Rhinogenic diseases of the lacrimal organs: causes, symptoms, diagnosis, treatment

Very often patients with acute or chronic rhinitis, allergic rhinopathy, with diseases of the paranasal sinuses complain of lacrimation, itching in the eyes or, on the contrary, dryness of the mucous membrane of the eyes. These complaints are caused by the involvement of the lacrimal organs in one or another pathological process of the nasal cavity.

The lacrimal organs are a rather complex anatomical and functional system designed to produce and remove lacrimal fluid, consisting of lacrimal glands and lacrimal drainage ducts. Anatomically and functionally, the lacrimal organs are closely connected with the nasal cavity, providing its mucous membrane with additional moisture (tears), which enriches the nasal mucous membrane's own secretion with biologically active and bactericidal substances.

Anatomy and physiology. The lacrimal glands are divided into main and accessory. The main gland consists of two parts - orbital and palpebral, accessory glands are located in the transitional fold and at the transition of the eyelid conjunctiva into the conjunctiva of the eyeball. Under normal conditions, only accessory glands function, which secrete 0.5-1 ml of tears per day, forming the so-called precorneal film on the surface of the cornea, which has a constant composition (12 ingredients), viscosity, humidity, balanced, so that it remains optically transparent. This film plays a vital role in preserving the cornea from harmful particles of the environment, cleaning the cornea from desquamated cellular elements and serves as a medium through which gas exchange between the air and the cornea occurs. The blinking reflex serves as a kind of mechanism for uniform distribution of tears along the anterior pole of the eyeball and its cleaning. The main gland begins to secrete tears only when there is a need for increased tear secretion (the presence of smoke, caustic vapors, foreign bodies in the atmosphere, psychoemotional tear secretion, etc.).

The system of innervation of the lacrimal glands is of great clinical and diagnostic importance. Secretory (parasympathetic) innervation of the lacrimal glands is carried out by the lacrimal nerve through the cells of the superior salivary nucleus. The lacrimal nerve begins in the ophthalmic nerve - a branch of the trigeminal nerve. Its preganglionic fibers are part of the intermediate nerve, join the facial nerve, pass the geniculate ganglion, and then as part of a branch of the facial nerve - the greater petrosal nerve through the pterygoid canal reach the pterygopalatine ganglion, where the irreganglion fibers are switched to postganglionic fibers.

Postganglionic fibers enter the maxillary nerve through the pterygopalatine nerves, and then into its branch, the zygomatic nerve, from which they enter the lacrimal nerve through the connecting branch and reach the lacrimal gland. Irritation of the sensory endings of the branches of the ophthalmic nerve in the conjunctiva of the eye leads to increased lacrimation. Impaired lacrimation in facial nerve paralysis (damage, compression by a tumor in the pterygopalatine nerve, etc.) occurs only when the facial nerve is damaged above the geniculate node. The center of reflex lacrimation is located in the medulla oblongata, and the center of mental crying is in the thalamus, where the center of facial expressive movements accompanying crying is also located. In addition to the parasympathetic innervation supplied to the lacrimal glands via the lacrimal nerves, it also receives sympathetic innervation, the fibers of which are supplied to the lacrimal glands via the sympathetic plexus of blood vessels originating in the sympathetic nerve originating in the superior cervical sympathetic ganglion.

The lacrimal drainage system serves to conduct tears and particles contained in them washed off the surface of the cornea into the nasal cavity and consists of the lacrimal stream, lacrimal lake, lacrimal puncta (upper and lower), lacrimal canaliculi (upper and lower), lacrimal sac and nasolacrimal duct.

Of greatest interest to a rhinologist are the lacrimal sac and the nasolacrimal duct, since many of them are proficient in the operation of dacryocystorhinostomy and often perform it when appropriate, combining it with reconstructive interventions on the nasal cavity.

The lacrimal sac is located under the skin of the inner corner of the eye in the bony depression of the lacrimal sac fossa between the anterior and posterior knees of the internal palpebral ligament. The lacrimal sac fossa is formed by the lacrimal groove of the lacrimal bone and the groove of the frontal process of the maxilla. The lacrimal bone is located in the anterior part of the medial wall of the orbit. Its posterior edge connects with the papillary plate, the upper edge - with the orbital part of the frontal bone, the lower edge - behind with the orbital surface of the maxilla, and in front - with the lacrimal process of the inferior nasal concha. The apex of the lacrimal sac lies slightly above the internal palpebral ligament, and its lower end passes into the nasolacrimal duct. The lacrimal sac is located in front of the tarso-orbital fascia, i.e. outside the orbit; in front and outside it is covered by a fascia that begins from the periosteum at the posterior lacrimal crest and continues to the anterior lacrimal crest. The vertical size of the lacrimal sac is 1-1.5 cm. Its walls consist of a mucous membrane covered with a two-layer cylindrical epithelium and submucous tissue.

The nasolacrimal duct. The upper part of the nasolacrimal duct lies in the bony canal, the lower part (membranous) has a bony wall only on the outer side, on the other sides it is adjacent to the mucous membrane of the nasal cavity. The length of the membranous part of the canal is 12-14 mm. The canal opens with a slit mouth under the inferior nasal concha on the border of its anterior and middle thirds. The outlet of the canal is surrounded by a venous plexus of the nasal mucosa. In acute inflammatory or vasomotor-allergic rhinitis, when this venous plexus swells, the mouth of the nasolacrimal duct closes, and lacrimation occurs. The same symptom occurs with inflammation of the lacrimal sac - dacryocystitis.

Dacryocystitis occurs in two forms: chronic and acute - catarrhal and phlegmonous. Due to the close anatomical relationship between the mucous membrane of the nose and the nasolacrimal duct and lacrimal sac, diseases of the latter can develop with various diseases of the mucous membrane of the nose, as well as with inflammatory processes in areas adjacent to the lacrimal sac: in the maxillary sinus, in the bones surrounding the lacrimal sac, with purulent inflammation of the eyelids, the lacrimal gland itself, etc. Chronic dacryocystitis is manifested by persistent lacrimation and purulent discharge. Along with these symptoms, blepharitis and conjunctivitis are often noted. In the area of the lacrimal sac, in most cases of chronic inflammation, there is swelling. When pressing on the lacrimal sac, pus is released from the lacrimal points. The mucous membrane of the eyelids, the semilunar fold and the lacrimal caruncle are hyperemic and edematous. The nasolacrimal canal is blocked. With prolonged chronic dacryocystitis, the lacrimal sac may become significantly stretched, reaching the size of a cherry, hazelnut or even a walnut.

Acute dacryocystitis is in most cases a complication of chronic inflammation of the lacrimal sac and manifests itself in the form of an abscess or phlegmon - purulent inflammation of the tissue surrounding the lacrimal sac. Only in rare cases does acute dacryocystitis develop primarily. In such cases, the inflammatory process most often spreads to the tissue from the maxillary sinus, ethmoid labyrinth or nasal mucosa, while in the area of the lacrimal sac and on the corresponding side of the nose and cheek, there is severe hyperemia of the skin and extremely painful swelling. The eyelids are edematous, the palpebral fissure is narrowed or completely closed. The formed abscess spontaneously opens, and the process can be completely eliminated, or a fistula can remain, through which pus is released for a long time.

Treatment of dacryocystitis is surgical. There are two types of surgical access: endonasal and external. We will focus on the description of the endonasal West method. The purpose of the operation is to create a wide anastomosis between the lacrimal sac and the nasal cavity. Indications for the West operation are the same as for external dacryorrhinocystostomy. According to F.I. Dobromylsky (1945), the advantages of the West operation are its lower trauma and the absence of a postoperative scar on the face.

The operation is performed with the patient in a sitting position, under local anesthesia - lubrication of the nasal mucosa with a 10-20% solution of cocaine with adrenaline and instillation of the same solution into the lacrimal sac. The author excludes infiltration endonasal anesthesia, since it leads to a narrowing of the already narrow surgical field, which complicates the operation. A high concentration of cocaine with individual intolerance can lead to anaphylactic shock, therefore, before the main anesthesia, a test for its tolerance should be carried out by lubricating the nasal mucosa with a 1% solution of this anesthetic. It is possible to use other anesthetics for application anesthesia.

The first stage: excision of the mucous membrane of the lateral nasal wall in front of the middle nasal concha by incisions to the bone along the lines limiting the rectangle ABCD. The mucous membrane lying in area S is separated and removed, exposing the underlying bone. Further incisions are then made to form a plastic flap from the mucous membrane. These incisions are also made to the bone along the bridge of the nose along the lines corresponding to the edge of the pyriform sinus (BE and EF). The CBEF flap is peeled away from the underlying bone, folded along the line CF and folded downwards, as a result of which it takes a position corresponding to the rectangle.

The second stage is the formation of a bone opening in the posterior part of the frontal process of the maxilla. To remove the bone in one piece, two deep cuts are made with a straight chisel on the bone exposed in the previous stage parallel to the lines AE and DF at a distance of 1.5 cm from each other, then the bone is gouged with the same instrument perpendicular to the first two cuts from the upper to the lower and removed with bone forceps. As a result, the lacrimal sac is exposed.

The third stage is resection of the inner wall of the lacrimal sac. By pressing on the inner corner of the eye, the lacrimal sac is displaced into the nasal cavity and its outer wall is opened with a vertical incision. A conchotome inserted through this incision into the cavity of the sac is used to resect its inner wall. The resulting opening in the inner wall of the lacrimal sac is the artificial anastomosis between it and the nasal cavity. After this, the surgical field is inspected for the presence of remaining bone fragments and their removal, the wound cavity is washed with an antibiotic solution corresponding to the microbiota, and the separated B'CFE' flap is put back in place (BCEF) and pressed with a tampon.

The tampon is removed after 3 days. In the postoperative period, granulations appearing in the anastomosis area are extinguished with a 2-5% silver nitrate solution. In case of excessive growth of granulations, they are removed with a curette, Hartmann nasal forceps or a nasal conchotome. As noted by F.S. Bokshteyn (1924, 1956), complete and stable recovery of patients suffering from chronic dacryocystitis as a result of the West operation occurs in 98% of cases, in 86% of patients there is a complete restoration of lacrimation.