FROM a GAKMISONSSJl:I iHL‘SE?’a , STOCKHOI,M. (PHYSICIAN IN C H A R G E : DR. 0. A L E M A N )

CONTRIBUTION TO THE KNOWLEDGE O F FISTULA INTERNA SACCI LACRYMALIS

BY

K. G. PLOMAN

In his fifth communication concerning rontgenological ex- amination of the lacrimal passages uon Szilg, in 1920 de- scribes two cases, where a communication had spontaneously arisen between the lacrimal sac and the nasal cavity, a clini- cal picture, called by him fistula interna sacci lacrymalis. As there are only three further cases of such fistulous formation described, one by Campbell, Carter and Doub, a second by Bockstein and a third by Dreuschuch and Sacha, a more de- tailed account of an allied case - a summarised report of which 1 had the opportunity of submitting at the Northern Opthalmological Congress in Copenhagen 1925 in connexion with demonstration of rontgenograms of the lacrimal ducts l )

- may perhaps be of some interest. M., recruit, aged 21. (1112/1923). In October 1922 operated

upon at another hospital for some trouble with his right la- crimal apparatus; has no knowledge of the nature of the operation. For the last two months has again been troubled with lacrimation on the right side.

No in- dications of tuberculosis or lues. About 1 cm. on the nasal side of the right internal canthus there is a 3 cm. long ver- tical operation scar. On pressure over the right lacrimal sac

Condition Aug. 10, 1923: General condition good.

’) Acta opthalmologica, Vol. 111, p. 198, 1925.

278

a small mucous bead is emitted from the lower punctum. Haab’s test is positive without the slighest difficulty: On probing there is a definite obstruction in the lower part of the nasal duct. On injection of fluorescin-coloured fluid in the lower canaliculus, rhinoscopical examination shows the middle turbinated bone to lake on a yellow c.olour but the point of

Fig. 1.

entrance of the fluid in the nose cannot be seen. -The left lacrimal duct of normal appearance.

RBntgenogram of the right lacrimal duct after injection of an aqueous suspension of barium sulphate (fig. 1--3): the lacrimal sac appears to consist of two parts, an upper and a lower, the former of being slightly larger, a narrow canal connecting the two. On fig. 2 the upper part of the nasal duct is also seen to contain some opaque substance; on the other pictures, however, this can only be seen excee- dingly faintly. From the upper of the two cavities of the

Fig. 2.

Fig. 3.

280

lacrimal sac a narrow canal can be seen to pass upwards and nasally, through which the opaque substance has passed into the nose. On fig. 3., taken after renewed injection of the opaque substance, a small quantity of this can be seen immediately above the entrance of the fistula in the nose, at the same time as the amount of opaque substance in the nose. is much increased.

Aug. 16. Right-sided dacryocystectomy. The lacrimal sac was found to be of about normal size, divided into an upper larger and a lower smaller part. After its removal a probe could be directly introduced into the nose through a small opening in the upper part of the lacrimal bone.

Healing by first intention. Microscopical exam in at ion of the ext irpa fed lacrima I sac

(Professor C. Sundberg) : Scattered subepithelial tubercles and a fairly marked epithelial proliferative reaction.

Readmitted Sept. 13, 1924 (1466/1924) on account of lacri- mation on the left side of about a months duration. The right eye, on the other hand, is not running at all,

Condition Sepf. 13, 1924: The general state of health still good. On irrigation of the left lacrimal sac a great amount of muco-purulent secretion comes away; with a probe, intro- duced into the nasal duct without difficulty, bare bone with rough surface can be felt in the lacrimal sac. Through the right lower canaliculus fluid can be injected into the nose without the slightest difficulty and the fluorescein test is positive. At extirpation of the left lacrimal sac, Sept. 26, this was found to be thickened with a rough and uneven mucous membrane. No direct communication into the nose, as found on the right side, could be demonstrated. Unfor- tunately the lacrimal sac was not kept for further examina- tion. Microscopical examinatiou of excised mucous membrane of the nose showed submucous giant cell tubercles (Professor C. Sundberg).

Rdntpnogram of the lacrimal passages, Oct. 20, 1924 (as opaque substance lipiodol was used. Fig. 4-5) shows the lacrimal sac and duct to be absent on the right side and

Discharged Aug. 34.

Fig. 4.

Fig. 5.

that a small quantity of opaque substance has extended on to the conjunctival sac and a greater quantity passed into the nose, occupying a position at about the level of the inner canihus. On the Zeft side there is only a sinall quantity of opaque substance at the site of the lacrimal sac, having no connexion with the nasal cavity (Haab negative).

The patient was discharged and I have since had no opport- unity of seeing him.

I t would seem propable in this case lhat a tuberculous dacryocystitis had developed secondarily to the tuberculous changes in the nasal mucous membrane, first on the right side and later on the left. To what exteiit the earlier opera- tive interference might have contributed to the formation of the fistula on the right side is, of course, impossible to say. I t could scarcely have been essential for thc fistula to form, as the bone was found to be affected also on the left side. That a similar fistulous formation might gradually have de- veloped also here is quite conceivable.

u. Szily is of the opinion that fistula interna might arise as a result of empyema in the ethmoidal sinuses or suppura- ting dacryocystitis with extention to surrouding tissues, or else through tuberculous processes in the nose. He further states that the congenital or spontaneous absorption foramina in the thin lacriinal bone, considered by Merkel and Kallius to be of fairly common occurrence, might contribute to their formation. In one of his cases there was a purulent ethmoi- ditis but in none of them was there any sign of tuberculosis. Bockstein’s case was one of lues nasi and that of Dreuschnch and Sacha showed a gummatous dacryocystitis, assumed to be of primary nature. The above described case, therefore, confirms the assumption that a fistula may also develop on the basis of a tuberculous infection.

In regard to the position of the fistula in this case, it dif- fers somewhat from those previously described, in that it terminates higher up in the nose. This is of course only one of a great many possible variations, rendering drainage more difficult. Similar to u. Szilg I find it difficult to imagine

283

a stenosis of the naso-lacrimal duct to be an essential pre- condition for formation of a fistula.

As opaque substance I have been using a suspension of bariumsulphate, either in water or in liquid parafin. Al- though the latter is to be preferred, the nozzle of the syringe is too easily obstructed by it. Similar to many others I have therefore later used lipiodol, which not only gives a good contrast but is also easy to handle. This is an important factor because if too great difficulties are attached to the technical procedure, it is to be feared that rontgenological examination of the lacrimal apparatus will be left out of use altogether. This would be a great pity, as in certain cases it is a valuable adjunct to our other methods of examination, of which, as has been emphasized by sacci lacrymalis is a satisfactory prof.

v. Szily, fistula interna

Fig. 1.

Fig. 2.

Fig. 3.

Explanation of the pictures on pages 278 and 279.

Lateral view. The lacrimal sac divided into two rooms of small size, connected by a narrow canal. The upper part of the nasal duct can be faintly seen. Behind the uppermost part of the lacrimal sac there is a thin horisontal shadow, which, as it were, serves to connect the sac with the great collections of opa- que substance situated more posteriorly in the nose. Frontal view. Canaliculi indicated, the upper part of the nasal duct fairly clearly marked. From the upper shadow, representing the lacrimal sac, a thin shadow continues inwards-upwards; this shadow probably corresponds to the shadow behind the upper part of sac on the previous pkture. Frontal view after renewed injection of opaque sub- stance. Canaliculi better defined, the shadow of the duct emerges into the shadow ol the great quantities

284

of opaque substance collected in the nose. The thin shadow, in this picture also, seen to extend from the upper part of the sac, appears to continue to a lesser amount of substance in the upper part of the nose.

Explanation of the pictures on page 281. Fig. 4. Lateral view after injection of opaque substance on

the right side. Scattered small collections of opaque substance in the conjunctiral sac, no indication of any nasal duct. Fairly abundant quantity of opaque substance in the nose on level with the inner can- thus.

Fig. 5. Frontal view after injection of opaque substance also on the left side. Lacrimal sac and duct also missing in this picture on the right side, nor does the sha- dows in the nose seem to be connected with the conjunctival sac. At the site of the left sac quite a small shadow is seen; no indication of any duct, none of the opaque substance has passed into the nose.

References. u. Szily, A . : Zur Pathologie der Tranenwege im Rontgenbild. V.

Mitteilung. Ueber spontan, ohne Dakryophlegmone entstandene Kommunikation des Triinensackes mit der Nasenhohle (Fistula interna sacci lacrymalis) und ihre Rontgendiagnose. Klin. Monatsbl. f. Aughk. Bd. LXIV, p. 31, 1920.

Campbell, iK, Carter, M. and Doub, H . P.: Rdntgen ray studies of the naso-lacrimal passageways. Archives of Ophthalm. Vol. LI, p. 462, 1922.

Bockstein, F. S. : Endonasale Fisteln des Tranensackes. Russki Oph- thalm. Journal, Bd. 3, S. 288. 1924 (Russisch). Ref. Zbl. f. d. ges. Ophthalm. Bd. 15, S, 141, 1926.

Dreuschuch, Fr. und Sacha, A.: Rontgenografie slznych cest (Die Rontgenographie der Tranenwege). Bratislavske lekarske listy (Tscheckisch mit englischer Referat), Vol. IV, S. 387, 1925. Ref. Zbl. 1: d. ges. Ophthalni. Bd. 15, S. 841, 1926.