Dacryocystitis

Introduction to dacryocystitis Non-specific dacryocystitis (dacryocystitis) generally appears as both chronic and acute, and the most common chronic, acute arachnulitis (acutedacryocystitis) is often an acute attack of chronic dacryocystitis, due to the virulence of bacteria such as chains Infection caused by cocci or mixed Streptococcus pneumoniae can occur suddenly without a history of tears. basic knowledge Sickness ratio: 0.1% Susceptible people: no special people Mode of infection: non-infectious Complications: suppurative endophthalmitis

Cause of dacryocystitis

Anatomical factors (30%):

There are many variations of the nasolacrimal duct, some of which are relatively narrow, especially those with low nasal or facial stenosis. The diameter of the tube is small, and the mucosa is slightly swollen to cause obstruction. During the development period, the nasolacrimal duct is incomplete or mucosal folds are formed. The inner diameter of the cavity will be too small and the mucosal swelling will completely block it.

The impact of nearby tissue disease (25%):

Nasal diseases such as turbinate hypertrophy or nasal septum deviation can cause mechanical obstruction of the lower end of the nasolacrimal duct; inflammation of the nasal cavity such as acute, vascular neuropathy, proliferative or purulent inflammation, etc., infection can spread directly to the lacrimal duct, also It can stimulate mucosal swelling and cause obstruction of the lower end of the nasolacrimal duct; atrophic rhinitis, its mucosa atrophy, the lower end of the nasolacrimal duct is enlarged, and the infection can directly spread upward; the infectious secretions at the nose are more likely to enter the nasolacrimal duct, causing the lacrimal sac Inflammation, paranasal sinus and lacrimal sac have a close anatomical relationship, and its inflammation is also an important cause of dacryocystitis, especially the ethmoid sinus, the tear bone is often gasified into a sputum, the bone is as thin as paper, and even the dimples are connected. The infection can thus spread directly to the lacrimal sac, or it can be transmitted through the abundant blood vessels or lymphatic vessels around the lacrimal sac, and there is less diffusion from the conjunctival infection to the lacrimal sac, except for certain invasive diseases such as trachoma.

Systemic infection (20%):

Such as influenza, scarlet fever, diphtheria, tuberculosis, etc., may be through blood-borne transmission.

Excessive secretion of tears and retention of tears (10%):

The tension of the lacrimal sac can be weakened, and at the same time it is chronic irritability, the resistance of the lacrimal sac wall is reduced, and it is susceptible to inflammation by bacteria.

Foreign body (5%):

Laryngeal inflammation can also be caused by eyelashes entering from the punctum or from the nasal cavity into the nasolacrimal duct.

The exact cause is still inconclusive. Laryngeal inflammation is often secondary to inflammation of adjacent tissues such as the conjunctiva, nasal and paranasal sinuses, or some special infections such as tuberculosis or syphilis, which originated in the lacrimal system. The cause is unclear and normal. In the case, the lacrimal mucosa is intact, the tears are circulated smoothly, the tears have certain antibacterial ability, and the lacrimal sac is not prone to inflammation. An important predisposing factor is tear retention caused by obstruction of the lower lacrimal duct, which is not an organic obstruction at the beginning. However, due to the temporary congestion and edema of the nasolacrimal duct mucosa, the membranous nasolacrimal duct resides in the bone tube, the blood vessels of the mucosa are rich in lymphatic vessels, and the swelling is caused by a slight swelling, which causes the contents of the lacrimal sac to be retained, which is prone to bacterial growth, mucous membrane For bacterial infection, inflammation promotes congestion and edema, forming a vicious circle. If the virulence of the bacteria is not strong, the lacrimal sac continues chronic inflammation, eventually forming a fixed obstruction of the nasolacrimal duct. Each virulence-prone bacteria enters the lacrimal sac, which can cause Acute attack, most infections come from the adjacent nasal cavity, paranasal sinus or tissue around the lacrimal sac, the main bacteria of non-specific dacryocystitis is Streptococcus pneumoniae, followed by Portugal Cocci, and Mo Lake bacteria Escherichia coli, Pseudomonas aeruginosa, or a small number of gonorrhea, there are many factors that affect this process.

Pathogenesis

The retention of tears in turn causes bacterial infections, which are more common in pneumococcal bacteria. Most of the local non-granulomatous inflammation occurs, and granulomatous inflammation often occurs in systemic or local tissue diseases caused by tuberculosis, syphilis, and leprosy.

Dacryocystitis prevention

1. Pay attention to eye health, check the eyes regularly to prevent poisonous evils from getting deep or repeated.

2, severe disease of pepper, tears and patients with eye surgery should pay attention to check whether the disease, so that early detection and timely treatment.

3, avoid eating spicy food and other irritating foods, especially those suffering from eye diseases, but also need to pay attention to avoid spleen and stomach accumulation of damp heat, causing eye disease.

4, timely and thorough treatment of trachoma, blepharitis and other external eye inflammation, do not give the bacteria to take advantage of.

5, there is a nasal septum deviation, lower turbinate hypertrophy or chronic rhinitis should be treated as soon as possible.

Dacryocyst complications Complications purulent endophthalmitis claudication corneal ulcer

Chronic dacryocystitis due to accumulation of pus, which is often toxic to strong bacteria, especially Streptococcus pneumoniae and hemolytic streptococcus are easy to breed, pus often discharged into the conjunctival sac, leading to chronic inflammation of the conjunctiva; when the cornea is slightly traumatic, or Intraocular surgery can cause limp corneal ulcer or suppurative endophthalmitis. Because of this potential danger, chronic dacryocystitis must be treated promptly. The inner eye should also be routinely examined for lacrimal passages before surgery, especially If there is abnormality, if there is abnormality, intranasal drainage surgery or removal of lacrimal sac should be performed before operation. In the emergency eye surgery, the upper and lower punctum electrocoagulation should be temporarily closed.

Acute dacryocystitis often complicated by acute conjunctivitis, marginal keratitis, etc., if it is a pneumococcal infection, it will cause lame corneal ulcer. If streptococcus, the infection spreads to the tissue around the lacrimal sac, it can lead to facial erysipelas; Backward can cause suppurative ethmoid sinusitis, can also spread to the eyelids and cause sputum cellulitis, full ocular inflammation, and even into the brain caused by meningitis and death.

Symptoms of lacrimal sac inflammation Common symptoms Old people tears more lacrimal duct obstruction cysts sinus sinus tear cysts tears lymph nodes swollen cystic mass mucous cysts skin adhesions purulent secretions

1. Chronic dacryocystitis: can be divided into catarrhal dacryocystitis, mucinous cysts and chronic suppurative dacryocystitis.

(1) catarrhal dacryocystitis (catarrhal dacryocystitis): manifested as tears, similar to simple lacrimal duct obstruction, accompanied by intrinsic conjunctival hyperemia and irritation, flushing lacrimal ducts with mucus secretion reflux, sometimes partially patency .

(2) mucocele: the lacrimal sac wall loses tension and expands, and the secretion accumulates in the lacrimal sac to form a cyst. There is a fluctuating protrusion under the medial malleolar ligament, and there is jelly-like transparent or milky white secretion when squeezed. The material flows back from the lacrimal canal or into the nasal cavity. Once the lower canaliculus is occluded due to inflammation, the cyst will continue to expand, forming a rather large blue cystic mass under the skin, but not adhering to the skin. CT scan shows tears. The cystic area is a cystic space-occupying lesion with medium to low density, and the medial aspect of the osseous structure is multi-directional to the iliac crest (Fig. 1).

(3) chronic suppurative dacryocystitis (chronic suppurative dacryocystitis): is the accumulation of secretions retained in the lacrimal sac, combined with bacterial growth caused by inflammation of the lacrimal sac wall, secretions initially mucinous, later became purulent, oppressed tears There is a yellow sticky pus reflux in the sac area, and often discharged into the conjunctival sac, which becomes a source of infection. Chronic dacryocystitis can be evolved from acute dacryocystitis, and it can also be repeated acutely. The wall of chronic dacryocystitis is chronic inflammation. Thickening, combined with pus accumulation, wall expansion, the formation of a purulent cyst similar to mucinous cysts, purulent discharge into the conjunctival sac, causing conjunctivitis and eczema blepharitis.

All the above types of chronic inflammation will not heal on their own, and there may be more acute exacerbations at any time. Whether mucus cysts or purulent cysts can communicate with the ethmoid sinus, forming ethmoid sinus sinus sinus, when the secretion passes through the ethmoid sinus The nasal cavity is discharged, the cyst can be reduced or even disappeared, the symptoms can be alleviated, and the same effect as nasal drainage surgery.

2. Acute dacryocystitis: It is caused by infections such as virulence bacteria such as streptococci or mixed pneumococcal bacteria. Most of them are acute episodes of chronic dacryocystitis, and can also occur suddenly without tears.

3. Special type of dacryocystitis:

(1) trachomatis dacryocystitis: primary trachomatis erythematosus is rare, secondary to trachoma lesions along the conjunctiva through the lacrimal canal to the lacrimal sac, the typical lesion is the lacrimal mucosa with trachoma follicles (with epithelium) Cell growth center), there is trachoma inclusion in the lacrimal sac mucosal epithelium. The incidence of lacrimal duct obstruction in trachoma patients is higher than that in non- trachoma patients. The ratio is about 15:4, which is more likely to cause mixed infection due to obstruction and retention. Symptoms such as pus and other common chronic dacryocystitis are no different, because trachoma lesions often cause obstruction of the lacrimal canal and the height of the lacrimal sac is reduced. In order to remove the lesion, it is advisable to perform lacrimal sac removal and lacrimal duct electrocoagulation.

(2) Tuberculous dacryocystitis: uncommon, and because there is no routine pathological examination, some cases have not been diagnosed, mostly in young people under the age of 20, especially in women, primary tuberculous lacrimal sac It is rare to see that there have been cases of no tuberculosis in the whole body. The secondary tuberculosis infection is mostly from the nasal cavity, skin, conjunctiva and adjacent bone tissue. The most common cases of nasal lupus spread, Caboche found that there are 13 cases of nasal tuberculosis. Involved in the lacrimal duct, in addition to the general symptoms of tears and pus, there are swelling of the ear and submandibular lymph nodes. The lacrimal wall of mucosal proliferation can produce caseous necrosis and form a cold abscess, and the lesion spreads to the surrounding tissue. Can damage adjacent bone tissue and skin, leading to the formation of typical tuberculous fistula, the treatment is first of all systemic anti-tuberculosis and primary treatment, if the effect is good, according to the condition of the lacrimal sac itself and surrounding tissue, choose lacrimal sac removal or nose Internal drainage.

(3) syphilitic dacryocystitis: syphilis and second-stage syphilis are extremely rare, three-stage syphilis is more common, forming a soft and fluctuating mass in the lacrimal sac area, which grows faster and affects the tissue surrounding the lacrimal sac. When ulceration or fistula is formed, the entire internal iliac crest is destroyed, and the medial and nasal sacs are depressed into a large cavity. Congenital syphilitic dacryocystitis is mostly bilateral and caused by nasal deformity. Especially the saddle nose, bone deformity, leading to obstruction of the lacrimal duct and secondary purulent infection, mostly not direct infection of syphilis, treatment of syphilis treatment, generally good effect, after systemic treatment, suppuration caused by obstruction of lacrimal duct Dacryocystitis can be treated according to the principle of non-specific dacryocystitis.

(4) Other infections: such as leprosy, diphtheria can be extended from the nasal cavity to the lacrimal sac and cause corresponding dacryocystitis. Various fungal dacryocystitis can also occur. Parasites such as aphids can enter the lacrimal sac through the nasal cavity; It can also enter the lacrimal sac from the nasal cavity or conjunctival sac to cause dacryocystitis.

Inspection of dacryocystitis

1. Blood routine examination: routine blood tests during acute dacryocystitis can determine the extent and nature of the infection.

2. Bacterial culture and drug susceptibility test of lacrimal sac secretion: to identify the nature of infection and the type of pathogenic bacteria, and provide an important reference for drug treatment.

3. Pathological examination: chronic inflamed lacrimal sac, cystic wall fibrosis, thickening can reach 2 to 3 times of normal, the cystic cavity is extremely reduced; but when expanded into mucinous cyst, the cyst wall is extremely thin, and the mucosa is rough. Velvet, wrinkles increase, granules or polyps can fill the cyst or cause complete obstruction at the lower end of the lacrimal sac, a large number of inflammatory cells infiltrate under the submucosal tissue, with acute and chronic different cell components, the acute phase is polymorphic Nuclear leukocytes and lymphocytes; in the chronic phase, monocytes, eosinophils, plasma cells and epithelioid cells; in the long course, fibroblasts are formed, the submucosal elastic tissue is replaced by fibrous tissue, scar tissue is formed, and the cystic space is reduced. The junction of the lacrimal sac and the nasolacrimal duct is fibrous cord occlusion. The mucosal surface of the lacrimal sac tube is a stratified epithelium, which is continuous with the epidermis of the skin. A large number of plasma cells are infiltrated around the fistula, and the pus is drained early in the fistula. For a long time, the acute inflammation subsides. Change to a water sample.

4. CT examination: When the chronic dacryocystitis forms a cyst, it shows a circular or round-like cystic water sample density, the density of the abscess is slightly higher than the density of the water, and the enhanced scan has different degrees of ring enhancement, CT for small Calcification and stones can also be shown as high-density shadows in the form of spots. In addition, changes in the proliferation, hypertrophy, and destruction of the tibia can be found. CT lacrimal sac angiography is to inject the contrast agent into the lacrimal sac system, and CT scan shows it. Internal structure, can be found in the nasolacrimal duct obstruction, the location and extent of stenosis and dilatation, and can show the lacrimal system and soft tissue inside the iliac crest, periorbital structure, nasal and paranasal sinus lesions, the author reported lacrimal stenosis, obstruction The correct CT diagnosis rate was 95.6%.

Diagnosis and differentiation of dacryocystitis

diagnosis

The diagnosis of chronic dacryocystitis, as long as there is tears and mucus or purulent discharge reflux, its diagnosis is easy, when the reflux is small, it is difficult to distinguish from simple lacrimal stenosis, unilateral refractory conjunctivitis should be suspected chronic Dacryocystitis.

Differential diagnosis

Mucinous cysts should be differentiated from tumors, tuberculosis, syphilis, imaging examination (CT, MRI), surgical exploration and biopsy. The dermoid cysts and sebaceous cysts in the internal iliac crest are generally superficial, and the lacrimal passage is smooth. The ethmoid sinus or frontal sinus cyst is located above the medial malleolar ligament. X-ray, CT, MRI and nasal examination can confirm the diagnosis.

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