DOI: 10.1148/radiol.2322011864
(Radiology 2004;232:370-372.)
© RSNA,
Case 73: Nasolacrimal Duct Mucocele1
B. L. Koch, MD
1 From the Department of Radiology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, ML# 5031, Cincinnati, OH 45229-3039. Received November 21, 2001; revision requested February 1, 2002; revision received February 26, 2003; accepted April 14. Address correspondence to the author (e-mail: koch.bl@cchmc.org).
Index terms: Diagnosis Please • Lacrimal gland and duct, 223.255 • Lacrimal gland and duct, CT, 223.12111 • Mucocele, 223.255
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HISTORY
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An infant presented with a nasal obstruction. The clinicians were unable to pass a nasoenteric tube via the left nares. For further assessment of the nasal obstruction, the infant underwent computed tomography (CT) that extended from the lower aspect of the orbits through the nasal cavity.
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IMAGING FINDINGS
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CT scans of the nose and nasopharynx showed an intranasal mass obstructing the left nasal passage just inferior to the inferior turbinate (Figure, parts a and b), dilatation of the osseous left nasolacrimal canal (Figure, part c), and a mass in the region of the medial canthus of the left orbit (Figure, part d). The pyriform aperture and choana are normal in caliber.
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Figure a. (a) Transverse unenhanced CT scan obtained through the midnasal passage shows a small low-attenuation mass in the anterior left nasal cavity (arrow). The appearance of the pyriform aperture (arrowheads) and posterior choana is normal. (b) Coronal unenhanced reconstruction CT scan obtained through the inferior meatus shows the intranasal mass (m) inferior to the left inferior nasal turbinate (arrow). (c) Transverse unenhanced bone window CT scan obtained through the upper nasal passage shows enlargement of the left nasolacrimal duct within the osseous nasolacrimal canal (arrows). (d) Transverse unenhanced CT scan obtained through the lower orbits shows an intermediate-attenuation mass (arrows) filling an enlarged left lacrimal sac fossa.
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Figure b. (a) Transverse unenhanced CT scan obtained through the midnasal passage shows a small low-attenuation mass in the anterior left nasal cavity (arrow). The appearance of the pyriform aperture (arrowheads) and posterior choana is normal. (b) Coronal unenhanced reconstruction CT scan obtained through the inferior meatus shows the intranasal mass (m) inferior to the left inferior nasal turbinate (arrow). (c) Transverse unenhanced bone window CT scan obtained through the upper nasal passage shows enlargement of the left nasolacrimal duct within the osseous nasolacrimal canal (arrows). (d) Transverse unenhanced CT scan obtained through the lower orbits shows an intermediate-attenuation mass (arrows) filling an enlarged left lacrimal sac fossa.
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Figure c. (a) Transverse unenhanced CT scan obtained through the midnasal passage shows a small low-attenuation mass in the anterior left nasal cavity (arrow). The appearance of the pyriform aperture (arrowheads) and posterior choana is normal. (b) Coronal unenhanced reconstruction CT scan obtained through the inferior meatus shows the intranasal mass (m) inferior to the left inferior nasal turbinate (arrow). (c) Transverse unenhanced bone window CT scan obtained through the upper nasal passage shows enlargement of the left nasolacrimal duct within the osseous nasolacrimal canal (arrows). (d) Transverse unenhanced CT scan obtained through the lower orbits shows an intermediate-attenuation mass (arrows) filling an enlarged left lacrimal sac fossa.
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Figure d. (a) Transverse unenhanced CT scan obtained through the midnasal passage shows a small low-attenuation mass in the anterior left nasal cavity (arrow). The appearance of the pyriform aperture (arrowheads) and posterior choana is normal. (b) Coronal unenhanced reconstruction CT scan obtained through the inferior meatus shows the intranasal mass (m) inferior to the left inferior nasal turbinate (arrow). (c) Transverse unenhanced bone window CT scan obtained through the upper nasal passage shows enlargement of the left nasolacrimal duct within the osseous nasolacrimal canal (arrows). (d) Transverse unenhanced CT scan obtained through the lower orbits shows an intermediate-attenuation mass (arrows) filling an enlarged left lacrimal sac fossa.
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DISCUSSION
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Patients with a nasolacrimal duct mucocele typically have the following triad of imaging findings: (a) a medial canthus mass that represents an enlarged lacrimal sac, (b) an enlarged osseous nasolacrimal canal secondary to an enlarged soft tissue nasolacrimal duct, and (c) an intranasal mass, which represents the inferior extension of the mucocele. Nasolacrimal duct mucocele is an uncommon cause of nasal obstruction and respiratory distress. A lacrimal sac mucocele occurs when the normal flow of tears through the nasolacrimal duct is obstructed, resulting in a medial canthus mass. Nasolacrimal duct mucocele occurs when a lacrimal sac mucocele (ie, dacryocystocele) is directly contiguous with a cystic intranasal mass via a dilated nasolacrimal duct (1).
In a patient with nasal obstruction, the differential diagnoses include masses such as hemangioma, glioma, cephalocele, and dermoid, as well as congenital osseous abnormalities, such as choanal atresia. In this infant, the presence of an enlarged nasolacrimal sac and duct, in association with a nasal mass, confirms the diagnosis of nasolacrimal duct mucocele.
Embryologically, at the distal end of the nasolacrimal duct, there is a thin mucus membrane (plica lacrimalis or valve of Hasner) that separates the nasal end of the nasolacrimal duct from the inferior meatus (2). This membrane, which usually becomes perforated, remains imperforate in 6%–12% of healthy subjects (3,4). The membrane is actually imperforate in most neonates at birth; however, it becomes perforated shortly thereafter, when crying and respiratory efforts increase intraluminal pressure (5). When there is persistent obstruction at the distal end of the lacrimal system, diffuse dilatation or mucocele formation involving the nasolacrimal sac and duct may result.
When the mass is large enough to obstruct the nasal passage, respiratory distress may result. Respiratory distress is most prominent when the lesions are bilateral, which is reported in approximately 10% of patients (4,6), because neonates are obligate nose breathers and do not spontaneously breathe through their mouths when the nasal passage is obstructed. In this situation, neonates have symptoms that are similar to those of neonates with choanal atresia. Another similarity is that in patients with nasolacrimal mucocele and patients with choanal atresia there is an inability to pass a nasoenteric tube via the affected side. In patients with nasolacrimal duct mucocele, in whom the endonasal mass obstructs the inferior meatus, the tube can only be inserted a short distance. In patients with choanal atresia, the obstruction is at the level of the choana (ie, the posterior aspect of the nasopharynx); thus, the nasoenteric tube can be advanced farther. Because the neonatal nasal cavity is very short, however, it is frequently difficult to determine whether the obstruction is anterior or posterior without imaging.
In addition to the nasal mass, patients with nasolacrimal duct mucocele may also present with symptoms related to the medial canthus mass. Dacryocystocele may result in epiphora, a palpable mass, accumulated mucoid material along the eyelids and eyelashes, or secondary inflammatory symptoms, such as dacryocystitis. If undiagnosed, inflammation of the lacrimal sac may spread, and patients may present with symptoms of periorbital cellulitis. In this scenario, edema and erythema from the periorbital cellulitis may obscure the medial canthus mass, as in this infant.
The imaging modality of choice is unenhanced transverse CT, which allows physicians to clearly identify the triad of findings associated with nasolacrimal duct mucocele (ie, enlarged lacrimal sac, enlarged nasolacrimal canal, and presence of an intranasal mass) and confirm the diagnosis. Magnetic resonance (MR) imaging will show the dilated duct and sac without ionizing radiation; however, if the medial canthus mass is not obvious and the patient is undergoing evaluation for choanal atresia, he or she should be evaluated with CT. In addition, many patients can undergo CT scanning without sedation, while MR imaging nearly always requires sedation if high-quality images are to be obtained.
Treatment of nasolacrimal duct mucocele includes massage and expectant waiting for spontaneous resolution. Surgical probing may be required, however, if there is not spontaneous resolution or if secondary infection occurs (7,8).
In a patient with nasal obstruction, the differential diagnoses include masses such as hemangioma, glioma, cephalocele, and dermoid, as well as congenital osseous abnormalities, such as choanal atresia. In this infant, the presence of an enlarged nasolacrimal sac and duct, in association with a nasal mass, confirms the diagnosis of nasolacrimal duct mucocele.
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FOOTNOTES
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Part 1 of this case appeared 4 months previously and may contain larger images.
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REFERENCES
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- Rand PK, Ball WS, Jr, Kulwin DR. Congenital nasolacrimal mucoceles: CT evaluation. Radiology 1989; 173:691-694.[Abstract/Free Full Text]
- Hollinshead WH, ed. The eyelids, orbit, and eyeball, in anatomy for surgeons In: The head and neck. Philadelphia, Pa: Lippincott-Raven, 1982; 106.
- Noda S, Hayasaka S, Setogawa T. Congenital nasolacrimal duct obstruction in Japanese infants: its incidence and treatment with massage. J Pediatr Ophthalmol Strabismus 1991; 28:20-22.[Medline]
- Guerry DI, Kendig EL, Jr. Congenital impatency of the nasolacrimal duct. Arch Ophthalmol 1948; 39:193-202.[Abstract/Free Full Text]
- Meyer JR, Quint DJ, Holmes JM, Wiatrak BJ. Infected congenital mucocele of the nasolacrimal duct. AJNR Am J Neuroradiol 1993; 14:1008-1010.[Abstract]
- Castillo M, Merten DF, Weissler MC. Bilateral nasolacrimal duct mucocele: a rare cause of respiratory distress—CT findings in two newborns. AJNR Am J Neuroradiol 1993; 14:1011-1013.[Abstract]
- Mansour AM, Cheng KP, Mumma JV, et al. Congenital dacryocele: a collaborative review. Ophthalmology 1991; 98:1744-1751.[Medline]
- Lavrich JB, Nelson LB. Disorders of the lacrimal system apparatus. Pediatr Clin North Am 1993; 40:767-776.[Medline]
Congratulations to the 98 individuals who submitted the most likely diagnosis (nasolacrimal duct mucocele) for Diagnosis Please, Case 73. Indication of involvement of the nasolacrimal duct was necessary to receive credit for this case. The names and locations of the individuals, as submitted, are as follows:
- Gholamali Afshang, MD, Tinley Park, Ill
- Oguz Akin, MD, New York, NY
- Canan Altay, MD, Izmir, Turkey
- Albert J. Alter, Madison, Wis
- A. Anbarasu, MD, FRCR, Coventry, England, United Kingdom
- Ken Baliga, Rockford, Ill
- Brian Bigoni, Del Mar, Calif
- Antonio Botero, MD, Bogotá, Colombia
- Eric L. Bressler, MD, Minnetonka, Minn
- Daniel F. Broderick, MD, Jacksonville, Fla
- Marcella Camicia, MD, Bari, Italy
- Can Cevikol, MD, Antalya, Turkey
- N. Chidambaranathan, MD, Chennai, India
- Bharath Chinta, MD, Rochester Hills, Mich
- James W. Cole, MD, Cincinnati, Ohio
- Y. S. Cordoliani, MD, Paris, France
- Thaworn Dendumrongsup, MD, Songkla, Thailand
- Sandro Fenelon, São Paulo, Brazil
- Laura Z. Fenton, MD, Denver, Colo
- Arie Franco, MD, PhD, Pittsburgh, Pa
- Dr Thiago Junqueira Franco, São Paulo, Brazil
- Akira Fujikawa, Tokyo, Japan
- Ann S. Fulcher, MD, Richmond, Va
- Thomas C. Gallagher, DO, Yardley, Pa
- Dr Ram Prakash Galwa, Chandigarh, India
- Mark Goldshein, MD, Andover, Mass
- John D. Grizzard, MD, Midlothian, Va
- D. Joseph Grunz, MD, Ladue, Mo
- Flavius Guglielmo, MD, Basking Ridge, NJ
- Yukihiro Hama, MD, Tokorozawa, Japan
- Hiroto Hatabu, MD, PhD, Boston, Mass
- Helen T. Ho, MD, Chicago, Ill
- Thomas C. Hoffer, MD, El Paso, Tex
- Rekha Jain, Pontiac, Mich
- Vinay Jain, Auburn Hills, Mich
- David B. Janizek, MD, Fort Wayne, Ind
- Unni Krishna Kaimal, Hyderabad, India
- Sanjeeva Prasad Kalva, MD, Boston, Mass
- Shinichi Kan, MD, Kanagawa, Japan
- Kamil Karaali, MD, Antalya, Turkey
- Steven A. Klein, MD, Shrewsbury, Mass
- Peter T. Koch-Weser, MD, Gloucester, Mass
- Kaori Koga, Tokyo, Japan
- Mark Kutler, MD, Dallas, Tex
- Mario Laguna, West Allis, Wis
- N. B. S. Mani, MD, Nassau, Bahamas
- John A. Mattingly, MD, Belleville, Ill
- Peter McGraw, Jacksonville, Fla
- Frank McKowne, MD, Vancouver, Wash
- Edward Menges, MD, Aptos, Calif
- Mehran Midia, MD, Hamilron, Ontario, Canada
- Tetsuo Nakayama, MD, Osaka, Japan
- Mizuki Nishino, MD, Boston, Mass
- Jim Nugent, MD, Victoria, British Columbia, Canada
- Mike O’Loughlin, MD, West Hartford, Conn
- Harish Panicker, MD, Washington, DC
- Narendrakumar P. Patel, MD, Newburgh, NY
- Ernesto Oscar Pearson, MD, Córdoba, Argentina
- Alex Petersen, MD, Nowra, Australia
- Hilton Pittman, Pensacola, Fla
- Mario P. Pliego, MD, Bloomington, Minn
- John M. Plotke, Naperville, Ill
- Dr Pieter M. Pretorius, Oxford, United Kingdom
- Henry W. Pribram, MD, Orange, Calif
- George T. Puskar, MD, Vero Beach, Fla
- Shawn P. Quillin, MD, Charlotte, NC
- Santosh B. Rai, MD, FRCR, Coventry, England, United Kingdom
- Lorenz (Larry) Ramseyer, MD, Enid, Okla
- Randall Rhodes, MD, Belvidere, Ill
- Luiz Antonio Rossi, São Paulo, Brazil
- Pedro Borrego Ruiz, Madrid, Spain
- Edmond Russ, Zanesville, Ohio
- Satyajit Sarangi, MD, Lewes, Del
- N. Saravanan, MD, DNB, DHA, Chandigarh, India
- Pierre J. Sauvage, MD, Mâcon, France
- Stephen I. Schabel, MD, Charleston, SC
- Dr Pierre Schmit, L’Haÿ les Roses, France
- Mahomed Seedat, Toowoomba, Australia
- Matt Shapiro, MD, Charlottesville, Va
- Taro Shimono, MD, Osaka, Japan
- Hiroshi Shinmoto, MD, Tokyo, Japan
- Darrin S. Smith, MD, Fresno, Calif
- David Sobel, MD, La Jolla, Calif
- Lachanis B. Stefanos, MD, Athens, Greece
- Dr Anne Stroh-Marcy, Arras, France
- Kouichi Sugiyama, Hamamatsu, Japan
- Smrita Swamy, MD, Bangalore, India
- Norio Takahashi, MD, Fukui, Japan
- Douglas L. Teich, MD, Brookline, Mass
- Hiroyuki Ueda, Kyoto, Japan
- Elida Vazquez, MD, Barcelona, Spain
- Kai Vilanova Busquets, MD, Girona, Spain
- Christopher Vittore, MD, Rockford, Ill
- Jeff West, MD, Jacksonville, Fla
- Satoru Yoshida, MD, Muroran, Japan
- Joe Yut, Olathe, Kan
- Jeffrey H. Zapolsky, MD, Oshkosh, Wis
- Yu Zhang, Nagoya, Japan
TOP
HISTORY
IMAGING FINDINGS
