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Incidence of neoplasia in patients with unilateral epiphora

Published online by Cambridge University Press:  15 July 2015

T Bewes ,
R Sacks ,
P L Sacks ,
D Chin ,
N Mrad ,
G Wilcsek ,
K Tumuluri  and
R Harvey
T Bewes*
Affiliation:
St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
R Sacks
Affiliation:
Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia Australian School of Advanced Medicine, Macquarie University, Sydney, Australia
P L Sacks
Affiliation:
Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
D Chin
Affiliation:
Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
N Mrad
Affiliation:
Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
G Wilcsek
Affiliation:
Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
K Tumuluri
Affiliation:
Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia Australian School of Advanced Medicine, Macquarie University, Sydney, Australia
R Harvey
Affiliation:
St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia Australian School of Advanced Medicine, Macquarie University, Sydney, Australia
*
Address for correspondence: Dr Therese Bewes, St Vincent's Centre for Applied Medical Research, Level 4 Lowy Packer Building, 405 Liverpool Street, Darlinghurst, NSW 2010, Australia Fax: (+61) 2 8382 4901 E-mail: tessbewes@gmail.com
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Abstract

Background:

Nasolacrimal duct obstruction is common and is usually a result of benign stricture formation. Although neoplasia near or around the lacrimal system may produce epiphora, the incidence of neoplasia from within the lacrimal system as a cause of nasolacrimal duct obstruction is not well documented.

Methods:

A retrospective study was performed on all patients undergoing dacryocystorhinostomy with a history of epiphora. The incidence of patients with operative findings of intra-lacrimal neoplasm was sought. Histopathologically confirmed cases were included.

Results:

The study comprised 537 patients, who underwent a total of 631 endoscopic dacryocystorhinostomy procedures between January 1998 and July 2013. Non-stenotic causes of nasolacrimal duct obstruction were encountered in 3.01 per cent of dacryocystorhinostomy procedures, and included neoplastic, inflammatory and infectious pathologies. Inverted papilloma was the most common cause, encountered in 0.79 per cent of dacryocystorhinostomy operations.

Conclusion:

These findings suggest that neoplasia is an uncommon but not a rare cause of nasolacrimal duct obstruction. Surgical teams performing high numbers of dacryocystorhinostomy procedures should be aware of such pathology and patients counselled appropriately.

Keywords

DacryocystorhinostomyLacrimal Apparatus DiseasesNeoplasmsIncidencePapilloma, Inverted

Information

Type
Main Articles
Information
The Journal of Laryngology & Otology , Volume 129 , Supplement S3 , July 2015 , pp. S53 - S57
Copyright
Copyright © JLO (1984) Limited 2015 

Introduction

Nasolacrimal duct obstruction is more common in females than males.Reference Nemet and Vinker1, Reference Woog2 In females, the anteroposterior and transverse diameters of the nasolacrimal canal are smaller, and the angle between the canal and the nasal floor is more acute than in males.Reference Shigeta, Takegoshi and Kikuchi3 Osteoporotic changes, and smaller dimensions in the lower nasolacrimal fossa and the middle nasolacrimal duct, have been proposed as factors contributing to the higher prevalence of benign stenotic nasolacrimal duct obstruction in middle-aged women.Reference Groessl, Sires and Lemke4 Additionally, early menopause, hormonal fluctuations and low oestrogen causing drying of lacrimal mucosa have been proposed as theories for the formation of nasolacrimal duct obstruction.Reference Nemet and Vinker1, Reference Zolli and Shannon5

Although neoplasia near or around the lacrimal system may produce epiphora, the incidence of neoplasia from within the lacrimal system as a cause of nasolacrimal duct obstruction is not well documented. In a previous report, neoplasms resulting in chronic nasolacrimal duct obstruction affected 4.6 per cent of patients, and were unsuspected before surgery in 2.1 per cent of patients.Reference Anderson, Wojno and Grossniklaus6 The current study aimed to document the incidence of neoplasia encountered during endoscopic dacryocystorhinostomy (DCR) surgery.

Materials and methods

A retrospective study was performed on all patients with symptoms of nasolacrimal duct obstruction who underwent endoscopic DCR between January 1998 and July 2013, using data collected from three surgeons (RS, GW and RJH). We sought to determine the incidence of patients with operative findings of non-stenotic causes of symptoms. Histopathologically confirmed cases were included.

Gender, age, previous surgery and symptom resolution were compared between these patients and those with common nasolacrimal duct obstruction. Statistical assessment was performed, via a chi-square analysis of proportions, using Prism 6 software (GraphPad, La Jolla, California, USA).

Results

The study comprised 537 patients (aged 62.66 ± 18.01 years; 68.62 per cent were female), who underwent a total of 631 endoscopic DCRs. Multiple cases of tumours arising within the nasolacrimal system together with nasal tumours obstructing the nasolacrimal system were encountered. Many of these were unsuspected prior to surgery.

From a total of 631 DCRs, non-stenotic causes of nasolacrimal duct obstruction were found in 3.01 per cent of cases (n = 19), and included neoplastic (1.43 per cent), inflammatory (1.27 per cent) and infectious (0.32 per cent) pathologies (Table I). Neoplasia accounted for 47.37 per cent of non-stenotic nasolacrimal duct obstructions, inflammatory causes accounted for 42.11 per cent and infection accounted for 10.53 per cent.

Table I

Rates of unsuspected non-stenotic causes of nasolacrimal duct obstruction

DCR = dacryocystorhinostomy

Inverted papilloma was the most common cause, encountered in 0.79 per cent of DCRs (n = 5) and confirmed histopathologically. Whilst inverted papillomas were suspected in two of these cases, they were unsuspected prior to surgery in the remaining three cases. Moreover, neo-osteogenesis secondary to previous inverted papilloma excision was the cause of nasolacrimal duct obstruction in three cases. Figure 1 demonstrates the macroscopic appearance of inverted papilloma at DCR, with Figure 2 demonstrating the histopathological features of inverted papilloma.

Fig. 1

(a) & (b) Endoscopic images demonstrating the macroscopic appearance of inverted papilloma at dacryocystorhinostomy.

Fig. 2

Histopathological features of inverted papilloma. (H&E; ×100)

Gender

Of the 631 DCRs performed, 31.38 per cent were conducted on male patients. However, 52.65 per cent of non-stenotic cases of nasolacrimal duct obstruction visualised during DCR were in male patients (non-stenotic causes were found in 5.05 per cent of males vs 2.08 per cent of females; p = 0.04). Male gender was significant as a predictor for inverted papilloma at DCR when compared to non-inverted papilloma related nasolacrimal duct obstruction (2.02 per cent vs 0.23 per cent; odds ratio = 8.91, p = 0.02) (Table II).

Table II

Relationship of gender to incidence of inverted papilloma in lacrimal system*

*p = 0.04

Age

The mean age for DCR was 62.84 ± 17.62 years for females and 62.61 ± 18.80 years for males (p = 0.88). For patients with nasolacrimal duct obstruction due to non-stenotic causes, this was 60.05 ± 13.97 years (vs 62.85 ± 18.12 years for patients with stenotic causes; p = 0.51). There was no statistical difference in age between inverted papilloma and benign stenotic nasolacrimal duct obstruction cases (52.99 ± 4.37 years vs 62.85 ± 18.12 years; p = 0.22). Ages for these groups are shown in Figure 3. Similarly, there was no statistical difference in age between neoplastic versus benign stenotic nasolacrimal duct obstruction cases (60.78 ± 12.23 years vs 62.85 ± 18.12 years; p = 0.73), nor between cases with an infectious or inflammatory cause versus a benign stenotic common cause of nasolacrimal duct obstruction (59.40 ± 16.00 years vs 62.85 ± −18.12 years; p = 0.55).

Fig. 3

Age of nasolacrimal duct obstruction patients with benign stenotic causes versus those presenting with inverted papilloma in the lacrimal system (p = 0.22).

Previous surgery

Previous nasolacrimal, eyelid, nasal or sinus surgery was documented in 26.94 per cent of DCR patients (stenotic patients 26.14 per cent vs non-stenotic patients 52.63 per cent; p = 0.01). Nasolacrimal surgery was the most common surgery, recorded prior to DCR in 15.37 per cent of all patients (stenotic patients 15.85 per cent vs non-stenotic patients 15.79 per cent; p = 0.99). Eyelid surgery had been performed prior to DCR in 4.91 per cent of patients (stenotic patients 5.07 per cent vs non-stenotic patients 0.00 per cent; p = 0.31), and 6.66 per cent had undergone prior nasal or sinus surgery (stenotic patients 6.86 per cent vs non-stenotic 36.84 per cent; p < 0.0001).

Resolution status

Symptom resolution (defined as complete resolution) was not associated with the underlying pathology. Symptom resolution was recorded in 88.07 per cent of stenotic cases and in 100 per cent of non-stenotic cases. In the recorded data, complete resolution was seen in 84.21 per cent of stenotic cases and in 81.08 per cent of non-stenotic cases (p = 0.73).

Discussion

The cumulative reported incidence of non-stricture related pathology at DCR, including neoplasia, inflammatory or infectious pathology, was 3.69 per cent, based on 1624 biopsies (Table III). The reported incidence of non-stricture related pathology in this study was 3.01 per cent, which is consistent with global literature (Table III).Reference Anderson, Wojno and Grossniklaus6–Reference Knežević, Stojković, Jovanović, Stanković and Rašić14 Whilst previous studies have demonstrated a range in the incidence of inverted papilloma at DCR from 0 to 1.06 per cent, inverted papillomas in this population have been found during 0.79 per cent of DCRs.Reference Anderson, Wojno and Grossniklaus6–Reference Knežević, Stojković, Jovanović, Stanković and Rašić14

Table III

Summary of relevant study findings

*Range = 0.00–14.29 per cent; †range = 0.00–7.14 per cent; ‡range = 0.00–1.06 per cent. DCR = dacryocystorhinostomy

  • • Neoplasia was found to be a cause of nasolacrimal duct obstruction in 1.43 per cent of cases

  • • Despite a female predominance in nasolacrimal duct obstruction patients, inverted papilloma was a more common cause in male patients

  • • Success rates for symptom resolution were not associated with underlying pathology

Non-stenotic causes of nasolacrimal duct obstruction were unsuspected prior to DCR in all patients, except for two patients with known inverted papillomas diagnosed pre-operatively. The tendency of local bony remodelling after resection was demonstrated in three cases where neo-osteogenesis secondary to previous inverted papilloma excision was the cause of nasolacrimal duct obstruction.Reference Sandison15

There was a female predominance of 68.62 per cent in this study, consistent with evidence that nasolacrimal duct obstruction is more common in female patients.Reference Anderson, Wojno and Grossniklaus6 Male gender was associated with both a higher chance of having a neoplastic-related nasolacrimal duct obstruction and inverted papilloma, a result that correlates well with the reported gender distribution of sinonasal inverted papillomas.Reference Linberg and McCormick9, Reference Sandison15

Conclusion

Neoplasia is an uncommon (1.43 per cent) but not a rare cause of nasolacrimal duct obstruction. Male patients presenting with unilateral epiphora were most commonly associated with inverted papilloma. Success was achieved at similar rates for non-stenotic causes of nasolacrimal duct obstruction. These results can be used to inform the DCR surgeon and patients regarding the causes of nasolacrimal duct obstruction.

Footnotes

Presented as a poster at the Australian Society of Otolaryngology Head and Neck Surgery 2014 Annual Scientific Meeting, 29 March – 1 April 2014, Brisbane, Australia.

References

1Nemet, AY, Vinker, S. Associated morbidity of nasolacrimal duct obstruction–a large community based case–control study. Graefes Arch Clin Exp Ophthalmol 2014;252:125–30CrossRefGoogle ScholarPubMed
2Woog, JJ. The incidence of symptomatic acquired lacrimal outflow obstruction among residents of Olmsted County, Minnesota, 1976–2000 (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc 2007;105:649–66Google ScholarPubMed
3Shigeta, K, Takegoshi, H, Kikuchi, S. Sex and age differences in the bony nasolacrimal canal: an anatomical study. Arch Ophthalmol 2007;125:1677–81CrossRefGoogle ScholarPubMed
4Groessl, SA, Sires, BS, Lemke, BN. An anatomical basis for primary acquired nasolacrimal duct obstruction. Arch Ophthalmol 1997;115:71–4CrossRefGoogle ScholarPubMed
5Zolli, CL, Shannon, GM. Dacryocystorhinostomy: a review of 119 cases. Ophthalmic Surg 1982;13:905–10Google ScholarPubMed
6Anderson, NG, Wojno, TH, Grossniklaus, HE. Clinicopathologic findings from lacrimal sac biopsy specimens obtained during dacryocystorhinostomy. Ophthal Plast Reconstr Surg 2003;19:173–6CrossRefGoogle ScholarPubMed
7Amin, RM, Hussein, FA, Idriss, HF, Hanafy, NF, Abdallah, DM. Pathological, immunohistochemical and microbiological analysis of lacrimal sac biopsies in patients with chronic dacrocystitis. Int J Ophthalmol 2013;6:817–26Google ScholarPubMed
8Merkonidis, C, Brewis, C, Yung, M, Nussbaumer, M. Is routine biopsy of the lacrimal sac wall indicated at dacryocystorhinostomy? A prospective study and literature review. Br J Ophthalmol 2005;89:1589–91CrossRefGoogle ScholarPubMed
9Linberg, JV, McCormick, SA. Primary acquired nasolacrimal duct obstruction. A clinicopathologic report and biopsy technique. Ophthalmology 1986;93:1055–63CrossRefGoogle ScholarPubMed
10Mauriello, JA Jr, Palydowycz, S, DeLuca, J. Clinicopathologic study of lacrimal sac and nasal mucosa in 44 patients with complete acquired nasolacrimal duct obstruction. Ophthal Plast Reconstr Surg 1992;8:13–21CrossRefGoogle ScholarPubMed
11Tucker, N, Chow, D, Stockl, F, Codère, F, Burnier, M. Clinically suspected primary acquired nasolacrimal duct obstruction: clinicopathologic review of 150 patients. Ophthalmology 1997;104:1882–6CrossRefGoogle ScholarPubMed
12Lee-Wing, MW, Ashenhurst, ME. Clinicopathologic analysis of 166 patients with primary acquired nasolacrimal duct obstruction. Ophthalmology 2001;108:2038–40CrossRefGoogle ScholarPubMed
13Bernardini, FP, Moin, M, Kersten, RC, Reeves, D, Kulwin, DR. Routine histopathologic evaluation of the lacrimal sac during dacryocystorhinostomy: how useful is it? Ophthalmology 2002;109:1214–17CrossRefGoogle Scholar
14Knežević, M, Stojković, M, Jovanović, M, Stanković, Z, Rašić, DM. A 7-year prospective study of routine histopathological evaluation of the lacrimal sac wall incisional biopsy specimens obtained during external dacryocystorhinostomy in adults and a review of the literature. Med Oncol 2012;29:396–400CrossRefGoogle Scholar
15Sandison, A. Common head and neck cases in our consultation referrals: diagnostic dilemmas in inverted papilloma. Head Neck Pathol 2009;3:260–2CrossRefGoogle ScholarPubMed
Figure 0

Table I Rates of unsuspected non-stenotic causes of nasolacrimal duct obstruction

Figure 1

Fig. 1 (a) & (b) Endoscopic images demonstrating the macroscopic appearance of inverted papilloma at dacryocystorhinostomy.

Figure 2

Fig. 2 Histopathological features of inverted papilloma. (H&E; ×100)

Figure 3

Table II Relationship of gender to incidence of inverted papilloma in lacrimal system*

Figure 4

Fig. 3 Age of nasolacrimal duct obstruction patients with benign stenotic causes versus those presenting with inverted papilloma in the lacrimal system (p = 0.22).

Figure 5

Table III Summary of relevant study findings