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Eyes wide apart!

¹ Departments of Otolaryngology ² Neuroradiology, Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London, WC1N 3JH, UK

Correspondence: Dr Wajanat Jan, MRI Department, Ground Floor of New Guy's House, Guy's Hospital, St Thomas' Street, London SE1 9RT, UK

A 1-day-old neonate was transferred to the ENT Department with difficult nasal breathing. Clinical examination showed hypertelorism and broadening of the nasal bridge, suggesting the presence of a nasal mass (Figure 1). The nasal passages were patent, although a nasogastric tube was passed with difficulty through the nostrils. A clinical diagnosis of a possible nasal mass was made and an examination under anaesthesia was arranged.

View larger version (130K): [in this window] [in a new window]   Figure 1. Photograph taken at 2 days of age, demonstrating the hypertelorism and widened nasal bridge.

View larger version (58K): [in this window] [in a new window]   Figure 2. Coronal contrast enhanced T1 weighted MRI of (a) the face and (b) the nasal cavity.

Congenital dacrocystocoeles are a rare cause of hypertelorism and a broad nasal bridge in neonates. They arise secondary to fluid collection in a non-patent nasolacrimal system. The incidence in anatomical studies ranges between 35–73% [1]. Congenital dacrocystocoeles typically present as smooth rounded swellings in the region of the medial canthus. Pain is an unusual feature. Other methods of presentation include cellulitis and respiratory obstruction [2]. Obstruction of the nasolacrimal duct resolves spontaneously with conservative management in up to 85% of all patients [3]. Initial management is therefore external massage.

The aetiology of hypertelorism in combination with a broad nasal bridge is difficult to makeonclinical grounds alone. Gliomas and encephalocoeles must be excluded as a priority. Differentiation between inflammatory and neoplastic conditions is often not possible when based solely on clinical assessment [4]. One helpful differentiating clinical feature is the presence of palpable pulsation with a meningocele, whilst dacrocystoceles do not typically pulsate [5].

MRI is the preferred method of radiological investigation and remains the gold standard method of imaging nasal masses.

Received for publication June 23, 2000. Accepted for publication July 7, 2000.

References

1. Cassady JV. Developmental anatomy of the nasolacrimal duct. Arch Ophthalmol 1952;47:141–58.[Abstract/Free Full Text]
2. Hepler KM, Wodson GE, Kearns DB. Respiratory distress in the neonate. Sequela of a congenital dacrocystocele. Arch Otolaryngol Head Neck Surg 1995;121:1423–5.
3. Peterson RA, Robb RM. The natural course of congenital obstruction of the nasolacrimal duct. J Paediatr Opthalmol 1978;15:246
4. Wright JE, Stewart WB, Krohel GB. Clinical presentation and management of lacrimal gland tumours. Br J Ophthalmol 1979;63:600–6.[Abstract/Free Full Text]
5. Day S, Lacrimal system. In: Taylor D, editor. Pediatric ophthalmology. London: Blackwell Scientific Publications, 1990:203–4.

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