Eosinophilic fungal rhinosinusitis of the lacrimal sac.

OBJECTIVES/HYPOTHESIS: Chronic sinusitis is a condition affecting millions of individuals each year. Recent findings indicate that chronic rhinosinusitis is a response to fungi mediated by the eosinophil in some of these individuals. We report a case of eosinophilic fungal rhinosinusitis of the lacrimal sac, an entity not previously reported.

STUDY DESIGN

Case report.

METHODS

A 69-year-old man presented with a 1-cm cystic lesion in the right-side medial canthal region. This lesion was fluctuant, and mucoid material was freely expressed from the medial canthal area. Endoscopic examination revealed bilateral nasal polyps anteriorly and superiorly with mucopurulent drainage from both maxillary sinuses. He had undergone three prior sinus surgeries and two prior lacrimal cannulations elsewhere. A computed tomography scan showed opacification of both maxillary sinuses, ethmoid sinuses, and the left sphenoid sinus and moderate thickening in the frontal sinuses. There was significant soft tissue prominence in the area of both lacrimal fossae with erosion into the medial orbit. The patient underwent bilateral endoscopic revision ethmoidectomies, middle meatal antrostomies, sphenoidotomies, frontal sinusotomies, and endoscopic right-side dacryocystorhinostomy at the Department of Otorhinolaryngology, Mayo Clinic (Rochester, MN).

RESULTS

At the time of surgery, massive amounts of thick mucoid material were aspirated from both lacrimal regions. The aspiration of the lacrimal duct on the left side was sufficient treatment, whereas the dacryocystorhinostomy was necessary to decompress the cyst of the face on the right side. The material aspirated was allergic mucin, and the patient met the criteria for diagnosing eosinophilic fungal rhinosinusitis. The patient was started on a regimen of antifungal nasal irrigations postoperatively and has done well in follow-up.

CONCLUSIONS

Although never previously reported, eosinophilic fungal rhinosinusitis can occur in the lacrimal sac. It is important to recognize this so that the underlying disease process can be treated appropriately.