|Year : 1958 | Volume
| Issue : 1 | Page : 5-8
Chronic and acute phlegmonous dacryocystitis as a cause of thrombophlebitis of the cavernous sinus
|Date of Web Publication||8-May-2008|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Pines P. Chronic and acute phlegmonous dacryocystitis as a cause of thrombophlebitis of the cavernous sinus. Indian J Ophthalmol 1958;6:5-8
|How to cite this URL:|
Pines P. Chronic and acute phlegmonous dacryocystitis as a cause of thrombophlebitis of the cavernous sinus. Indian J Ophthalmol [serial online] 1958 [cited 2020 Jul 14];6:5-8. Available from: http://www.ijo.in/text.asp?1958/6/1/5/40712
The purpose of this paper is to offer an explanation why chronic and even phlegmonous dacryocystitis so rarely causes a septic thrombophlebitis of the sinus cavernosus. This fact is well-recognised and is usually mentioned in the literature en passant, but no attempt is made to explain it.
| Frequency|| |
The complication of sinus cavernosus thrombophlebitis may arise in 2 ways(i) by involving the orbital tissues as an intermediate stage, or (ii) missing the orbital tissues, at least clinically, attacking the sinus directly.
Several cases of a local phlegmon of the lacrimal sac have been described as having taken place after probing of an inflamed lacrimal sac, but the formation of an orbital phlegmon has been described very rarely (Fulton, 1885; Hirshberg, 1892); whereas a few do not mention the lacrimal sac at all while discussing the causes of orbital phlegmon or thrombophlebitis of the cavernous sinus (MacEwen, 1893, Nagy, 1929; Walsh, 1947; Dorland Smith, 1918); and yet again a few have described blindness and fatal results after a probing and irrigation or even excision of an inflamed lacrimal sac (Lamm, 1910, Lewis, 1907; Isaac, 1931; Erickson, 1949; Lanner, 1916; Vejdofsky, 1935). Duke-Elder (1952) sums up when he writes, "as a rare event the pus (from the lacrimal sac) may track into the orbit and there set up an orbital cellulitis which may result in necrosis of the cornea, panophthalmitis, orbital thrombophlebitis, optic atrophy or meningitis and death. My own two cases of orbital phlegmon, both in children and both fatal, seen in pre-sulpha-antibiotic era were caused by hordeolum. Some are of the opinion that orbital cellulitis and its consequences are more due to sinus infections than to a lacrimal abscess.
As regards the mode of spread, the complications of dacryocystitis arise by spread along venous or lymphatic channels, by contiguity or continuity. Johnson while discussing a paper by West (1926) describes an anterior route through the orbital veins, and a posterior route along the medial orbital wall.
| Anatomy|| |
What may be the cause of this extreme rarity ? Since the affection of the cavernous sinus results as a travel upwards of the infection from the lacrimal sac region we must explore the lymphatic and venous systems. The role of the lymphatics is doubtful because the existence of lymphatics in the orbit does not bear sufficient evidence (Batson, 1938).
So we are left with the venous system and the structure of the lacrymal sac itself. The latter consists of an outer layer of fibrous tissue, the part of the fascia that lines the fossa lacrymalis, and an inner one consisting of a rich mucous membrane loosely attached to the fascia by connective tissue. A rich plexus of small veins lies between these layers especially between the wall of the ductus lacrymalis and the surrounding nasal tissues. About that all authorities agree, but from this point there is slight although not important disagreement.
The Cavernous Sinus: The passage of venous blood to the cavernous sinus is through the orbital veins. Some describe a special small vein from the lacrimal sac, the vena sacci lacrymalis that goes to the supra orbital vein along with many small twigs coming from the inner corner of the eye, whereas the anterior facial and the inferior ophthalmic veins drain the blood from the lacrymal duct region. Some blood from the lower part of the passages drains through the sphenopalatine veins into the pterygoid plexus and internal maxillary veins. There is venous connection between the lacrymal plexus and the mucous membrane of the ethmoids through little venules. [Figure - 1].
Batson (1936) in an experimental study on the cadaver by ligating the angular vein at the lower border of the orbit and by injecting a radio opaque substance into the anterior facial vein has demonstrated the close venous connections between the lacrymal plexus, the nasal plexuses in the turbinates of both the sides, the veins in the wall of the maxillary sinuses and finally the cavernous sinus. This appears to be the probable and easy pathway for the spread of infection to the cranium from infections of the lacrymal sac, paranasal sinuses and the orbit. And yet the rarest cause of cavernous sinus infection is infection from the lacrymal passages.
Do these veins possess any valves ? There is little evidence from anatomists working on this subject to suggest the presence of protective valves in the course of the angular or ophthalmic veins.
Although ordinarily the current of blood runs antero-posteriorly in the cavernous sinus, the current may be slowed, stopped or deflected in inflammatory conditions by change in pressure relations so that the direction of the flow is deflected away from the inflamed area (MacNeal, Frisbee and Blevins, 1943). Thus, an indirect resistance is offered to the spread of infection to the sinus.
A septic thrombus however may get detached and enter the cavernous sinus as an embolus. In whichever way the septic clot reaches the sinus, once it is reached there are present all possible factors to provide a nice catchment area for the bacteria - presence of several small anastamotic venous channels, an irregular meshwork of fibrillar tissue clothed in endothelium within the lumen, and the passage of big internal carotid artery through it, all contributing to the slowing down of the flow of blood.
Can lacrymal sac infection spread by continuity or contiguity and if so, how ? Let us consider the probable factors.
Muscular Relations: The muscles round the lacrymal sac - the orbicularis and m. transverse raclicis nasi go round the lacrymal fossa and do not touch the lacrymal sac. The only muscle connected with the lacrymal sac is Homer's muscle, which is the medial continuation of the ciliary part of the orbicularis (Wolf 1948).
Other Relations: The sac sitting on the thin lacrymal bone is in close proximity with the nasal mucous membrane and the paranasal sinuses.
The presence of a necrosed bone or even a hiatus in the bony floor in cases of chronic and acute infections of the sac as reported by several authors (West, 1926; Snell, 1914; Fuchs, 1880;) and the frequency of paranasal sinus infections associated with lacrymal infections - (Cordero, 1934; Kuhnt, 1938) suggests that the spread of infection to the neighbouring nasal turbinates and mucous membrane and to the paranasal sinuses by contiguity through the floor of the lacrymal fossa is easily possible. Spread by continuity along the venous connections and through the continuity of the mucous membrane from the sac to the nose offers the other possibility. In the latter case, however, the presence of various valves in the lacrymal passage may offer resistance to infection in either direction, that is, to or from the nasal passages. A spread anteriorly through the resistant lacrymal fascia is more difficult than posteriorly through an easily necrotible bony floor.
The infection having reached the ethmoids or the nose, may travel along the spheno-palatine vein to the pterygoid plexus and further to the cavernous sinus by venous continuity.
Trauma : In most of the reported cases the history suggests a surgical interference during the inflammatory process. In the case of the lacrymal sac probing can be a traumatising, operation, resulting in false-passage and bleeding, especially in cases of trachomatous sacs. Such interference could become extremely dangerous if after a false-passage the sac is syringed and the infected material is thus driven into the tissues surrounding the sac. Under the circumstances it is advisable to observe caution and delay any kind of probing and syringing during or soon after an acute dacryocystitis, or a dacryocystotomy. Especially in modern times with sulpha drugs and antibiotics it is advisible to defer all surgical interference until the acute inflammation subsides.
Propulsion of Infection Once a septic thrombus forms it has to be dislodged and carried to the orbital veins to reach the cavernous sinus, or it may reach the cavernous sinus, by a continuous extension. The capillaries round about an acute focus of infection are full of septic thrombi. The dislodging of these can be achieved either by an external force, squeezing for instance in the case of a furuncle on the nose, and further helped by muscular activity in regions with muscle fibres surrounding the inflammatory focus.
In the case of the lacrimal sac, it is well-known that only the fundus of the sac, surrounded by Homer's muscle only is capable of causing some movement of the sac which is very little. The activity of this muscle is reduced to a zero in inflammatory states when it becomes cedematous. So this factor is also minimised in the case of acute dacryocystitis. This is also one of the reasons for the extreme rarity of an orbital phlegmon resulting from a dacryocystitis.
| Conclusion|| |
Although anatomically the lacrimal sac is closer to the orbit and the cavernous sinus than many other structures, whose infection may cause an orbital cellulitis or cavernous sinus thrombosis, the lacrimal sac is the least responsible for these ghastly complications for the following probable reasons.
1.The presence of folds , the so called valves in the lacrimal sac, which prevent spread of infection to and from the nasal cavity.
2. The comparative immobility of the sac, especially in a swollen oedematous condition.
3. Its secluded position in a bony bed covered by resistant fascia.
Once the infection has spread to the neighbouring sinuses by contiguity, helped by trauma (probing and irrigation) or by extension of septic thrombi in the capillaries round the focus of infection, by continuity to the angular veins anteriorly or the pterygoid plexus of veins posteriorly, the chances of spread to the orbit through the orbital veins and further to the cavernous sinus become even with those of infections from the nose, face and paranasal sinuses.
| Summary|| |
A historical, anatomical, clinical and pathological study of the lacrimal sac and its infections is presented to offer an explanation for the rarity of extension of infection to the orbit and the cavernous sinus from infections of the lacrimal sac.
Incidentally one is cautioned to the dangers of probing and irrigation, especially in cases of more acute inflammations of the lacrimal sac.
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[Figure - 1]