Lacrimal sac phlegmon is an acute diffuse purulent inflammation of the lacrimal sac with the spread of infection to the surrounding fiber. The disease is manifested by pain, swelling and hyperemia in the inner corner of the eye, an increase in body temperature. In the process of diagnosing the phlegmon of the lacrimal sac, the West test, MSCT orbits, magnetic resonance dacryocystography are used. Conservative therapy includes the use of antibacterial, nonsteroidal anti-inflammatory and hormonal agents. Surgical treatment is reduced to opening the phlegmon, followed by dacryocystorinostomy.
H04.3 Acute and unspecified inflammation of the tear ducts
Phlegmon of the lacrimal sac (acute purulent peridacryocystitis) in most cases is a complication of chronic dacryocystitis. The disease is diagnosed in 3-5% of newborns suffering from inflammation of the tear ducts. According to statistics, with timely surgical treatment, 96.9% of patients have a complete recovery, only 3-4% of patients have a recurrent course. In 12.5% of cases, multi-stage surgical interventions are required. Male and female individuals get sick with the same frequency. Pathology is widespread everywhere.
There are acquired and congenital variants of the disease. The congenital form is extremely rare, the disease occurs in newborns due to obstruction of the nasolacrimal canal. Trigger factors are also anomalies of the structure of the eyelids, the facial part of the skull and, as a consequence, the structures of the lacrimal system. The main causes of the acquired form of the phlegmon of the lacrimal sac are considered:
- Purulent chronic dacryocystitis. In the presence of a focus of infection, another exacerbation of dacryocystitis can lead to phlegmon. The development of pathology is indicated by hyperthermia and the lack of effect from the prescribed antibacterial therapy.
- Stenosis of the nasolacrimal canal. Patients with anatomical predisposition have frequent relapses of dacryocystitis and the formation of dacryoadenitis. With blockage of the nasolacrimal duct or violation of the outflow of tears due to stenosis, the growth and reproduction of pathogenic bacteria lead to peridacryocystitis.
- Inflammation of the paranasal sinuses. Phlegmonous inflammation is a consequence of the dissemination of the infectious process from the paranasal sinuses. Risk factors are considered to be inflammation of the maxillary sinus and the trellis labyrinth (chronic sinusitis, ethmoiditis).
- Rhinitis. The spread of infection from the nasal cavity occurs through an anatomical message – the nasolacrimal canal, which opens in the lower nasal conch. The most common phlegmon occurs in people suffering from chronic atrophic rhinitis (ozen).
Iatrogenic effects. Scientists believe that the use of tetracycline ointment in the early neonatal period for the prevention of gonoblennorrhea significantly increases the likelihood of developing phlegmon. This is due to the fact that the ointment base contributes to the obstruction of the lacrimal pathways with an existing gelatinous plug.
The mechanism of development of purulent peridacryocystitis is based on the penetration of infectious agents into the lacrimal sac, followed by the spread of the pathological process to the thinned mucous membrane and surrounding tissue. Initially, an infiltrate appears, in the center of which an abscess cavity is formed over time, and later – a phlegmon. After spontaneous opening of the abscess, an external fistula may form, opening in the medial corner of the eye. An internal fistula occurs when the phlegmon breaks into the nasolacrimal canal. In the severe course of the disease, inflammation of nearby anatomical structures (eyelids, nasal mucosa and adnexal sinuses, subcutaneous fat in the face area) is observed.
The first symptoms of purulent peridacryocystitis are swelling and sharp soreness in the medial corner of the eye. Due to the pronounced swelling of the eyelids, the eye slit is sharply narrowed or completely closed. Edema spreads to the paranasal region and cheeks, less often to the opposite half of the face. An increase in body temperature is characteristic. Patients complain of severe headache, general weakness. With the development of the disease in the first days of life, parents notice that the child behaves restlessly, refuses to feed. The condition of patients improves with the breakthrough of purulent contents through the skin in the middle third of the lacrimal sac. When forming an external fistula, patients note the release of tears with purulent masses in the inner corner of the eye.
Frequent complications of phlegmon are blepharitis, rhinitis. Cases of the formation of an internal or external lacrimal fistula are described. Spontaneous opening of the phlegmon through the tarzo-orbital fascia into the cavity of the eye socket is possible. With an independent transcutaneous breakthrough of the phlegmon, a skin scar appears during the secondary healing of an infected wound. A fistula may form, through which purulent masses are released. When the infection spreads to the paraorbital tissue, a phlegmon of the eye socket occurs. In rare cases, the membranes of the eyeball are affected with the development of endo- and panophthalmitis.
On examination, edema and hyperemia are visualized in the projection area of the lacrimal sac and surrounding tissues. Palpation is determined by fluctuation. At the stage of physical examination, it is possible to use the lacrimal-nasal test Vesta, which allows you to assess the condition of the tear ducts before the exit of tear fluid into the lower nasal conch. Hardware imaging methods are used to confirm the diagnosis:
- Tomography of orbits. MSCT of orbits is performed in three projections – axial, sagittal and coronal. A rounded infiltrate filled with purulent masses is determined. The affected area is indistinctly delimited from reactively thickened, edematous soft tissues.
- Magnetic resonance dacryocystography. The technique makes it possible to assess the condition of soft tissue structures surrounding the nasolacrimal canal. The fiber is infiltrated, edematous. In the postoperative period, to study the condition of the lacrimal system, the study is performed with contrast.
In acute inflammatory process, contrast dacryocystography is strictly contraindicated. Differential diagnosis is carried out with a hemangioma. Unlike phlegmon, with a vascular tumor, the body temperature does not rise, there are no general and local signs of inflammation, MSCT reveals vascular malformation, and not purulent contents.
Treatment of acute purulent peridacryocystitis requires a comprehensive approach. Conservative therapy is reduced to the appointment of broad-spectrum antibacterial drugs. The route of administration is intramuscular in combination with instillations into the conjunctival cavity. Nonsteroidal anti-inflammatory drugs are indicated with a short course (5-7 days). With a complicated course of pathology, local forms of glucocorticosteroids are included in the complex of therapeutic measures. Physiotherapeutic treatment is based on the regional application of dry heat and the appointment of UHF to the affected area.
With an already formed fluctuating phlegmon, its percutaneous opening and drainage is shown. The phlegmon cavity is washed with antibacterial agents and antiseptic solutions. Daily dressings are carried out with a hypertonic sodium chloride solution. After the acute process is stopped, endonasal dacryocystorinostomy is performed to restore the physiological pathway of the outflow of tears. With post-traumatic retraction of the medial corner of the eye and damage to the tubules, multi-stage reconstructive surgical interventions are performed. In the absence of the effect of the prescribed treatment and frequent relapses of the disease, extirpation of the lacrimal sac is carried out.
Prognosis and prevention
Prevention of the development of phlegmon is reduced to early diagnosis and timely treatment of dacryocystitis. During the newborn period, it is recommended to use only drops for instillation into the conjunctival cavity, do not use ointments and gels. With symptoms of lacrimal obstruction, children in the neonatal period are shown a descending massage of the lacrimal sac. In adults, rinsing and probing of the nasolacrimal duct is carried out for preventive purposes. The prognosis for life and working capacity is favorable. In 96.9% of cases, the outcome of the disease is a complete recovery.