10.14639/0392-100X-suppl.1-41-2021-10
Pathologies of the lacrimal drainage system range from benign to malignant lesions. However, independently of the etiological origin, the most common presenting symptom is represented by epiphora due to the dysfunction of the lacrimal system. Different diagnostic tools are now available, but for the most the first diagnostic approach is characterized by an ophthalmological visit, associated with nasal endoscopy, usually performed by an otolaryngologist. Frequently the diagnostic work-up is completed with a radiological exam (e.g. maxilla-facial CT or dacryocystography), whose role is still to be determined. Once a diagnosis has been made, different treatments are available in relation to the type of the disease, and commonly need close cooperation between an ENT and ophthalmic surgeon given the close anatomical structures involved. Taking into account all these aspects, the aim of this review is to highlight how a multidisciplinary approach to lacrimal pathologies is mandatory from diagnosis to treatment in order to offer the best clinical approach.
application/xml
1827-675X
1691
en
Mario Bussi
https://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
lacrimal obstruction
Multidisciplinary approach to lacrimal system diseases
Text.Serial.Journal
https://www.actaitalica.it/
41
Annual congress report
2021-05-14
2021-05-10
2021-05-14
2021-05-14
102-107
1
Mario Bussi
2021/05/14
10.14639/0392-100X-suppl.1-41-2021-10
102
Otorhinolaryngology unit, Head and Neck department, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
1827-675X
lacrimal obstruction
107
Multidisciplinary approach to lacrimal system diseases
https://www.actaitalica.it/article/download/1691/564
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ACTA OTORHINOLARYNGOLOGICA ITALICA 2021;41(SUPPL.1):S102-S107; doi: 10.14639/0392-100X-suppl.1-41-2021-10




Multidisciplinary approach to lacrimal system
diseases
Approccio multidisciplinare alle patologie del sistema lacrimale
Matteo Trimarchi1,2, Alessandro Vinciguerra1,2, Antonio Giordano Resti3, Leone Giordano1, Mario Bussi1,2
1
  Otorhinolaryngology Unit, Head and Neck Department, IRCCS San Raffaele Scientific Institute, Milan, Italy; 2 School of Medicine,
Vita-Salute San Raffaele University, Milan, Italy; 3 Ophthalmologic Unit, Head and Neck Department, IRCCS San Raffaele Scientific
Institute, Milan, Italy


SUMMARY
Pathologies of the lacrimal drainage system range from benign to malignant lesions. How-
ever, independently of the etiological origin, the most common presenting symptom is rep-
resented by epiphora due to the dysfunction of the lacrimal system. Different diagnostic
tools are now available, but for the most the first diagnostic approach is characterized by an
ophthalmological visit, associated with nasal endoscopy, usually performed by an otolar-
yngologist. Frequently the diagnostic work-up is completed with a radiological exam (e.g.
maxilla-facial CT or dacryocystography), whose role is still to be determined. Once a diag-
nosis has been made, different treatments are available in relation to the type of the disease,
and commonly need close cooperation between an ENT and ophthalmic surgeon given the
close anatomical structures involved. Taking into account all these aspects, the aim of this
review is to highlight how a multidisciplinary approach to lacrimal pathologies is manda-
tory from diagnosis to treatment in order to offer the best clinical approach.
                                                                                                  Received: October 25, 2020
KEY WORDS: multidisciplinary approach, dacryocystorhinostomy, lacrimal pathology,                 Accepted: January 21, 2021
nasolacrimal duct, lacrimal obstruction
                                                                                                  Correspondence
                                                                                                  Matteo Trimarchi
RIASSUNTO                                                                                         Otolaryngology Department, San Raffaele Hospital,
Le patologie della via lacrimale variano da malattia di natura benigna a maligna. Indi-           via Olgettina 68, 20100 Milan, Italy
pendentemente dall’origine etiologica, il sintomo di presentazione clinica più frequente è        Tel. +39 02 26432172
rappresentato dall’epifora, causata dalla disfunzione della via lacrimale. Oggigiorno sono        E-mail: trimarchi.matteo@hsr.it
disponibili diversi strumenti diagnostici per questo tipo di patologia ma, per la maggior
parte della comunità scientifica, il primo step diagnostico è rappresentato dalla visita of-      Funding
talmologica, associato a un’endoscopia nasale eseguita solitamente da un otorinolaringo-          None.
iatra. Frequentemente, questo work-up diagnostico è completato da un esame radiologico
(es: Tomografia Computerizzata o Dacriocistografia), il cui ruolo è ancora da determinare.        Conflict of interest
Una volta eseguita una corretta diagnosi, differenti opzioni terapeutiche sono attualmente        The Authors declare no conflict of interest.
disponibili in relazione alla tipologia eziologica ed è necessaria, frequentemente, una stret-
ta collaborazione tra otorinolaringoiatra e oculista, dati gli stretti rapporti anatomici delle     How to cite this article: Trimarchi M, Vin-
strutture coinvolte.                                                                                ciguerra A, Resti AG, et al. Multidisciplinary ap-
Tenendo in considerazione gli aspetti sopracitati, lo scopo della presente review è di evi-         proach to lacrimal system diseases. Acta Otorhi-
denziare come l’approccio multidisciplinare alla patologia delle vie lacrimali sia mandato-         nolaryngol Ital 2021;41(SUPPL.1):S102-S107.
rio dalla diagnosi alla terapia, in modo da offrire al paziente un approccio clinico ottimale.      https://doi.org/10.14639/0392-100X-sup-
                                                                                                    pl.1-41-2021-10
PAROLE CHIAVE: approccio multidisciplinare, dacriocistorinostomia, patologia della
via lacrimale, dotto naso-lacrimale, ostruzione lacrimale
                                                                                                  © Società Italiana di Otorinolaringoiatria
                                                                                                  e Chirurgia Cervico-Facciale


                                                                                                                 OPEN ACCESS
Introduction                                                                                      This is an open access article distributed in accordance with
                                                                                                  the CC-BY-NC-ND (Creative Commons Attribution-Non-
The lacrimal drainage system (LDS) is a complex apparatus that is responsible                     Commercial-NoDerivatives 4.0 International) license. The
for flow of tears from the eye (medial cantus) to the nasal cavity (inferior mea-                 article can be used by giving appropriate credit and mentio-
                                                                                                  ning the license, but only for non-commercial purposes and
tus). Any pathology of this system usually appears as watery eye, also known                      only in the original version. For further information: https://
as epiphora, which is a common clinical sign that can be caused by different                      creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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                                                                                                              Multidisciplinary management of lacrimal pathologies




factors that are mainly classified as reduced outflow (e.g.                           cal variations that can affect the surgery (e.g. nasal sep-
lacrimal obstruction, eyelid malposition), hypersecretion of                          tum deviation, paradoxical middle turbinate). Additionally,
tears and reflex tearing 1. Among all these, lacrimal obstruc-                        endoscopic instrumentation can be used post-operatively,
tion is the most common cause and can be distinguished in                             thanks to the importance of direct visualization of the heal-
congenital, if it appears before the first year of life, and                          ing process. Surprisingly, it has been reported that nasal
acquired forms 2,3. Additionally, if considered the site of the                       examination is not usually performed by most ophthal-
obstruction, it can also be divided in proximal (punctum,                             mologists, with potential consequences on treatment out-
superior, inferior and common canaliculus) and distal (or                             comes 15.
post-canalicular) lacrimal obstruction, which is the most                             In the past, several authors have tried to identify the best
common 2. The latter form is most commonly encountered                                clinical practice for lacrimal diseases, but no one has taken
in middle-aged female patients in whom different local and                            into account the role of multidisciplinary consultation be-
systemic pathologies may cause lacrimal obstruction 1,4-12.                           tween an ophthalmologist and otorhinolaryngologist in the
Regardless of its etiology, epiphora has substantial impact                           management of lacrimal pathologies. The aim of this re-
on the quality of life, thus making its correct approach                              view is to analyze the role of a multidisciplinary approach
fundamental 13,14. In past years, lacrimal pathologies were                           to lacrimal pathologies, from the diagnosis to treatment.
mainly managed by an ophthalmologist due to the clinical
presentation and the treatments that were available. Nowa-
                                                                                      Diagnosis
days, with the advent of rigid endoscopes, the approach of
these types of pathologies has radically changed, leading                             The pathologies that may affect the lacrimal pathway are
to cooperation with an otolaryngologist (ENT). Moreover,                              numerous and differential diagnosis between them can be
thanks to this technological implementation, not only has                             challenging 16. The finer aspects of a precise assessment
it permitted executing standard dacryocystorhinostomy                                 of the lacrimal pathology is beyond the scope of this pa-
through an endonasal endoscopic approach (END-DCR),                                   per. However, most of the literature agrees that in-office
but it has also gained a major role pre-operatively: in fact,                         ophthalmologic examination is the first diagnostic step that
endoscopic analyses of the nasal fossa permits direct and                             should be taken in case of suspicion of lacrimal pathologies
optimal identification of surgical landmarks and anatomi-                             (Fig. 1) 17. In fact, clinical examination provides an assess-




                           BUT: break up time test; NLPO: naso-lacrimal pathways open; NLPC: naso-lacrimal pathway closed; PD: pump defect

Figure 1. Multidisciplinary diagnostic flow-chart for epiphora.



                                                                                                                                                           S103
M. Trimarchi et al.




ment of lacrimal structures, eyelids, punctal position, mei-       presence of anatomical malformation that can be missed
bomian gland, lacrimal gland and possible pathology of the         with clinical/endoscopic exam 16.
ocular bulb, providing an initial differential diagnosis of the    At present, different imaging techniques are available (e.g.
primary lacrimal pathway pathologies to secondary ones             maxillo-facial CT, dacryocystography, MRI, dacryoscin-
and its potential functional/obstructive nature 1. Such an         tigraphy, single-photon emission computed tomography);
initial diagnostic step is a non-invasive, easy and low-cost       however, no unanimous consensus on the gold standard ra-
way to establish an initial diagnosis, and if the result of this   diologic tool has been achieved 17.
examination confirms a pathology of the eyelid, lacrimal
gland, ocular bulb or meibomian gland, an otolaryngologist         Treatment
is not always required 16. On the contrary, clinical examina-
tion of the nasal cavities by an otolaryngologist remains          Given the large range of lacrimal pathologies described,
of major interest in case of both functional and obstructive       analysis of their treatment needs to be divided into proxi-
lacrimal pathway pathologies 15. In fact, even if in some          mal and distal lacrimal pathologies, related to the site of the
lacrimal pathologies, like functional diseases, the available      disease. A complete assessment of the possible treatments
treatments are primarily performed by an ophthalmologist,          available for lacrimal pathologies is beyond the scope of
the role of an otolaryngologist remain fundamental since he        this manuscript, although generally speaking collaboration
can provide an endoscopic assessment of the nasal fossa,           between an ENT surgeon and ophthalmologist is mandato-
excluding any form of influencing factors 15. Similarly, in        ry in distal lacrimal obstructions, whereas in proximal pa-
case of lacrimal obstructive pathologies, endoscopic as-           thologies it can be recommended in relation to the type of
sessment of the nose is important for diagnostic purposes          the disease. Conversely, in case of a pump defect or func-
(e.g. presence of neoplastic mass), direct evaluation of the       tional disease, multidisciplinary treatment is not generally
endonasal space that can influence the decision of the treat-      required since these are primary ophthalmologic patholo-
ment to be performed, and for identification of the potential      gies.
surgical influencing factors such as the nasal septum de-
viation, nasal mucosa pathologies, paradoxal middle turbi-         Proximal lacrimal obstructions
nate, and abnormalities of the nasal fossa 8.                      Lacrimal pathologies proximal to the valve of Rosenmul-
As a result, to establish the best diagnosis for each patient      ler are mainly divided into punctum (e.g. punctual stenosis,
affected with a pathology of the lacrimal drainage system,         punctual membrane, cicatrizing disease) and canaliculus
accurate and specific work-up is fundamental and needs to          disease (e.g. stenosis, scarring and foreign bodies) 1. If the
be done through multidisciplinary consultation between an          former can be generally treated with punctoplasty, i.e. a
ophthalmologist and otorhinolaryngologist.                         surgical procedure with the aim of widening the tight punc-
In addition to this, different radiological studies are now        tum, canaliculus disease can be approached conservatively
available with the aim of precise identification of the lac-       or surgically. In particular, a probing stenting of the proxi-
rimal disease etiology: in particular, this diagnostic step is     mal lacrimal pathway can be done and, if not successful,
fundamental in case of neoplastic disease, since the clinical      conjunctivodacryocystorhinostomy can be perfomed. The
presentation of the tumor can be non-specific, such as me-         latter is a surgical procedure that creates a neo-passage
dial cantus tender mass, bloody tears and epiphora, painless       from the conjunctiva to the middle meatus of the nose 19.
and with no endoscopic endonasal signs 11. Nevertheless,           All the treatments described for proximal obstruction of
its application in non-oncologic lacrimal pathologies is           the lacrimal pathway are generally performed by an oph-
controversial 17. A recent survey has demonstrated a rela-         thalmic plastic surgeon and the collaboration with an ENT
tive lack of interest for lacrimal imaging among ophthal-          is not always mandatory. However, conjunctivodacryocys-
mic plastic surgeons 18. However, there are times in which         torhinostomy is an approach in which the otolaryngologist
a specific diagnosis remains unclear and imaging of the            can be helpful, since endoscopic assessment of the nasal
lacrimal system may be used to help evaluate its function          cavity allows easy visualization of the correct position of
and anatomy. Specifically, Lefebvre et al. suggested that ra-      the lacrimal tube and implementation of nasal co-interven-
diologic tools must be used in case of neoplastic suspicion        tions during the approach 20.
and should be applied in case of re-operation or when there        Nevertheless, these rules concern benign lesions since
is suspicion of complicated anatomy 17. The adjunctive in-         malignant ones require close collaboration with the ENT
formation that can be obtained through radiological exams          surgeon: in fact, even if a primary malignancy of the proxi-
are important for both ophthalmic and ENT surgeons since           mal lacrimal tract is rare, stenosis of the lacrimal pathway
they can provide the exact position of the obstruction and         secondary to extrinsic compression due to sino-nasal, or-



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                                                                                                              Multidisciplinary management of lacrimal pathologies




 A                                          B                                        C                                          D

Figure 2. Endoscopic dacryocystorhinostomy surgical procedure. (A) Using 30° endoscope, the maxillary line is identified and a mucosal flap (“L-shaped”) is
raised posteriorly to expose the lacrimal bone; (B) the lacrimal bone is than removed using powered instrument; (C) while a Bowman’s probe was used by an oph-
thalmologist to tent the medial sac, the ENT surgeon used its as a guide to make a vertical incision of the lacrimal sac; (D) the initial mucosal flap is reflected back
and the ophthalmologist positioned a bicanalicular stent that is retrieved endonasally and looped.


bital and cutaneous malignancy can occur and needs to be                              END-DCR present higher functional success rates com-
treated in a multidisciplinary manner in order to eradicate                           pared to other techniques, and should be considered as
the tumor and re-establish functional eye to nose tear flow.                          treatments of choice 27. In these cases, the collaboration
                                                                                      between ophthalmic plastic and ENT surgeons is neces-
Distal lacrimal obstructions                                                          sary because, if a END-DCR is performed, management
Distal acquired lacrimal obstructions present different                               of the proximal lacrimal pathway is required and needs the
treatments related to the etiology and age of the patient. In                         presence of the ophthalmologist (Fig. 2); conversely, if an
general, the most common location of the stenosis of this                             EXT-DCR is performed, endoscopic direct visualization of
form is the nasolacrimal duct (NLD) 9.                                                the surgical landmark and potential anatomic variation can
If the congenital form is taken into account, lacrimal duct                           be helpful in order to decrease potential influencing factors
closure is usually caused by a mucosal membrane at the                                of the surgical outcome 15.
level of Hasner’s valve or by a bony constriction of the                              If a secondary re-stenosis of the neo-rhinostomy occurs,
NLD 21,22. Congenital NLD obstruction is commonly man-                                END-DCR seem to be the treatment of choice since it pro-
aged conservatively: in particular, most patients experience                          vides direct visualization of intranasal abnormalities which
spontaneous resolution of the pathology by the end of the                             cause surgical failure, with no superiority demonstrated
first year, thanks to a bony development that allows an en-                           over EXT-DCR 28. In addition to this, a new endoscopic
largement of the lacrimal duct 23. Some clinicians usually                            approach has been proposed, based on endonasal balloon
prescribe a non-invasive procedure, Crigler’s lacrimal sac                            dilatation of the stenotic neorhinostomy, with encouraging
compression, with which a simple inward lacrimal com-                                 data 29,30 (Fig. 3). In general, it seems that both primary and
pression of the lacrimal sac enhances hydrostatic pressure                            secondary approaches to non-oncologic DALO would ben-
within the system in order to overcome the common mem-                                efit from a multidisciplinary approach 28.
branous obstruction 24. As an alternative, a stenting-probing                         Malignancies of the distal lacrimal pathway have a wide
of the lacrimal system can be performed 25. All these dif-                            range of histologies, with an epithelial origin the most
ferent approaches, commonly performed by an ophthalmic                                common form. In general, treatment is based on complete
plastic surgeon, provide a success rate of up to 90%. In the                          and wide surgical resection, which commonly requires ex-
event of challenging cases, endoscopic endonasal dacryo-                              cision of adjacent structures. As a result, considering the
cystorhinostomy (END-DCR) is an established procedure                                 necessary reconstruction of the lacrimal pathway and the
to address unmanageable congenital obstructions, making                               potential combined approach to the orbital area, a multidis-
a multidisciplinary approach with an ENT a possibility in                             ciplinary approach is indispensable 11.
case of this refractive form 26.
Considering the adult form of distal lacrimal obstruc-
tion (DALO), the most common pathologies can be dis-
                                                                                      Post-surgical management and follow-up
tinguished as oncologic and non-oncologic (primary and                                Following proper treatment, several post-surgical medical
secondary) forms. Primary acquired and secondary, non-                                therapies are available, and, seem particularly useful in
oncologic, diseases have several treatments available, both                           case of non-oncologic DALO. However, with the available
surgical and non-surgical, that can be performed by dif-                              data, the actual influence of adjunctive medical therapies
ferent clinicians. Among all, a recent review has pointed                             is difficult to demonstrate 31, and endoscopic visualization
out that external dacryocystorhinostomy (EXT-DCR) and                                 of the healing process associated with nasal medication



                                                                                                                                                                S105
M. Trimarchi et al.




 A                                         B




 C                                         D

Figure 3. Using 30° endoscope, the stenotic neo-rhinostomy is identified          Figure 4. Endoscopic endonasal direct visualization of the neo-rhinostomy
thanks to soft lavage of the lacrimal pathway with fluorescein, performed by an   during a follow-up visit.
ophthalmologist (A); identification of the exact position of the neo-rhinostomy
thanks to “high” pressure lavage of the lacrimal pathway with fluorescein (B);
pneumatic dilatation of the neo-rhinostomy using a trans-nasal balloon cath-
eter (C); enlarged revised neo-rhinostomy (D).                                    doscopically evaluate the neo-rhinostomy and provide ad-
                                                                                  ditional information about the healing process (Fig. 4) 15.
                                                                                  At present, no definitive follow-up timing has been estab-
and lacrimal pathway irrigation remain the prevalent post-                        lished, but it seems reasonable that this should be at least
surgical management tools that can positively influence the                       6 months for non-oncologic DALO 27, up to 18 months
surgical outcome of all forms of DALO. In fact, the peri-                         for failure surgeries 32, and at least 5 years for oncologic
odic washing procedure of the lacrimal pathway and endo-                          DALO 11.
scopic treatment of the neo-rhinostomy can allow for better
healing, and thus leading to better surgical outcomes 15. As                      Conclusions
a result, post-surgical multidisciplinary approach remains                        The correct approach to lacrimal drainage system patholo-
of vital importance in long-term follow-up: in fact, on one                       gies can be challenging due to the location of this apparatus
hand the ophthalmologist can perform clinical evaluation                          and the different diseases that can influence physiological
of the lacrimal pathway, and on the other the ENT can en-                         lacrimal flow. Considering both its diagnosis and treatment,

Table I. Recommendations for multidisciplinary assessment.
 Diagnosis
 Diagnosis of lacrimal pathway disorders                                                   Multidisciplinary assessment “strongly recommended”
 Treatment
 Pump defects (e.g. medial ectropion or eyelid laxity)                                            Multidisciplinary assessment “optional”
 Functional diseases (e.g. Dry eye or other causes)                                               Multidisciplinary assessment “optional”
 Proximal lacrimal obstructions
   Punctum diseases                                                                                Multidisciplinary assessment “optional”
   Non-oncologic canaliculus diseases                                                            Multidisciplinary assessment “recommended”
   Primary/secondary oncologic canaliculus diseases                                               Multidisciplinary assessment “mandatory”
 Distal lacrimal obstructions
   Distal congenital lacrimal obstruction                                                          Multidisciplinary assessment “optional”
   Non-oncologic distal acquired lacrimal obstruction                                             Multidisciplinary assessment “mandatory”
   Oncologic distal acquired lacrimal obstruction                                                 Multidisciplinary assessment “mandatory”
 Post-surgical management and follow-up
 Post-surgical management and follow-up                                                          Multidisciplinary assessment “mandatory”




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                                                                                                      Multidisciplinary management of lacrimal pathologies




a multidisciplinary approach with an ophtalmic plastic and                     16
                                                                                    Trimarchi M, Giordano Resti A, Vinciguerra A, et al. Dacryocystorhinos-
                                                                                    tomy: evolution of endoscopic techniques after 498 cases. Eur J Ophthal-
ENT surgeons is frequently required, especially in distal                           mol 2020;30:998-1003. https://doi.org/10.1177/1120672119854582
forms, since such cooperation offers the best clinical ap-                     17
                                                                                    Lefebvre DR, Freitag SK. Update on imaging of the lacrimal drainage
proach available. In fact, even if most treatments of this ap-                      system. Semin Ophthalmol 2012;27:175-186. https://doi.org/10.3109
paratus are generally performed by an ophtalmologist, the                           /08820538.2012.711413
additional information and surgical approach (END-DCR)                         18
                                                                                    Nagi KS, Meyer DR. Utilization patterns for diagnostic imaging in
that an ENT clinician provides can radically influence the                          the evaluation of epiphora due to lacrimal obstruction: a national sur-
                                                                                    vey. Ophthalmic Plast Reconstr Surg 2010;26:168-171. https://doi.
decision making process and final success rate, making                              org/10.1097/IOP.0b013e3181b8c747
this cooperation of vital importance. Recommendations for                      19
                                                                                    Jones LT. Conjunctivodacryocystorhinostomy. Am J Ophthalmol
multidisciplinary approach have been resumed in Table I.                            2018;187:xxxvi-xliv. https://doi.org/10.1016/j.ajo.2018.02.004
                                                                               20
                                                                                    Eisenbach N, Karni O, Sela E, et al. Conjunctivodacryocystorhinos-
                                                                                    tomy (CDCR) success rates and complications in endoscopic vs non-
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