CASE REPORT

Resolution of Dacryostenosis After

Osteopathic Manipulative Treatment
Theresa E. Apoznanski, OMS III; Reem Abu-Sbaih, DO; Michael J. Terzella, DO;
and Sheldon Yao, DO

From the New York Dacryostenosis is an obstruction of the nasolacrimal duct and is the most
Institute of Technology
common cause of epiphora and ocular discharge in newborns. Whereas most
College of Osteopathic
Medicine (NYIT-COM) cases resolve spontaneously, invasive treatment may become necessary if
in Old Westbury. symptoms persist past age 6 to 12 months. In the present case, a 9-month-old
Financial Disclosures: boy with persistent dacryostenosis was scheduled for lacrimal duct probing
None reported.
after first-line treatments failed. After a single session of osteopathic manipu-
Support: None reported. lative treatment, the patient’s epiphora and other symptoms resolved, and
Address correspondence to he no longer needed surgical probing. A review of the literature highlights
Sheldon Yao, DO,
key pathophysiologic processes, management options, and musculoskeletal
Department of Osteopathic
Manipulative Medicine, aspects of dacryostenosis. Physicians should consider osteopathic manipula-
NYIT-COM, PO Box 8000, tive treatment in the management of dacryostenosis.
Old Westbury, NY
J Am Osteopath Assoc. 2015;115(2):110-114
11568-8000.
doi:10.7556/jaoa.2015.022
E-mail: [email protected]

Submitted July 25, 2014;

D
final revision received
September 18, 2014;
acryostenosis, an obstruction of the nasolacrimal duct (NLD),1 is found in up
accepted October 2, 2014.
to 20% of newborns2 and is the most common cause of epiphora and ocular
discharge in this patient population. Dacryostenosis results from either in-
complete canalization of the nasolacrimal epithelial cord in utero or from misaligned
cranial bones that have shifted due to forces in utero, during childbirth, or during the
postpartum period.3,4
The criterion standard of care for patients with dacryostenosis is nasolacrimal mas-
sage, a noninvasive technique in which a nonspecific pressure is applied over the lacrimal
sac to force tears into the NLD. The primary role of the NLD is to drain tears from the
eye. Although 96% of dacryostenosis cases resolve spontaneously by age 12 months, the
likelihood of spontaneous resolution decreases with age.5 If symptoms persist for infants
aged 6 to 12 months, nasolacrimal probing with the use of anesthesia may be required.6
If dacryostenosis is left untreated, patients are at risk for complications such as infection
and anisometropia.1,5
We report the case of an infant boy whose persistent dacryostenosis resolved after os-
teopathic manipulative treatment (OMT). To our knowledge, the current report is the first
to discuss OMT for dacryostenosis.

110 The Journal of the American Osteopathic Association February 2015 | Vol 115 | No. 2
 CASE REPORT

Report of Case and spinal level T1 flexed, rotated, and sidebent right.
A 9-month-old boy was brought to the health care clinic The patient was treated with OMT techniques including
by his mother, who reported increased tearing and nasion spread, cranial bone lifts such as frontal lift and
crusting around the boy’s right eye upon waking. The maxillary lift, balanced ligamentous tension of the cer-
patient had a history of dacryostenosis and recurrent vical and upper thoracic regions, bilateral condylar
dacryocystitis since birth, as diagnosed by his pediatri- decompression, and myofascial release of the cervical
cian and ophthalmologist. The mother had been per- spine and thoracic inlet.
forming nasolacrimal massage on the patient twice per Immediately after treatment, edema around the pa-
day as symptoms occurred since the patient’s birth. At tient’s right eye decreased. During 3 follow-up telephone
the time of the visit, the patient was on day 5 of poly- calls, the patient’s mother reported the following: At 1
myxin B sulfate-trimethoprim ophthalmic solution week after treatment, epiphora and ocular discharge had
(10,000 U-1 mg/mL) and bacitracin ophthalmic ointment decreased. At 3 weeks after treatment, epiphora had re-
(500 U/g). The mother reported that the antibiotics would solved, ocular discharge was present, and the edema
alleviate the patient’s symptoms temporarily, but that his around the right eye had decreased (Figure 1B). At 6
symptoms would reappear within a few weeks after stop- months after treatment, no symptoms were present. Sur-
ping antibiotics. Because of the recurrent symptoms, the gical nasolacrimal probing or nasolacrimal massage
patient was scheduled for nasolacrimal probing. were no longer required, and the patient had not needed
The patient had no notable medical or family history. antibiotics since receiving OMT.
He was born at 38 weeks gestation to a primigravid
mother by cesarean delivery for failure to progress. He
had no known drug or seasonal allergies. His ophthal- Discussion
mologist reported no additional vision or ocular prob- Physiologic and Pathologic Process
lems. No pets were in the patient’s home and neither The NLD originates at the nasolacrimal fossa in the me-
parent smoked cigarettes or used drugs. dial wall of the orbit. The nasolacrimal fossa comprises
Physical examination revealed that vital signs were the lacrimal bone posteriorly and the frontal process of
within reference range. The patient was meeting all the maxilla anteriorly. Canalization begins during the
developmental milestones appropriately. Examination third month in utero and starts superiorly at the punctum
of the head was notable for increased tearing of the and ends distally at the Hasner valve, which covers the
right eye without pus or blood. The right orbit appeared opening to the inferior meatus of the nasal cavity (Figure
smaller compared with the left orbit because of in- 2).3 When tears enter the puncta, a combination of orbi-
creased edema of the soft tissue surrounding the eye cularis oculi muscle contraction, fascial traction, and
(Figure 1A). The remainder of the physical examination negative pressure creates a pumping action to force tears
findings were unremarkable. farther into the NLD.7
Osteopathic structural examination findings in- The most common cause of dacryostenosis is an un-
cluded internal rotation somatic dysfunction of the opened membrane at the Hasner valve (Figure 2).7 Other
right nasal bone, right frontal bone, and right maxillary causes include interosseous narrowing from dysfunc-
bone; bilateral condylar compression; right scalene tions of the adjacent frontal, maxilla, and ethmoid bones.
spasm; spinal levels C2 through C3 flexed, rotated, and Intraosseous compression may also occur within the
sidebent right; spinal level C5 extended, rotated, lacrimal bone, because the bones of an infant are soft and
and sidebent left; right first rib inhalation dysfunction; easily molded by surrounding stressors.4

The Journal of the American Osteopathic Association February 2015 | Vol 115 | No. 2 111
 CASE REPORT

A the lacrimal sac.6,7 It may also help to rupture the un-

opened Hasner valve.6 If symptoms persist after the
patient is aged 6 to 12 months, NLD probing may be
necessary. If probing fails, balloon dilation or tempo-
rary silicone stents may be used. In rare cases, perma-
nent measures are available, such as the construction of
B a window between the lacrimal sac and nasal cavity.2

Osteopathic Approach and Considerations

To understand the role of OMT in alleviating stenosis,
one must be familiar with the anatomy of the NLD
and its surrounding bones, muscles, and fasciae. Struc-
Figure 1.
turally, the osseous canal through which the NLD
Eyes of a 9-month-old boy with dacryostenosis
before (A) and 3 weeks after (B) osteopathic traverses can narrow if the frontal process of the maxilla
manipulative treatment. In image A, the right is driven posteriorly or if the lacrimal bone is driven an-
orbit appears smaller than the left orbit because
of increased edema of the soft tissue surrounding teriorly.4 One objective of a cranial bone lift is to manage
the eye. In image B, a complete resolution of dysfunctions of the associated bones in relation to their
epiphora and ocular discharge and a decrease in
sutural or dural connections.8 In cases of dacryostenosis,
the edema around the right eye can be observed.
cranial bone lifts can be used to manage the stresses
placed on the lacrimal bone by the surrounding maxil-
Diagnosis and Complications lary, frontal, and ethmoid bones. The canal may become
Diagnosis of dacryostenosis is usually clinical, more patent and drain more easily if the bony articula-
marked by the presence of ocular symptoms such as tions are decompressed.
discharge and epiphora. If dacryostenosis is suspected Orbital muscles also play a role in dacryostenosis.7
but no symptoms are present at the time of evaluation, The orbicularis oculi muscle originates at the lacrimal
physicians may deposit fluorescein-stained saline on bone and inserts into the zygomatic bone. A small
the lens to evaluate drainage through the NLD. Other portion, known as the Horner muscle, runs posteriorly to
causes of these symptoms that must be considered in the lacrimal sac and posterior lacrimal crest (Figure 2).
the differential diagnosis include conjunctivitis, The Horner muscle is responsible for proper NLD func-
blepharitis, and trauma. Complications of persistent tion and contracts to pump tears through the canal. An-
dacryostenosis include anisometropia, dacryocystitis, other portion of the orbicularis oculi muscle surrounds
and orbital cellulitis.6 the ampulla and tightens to prevent retrograde movement
of tears.7 In our case, cranial bone lifts at the bony origins
Management and insertions of the orbicularis oculi muscle addressed
First-line treatment for patients with dacryostenosis is muscular restrictions with the goals of improving muscle
nasolacrimal massage, which is performed by applying function and increasing the efficacy of the pumping
pressure to the tissues over the NLD and massaging mechanism of tear drainage.
from the lacrimal sac toward the distal NLD. The pres- Osteopathic manipulative treatment may have a role
sure assists in forcing tears into the NLD by enhancing in normalizing autonomic tone of the orbit. Somatic
the mechanism of capillary action that draws tears into dysfunctions along the pathways of cranial nerves and

112 The Journal of the American Osteopathic Association February 2015 | Vol 115 | No. 2
 CASE REPORT

Canaliculus
Ampulla

Posterior lacrimal crest Supporting fascia

Bony orbital rim

F
F

L Tendinous
N raphe
E

M
N
M

Nasolacrimal sac

Horner muscle
(pretarsal orbicularis)

Orbicularis oculi Preseptal orbicularis

(inferior)
Approximate location
of Hasner valve

Figure 2.
Anatomy of the lacrimal duct in the eye. A small portion of the orbicularis oculi muscle,
known as the Horner muscle, runs posteriorly to the lacrimal sac and posterior lacrimal crest.
Abbreviations: F, frontal bone; N, nasal bone; M, maxilla bone; E, etnmoid bone; L, lacrimal bone.
Illustration by Nikos Solounias, PhD.

their ganglia can cause symptoms of dacryostenosis, orbital fissure.7 The innervations of the orbicularis oculi
which may be alleviated as the strain patterns are man- muscle and lacrimal gland take a rather tortuous course
aged. The orbicularis oculi muscle is innervated by the
9
through the cranium. Cranial bone lifts and myofascial
temporal and zygomatic branches of the facial nerve techniques to restricted areas may improve autonomic
(cranial nerve VII), which course through the facial balance, and direct inhibition of the pterygopalatine
canal and exit at the stylomastoid foramen. The oph- ganglion may affect lacrimation.10
thalmic branch (cranial nerve VI) of the trigeminal Addressing the myofascial strains that create bony
nerve provides the afferent innervation to the lacrimal restrictions may augment lymph drainage by activating
gland. The efferent parasympathetic nerves originate in lymphatic stretch reflexes and normalizing sympathetic
the brainstem, travel through the pterygoid canal, and effects on the contractile elements of lymphatic vessels.11
ultimately synapse at the pterygopalatine ganglion. Even indirect techniques, such as cranial bone lifts, alter
Postganglionic fibers exit the skull through the inferior the pressure on smaller lymphatic vessels.10 In our case,

The Journal of the American Osteopathic Association February 2015 | Vol 115 | No. 2 113
 CASE REPORT

the management of cervical and thoracic somatic dys- 3. Takahashi Y, Kakizaki H, Chan WO, Selva D. Management
of congenital nasolacrimal duct obstruction [published
functions potentially addressed restrictions that were online July 21, 2009]. Acta Ophthalmol. 2010;88(5):506-513.
preventing proper lymphatic drainage from the head and doi:10.1111/j.1755-3768.2009.01592.x.

neck, which may have facilitated the subsequent de- 4. MacEwen CJ, Young JD. Epiphora during the first
year of life. Eye (Lond). 1991;5(pt 5):596-600.
crease in periorbital edema. Orbital lymphatic vessels
5. Piotrowski JT, Diehl NN, Mohney BG. Neonatal
first drain into the preauricular, parotid, and submandib- dacryostenosis as a risk factor for anisometropia.
Arch Ophthalmol. 2010;128(9):1166-1169.
ular nodes and then drain into the right thoracic duct. By
doi:10.1001/archophthalmol.2010.184.
understanding the anatomy of the venous and lymphatic
6. Dutton JJ. Atlas of Clinical and Surgical Orbital Anatomy.
systems surrounding the NLD, physicians can better 2nd ed. Philadelphia, PA: Elsevier/Saunders; 2011.

orient their application of OMT. 7. Casady DR, Meyer DR, Simon JW, Stasior GO, Zobal-ratner JL.
Stepwise treatment paradigm for congenital nasolacrimal duct
obstruction. Ophthal Plast Reconstr Surg. 2006;22(4):243-247.

8. Nicholas A, Nicholas E. Osteopathy in the cranial field. In:

Conclusion Nicholas AS, Nicholas AE, eds. Atlas of Osteopathic Techniques.
Philadelphia, PA: Lippincott Williams & Wilkins; 2008:493.
As demonstrated in the present case, OMT may decrease
9. Chila AG. Child with ear pain. In: Chila AG, executive ed.
the need for antibiotics and invasive procedures in patients Foundations of Osteopathic Medicine. 3rd ed. Baltimore, MD:
with persistent dacryostenosis. Additional research is Lippincott Williams & Wilkins; 2011:927.

needed to support these findings and to evaluate the role of 10. Kuchera ML, Kuchera WA. Techniques for homeostasis,
healing and symptom relief. In: Osteopathic Considerations in
OMT as a potential conservative first-line treatment for HEENT Disorders. Dayton, OH: Greyden Press; 2005:13,180.
these patients. 11. Rivers WE, Treffer KD, Glaros AG, Williams CL.
Short-term hematologic and hemodynamic effects
of osteopathic lymphatic techniques: a pilot crossover trial.
References J Am Osteopath Assoc. 2008;108(11):646-651.

1. de la Cuadra-Blanco C, Peces-Peña MD, Jáñez-Escalada L, © 2015 American Osteopathic Association

Mérida-Velasco JR. Morphogenesis of the human excretory
lacrimal system. J Anat. 2006;209(2):127-135.

2. Carreiro JE. An Osteopathic Approach to Children.

2nd ed. Edinburgh, Scotland: Churchill Livingston
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114 The Journal of the American Osteopathic Association February 2015 | Vol 115 | No. 2