Ethmoid dacryocyst fistula

Introduction The mucinal cyst or purulent cyst of dacryocystitis can communicate with the ethmoid sinus to form the ethmoid sinus. When the secretion is discharged from the nasal cavity through the ethmoid sinus, the cyst can be reduced or even disappeared, and the symptoms can be alleviated, just like nasal drainage surgery. Effect.

Cause

(1) Causes of the disease

The exact reason is still inconclusive. Dacryocystitis is often secondary to inflammation in adjacent tissues such as the conjunctiva, nasal and paranasal sinuses, or some specific infections such as tuberculosis or syphilis. The original origin in the lacrimal system, the reason is not clear. Under normal circumstances, 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. Initially it is not organic obstruction, but due to temporary congestion and edema of the nasolacrimal duct mucosa, and the membranous nasolacrimal duct is in the bone tube. The blood vessels and lymphatic vessels of the mucosa are rich, and a little swelling can cause obstruction, making the contents of the lacrimal sac. Retention of matter, easy to breed bacteria, mucosa is a 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. Every time a virulent bacteria enters the lacrimal sac, it can cause an acute attack. Most infections come from the adjacent nasal cavity, paranasal sinus or tissues around the lacrimal sac. The main bacteria of non-specific dacryocystitis are Streptococcus pneumoniae, followed by Staphylococcus, Escherichia coli and Moraxella, and a few are Pseudomonas aeruginosa or Gonococci. There are many other factors that influence this process:

Anatomical factor

There are many variations of the nasolacrimal duct, and some are relatively narrow. Especially for patients with low nasal or facial stenosis, the diameter of the tube is small, and the mucosa is slightly swollen to cause obstruction. During the developmental period, the nasolacrimal duct is incomplete or the mucosal folds are formed, the inner diameter of the lumen is too small, and the mucosal swelling can completely block it.

2. The impact of nearby tissue diseases

Nasal diseases such as turbinate hypertrophy or nasal septum deviation can cause mechanical obstruction at the lower end of the nasolacrimal duct; inflammation of the nasal cavity such as acute, vascular nerve, 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. The paranasal sinus has a close anatomical relationship with the lacrimal sac, and its inflammation is also an important cause of dacryocystitis, especially the ethmoid sinus. The tear bone is often gasified into a sieving bubble. The bone is as thin as paper, and even the lacunae communicate. The infection can be directly spread to the lacrimal sac, or it can be transmitted through the abundant blood vessels or lymphatic vessels around the lacrimal sac. Less diffuse from the conjunctival infection to the lacrimal sac, except for certain invasive diseases such as trachoma

3. Systemic infection

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

4. Excessive secretion of tears and retention of tears

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.

5. Foreign bodies such as eyelashes entering from the tears or foreign objects entering the nasolacrimal duct from the nasal cavity can also cause dacryocystitis.

(two) pathogenesis

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

an examination

Related inspection

Blood routine endoscopic sinus examination

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 a jelly-like transparent or milky white secretion that is regurgitated from the lacrimal canal or pressed into the nasal cavity. Once the upper and lower lacrimal ducts are occluded, the cyst will continue to expand, forming a rather large blue cystic mass under the skin, but not adhering to the skin. CT scan showed that the lacrimal sac area was a cystic space-occupying lesion with medium to low density.

(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. The secretion is mucoid at first, and then becomes purulent. When the lacrimal sac area is compressed, there is a yellow sticky pus reflow, and it is often discharged into the conjunctival sac and becomes a source of infection. Chronic dacryocystitis can be evolved from acute dacryocystitis, and it can also be repeated episodes. The wall of chronic dacryocystitis is thickened by chronic inflammation, and the accumulation of pus and the expansion of the cyst wall form a suppurative cyst similar to a mucinous cyst. Purulent secretions are discharged into the conjunctival sac, causing conjunctivitis and eczema blepharitis.

All of 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 lacrimal sac, when the secretions are discharged from the nasal cavity through the ethmoid sinus, 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 pneumococci. Mostly, the acute onset of chronic dacryocystitis can also occur suddenly without a history of tears.

3. Special type of dacryocystitis

(1) Trachoma dacryocystitis: Primary trachoma and dacryocystitis are rare. Secondary to the trachoma lesions along the conjunctiva through the canaliculus to the lacrimal sac. Typical lesions are trachoma follicles in the lacrimal mucosa (with epithelial cell growth centers) and trachoma inclusions in the lacrimal sac mucosal epithelium. The incidence of lacrimal duct obstruction in trachoma patients is higher than in non- trachoma patients, with a ratio of approximately 15:4. Concomitant infections are more likely to result from blockages and retention. Symptoms such as tears and pus are the same as those of chronic dacryocystitis. 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. Most of the young people under the age of 20 are particularly common in women. Primary tuberculous dacryocystitis is rare, and cases have been reported in the body without any tuberculosis. Secondary tuberculosis infections originate from the nasal cavity, skin, conjunctiva and adjacent bone tissue, with the most spread of nasal lupus. Caboche found that 13 of 24 nasal tuberculosis involved the lacrimal duct. In addition to the general symptoms of tears and pus, there are still enlarged ear and submandibular lymph nodes. Mucosal proliferation of the lacrimal sac wall can produce caseous necrosis and form a cold abscess. The lesion spreads to the surrounding tissue, which can damage adjacent bone tissue and skin, leading to the formation of typical tuberculous fistula. Treatment is first of all systemic anti-tuberculosis and primary lesions. If the effect is good, choose lacrimal sac removal or intranasal drainage according to the condition of the lacrimal sac itself and the surrounding tissue.

(3) syphilitic dacryocystitis: syphilitic early sores and secondary syphilis are extremely rare. The third stage syphilis is more common, forming a soft and fluctuating mass in the lacrimal sac area, which grows faster, affects the tissue surrounding the lacrimal sac, and forms ulcers or fistulas when ruptured, destroying the entire internal iliac crest, medial and nasal The subordinates are trapped in a large cavity. Congenital syphilitic dacryocystitis, mostly bilateral, caused by nasal deformities, especially 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 results. After systemic treatment, suppurative dacryocystitis caused by obstruction of the lacrimal duct 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; maggots can also enter the lacrimal sac from the nasal cavity or conjunctival sac and cause dacryocystitis. The diagnosis of chronic dacryocystitis is easy to diagnose as long as there is tears and reflux of mucus or purulent secretions. When the reflux is small, it is difficult to distinguish it from the simple lacrimal stenosis. Unilateral refractory conjunctivitis should be suspected of chronic dacryocystitis.

Differential diagnosis

Lacrimal gland cyst: lacrimal gland cyst is rare, usually seen in inflammation or trauma, the formation of chronic inflammation affects the muscular nerves of the lacrimal duct, which reduces the contractile force of the lacrimal duct, and the inflammatory infiltration around the duct makes the wall weak, inflammatory Stimulation promotes increased secretion of tears, causing the gland to passively expand to form a cyst.

Obstruction of the lacrimal duct: The lower end of the nasolacrimal duct is an anatomical stenosis segment that is susceptible to obstruction by nasal lesions. The beginning of the lacrimal duct (puncture, lacrimal canal, and lacrimal duct) has a narrow diameter, a shallow surface, and is adjacent to the conjunctival sac, which is easily blocked by inflammation and trauma. Under normal circumstances, tears flow through the surface of the eyeball and then exit through the two small openings (tears) inside the eyelid. The lacrimal passage is connected to the nasal lacrimal passage, and the nasal lacrimal passage is opened under the nasal passage. The tears flow through the nasal lacrimal passage. If the lacrimal passage is narrow and the nasal lacrimal duct is blocked, the tears will spill over to the cheeks. The lacrimal duct obstruction is divided into complete obstruction and incomplete obstruction. For the examination, just insert a probe from the inside of the orbital opening of the eyelid and inject saline to see if the saline enters the throat through the nasal cavity. If the lacrimal duct is blocked, the salt water will not pass. Aunt Chen often shed tears, which is caused by obstruction of the right nasal lacrimal duct.

The sputum conjunctiva tears area gray-black mass: sputum conjunctiva tear area gray-black mass is one of the clinical manifestations of palpebral conjunctival melanoma. Melanoma is a malignant tumor of melanocytes derived from the skin, mucous membranes, and pigmented areas of the central nervous system.

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