What is the diagnosis and treatment of dacryocystitis (inflammation of the lacrimal sac) with rhinitis (inflammation of the nasal mucous membranes)?

Diagnosis and Treatment of Dacryocystitis with Rhinitis

The diagnosis of dacryocystitis with rhinitis requires a combination of clinical examination, nasal endoscopy, and possibly imaging studies, with treatment involving antibiotics targeting both gram-positive and gram-negative bacteria, followed by surgical intervention to address the underlying nasolacrimal duct obstruction.

Diagnosis

Clinical Presentation and Physical Examination

• Dacryocystitis presents with inflammation of the lacrimal sac, often with pain, swelling, and erythema in the medial canthal area, accompanied by epiphora (excessive tearing) 1
• When associated with rhinitis, patients may also exhibit nasal congestion, anterior or posterior mucopurulent drainage, and possibly reduced sense of smell 1
• A thorough examination should include:
  • Assessment of the lacrimal sac area for swelling, tenderness, and discharge 1
  • Evaluation of nasal patency, turbinate hypertrophy, septal deviation, and presence of nasal polyps 1
  • Observation of discharge quality and quantity (purulent discharge suggests infection) 1

Diagnostic Procedures

• Nasal endoscopy is strongly recommended as the primary diagnostic tool to:

  • Visualize the nasal cavity, middle meatus, and nasopharynx 1
  • Identify potential nasal pathologies contributing to nasolacrimal duct obstruction 1
  • Document presence of inflammation, purulent discharge, or nasal polyps 1

• Lacrimal system evaluation:

  • Lacrimal sac massage to check for reflux of purulent material 1
  • Nasolacrimal duct irrigation to confirm obstruction 1

• Imaging studies (when indicated):

  • CT scan is not essential for initial diagnosis but should be considered in:
    • Cases with persistent symptoms despite treatment 1
    • Suspected complications or anatomical abnormalities 1
    • Pre-surgical planning 1

Treatment

Medical Management

• Initial antibiotic therapy should target both gram-positive and gram-negative bacteria 2:

  • Common pathogens include:

    • Gram-positive: Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae 2, 3
    • Gram-negative: Pseudomonas aeruginosa, Haemophilus influenzae, Klebsiella pneumoniae 2, 3

  • Recommended antibiotics:

    • Amoxicillin-clavulanic acid as first-line therapy 2, 4
    • Fluoroquinolones for cases with suspected gram-negative involvement 3
    • Intravenous antibiotics may be required for severe cases, particularly in pediatric patients 2

• Management of rhinitis component:

  • Nasal decongestants to reduce mucosal edema 5
  • Topical nasal corticosteroids if allergic rhinitis is suspected 1

Surgical Management

• Surgical intervention is necessary to address the underlying nasolacrimal duct obstruction 2, 6

• Timing of surgery:

  • In acute cases with abscess formation, primary endoscopic dacryocystorhinostomy (EN-DCR) within 2 weeks of presentation results in faster symptom resolution (13.8 days vs 31.7 days with delayed surgery) 4
  • For chronic cases, surgery can be scheduled after controlling the acute infection 3

• Surgical options:

  • Endoscopic dacryocystorhinostomy (EN-DCR) is the preferred procedure with 87.5% success rate at one year 4
  • External dacryocystorhinostomy is an alternative approach 3
  • In severe cases with abscess, incision and drainage with direct application of antibiotics inside the infected sac provides immediate pain relief and rapid infection control 6

Special Considerations

• Patients with dacryocystitis and rhinitis should be evaluated for:

  • Underlying nasal pathologies (found in 19.6% of chronic dacryocystitis cases):
    • Hypertrophied inferior turbinate
    • Deviated nasal septum
    • Nasal polyps
    • Allergic rhinitis 3

• Potential complications requiring urgent attention:

  • Conjunctivitis
  • Corneal ulcer
  • Lacrimal abscess and fistula
  • Orbital cellulitis 3

• For recurrent cases, consider:

  • Allergy testing if allergic rhinitis is suspected 1
  • Culture and sensitivity testing to guide antibiotic selection 6, 3
  • Evaluation for systemic conditions that may predispose to recurrence 1