Pseudodacryocystitis: paediatric case series of infected atypical ethmoid air cells masquerading as recurrent dacryocystitis

Abstract

PurposeTo highlight the clinical and surgical considerations in treating patients with apparent recurrent acute dacryocystitis with a patent lacrimal system.MethodsThree children referred to a tertiary unit as recurrent acute dacryocystitis were reviewed retrospectively. Imaging and subsequent surgical intervention revealed the underlying diagnosis.ResultsAll three cases presented with recurrent abscesses in the region of the lacrimal sac that failed to respond to incision and drainage. The lesions were lower and more lateral to the usual location of a sac abscess and closer to the inferior orbital rim. All three cases were found to have patent lacrimal systems on syringing, and all were found to have infected, low-lying, anteriorly placed aberrant ethmoid air cells on computed tomography and magnetic resonance imaging. These were confirmed on subsequent surgical exploration.ConclusionsInfected low-lying ethmoid air cells can mimic dacryocystitis with recurrent abcesses. In cases where a patent nasolacrimal system is demonstrated and a more inferolateral location of the swelling than would be expected in dacryocystitis is seen, imaging is warranted to ensure the appropriate intervention is undertaken. Anterior ethmoidectomy as opposed to dacryocystorhinostomy is the appropriate treatment in these cases.

Figure 1

(a, b) Clinical progression of recurrent right lower lid swelling, with spontaneous rupture of abscess. (c) Excision of entire lesion sent for histology and microbiology. (d) Presence of ethmoid air cell corresponding to area of bony defeat at the bottom of abscess tract. (e) Corresponding air cell without any bony erosion suggesting infection came from the infected ethmoid air sinus.

Figure 2

(a, b) Clinical photographs showing inflamed swelling inferior and lateral to right medial canthal tendon. Fluorescein pooling with acute inflammation. (c) Post-operative appearance following syringing and probing demonstrating a patent nasolacrimal system and anterior ethmoidectomy. (d, e) Axial and coronal CT images demonstrating abscess location. (f) T1-weighted axial MRI scan showing soft-tissue oedema with rim of fluid near medial canthal tendon, extending to inferior right meatus.

Figure 3

(a) Clinical photograph of left lower lid abscess. (b) Contrast-enhanced MRI scan showing mild expansion with associated increased enhancing soft tissue in the mid-distal portion of the left nasolacrimal duct. (c) CT scan of orbits showing extension of inflammation in the region of the nasolacrimal duct.