Successful endonasal dacryocystorhinostomy in a patient with Wegener's granulomatosis

Abstract

Wegener's granulomatosis (WG) is one form of idiopathic autoimmune vasculitis. The disease has a predilection for the upper and lower respiratory tracts (lungs, nose, sinus), and kidneys. WG may be systemic, severe, and potentially lethal, but it may also be limited to the otolaryngological area or to the eyes and the orbits. Obstruction of the lacrimal pathway is a possible complication of the disease that affects approximately 7% of patients with WG. It usually occurs as a direct extension of sinonasal disease and typically is a late manifestation. Management of such a condition is generally viewed as difficult. We report the case of a patient with a quiescent WG limited to the otolaryngological area. This patient presented a bilateral obstruction of the nasolacrimal ducts caused by bilateral extensive adhesions in the nasal cavity. Because she had several episodes of left-side acute dacryocystitis which necessitated several courses of broad-spectrum antibiotics, she successfully underwent an endonasal endoscopic dacryocystorhinostomy using a diode laser and powered instrumentation. The authors describe the clinical case, the surgical technique, and review the literature.

Keywords: Wegener’s granulomatosis; diode; endonasal DCR; laser; powered instrumentation; recurrent dacryocystitis.

Figure 1

A) Preoperative view of the patient showing a dacryocele (black arrows) and a saddle-nose deformity (white arrows), consequences of a Wegener’s granulomatosis. B) Nasal endoscopy of the left nasal cavity. Extensive adhesions developed between the nasal septum and the inferior turbinate reducing dramatically the diameter of the nasal cavity. C) Preoperative sinus CT scan showing bilateral extensive adhesions in the nose (white arrows). D) Preoperative dacryoscan showing an opacification of all the lacrimal outflow system (white arrows). Abbreviations: Adh, adhesions; CT, computed tomography; IT, inferior turbinate; S, nasal septum.

Figure 2

A) Postoperative view of the patient confirming the disappearance of the dacryocele (black arrows). B) Postoperative endoscopy of the left nasal cavity showing the absence of recurrence of the adhesions posteriorly. C and D) Postoperative dacryoscan confirming the patency of the surgical opening on the left side: presence of medium contrast in the nasal cavity (white arrow).