Evaluation and Management of Post-Septoplasty Tear Duct Pressure
This patient requires urgent ophthalmologic evaluation to assess for nasolacrimal duct injury or obstruction, as pressure in the tear duct following septoplasty suggests potential surgical trauma to the lacrimal drainage system.
Immediate Assessment Required
Obtain ophthalmology consultation within 24-48 hours to evaluate for:
- Nasolacrimal duct obstruction or injury 1
- Dacryocystitis (infection of the lacrimal sac) 1
- Epiphora (excessive tearing) indicating drainage pathway compromise 1
The proximity of the nasolacrimal duct to the surgical field during septoplasty creates risk for iatrogenic injury, particularly when addressing anterior septal deviations 2, 3.
Diagnostic Workup
Clinical examination should specifically document:
- Presence of epiphora (tearing) on the affected side 1
- Tenderness over the lacrimal sac region (medial canthus) 1
- Mucopurulent discharge from the punctum with pressure over lacrimal sac 1
- Nasal endoscopy to assess for hematoma, adhesions, or anatomic distortion near the nasolacrimal duct opening 2, 1
Imaging considerations:
- CT imaging may be warranted if clinical examination suggests bony injury or if symptoms persist, as the nasolacrimal duct courses through the maxillary bone adjacent to the surgical field 2
Management Algorithm
If Nasolacrimal Duct Obstruction Confirmed:
Conservative management initially:
- Warm compresses to the medial canthal region 1
- Topical antibiotic drops if signs of infection 1
- Nasal decongestants to reduce mucosal edema that may be compressing the duct 2
Surgical intervention if conservative measures fail:
- Dacryocystorhinostomy (DCR) may be required for persistent obstruction, which creates a new drainage pathway between the lacrimal sac and nasal cavity 1
- Timing: typically delayed 3-6 months to allow post-operative inflammation to resolve unless acute dacryocystitis develops 1
If Adhesions or Scar Tissue Identified:
Endoscopic lysis of adhesions may be performed if scar tissue is compressing the nasolacrimal duct opening 2, 1. This should be done under direct visualization to avoid further injury 1.
Common Pitfalls to Avoid
Do not dismiss symptoms as "normal post-operative swelling" - while some edema is expected, specific pressure localized to the tear duct warrants investigation 2, 1.
Avoid prolonged observation without specialist evaluation - early identification of nasolacrimal duct injury allows for timely intervention before permanent scarring occurs 1.
Do not restart nasal steroids without ruling out infection - if dacryocystitis is present, steroids could worsen the infection 2.
Timeline Considerations
The fact that symptoms developed "since" the surgery (implying immediate onset) rather than weeks later suggests direct surgical trauma rather than delayed scarring 1, 4. This makes urgent evaluation even more critical, as early intervention may prevent permanent obstruction 1.
Documentation for Surgical Team
Notify the operating surgeon to document this complication and review operative notes for any intraoperative concerns near the lacrimal system 4. The incidence of complications following septoplasty ranges from 21% overall, with adhesions occurring in approximately 7% of cases 4.