child, and the distress of the infant and the parents.
Wagner: I agree. I had a bilateral case that was seen initially by an otolaryngologist because there were some breathing difficulties. He managed to get a scan that actually showed bilateral intranasal cysts. Because it was seen by the pediatric otolaryngologist primarily, he requested that I join him in the operating room for a nasolaryngoscopy. I could visualize the cyst in the nasal cavity and see the probe when I probed through the cavity. I could see it inside the cyst and perforate out. Then the otolaryngologist marsupialized the remainder of the cyst on both eyes. But most seem to resolve either spontaneously or with the regular probing that we would do for a more routine nasolacrimal duct obstruction. Has anyone else had experience with nasal endoscopy?
Kipp: I had one a couple of months ago. The infant had developed a severe dacryocystitis at approximately 1 month of age. He was admitted to the hospital and given intravenous antibiotics. I operated with the otolaryngologist and I was able to probe superiorly, at least in the nasolacrimal sac. I was not able to get down the nasolacrimal duct at all. The otolaryngologist ultimately opened up the cyst and then I was able to get down. So the otolaryngologist was invaluable on that one. In my experience, the otolaryngologist finds a cyst every single time.
Dumitrescu: My operating day is the same day as the otolaryngologists, so I have done a couple of cases with them. Now that they have showed me how they do it, I use the endoscopy almost every time just to verify that it's open and there is no cyst.
Wagner: Do you use the endoscope in a 13-month-old child who you're going to probe?
Dumitrescu: No, unless I'm not sure where my probe is or it's something unusual. But I use it for the dacryocystocele.
Kipp: I have also learned a lot about nasal endoscopy from working with the otolaryngologist. When we are both in the operating room, I also look through the scope to familiarize myself. I have not gotten comfortable using it in the neonates, but if I am probing an older child and I am not sure of the location of my probe, I will use the nasal endoscope. I am gaining more confidence as I go. It is a good tool for us to have and to learn.
Wagner: Would anyone like to add anything else about your experience with these patients?
de Beaufort: In the past year I have had a significant increase in prenatal dacryocystocele consultations. I suspect this will become more widespread with increasing prenatal imaging, so it would be good for practitioners to think about what they want to say to prenatal specialists about these patients and how to plan.
Wagner: I think that's a good point. During this past year, I had a patient with a cataract diagnosed prenatally. The parents were prepared to expect the cataract to be present at birth and have the surgery before they delivered. Thank you all for participating in this discussion.
This Eye to Eye session was conducted on March 30, 2020.