Auris Nasus Larynx 39 (2012) 233–235

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Lacrimal dacryostenosis with severe facial pain misdiagnosed as

trigeminal neuralgia
Tohru Tanigawa a,b,*, Hirokazu Sasaki b, Masahiro Kaneda c, Tessei Kuruma a, Hiromi Ueda a
a
Department of Otolaryngology, Aichi Medical University, Aichi, Japan
b
Department of Otolaryngology, Tohno-Kousei Hospital, Gifu, Japan
c
Department of Ophthalmology, Tohno-Kousei Hospital, Gifu, Japan
Received 25 January 2011; accepted 20 April 2011
Available online 14 May 2011

Abstract

A 47-year-old woman developed intermittent shooting pain around the right side of the nose and eyes. A neurologist initially diagnosed
trigeminal neuralgia, but carbamazepine did not improve the pain. Two months later, she presented with a pus-like eye discharge and was
referred to us for further examination. Poor saline irrigation from the lacrimal puncta and computed tomography findings of a swollen lacrimal
sac indicated a diagnosis of lacrimal dacryostenosis. At this point, the pain and dizziness as a side effect of carbamazepine had become
intolerable. Endoscopic intranasal dacryocystorhinostomy confirmed stenosis of the nasolachrymal duct and a thickened lacrimal sac. The
postoperative course was uneventful, and the facial pain disappeared. This experience suggests the importance of recognizing lacrimal
dacryostenosis as a differential diagnosis of facial pain around the eyes and nose. We also recommend a review of an original diagnosis of
trigeminal neuralgia if carbamazepine fails to relieve facial pain.
# 2011 Elsevier Ireland Ltd. All rights reserved.

Keywords: Lacrimal dacryostenosis; Facial pain; Intranasal dacryocystorhinostomy; Trigeminal neuralgia; Carbamazepine

1. Introduction resulted in the administration of carbamazepine before a

Trigeminal neuralgia is characterized by unilateral
shooting pain in the face. Even washing the face or
applying make-up can be triggers, and some patients tend to
avoid such activities. Pain attacks become prolonged and a
dull background pain sometimes becomes chronic [1].
Prolonged episodes of severe facial pain can cause
depression [2].
A differential diagnosis of facial pain can be difficult and
occasionally challenging even for experienced physicians.
This case report describes the clinical findings of lacrimal
dacryostenosis that mimicked trigeminal neuralgia and
* Corresponding author at: Department of Otolaryngology, Aichi Medical
University, Nagakute, Aichi 480-1195, Japan. Tel.: +81 561 62 3311;
fax: +81 561 63 3403.
E-mail address: tanigawa@aichi-med-u.ac.jp (T. Tanigawa).
final diagnosis resulted in appropriate treatment.
2. Case report
Intermittent right shooting pain suddenly developed
around the nose and eyes of a 47-year-old woman during
early September, 2008. A neurologist had diagnosed right
trigeminal neuralgia and had prescribed carbamazepine
(400–600 mg/day) together with an analgesic, but the pain
persisted. Head MRI findings were normal. Her right
eyelid started to swell and the inner corner of the eye
started to redden. A pus-like discharge exuded from the
right eye during late October. She had no history of
epiphora or nasolacrimal infections. An ophthalmologist
diagnosed acute dacryocystosis on October 27 and
referred the patient to us for intranasal dacryocystorhi-
nostomy (DCR).

0385-8146/$ – see front matter # 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.anl.2011.04.005
234 T. Tanigawa et al. / Auris Nasus Larynx 39 (2012) 233–235
Fig. 1. Nasal CT scan. Axial (A) and coronal (B) views show inflamed and swollen right lacrimal sac (circled). Swollen lacrimal sac (circled) confirmed by
retrospective axial T2-weighted MRI image (C).
When she presented at our clinic on November 6, the
painful red swelling had improved, but tearing was
persistent. In addition, dizziness as a side effect of
carbamazepine [3] together with the shooting pain that
had become more frequent and persistent throughout the day
had become intolerable. The severe pain around the right eye
and nose had spread to the right occipital area and
sometimes beyond, which impaired her ability to perform
routine daily activities. Touch and vibratory sensations on
her face were normal.
Nasal fiberscopy revealed no abnormal findings such as a
deviated nasal septum or nasal polyps. A probe could not be
inserted into the nasolacrimal duct because of stenosis due to
scar formation. Irrigation with physiological saline from the
puncta did not flow into the nasal cavity. Nasal CT revealed
an extremely swollen right lacrimal sac (Fig. 1A and B),
which we speculated was due to prolonged inflammation of
the sac itself and an obstructed nasolacrimal duct. Recurrent
distension of the lacrimal sac might have caused the pain.
The patient underwent endoscopic intranasal DCR under
general anesthesia on November 28, 2008. Vasoconstriction
of the nasal mucosa was achieved by applying a small piece
of gauze containing 4% lidocaine and epinephrine (diluted
1:5000) followed by a submucosal injection of 2 mL of 0.5%
Xylocaine E. A fiberoptic light probe was placed via the
inferior canaliculus into the lacrimal sac to visualize the
lacrimal fossa intranasally by transillumination. The nasal
mucosa of visualized area was incised, elevated and
removed. The bone medially to the lacrimal sac was
removed using a power drill (Xomed Power Drill System
Model 2000; XPS). A Bowman probe was placed through
the canaliculus into the exposed lacrimal sac, which we then
incised and removed its medial wall. These procedures
revealed a thickened lacrimal sac wall, but no purulent
discharge. The superior, inferior and common canaliculi
were free of obstruction. Patency was confirmed by
irrigating the lacrimal passage with physiological saline.
Thereafter, a U-shaped silicone tube with a constriction at
the bend (Kaneka Medics NS-tube, 910–090 N) was inserted
from the superior and inferior lacrimal puncta to stent the
intranasal opening. Carbamazepine was stopped two days
after the procedure since the pain and epiphora had
disappeared. Based on these clinical findings, we concluded
that the severe facial pain was due to lacrimal dacryostenosis
mimicking trigeminal neuralgia. The silicone tube was
removed six months later. The lacrimal irrigation test
confirmed good patency and the patient has remained pain-
free for 14 months.
3. Discussion
We described a patient without a history of epiphora or
nasolacrimal infections, who presented with severe facial
pain due to lacrimal dacryostenosis. Smith et al. also
described unusual acute dacryocystic retention that is
characterized by the sudden onset severe facial pain without
significant localized swelling or erythema [4]. Our
experience suggests the importance of recognizing that
lacrimal dacryostenosis without eye symptoms comprises a
 T. Tanigawa et al. / Auris Nasus Larynx 39 (2012) 233–235
differential diagnosis of facial pain and that such conditions
should be accurately diagnosed.
Other disorders presenting as facial pain should include
trigeminal neuralgia, inflammation and/or tumors of the
paranasal sinuses, multiple sclerosis, migraine, temporo-
mandibular joint disorders, and reactivation of herpes zoster
virus in the trigeminal nerve [5,6]. Our patient was treated
for two months based on a misdiagnosis of trigeminal
neuralgia, the common cause of which is compression of the
trigeminal nerve root by an aberrant blood vessel loop.
Carbamazepine can control pain for many patients with
trigeminal neuralgia and the outcomes of the Janetta
operation (extended pain relief) are excellent [7]. Therefore,
we recommend re-evaluation of the original diagnosis if
carbamazepine does not relieve facial pain. In fact, our
retrospective MRI study revealed swelling of the right
lacrimal sac in our patient (Fig. 1C).
Intractable dacryocystitis and severe obstructions of
nasolacrimal duct are indications for the DCR operation [8].
External DCR requires a facial skin incision [9] and carries
the inherent risks of postoperative facial swelling, keloid
scars and paresthesia and our patient strenuously objected to
this procedure. However, the results of endoscopic intranasal
DCR are now better than those obtained with external DCR
[8,10] and our patient agreed to undergo this procedure.
Further advantages of endoscopic intranasal DCR include
minimal postoperative pain and hemorrhage, rapid resolu-
tion of symptoms and preservation of the tear-pumping
function of the orbicularis oculis muscle [8].
In conclusion, the present case is a rare example of severe
facial pain due to lacrimal dacryostenosis that was
misdiagnosed as trigeminal neuralgia. Endoscopic intrana-
235
sal DCR completely resolved the pain. We recommend that
the original diagnosis should be reconsidered if carbama-
zepine does not relieve facial pain. Our experience
highlights the need to consider these options because pain
arising from different origins requires very different types of
management.
References
[1] Siccoli MM, Bassetti CL, Sandor PS. Facial pain: clinical differential
diagnosis. Lancet Neurol 2006;5:257–67.
[2] Lee KH. Facial pain: trigeminal neuralgia. Ann Acad Med Singapore
1993;22:193–6.
[3] Elger C, Halasz P, Maia J, Almeida L, Soares-da-Silva P. BIA-
2093-301 Investigators Stud y G roup. Efficacy and safety of
eslicarbazepine acetate as adjunctive treatment in adults with
refractory partial-onset seizures: a randomized, double-blind, pla-
cebo-controlled, parallel-group phase III study. Epilepsia 2009;50:
454–463.
[4] Smith B, Tenzel RR, Buffam FV, Boynton JR. Acute dacryocystic
retention. Arch Opthalmol 1976;94:1903–4.
[5] Sjaastad O, Kruszewski P. Trigeminal neuralgia and SUNCT syn-
drome: similarities and differences in the clinical pictures. An over-
view. Funct Neurol 1992;7:103–7.
[6] Low AS, Lilly JP. Trigeminal neuralgia mimicking odontogenic pain.
A report of two cases. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 1995;80:96–100.
[7] Janetta PJ. Arterial compression of the trigeminal nerve at the pons in
patients with trigeminal neuralgia. J Neurosurg 1967;26:159–62.
[8] Ishio K, Sugasawa M, Tayama N, Kaga K. Clinical usefulness of
endoscopic intranasal dacryocystorhinostomy. Acta Otolaryngol
2007;Suppl127:95–102.
[9] Shun-Shin GA, Thurairajan G. External dacryocystorhinostomy—an
end of an era? Br J Opthalmol 1997;81:716–7.
[10] Metson R, Woog JJ, Puliafito CA. Endoscopic laser dacryocystorhi-
nostomy. Laryngoscope 1994;104:269–74.