Outcomes of posterior lacrimal sac approach in endoscopic dacryocystorhinostomy: review of 35 cases

BACKGROUND: The purpose of this study was to describe the posterior lacrimal sac approach in endoscopic dacryocystorhinostomy (DCR) performed at our institute and report perioperative results achieved with this procedure. METHODS: A prospective clinical study was performed of 35 adult patients with nasolacrimal duct obstruction who underwent posterior lacrimal sac approach DCR from March 1998 to May 2005. Follow-up period ranged from 13 to 30 months (average, 17.5 months; SD, 6.8 months). "Surgical success" was defined as complete relief of epiphora and patent surgical ostium on endoscopic assessment. RESULTS: Surgical success was achieved in 30/35 (85.7%) patients after the primary surgery. Of 5 unsuccessful patients who complained of occasional epiphora, 4 patients had formed stenosis and 1 patient had granulation around the surgical opening, and all had revision surgery. Four of 5 (80.0%) patients achieved surgical success. Thus, including the result of revision surgery, 34/35 (97.1%) patients were successful. CONCLUSION: Posterior lacrimal sac approach in endoscopic DCR has several advantages: good sac accessibility, a low complication rate, and a relatively high success rate. Therefore, the posterior lacrimal sac approach appears to offer a useful alternative approach for the surgical treatment of nasolacrimal duct obstruction.     

Squamous cell carcinoma of the nasolacrimal duct

Tumors originating from the nasolacrimal duct are exceedingly rare. Only a few cases have been reported previously. In advanced cases with extended tumor, differential diagnosis from lacrimal sac tumor is difficult. A 68-year-old Japanese man with intractable dacryocystitis was examined with intranasal endoscopy, computed tomography (CT) and magnetic resonance imaging (MRI). Squamous cell carcinoma extended from a medial site in the left orbit to the lacrimal orifice. En bloc resection was performed and histopathological examination of the surgical specimen using serial section suggested that the origin of the tumor was located in the nasolacrimal duct. This is the first case in nasolacrimal duct carcinoma whose differential diagnosis of origin has been studied in detail. We showed that pathological study using serial section along the duct provides useful information for diagnosing the tumor origin in addition to that obtained from imaging studies.     

Intranasal laser-assisted dacryocystorhinostomy with the use of a surgical microscope

PURPOSE: Obstruction of the nasolacrimal duct is a serious chronic condition, treatment for which has not yet been successfully resolved. Several methods have been proposed for the management of chronic epiphora. A modified method of intranasal laser-assisted dacryocystorhinostomy with the use of a surgical microscope is described. MATERIALS AND METHODS: The procedure is a modification to the West and Veis-Claus-Guttich method. The primary and late results of this method are presented for 53 patients over the past 7 years with chronic epiphora caused by stenosis of the nasolacrimal duct. Selection criteria included chronic epiphora, nasolacrimal duct stenosis due to Down syndrome, empyema of the lacrimal sac, and recurrence from previous operations. Patients were operated on under general anesthesia. RESULTS: Fifty-one patients (96.3%) were free of symptoms postoperatively (mean follow-up time, 6 months). CONCLUSION: The simplicity of this method compared with traditional methods is correlated with excellent postoperative results and patient satisfaction.     

Primary nasolacrymal tuberculosis diagnosed after dacryocytorhinostomy

Although tuberculosis (TB) is common and well recognized in many countries, unusual presentations of the disease sometimes raise difficulties in differential diagnosis. Primary tuberculosis of the lacrimal sac and the nasolacrimal duct is an extremely rare presentation of extra-pulmonary tuberculosis. Dacryocystorhinostomy alone is not sufficient for the treatment of these patients and an anti-tuberculous therapy has to be added. Here we present a patient with primary tuberculosis, which is limited to the inferior meatus and filled the entire lacrimal sac on the left side. The patient underwent endoscopic dacryocystorhinostomy due to obstruction of the nasolacrimal duct and culture of the granulation tissue, taken from the lacrimal sac revealed mycobacterial tuberculosis. The patient was improved with anti-tuberculous therapy that was added to the surgery. Primary tuberculosis is a rare granulomatous disease of the nasolacrimal system, which should be considered in the differential diagnosis to plan the effective treatment.     

Adenokarzinom des Tränensackes nach endonasaler Dakryozystorhinostomie

Primary adenocarcinoma of the nasolacrimal drainage system is a highly uncommon diagnosis, which is presumably derived from malignantly transformed glandular cells that are interspersed amongst the epithelium of the nasolacrimal duct. The patients usually present with unspecific orbital or sinus-nasal symptoms. An appropriate therapeutic regime consists of a preferably early, radical resection and local postoperative radiation therapy. This brief contribution deals with an especially uncommon case of a carcinoma of the nasolacrimal drainage system. On his first presentation, the 62-year old patient complained about right sided epiphora which had been present over the last few weeks. Eight years prior to presentation, he had been treated for a nasolacrimal duct stenosis by endoscopic dacryocystorhinostomy on this side. Diagnostic imaging revealed a soft tissue mass in the right nasolacrimal duct which was removed by a combined extra-endonasal approach. The final histopathological evaluation was adenocarcinoma. Following postoperative radiotherapy, the patient has been free of disease for 42 months. The occurrence of adenocarcinoma of the nasolacrimal drainage system in the setting of previous surgery may provide a new insight into the clinical spectrum of the natural history of this disease.     

Nasolacrimal duct obstruction caused by an oncocytoma

We report the case of a woman with epiphora and purulent rhinorrhea for which she initially underwent a dacryocystorhinostomy. The unilateral rhinorrhea was persistent and one year later an oncocytoma of the lacrimal sac with extension to the nasolacrimal duct was diagnosed. Surgical excision of the tumour via a medial maxillectomy was accomplished. Long-term follow-up for 10 years was without evidence of recurrence. To our knowledge only 22 oncocytomas of the lacrimal sac but none involving the duct have so far been reported. In patients with acquired nasolacrimal duct obstruction a lacrimal sac or nasolacrimal duct tumour though rare is a possibility and should be kept in mind. The majority of these tumours are malignant and oncocytomas may undergo malignant transformation.     

Bilateral congenital lacrimal fistulae: a case report and review of the literature

The lacrimal system is comprised of the lacrimal glands for tear production and the lacrimal drainage system for draining tears away from the eyes. Congenital lacrimal system anomalies other than nasolacrimal duct obstruction are uncommon. Congenital lacrimal fistulae are a rare developmental anomaly, and when they occur, they are usually unilateral. Fistulae and diverticulae can originate from the canaliculus, lacrimal sac, or nasolacrimal duct. They can be seen externally as small orifices or pits located inferior and/or medial to the medial canthi. These anomalies are often asymptomatic and may go undetected. However, they can also present with epiphora or discharge. We report the case of a 4-year-old male with bilateral congenital lacrimal fistulae. The patient presented to our clinic after his parents discovered bilateral pits located inferior and medial to the medial canthi. The pits had first been noticed only a few weeks prior to presentation. There was no history of drainage or infection. The diagnosis of bilateral congenital lacrimal fistulae was confirmed with computed tomographic imaging. No other systemic, nasal, or ocular anomalies were found. The patient was referred to pediatric ophthalmology and because the lacrimal fistulae have been asymptomatic to this point, it was decided to proceed with a course of observation. We will discuss the embryologic basis for congenital lacrimal fistulae, as well as the typical presentation and possible treatment modalities. The presence of lacrimal fistulae is an indicator to search for a variety of underlying systemic and ocular anomalies.     

Primary diffuse large B-cell lymphoma of the lacrimal sac simulating chronic dacryocystitis

Primary diffuse large B-cell lymphoma of the lacrimal sac is rare. Herein we report a 55-year-old female presented with epiphora in the right eye. Distention of the lacrimal sac secondary to nasolacrimal duct obstruction was observed. She was scheduled for external dacryocystorinostomy for the next month. When she came for surgery, a growing mass was recognised over the lacrimal sac region. On computer tomography scan, a subdermal mass causing nasal bone destruction was detected. Excisional biopsy of the mass was performed. Histopathologic and immunohistochemical evaluations revealed primary diffuse large B-cell non-Hodgkin lymphoma of the lacrimal sac. She was treated with cyclophospamide, vincristine, adriablastine and prednisone for eight courses combined with rituximab for 6 months. During a follow-up period of 25 months, patient is stable with no systemic disease. Although rare, lacrimal sac tumors can mimic dacryocystitis and must be considered in differential diagnosis. In suspicious cases incisional biopsy is recommended.     

Endoscopic laser dacryocystorhinostomy. An unusual post-operative finding: re-opening of the nasolacrimal duct.

Endoscopic laser dacryocystorhinostomy (DCR) is a recognized technique for the surgical treatment of epiphora. Nasolacrimal duct obstruction is surgically bypassed by creating a passage from the lacrimal sac to the nasal cavity (rhinostomy). Some patients have undergone endonasal laser-assisted DCR, and were found to have an obstructed rhinostomy at follow-up. However, they reported a subjective improvement in their symptoms. Five such patients, at six months follow-up, were found to have a non-functioning rhinostomy with fluorescein dye emerging from under the inferior turbinate. These five patients along with four controls had post-operative macrodacryocystograms (MDCG) to delineate the anatomical passage by which tears were entering the nasal cavity. In the control group, clear passage of contrast into the middle meatus was demonstrated in three of the four subjects. In the study group, passage of dye to the inferior meatus, via the nasolacrimal duct was demonstrated in four of the five subjects. It is well recognized that a proportion of patients suffering from epiphora will have a natural resolution of their symptoms. Our results demonstrate that the resolution of epiphora in some operated patients was due to a re-opening of the nasolacrimal duct, and not because of a patent rhinostomy.     

Nasolacrimal duct orifice cysts in adults: a previously unrecognized, easily treatable cause of epiphora

BACKGROUND: Epiphora is a common problem evaluated by ophthalmologists and otolaryngologists. It is typically the result of obstruction at some level of the nasolacrimal system, either the canaliculi, sac, or duct. Multiple etiologies exist, including scarring from infection or trauma, tumors, or masses. Cysts of the nasolacrimal duct orifice (dacryocystoceles) in the inferior meatus have been described in neonates, usually presenting as obstructive nasal masses shortly after birth. Nasolacrimal duct orifice cysts have not been described in the adult population in the medical literature. PATIENTS: Three patients were identified with epiphora as a result of cysts in the inferior meatus at the opening of the nasolacrimal duct. All patients presented with constant epiphora and were referred for dacryocystorhinostomy by an ophthalmologist or an otolaryngologist. None of the patients had a previous history of nasolacrimal duct (NLD) surgery. One patient had previous endoscopic sinus surgery for nasal polyps. Cysts were identified by nasal endoscopy of the inferior meatus in all patients. RESULTS: All patients underwent endoscopic resection of the inferior meatus cyst to relieve the obstruction of the NLD. Two procedures were performed under general anesthesia and one under intravenous sedation. All patients had complete relief of epiphora and have had no evidence of recurrence of the symptoms or the cyst in 4 to 10 months follow-up. CONCLUSIONS: NLD orifice cysts are easily correctable causes of epiphora. Routine inferior meatus endoscopy should be routinely performed in patients with epiphora to identify whether on not this pathology is present prior to performing dacryocystorhinostomy.     

Nasal endoscopy in the treatment of congenital lacrimal sac mucoceles

PURPOSE: To determine the incidence of intranasal cysts associated with lacrimal sac mucoceles and the cure rate with nasal endoscopic cyst marsupialization. DESIGN: Interventional case series. METHODS: SETTING: University-affiliated teaching hospital. PATIENT POPULATION: Twenty-five infants with non infected or infected lacrimal sac mucoceles or dacrocystitis without obvious mucocele were consecutively enrolled. INTERVENTION PROCEDURES: Management included local lacrimal massage, parenteral antibiotics, and when still symptomatic, nasolacrimal duct probing with concomitant nasal endoscopy. Intranasal cysts identified were marsupialized until the distal end of the nasolacrimal duct probe was visualized. MAIN OUTCOME MEASURES: Presence of intranasal cyst identification and cure rate. RESULTS: Infants were 4 days to 10 weeks old (mean 19 days). Forty-eight percent had a bluish cutaneous mass inferior and lateral to the lacrimal sac. Twenty percent were bilateral. At presentation, 76 percent had dacrocystitis. Fourteen percent had respiratory distress. Only one child responded to medical management. At endoscopy, 23 of 24 infants had ipsilateral intranasal cysts. The one child without nasal cyst had recurrent dacrocystitis and no mucocele. All children with mucocele were cured except one child with residual nasolacrimal duct obstruction. CONCLUSIONS: Lacrimal sac mucoceles were almost always associated with intranasal cysts. Nasal endoscopy is a valuable addition to the treatment plan for lacrimal sac mucoceles not responding to a brief trial of massage or infantile dacrocystitis. To avoid potential complications, we recommend against waiting until infection occurs before proceeding with surgery.     

Management of the lacrimal system during maxillectomy

BACKGROUND: Oncologic resection of the maxilla requires management of the nasolacrimal sac/duct system (NLS). A variety of techniques may be used: simple transection, transection with transcanalicular stenting, drilling of the entire nasolacrimal bony canal to the inferior meatus with mobilization of an intact NLS, marsupialization of the NLS with or without stenting, and simple transection with routine delayed dacryocystorhinostomy (DCR) for symptomatic epiphora. Rates of prolonged epiphora range from 13 to 63%. OBJECTIVES: We present our approach to NLS management during maxillectomy, and our rates of epiphora. STUDY DESIGN: Review of 212 consecutive patients who underwent transection of the NLS during medial maxillectomy, complete maxillectomy with preservation of orbital contents, suprastructure maxillectomy, or maxillectomy as part of anterior craniofacial resection. Patients with primary NLS tumors were excluded. Prolonged epiphora is defined as persistent if it lasts more than 6 months. METHODS: After exposure of the anterior maxillary wall and inferior and medial orbital rim, a high-speed drill and Kerrison rongeurs are used to remove the anterior wall of the nasolacrimal canal. The NLS is transected 12-15 mm distal to the periorbita and removed from the canal. Two 4-6-mm opposing incisions are made at the distal duct. Two semicircular flaps are everted, folded, and sutured to the proximal sac or periorbita. A transcanalicular stent is not placed. RESULTS: Two-hundred twelve patients underwent the above-mentioned procedure. Four patients (1.9%) developed prolonged epiphora, which required delayed DCR. CONCLUSIONS: Marsupialization of the NLS without stenting provided us with an acceptably low rate of prolonged epiphora.     

Long-term follow-up of patients with microscopic endonasal dacryocystorhinostomy

BACKGROUND: Stenosis of the nasolacrimal drainage system is a relatively frequent complication of acute or chronic inflammation, trauma, tumor, or congenital malformation. Symptoms include epiphora, intermittent purulent secretion, and swelling of the nasolacrimal sac. The principle of dacryocystorhinostomy (DCR) is to create an artificial opening of the lacrimal sac into the nasal cavity. This can be done via an external as well as an endonasal route. METHODS: In this retrospective study, we examined 74 microscopic endonasal DCRs. which were performed on 70 patients between 1990 and 2000. All of the 74 DCR operations had no major complications intraoperatively. RESULTS: Sixty DCR procedures (81.1%) were successful after a mean follow-up time of 3.18 years. This success rate is lower than those rates reported in the literature for the external approach, which range between 85 and 99%, although follow-up times were shorter in most of these studies. CONCLUSIONS: Advantages of the endonasal approach such as saving the medial palpebral ligament, the lacrimal pump mechanism, and the horizontal apparatus are obvious. If necessary, additional management of sinus, septal, and conchal disease can be performed simultaneously. Our results reveal that the microscopic endonasal approach is a safe and reliable procedure in the management of postsaccular or saccular nasolacrimal duct obstruction and is an alternative to the traditional external route.     

Unexpected pathologies in patients referred for endoscopic DCR

The objective of this study is to describe a series of patients with different pathologies mimicking nasolacrimal duct obstruction (NLDO), diagnosed with the use of a computed tomography (CT) scan prior to a scheduled endoscopic dacryocystorhinostomy (DCR). This study is a retrospective report. We reviewed the medical records of 47 consecutive patients (57 sides) with long-standing epiphora between 2007 and 2012. All patients were referred to our tertiary Medical Center with a diagnosis of NLDO and were expected to undergo endoscopic dacryocystorhinostomy (DCR). They all underwent routine sinus CT scan prior to surgery. All scans, as well as the demographic and medical characteristics of these patients were reviewed. Of all 47 patients enrolled, in 4 patients (7 % of all sides), unexpected pathologies, other than nasolacrimal system distention, inflammation or infection were identified preoperatively. These included squamous cell carcinoma of the lacrimal sac and nasolacrimal duct, rhinoscleroma at Hasner’s valve region, a compressing ethmoidal mucocele and a case of dacryocystocele. These unusual pathologies mandated a different management and surgical approach. In all four cases, a preoperative CT scan helped in identifying the pathology and in localizing the lacrimal apparatus in relation to the paranasal sinuses. Different nasal, paranasal and lacrimal pathologies may mimic primary acquired NLDO. A high index of suspicion, a thorough clinical evaluation and utilizing preoperative imaging may lead to an alteration of patient management and to a completely different surgical approach.     

Endoscopic dacryocystorhinostomy: anatomical approach

Dacryocystorhinostomy is the surgical treatment for nasolacrimal blockage. In recent years, the endoscopic approach has become more popular due to the development of nasal endoscopes and the ease of surgery in comparison to the external approach. In order to identify the lacrimal duct during surgery, surgeons insert a light pipe into the lacrimal duct and then drill or chisel the hard bone of the frontal process of the maxilla to remove the bony covering of the sac and duct. It is obvious that knowledge of the anatomy of the lacrimal sac/duct within the nose is essential for the surgeon. The lacrimal apparatus in the nose was studied using 10 cadaveric half-heads (5 males and 5 females) to establish the anatomical landmarks and most accessible part of the lacrimal duct from within the nose. Although there was solid bone covering the whole length of the sac and the duct, the posteromedial aspect of the lower sac and upper duct was covered by the ultra thin lacrimal bone (average thickness 0.057 mm) which was consistently found to be lying immediately anterior to the uncinate process in the middle meatus, thus constituting a "surgical window" (average size 2.5 mm x 7.2 mm) whereby surgical entry into the lacrimal duct becomes relatively easy. The lower part of the lacrimal sac and the upper part of the lacrimal duct can therefore be easily accessed from within the nose by following this anatomical approach, thus avoiding the need to drill or chisel the dense frontal process of the maxilla.     

Nasolacrimal obstruction after maxillary sinus and rhinoplastic surgery.

Transient nasolacrimal obstruction is a common complication of maxillary sinus, as well as rhinoplastic surgery. Permanent epiphora, however, is unusual. This communication describes 11 patients with surgical injury to the lacrimal drainage system, which necessitated dacryocystorhinostomy for correction. Seven of these cases occurred subsequent to nasoantral window procedures, three occurred after rhinoplasty, and one resulted from a partial maxillectomy. It has been shown that the two areas most vulnerable to inadvertent surgical injury are the nasolacrimal sac, located just beneath the medial canthal ligament, and the ductal ostium in the inferior meatus. We discuss the relevant anatomy of the nasolacrimal apparatus, in addition to surgical methods for avoiding injury to the system. We also describe the currently applied techniques for diagnosing and managing lacrimal obstruction and review the literature.     

Outcomes after endoscopic dacryocystorhinostomy without mucosal flap preservation

BACKGROUND: The purpose of this study was to evaluate outcomes of powered endoscopic dacryocystorhinostomy (DCR) without the preservation of mucosal flaps for the management of acquired nasolacrimal duct obstruction. METHODS: A retrospective review was performed of patients undergoing endoscopic DCR without mucosal flap preservation from May 2003 to October 2006 at a tertiary referral medical center. Twenty-seven procedures were performed on 20 patients with epiphora secondary to acquired nasolacrimal duct obstruction. Main outcome measures were subjective improvement in epiphora and assessment of anatomic patency based on lacrimal irrigation. RESULTS: Mean follow-up was 16 months. Mild intermittent postoperative epiphora or complete resolution of epiphora was noted in 100% (27/27) of procedures; complete resolution was recorded in 93% (25/27) of procedures. Eighteen patients (25 procedures) were available for lacrimal irrigation at a mean of 16 months follow-up. Anatomic patency was confirmed in 100% (25/25) of procedures. CONCLUSION: Our results with endoscopic DCR are comparable with previously published outcomes. These data suggest that successfully powered DCR may be performed without the preservation of mucosal flaps.     

Powered endoscopic dacryocystorhinostomy with radiowave instruments: surgical outcome according to obstruction level

Endoscopic endonasal dacryocystorhinostomy (EDCR) is an accepted alternative to external dacryocystorhinostomy (DCR) for relieving obstruction of the lacrimal drainage system. Powered and radiowave instruments are useful for the control of bleeding and for wide exposure of the lacrimal sac and canaliculus. In this study, we evaluated the surgical outcome of powered EDCR with radiowave instruments at five obstruction levels: (1) upper and/or lower canaliculi (obstruction was located less than 8 mm from puncta); (2) common canaliculus (obstruction was less than 10 mm from puncta); (3) lacrimal sac; (4) duct-sac junction; and (5) nasolacrimal duct. The overall success rate was 93.6 % (104/111), with 60.0 % (3/5) success for upper and lower canalicular stenosis, 85.0 % (17/20) for common canalicular stenosis, 92.0 % (23/25) for obstruction at the lacrimal sac, 100 % (41/41) for obstruction at the duct-sac junction, and 100 % (20/20) for nasolacrimal duct obstruction. EDCR resulted in a good overall surgical outcome for any obstruction of the lacrimal drainage pathway compared with external DCR. Powered EDCR using radiowave instruments is useful for not only obstruction of the lacrimal sac and duct-sac junction, but also for that of the upper/lower and common canaliculi.     

Manometric measurement of lacrimal sac pressure after endoscopic and external dacryocystorhinostomy

OBJECTIVE: To evaluate endoscopic and external dacryocystorhinostomy (DCR) using a quantitative, objective functional tool. MATERIAL AND METHODS: This study comprised 58 cases divided into 4 groups: healthy controls; patients suffering from epiphora due to nasolacrimal duct (NLD) obstruction; patients who had undergone endoscopic DCR; and patients who had undergone external DCR. The lacrimal sac pressure was measured during blinking, forced blinking and the Valsalva maneuver using a polygraph. RESULTS: Negative pressure was detected during blinking and forced blinking in all normal subjects and in most patients who had successfully undergone DCR. In contrast, positive pressure was detected in cases with epiphora and patients in whom DCR had failed. Negative pressure was higher after endoscopic than external DCR. During the Valsalva maneuver there were no pressure changes in normal cases and patients with epiphora. In contrast, positive pressure was detected after all of the successful procedures (being higher after external than endoscopic DCR) and in most of the patients in whom external DCR failed. CONCLUSIONS: In normal subjects, negative pressure is created during blinking. In cases with epiphora due to NLD obstruction, the lacrimal pump is affected but its function is restored after successful DCR. The suction power of the pump mechanism is more effective after endoscopic than external DCR.     

Evaluation of nasolacrimal duct function in chronic paranasal sinus infections with 99mTc dacryoscintigraphy]

BACKGROUND: Paranasal sinus infections and nasolacrimal duct obstructions are commonly encountered problems. However the relationship between these two conditions is not yet clear. Trauma, surgery, tumors, and systemic diseases are among the causes of acquired nasolacrimal duct obstructions but most of the cases are idiopathic. In this study patients diagnosed with chronic paranasal sinus infection were examined with 99mTc lacrimal dacryoscintigraphy to assess their nasolacrimal duct function. METHODS: Twenty-four patients diagnosed with chronic paranasal sinus infection are included in the study. These patients were observed for at least three months awaiting surgical treatment following unsuccessful medical treatment. The control group included 16 persons admitted to the ophthalmology department without any nasolacrimal duct disease. Nasal endoscopy and paranasal sinus CT revealed normal findings. The age of the patients with chronic paranasal sinus infection and examined in regard to nasolacrimal duct function was between 15 to 17 with a mean age of 34.2 years. Fourteen patients were male and 10 patients were female. The control group included 9 male and 7 female patients between 18 to 60 years with a mean of 30.5 years. RESULTS: The dacryoscintigraphic examination of 48 nasolacrimal ducts in 24 patients with chronic paranasal sinus infection revealed 7 complete and 18 partial obstructions of the duct, and 23 normal findings. In the control group with 32 nasolacrimal ducts of 16 patients, there was no complete obstruction. Partial obstruction (10.6, 12.0, 14.7 minutes) was be observed in three cases. The statistical workup resulted in a significant difference between paranasal sinus patients and control group (x2 = 15,840 p < 0.001). The paranasal sinus CTs of the patients with paranasal sinus disease were staged using the Lund-Mackay staging system: There is no correlation between the staging score of the paranasal sinus infection and the degree of the obstruction the nasolacrimal duct. CONCLUSION: This study shows that chronic paranasal sinus disease plays an important role in the pathogenesis of nasolacrimal duct obstructions. The presence of infection has an influence on the nasolacrimal drainage system, but the distribution (staging) of the infection does not appear to correlate with the degree of nasolacrimal duct obstruction. Partial obstruction cases that may progress to complete obstruction may be detected by dacryoscintigraphy, and the treatment of chronic paranasal sinus disease may help to overcome the lacrimal drainage problems in these cases.