Lacrimal sac compression by an anterior ethmoidal mucocele: A rare case report

Rahul Bhatia; Priyanka Gautam; Nitika Beri; Isha Sharma; Pramod Kumar Sahu; Gopal K Das

doi:10.4103/pajo.pajo_6_23

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CASE REPORT

Year : 2023 | Volume : 5 | Issue : 1 | Page : 23

Lacrimal sac compression by an anterior ethmoidal mucocele: A rare case report

Rahul Bhatia, Priyanka Gautam, Nitika Beri, Isha Sharma, Pramod Kumar Sahu, Gopal K Das
Departments of Ophthalmology University College of Medical Sciences, Delhi, India

Date of Submission	27-Jan-2023
Date of Decision	25-Feb-2023
Date of Acceptance	27-Feb-2023
Date of Web Publication	27-Jun-2023

Correspondence Address:
Rahul Bhatia
Department of Ophthalmology, UCMS and GTB Hospital, Shahdara, Delhi - 110 095
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/pajo.pajo_6_23

Abstract

The lacrimal sac compression by an anterior ethmoidal mucocele is unusual. The ethmoidal mucocele may masquerade as lacrimal sac mucocele and may lead to disastrous consequences if treated along the lines of lacrimal mucocele. We present a case of an 18-year-old female presenting with a mass lesion over the medial canthal area causing a dilemma in diagnosis.

Keywords: Dacryocystitis, dacryocystorhinostomy surgery, ethmoidal mucocele

How to cite this article:
Bhatia R, Gautam P, Beri N, Sharma I, Sahu PK, Das GK. Lacrimal sac compression by an anterior ethmoidal mucocele: A rare case report. Pan Am J Ophthalmol 2023;5:23

How to cite this URL:
Bhatia R, Gautam P, Beri N, Sharma I, Sahu PK, Das GK. Lacrimal sac compression by an anterior ethmoidal mucocele: A rare case report. Pan Am J Ophthalmol [serial online] 2023 [cited 2023 Sep 27];5:23. Available from: https://www.thepajo.org/text.asp?2023/5/1/23/379762

Introduction

The lacrimal sac compression by an anterior ethmoidal mucocele is unusual. The ethmoidal mucocele may masquerade as lacrimal sac mucocele and may lead to disastrous consequences if treated along the lines of lacrimal mucocele.

We present the joint management of our case by the ophthalmologists and ENT surgeons, describing the diagnostic dilemma.

Case Report

An 18-year-old female presented to the ophthalmology outpatient department with complaints of watering from the right eye, on and off for 7 years, and a painless mass over the medial end of the right eye. The mass used to increase with episodes of upper respiratory tract infection. There was no history of any trauma or surgical intervention. There was no history of any diplopia or protrusion of the eyeball. The systemic history was unremarkable. On clinical examination, there was a soft, cystic, nontender, bilobed mass of about 4 cm × 3 cm, 1 cm inferior to the medial canthus of the right eye, with no signs of any inflammation [Figure 1]. The swelling was noncompressible. Rest ocular examination was within normal limits. The regurgitation test was negative. On syringing, the nasolacrimal pathway was patent.

Figure 1: Image showing soft, cystic, nontender, bilobed mass of about 4 cm × 3 cm, 1 cm inferior to the medial canthus of the right eye, with no signs of any inflammation)

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The contrast-enhanced computed tomography (CT) scan revealed a well-defined nonenhancing soft-tissue cyst of size (1.8 cm × 2.3 cm × 1.5 cm) inferomedial to the nasolacrimal duct (NLD), with no bony involvement [Figure 2] and [Figure 3].

Figure 2: The sagittal CECT scan revealed a well-defined nonenhancing soft tissue cyst of size (1.8 cm × 2.3 cm × 1.5 cm) inferomedial to the nasolacrimal duct, with no bony involvement). CECT: Contrast-enhanced computed tomography

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Figure 3: The Axial CECT scan revealed a well-defined nonenhancing soft tissue cyst of size (1.8 cm × 2.3 cm × 1.5 cm) inferomedial to the nasolacrimal duct, with no bony involvement). CECT: Contrast-enhanced computed tomography

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Dacrocystography revealed a patent nasolacrimal pathway, with a linear tract seen along the superior medial margin of the mass going downward, backward, and medially along the NLD. The lacrimal drainage system including the NLD is displaced medially by the mass lesion. Free spillage of dye is seen in the inferior meatus [Figure 4].

Figure 4: Dacrocystography revealed a patent nasolacrimal pathway, with a linear tract seen along the superior-medial margin of the mass going downward, backward, and medially along the nasolacrimal duct. The lacrimal drainage system including the NLD is displaced medially by the mass lesion. Free spillage of dye is seen in the inferior meatus. NLD: Nasolacrimal duct

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Anterior rhinoscopy revealed a normal nasal airway with a healthy mucosal lining. Flexible nasal endoscopy revealed a soft bulge anterior to the superior attachment of the middle turbinate.

Based on clinical examination and investigations, a diagnosis of ethmoidal mucocele was made. Endoscopic drainage with marsupialization of the cyst was done. The patient is asymptomatic on follow-up [Figure 5].

Figure 5: Postoperative photograph

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Discussion

A mucocele is a benign, ciliated columnar epithelium-lined, mucus-filled lesion. Upon gradual expansion, it is locally destructive and may lead to bony erosion and remodeling. The etiology of mucocele formation is multifactorial.^[1] In the paranasal sinuses, it may occur primarily as a mucus retention cyst^[2] or can be secondarily caused by obstruction of the sinus ostia due to infection, allergy, trauma, or surgery. A secondary infection can cause a period of rapid expansion with complications.^[2]

Typically, mucoceles are found to involve the frontal sinuses most commonly (65%), followed by the ethmoidal sinuses (30%) and rarely the maxillary or sphenoid sinuses (1%–10%).^[3],[4]

Symptoms depend on the site, size, and extent of the mucocele.^[5]

The patient may present with headaches mainly in the periorbital region, exophthalmos, ophthalmoplegia, proptosis, and diplopia. Rarely, anterior ethmoidal mucocele may present as a mass below the medial palpebral ligament, as in our case.

Other rare presentations have been reported, including a posterior ethmoid mucocele causing ipsilateral oculomotor nerve palsy^[6] and an ethmoid mucocele causing acute severe orbital pain with nonaxial proptosis without diplopia.^[7]

Diagnosis can be made through a combination of physical examination and radiographic studies including CT scan, magnetic resonance imaging (MRI) scan, and dacryocystography if the lesion is adjacent to the lacrimal pathway. CT provides anatomical detail and bony delineation which is helpful in correct diagnosis and management. MRI is superior to CT in demonstrating the relationship between the mucocele and adjacent soft tissue, as well as differentiating mucoceles from other soft-tissue neoplasms.^[8] Surgical excision is the treatment of choice and is necessary to prevent a recurrence.^[9],[10]

Joint management by ophthalmic and ENT surgeons has been shown to yield good results. Paranasal sinus mucoceles can be effectively managed using the transnasal endoscopic approach and marsupialization with complete recovery reported in 82%–96% of cases, while an extranasal approach can be used for recurrence.^[11],[12]

Lacrimal mucocele presents as a slowly progressive cystic swelling over the sac area and is managed with dacryocystorhinostomy surgery (DCR). This patient was referred to us with the diagnosis of lacrimal mucocele for DCR surgery. Routine and radiological investigation revealed patent NLD with medial displacement by the mass lesion. Epiphora in this patient was due to mechanical compression of the NLD by the mass lesion.

This case highlights that any cystic swelling in the lacrimal sac area needs thorough evaluation to rule out other uncommon causes for which the management is entirely different.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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