Posttraumatic Obstruction of Lacrimal
Pathways: A Retrospective Analysis of 58
Consecutive Naso-Orbitoethmoid Fractures
Roberto Becelli, MDS, PhD,* Giancarlo Renzi, MD,† Giuseppe Mannino, MD,‡ Giulio Cerulli, MD,†
Giorgio Iannetti, MDS, PhD, ENT†
Rome, Italy
Posttraumatic dacryostenosis represent a trouble-
some sequela for patients who have sustained cen-
trofacial trauma and can determine complexity in
diagnosis and treatment. This article, based on a
retrospective analysis of 58 patients with naso-
orbitoethmoidal (NOE) trauma, reports the inci-
dence of posttraumatic dacryostenosis and the evo-
lution of such impairments in consideration of
fracture type. Experience in diagnosis and treat-
ment is illustrated, and surgical outcomes 6 months
after external dacryocystorhinostomy (DCR) are re-
ported. Posttraumatic epiphora was observed in 27
patients with NOE fractures (46.5%). In 10 cases,
temporary epiphora was encountered and sponta-
neous recovery of lacrimal drainage within 5
months was observed. In the remaining 17 cases,
permanent epiphora was registered and a frequent
association with delayed treatment of facial frac-
ture repair or bone loss in the lacrimal district was
found. Surgical reconstruction of lacrimal path-
ways was performed 6 months after primary sur-
gery, with external DCRs in all 17 patients with
epiphora and the presence of nasolacrimal duct ob-
struction observed with dacryocystorhinography.
External DCR with a large rhinostomy achieved a
success rate of 94% in the reconstruction of lacrimal
drainage. Such a technique proved to be effective
in the treatment of posttraumatic dacryostenosis,
although patients considered the temporary pres-
ence of external scars and stenting material to be a
major problem.
Key Words: Posttraumatic epiphora, Naso-orbito-
ethmoidal fractures, dacryocystorhinostomy
From the Departments of *Maxillo-facial Surgery, Policlinic
Sant’Andrea, II Faculty of Medicine and Surgery; †Maxillo-facial
Surgery, Policlinic Umberto I; ‡Ophthalmology, Policlinic Um-
berto I, La Sapienza University, Rome, Italy.
Address correspondence and reprint requests to Dr Renzi, Via
Raffaele Stern, 4, Pal. III, Scala A 00196, Rome, Italy. E-mail:
renzi.g@libero.it
A
cquired lacrimal obstruction is caused by
trauma, inflammation, or tumor surgery,
and stenosis can occur in various anatomi-
cal regions of the lacrimal system. Epi-
phora, dacryocystitis, and recurrent infections of the
lacrimal pathways or conjunctiva can be caused.1,2
Posttraumatic dacryostenosis is mainly the result of
midface trauma with involvement of the naso-
orbitoethmoid (NOE) district and can present with
diagnostic difficulties.2–6 Intubation of lacrimal path-
ways during primary surgery of facial fractures can
produce injuries to an intact lacrimal system and can
lead to diagnostic pitfalls, because edema and bone
displacement can simulate anatomical posttraumatic
obstructions. Therefore, when a clear laceration is
not observed, a diagnosis of eventual lacrimal ob-
struction is generally not made during surgical treat-
ment of facial fractures. Postsurgical lacrimal dys-
function can spontaneously resolve a few months
after the trauma; therefore, eventual surgical recon-
struction of lacrimal pathways should be performed
by means of a delayed approach. Surgical treatment
of posttraumatic lacrimal obstructions is generally
performed with an external dacryocystorhinostomy
(DCR) 3 to 6 months after primary surgery of frac-
tures.5–7
The aims of this report are to illustrate the inci-
dence of lacrimal obstruction after midface fractures
as observed in a series of 58 consecutive patients
with NOE fractures and to report our diagnostic and
surgical experience with surgical reconstruction.
MATERIAL AND METHODS
etween January 1998 and December 2000, 58 con-
B secutive patients with NOE trauma were treated
at the Policlinic “Umberto I” of the “La Sapienza”
University of Rome. There were 37 male patients and
21 female patients with a mean age of 27 years, rang-
ing from a minimum of 20 years to a maximum of 67
years. The NOE fractures observed were pure in 4
cases, associated with craniofacial trauma in 7 cases,
associated with panfacial fractures in 11 cases, and
29
THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 15, NUMBER 1 January 2004
associated with orbitozygomatic fractures in 36 cases
as shown in Table 1.
The NOE fractures in our series received surgi-
cal treatment consisting of open reduction via a
transconjunctival or subciliary incision. Coexisting
midfacial fractures (eg, Le Fort fractures, zygomatic
fractures) were approached via an upper eyebrow
and transoral approach. Coexisting upper-third frac-
tures were approached via a coronal incision. After
subperiosteal dissection was carried out, all fractures
were adequately reduced and subsequently fixed
with rigid interanl fixation (RIF). Primary DCR was
not performed in any case, because evident lacera-
tion of lacrimal pathways was not observed.
Lacrimal functionality was evaluated at follow-
up in all 58 patients. Patients with postsurgical epi-
phora underwent irrigation within 3 months after
surgery with diluted methylene blue with saline. In
case of reflux of the irrigation solution, nasal endos-
copy was carried out to identify eventual nasal
pathological findings such as polyps, septal devia-
tion, or middle turbinate hypertrophy.
In patients having permanent epiphora with ob-
struction of lacrimal pathways demonstrated during
previous irrigation, dacryocystorhinography was
performed after at least 5 months after surgical treat-
ment of fractures.
External DCR was subsequently carried out 6
months after trauma in all patients with persistent
epiphora and lacrimal pathway obstruction observed
at dacryocystorhinography. Dacryocystorhinostomy
was performed with a larger incision than the tradi-
tional technique so as to obtain a better view of the
surgical site and with careful dissection of the orbicu-
laris muscle. Rhinostomies with a large diameter of
approximately 12 to 14 mm were carried out; in na-
solacrimal bone loss, a wide anastomosis between
the lacrimal sac and nasal duct was obtained. Sili-
cone stents were placed in all cases and removed
after 3 months.
The patency of anastomosis after reconstruction
of lacrimal pathways was evaluated by probing and
irrigating with diluted methylene blue and saline 7,
Table 1. Naso-orbitoethmoidal (NOE) Fracture
Typology Observed in 58 Consecutive Patients
NOE Fracture Typology
Pure NOE fracture
NOE fracture associated with orbitozygomatic fracture
NOE fracture associated with craniofacial fracture
NOE fracture in panfacial fracture pattern
30
14, and 30 days after DCR and with further dacryo-
cystorhinography 6 months later.
By means of chart and follow-up reviews, a ret-
rospective analysis concerning diagnostic and surgi-
cal outcomes of posttraumatic dacryostenosis was
carried out in the 58 patients. A description of the
primary surgical treatment of facial fractures was re-
corded for each patient so as to achieve better com-
prehension of the importance of fracture typology in
determining lacrimal impairment.
RESULTS
osttraumatic postsurgical epiphora was encoun-
P tered in 27 of 58 patients having NOE fractures,
corresponding to 46.5% of our series. At irrigation,
normal patency of lacrimal pathways was observed
in 10 of 27 patients (17.2% of patients with NOE frac-
ture and 27% of patients with epiphora), whereas in
the remaining 17 patients (46.5% of patients with
NOE fracture and 73% of patients with epiphora),
nasolacrimal obstruction was confirmed as shown in
Table 2. No coexisting nasal pathological findings
were encountered in this series.
In the 10 patients with normal patency of lacri-
mal pathways, spontaneous resolution of dysfunc-
tion was observed, on average, within 5 months after
trauma as reported in Table 2.
All 17 patients with permanent epiphora under-
went external DCR. After reconstruction of lacrimal
pathways, irrigation and dacryocystorhinography
Table 2. Lacrimal Drainage After Naso-Orbitoethmoidal
(NOE) Fractures in 58 Consecutive Patients in
Consideration of Fracture Typology and Timing of
Primary Surgery
No.
Lacrimal Drainage Cases Resolution
Epiphora 27
Temporary epiphora 10 Spontaneous
Permanent epiphora with nasolacrimal 17
obstruction
Early treatment with no bone loss in 8 DCR
lacrimal area
Bone loss in lacrimal area 6 DCR
Delayed treatment 3 DCR*
No epiphora 31 —
No. Cases Early treatment with no bone loss in 30 —
lacrimal area
4 Bone loss in lacrimal area 1 —
36 Delayed treatment — —
7
11 *One case of DCR failure.
DCR = dacryocystorhinostomy.
 POSTTRAUMATIC OBSTRUCTION OF LACRIMAL PATHWAYS / Becelli et al
confirmed correct lacrimal patency in 16 cases,
whereas in 1 case, DCR was not successful. The fail-
ure of DCR was the result of a rhinostomy with an
insufficient diameter, with the consequent formation
of granulation tissue and scar retraction after stent
removal. In this patient, a further DCR procedure
was carried out 5 months after the primary DCR and
a larger rhinostomy was performed. The ultimate
success of DCR was confirmed by an irrigation test
and dacryocystorhinography. During primary sur-
gery of facial trauma, detachment of the medial can-
thal ligament was observed in 3 of 58 patients, and it
was correctly repositioned and fixed; in none of these
3 patients was posttraumatic postsurgical epiphora
observed.
A clear association between permanent epi-
phora and bone loss in the nasolacrimal district or
delayed treatment of primary facial fractures was
found in our analysis (see Table 2).
Bone loss in the nasolacrimal area was recog-
nized in 7 cases of NOE trauma: 4 cases of NOE
fractures with midface fractures and 3 cases of NOE
fractures with a panfacial injury pattern. Posttrau-
matic permanent epiphora was encountered in six of
these seven patients (35.3% of patients with perma-
nent epiphora and 85.7% of patients with lacrimal
bone loss). In 3 of 58 cases of our series, primary
treatment of facial fractures was performed with
more than a 2-week delay after trauma because of the
neurological and general condition of patients. In
these 3 cases, permanent epiphora was observed
(17.7% of patients with permanent epiphora and
100% of patients with a delayed treatment).
In our experience, 12 of 17 patients who under-
went DCR subjectively reported discomfort. In 6
cases, silicone stents caused adherences with sur-
rounding structures, and consequent difficulties at
their removal were noticed. Eight patients com-
plained of the presence of temporary scars from sur-
gical incisions. Temporary diplopia, resolving spon-
taneously 7 days after DCR, was found in 3 of 17
cases.
DISCUSSION
s previously reported in the literature, posttrau-
A matic dacryostenosis can be observed in be-
tween 5% and 21% of cases of NOE trauma5–7 and
can be determined by direct involvement of lacrimal
pathways or by indirect injuries at the canaliculus.8
Trauma to lacrimal pathways can produce tem-
porary or permanent dysfunction.5,6,9 Temporary
dysfunction is caused by lacrimal compression by
posttraumatic edema. In 10 of 27 patients included in
our analysis who had posttraumatic epiphora, a
spontaneous resolution was observed within 6
months after primary surgery.
Permanent dysfunction is a result of direct
causes such as lacerations or interruptions of the na-
solacrimal duct and indirect causes such as detach-
ment of the medial canthal ligament with subsequent
sac compression. Indirect causes of compression
were resolved in all cases during primary treatment
of facial fractures by correct realignment and fixation
of the ligament. As previously reported, the early
repositioning of canthal ligament helps to avoid
posttraumatic telecanthus and permits decompres-
sion of the lacrimal sac and upper lacrimal path-
ways.5,6,10,11
Based on the results of our analysis, posttrau-
matic permanent lacrimal dysfunction is frequently
associated with lacrimal bone loss and delayed treat-
ment of facial fractures. In our analysis, 6 of the 17
patients with permanent dacryostenosis (35.3%) had
bone loss in the lacrimal area, and 3 (17.6%) of these
6 patients underwent surgical treatment about 20
days after trauma because of their neurological and
general condition. More interestingly, such data il-
lustrate permanent epiphora in 100% of cases with
delayed primary treatment and in 85.7% of patients
with lacrimal bone loss. Delayed treatment for a pe-
riod of 2 weeks is frequently observed in high-energy
trauma, resulting in severe conditions in the patients,
and can lead to permanent dysfunction of lacrimal
drainage. Two weeks after trauma, various factors
producing lacrimal obstructions can occur, including
1) definitive malpositioning of NOE fractures with
subsequent permanent compression of lacrimal path-
ways, 2) further bone loss in the lacrimal area, and 3)
retractions of scars involving the lacrimal sys-
tem.10,12–14 Therefore, primary early treatment of
midfacial fractures with wide open reduction and
stable fixation helps to reduce the rate of posttrau-
matic lacrimal permanent dysfunction in NOE frac-
tures, as confirmed by our analysis and according to
previous reports.11
In the patients in our series, lacrimal pathways,
if not clearly lacerated or damaged, were not ex-
plored or assessed during primary surgical repair of
facial fractures as previously suggested.5–7,10,11 Post-
traumatic soft tissue swelling and bone displacement
may indicate an apparent obstruction to an intact
lacrimal system7; in such cases, intubation can pro-
duce injuries to intact lacrimal pathways.5,6
Diagnosis and surgical planning for correction
of posttraumatic dacryostenosis are better assessed 5
or 6 months after trauma when resolution of edema
and soft tissue injuries permits the definitive evalu-
31
THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 15, NUMBER 1 January 2004
ation of lacrimal pathway obstruction. In our expe-
rience, in 10 of the 27 cases of permanent epiphora,
spontaneous resolution was observed within 4
months after trauma.
Reconstruction of lacrimal pathways is com-
monly achieved by several surgical techniques con-
sisting of various methods for rhinostomy with can-
alicular intubation. External DCR was first illustrated
by Toti in 190415 and was modified by Ohm16 and
Dupuy-Dutemp and Bourguet17 in 1921. Since then,
various alternatives techniques have been proposed
in literature, such as endoscopic or nonendoscopic
endonasal DCR and laser-assisted DCR.18-24
External traditional DCR is still considered to be
the most reliable technique, having a success rate of
90%.3,25,26 Failure of DCR can be the result of several
factors, such as inappropriate size and location of
rhinostomy, excessive granulation tissue/scar for-
mation, inadvertent laceration of the middle turbi-
nate mucosa or nasal septum, or canalicular obstruc-
tion.20,24,25
Zapala et al,3 Bolger et al,24 McLean et al,25 and
Ezra et al27 suggested performing large rhinostomies
with a diameter of 12 mm to avoid scar formation at
the osteotomy site, with subsequent long-term fail-
ure.
Canalicular intubation is commonly carried out
to maintain the patency of the lacrimal passages and
can be performed with various materials such as sili-
cone stents,3,5,6 Crawford tubes,18 or otological T-
tubes.19 Such stents are commonly removed after 3 to
4 months or 6 months19 after DCR. As previously
reported,24 when such material is not removed, it
becomes a retained stenting material that is respon-
sible for DCR failure.
External DCR also proved to be effective in cases
with bone loss in the lacrimal district, where a large
anastomosis between the lacrimal sac and nasal duct
is required, as suggested by Zapala et al.3 Dacryo-
cystorhinostomy in posttraumatic reconstruction of
lacrimal pathways should be modified from tradi-
tional DCR. In our experience, larger incisions were
performed and the orbicularis muscle was not cut
whenever possible so as to preserve sufficient lacri-
mal pump function, which could have been dam-
aged by the fracture. In case of extreme fragility of
the nasal mucosa or in case of fibrous retraction of
the lacrimal sac, anastomoses between the anterior
and posterior flaps of the lacrimal sac and nasal mu-
cosa are hard to obtain. In such cases, nasal perios-
teum can be used in an anastomosis with the lacrimal
sac.
In our experience, external DCR proved to be a
rapid and effective technique of posttraumatic dacry-
32
ostenosis, with a success rate of 94%. Conversely, as
subjectively reported by patients, the temporary
presence of external scars or discomfort caused by
stenting material represents a major problem. There-
fore, innovation or modification in the surgical pro-
cedure of external DCR for lacrimal pathway recon-
struction after trauma could be useful to limit
discomfort to patients.
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