P1092 - Respiratory Distress in a Newborn: Who Nose?

Introduction: Respiratory distress frequently occurs in neonates and has a broad differential diagnosis. Although the majority of cases are due to lower respiratory pathology, anatomic defects of the upper respiratory tract must be considered. We present a case of neonatal respiratory distress caused by a congenital dacrocystocele.

Case Description: A term female infant was born via vaginal delivery. Initial physical exam was normal. At approximately 6 hours of life, the infant developed retractions, nasal flaring, and high pitched inspiratory stertor appreciated best over the left nare. No external malformations were noted. The patient was transferred to intensive care for further evaluation. Cardiorespiratory monitoring revealed intermittent desaturations at rest and during feeds. A 5 French nasogastric tube was unable to be passed through the left nare but did pass through the right nare. Pediatric otolaryngology and ophthalmology were consulted. Flexible endoscopy revealed an obstructing left nasal mass. Computed tomography revealed a dumbbell-shaped soft tissue mass within the left nasolacrimal duct suggestive of a dacrocystocele. Nasal dexamethasone drops were started to alleviate swelling, and the desaturations improved with conservative management. The patient discharged home in stable condition with close outpatient follow up.

Discussion: Newborns commonly have nasolacrimal duct obstruction that presents with epiphora or purulent discharge at the medial canthus. This is often due to the persistence of Hasner’s membrane at the distal end of the nasolacrimal duct. In some instances this obstruction leads to a cystic expansion of mucosa known as a dacrocystocele. The diagnosis is typically suggested by bluish skin swelling near the medial canthus, but other considerations include hemangiomas, lymphangiomas, teratomas, encephaloceles, and dermoid cysts. Intranasal protrusion of enlarged dacrocystoceles can lead to obstruction and respiratory distress, as seen in our case. Endoscopy or radiological imaging can be used to confirm the diagnosis. Although dacrocystoceles are rare, it is important for pediatricians to recognize them and their associated complications. Stasis of cyst contents can lead to dacrocystitis or cellulitis. Urgent ophthalmology referral is warranted whenever a dacrocystocele is suspected, and involvement of otolaryngology should be strongly considered in cases with bilateral involvement or respiratory distress. Management depends on the individual symptoms and degree of nasal obstruction. Outpatient observation is reasonable for asymptomatic patients to assess for spontaneous resolution, which occurs in 50-85% of cases. Crigler massage of dacrocystoceles may be effective at relieving the obstruction. Intranasal steroids were used to alleviate swelling from endoscopy in our case, but there is no data for their long term use. Cases of persistent nasal obstruction or infection may require nasolacrimal probing or cyst marsupialization.

Conclusion: Congenital dacrocystocele is an uncommon anatomic defect of the nasolacrimal duct. Although they are commonly asymptomatic, they can present with nasal obstruction and respiratory distress in newborns.