Angelo Martin B. Catacutan Pediatric Resident The Medical City Baby MAA Angelo Martin B. Catacutan Pediatric Resident The Medical City

Upon Delivery DOB: 12/4/2013 TOB: 8:01am Male Anthropometrics HEENT BW 3085g, BL 51cm, HC 35cm, CC 33cm, AC 28cm APGAR 9,9 MT 37AGA HEENT Flat fontanelles, patent nares, no cleft lip or palate Respiratory No chest deformities, equal expansion

Upon Delivery Cardiac Abdominal Genital Anus HR 140’s, no murmurs, regular rhythm Abdominal Soft abdomen, no palpable masses, umbilicus has 2 arteries and one vein Genital Grossly male genitalia, descended testes Anus Patent anus

Upon Delivery Term Baby Boy delivered via stat CS to a 29yo G1P1 (1001) at 37 1/7 weeks AOG, BW 3085g, BL 51cm, AS 9,9, MT 37AGA

Upon Delivery Management Admitted to level II for emergency Cesarean section Vitamin K 0.1mL IM Hepatitis B vaccine 0.5mL IM Erythromycin eye ointment OU For blood typing, newborn screening, hearing screening

At 1st Hour of Life Subjective Good suck, active Latches to mother Objective Stable vitals + Facial asymmetry Shallow R nasolabial fold 0.5cm x 0.5cm violaceous, soft, non-tender mass at R nasal bridge Assessment Term Baby Boy t/c Naso-lacrimal duct obstruction r/o Malignancy Plan Continue newborn care Refer to ENT for co-management

At 6th Hour of Life Patient seen by ENT service Findings: R upper nasomaxillary mass, 1x1cm violaceous, rubbery, non-tender, slightly movable Otoscopy: unremarkable Anterior Rhinoscopy: minimal mucoid discharge, R nostril

At 6th Hour of Life Assessment: t/c Nasolacrimal duct obstruction r/o neoplasm Suggestions: Ophtha referral, NaCl nasal drops TID for nasal secretions

At 10th Hour of Life Subjective Good suck, active Mother unable to breastfeed due to post-op status Objective Stable vitals Blood type A+ + Facial asymmetry Shallow R nasolabial fold 1cm x 1cm violaceous, soft, non-tender mass at R nasal bridge Assessment Term Baby Boy t/c Naso-lacrimal duct obstruction r/o Malignancy Plan Continue newborn care Awaiting ophtha assessment Start supplemental feeding

Day 1 of Life Ophtha Findings: Dacryocystocoele 1x1cm solitary, soft, hyperpigmented, slightly moveable, non-tender nodule slightly inferior to R medial canthus No eye discharge or matting of lashes Pupils 2m EBRTL, Dacryocystocoele For possible probing of dacryocystocoele

Day 2 of Life Subjective Good suck, active Tolerates 20-30mL of milk feedings Objective Stable vitals 1cm x 1cm violaceous, soft, non-tender mass at R nasal bridge No marked increase in size of mass Light jaundice to thighs Assessment Term Baby Boy t/c Naso-lacrimal duct obstruction r/o Malignancy t/c Physiologic jaundice Plan Continue newborn care Acquiring consent for probing Observe for progression of jaundice

Day 3 of Life Subjective Good suck, active Tolerates 20-30mL of milk feedings Objective Stable vitals 1cm x 1cm violaceous, soft, non-tender mass at R nasal bridge No marked increase in size of mass Light jaundice to abdomen Assessment Term Baby Boy t/c Naso-lacrimal duct obstruction r/o Malignancy Hyper- bilirubinemia, unspecified Plan Continue newborn care Acquiring consent for probing For serum bilirubin levels

Day 3 of Life Bilirubin levels For double phototherapy Total: 15.81mg/dL, DB 0.46mg/dL, IB 15.61mg/dL High Intermediate Risk Zone For double phototherapy Planning for probing of dacryocystocoele

Day 4 of Life Decreased intensity of jaundice   TB DB IB 12/7/2013 75thHOL 15.81 0.46 15.61 HIRZ 12/9/2013 118th HOL 11.84 0.47 11.56 LRZ Decreased intensity of jaundice Continue double phototherapy

Day 5 of Life Probing procedure performed Placed on NPO, IVF (D10IMB at TFR 110mL/kg/d) No problems encountered Tobramycin + Dexamethasone started on right eye and nostril BID IVF discontinued post-op Feeding resumed

Day 6 of Life Day 1 post-op Marked decrease in jaundice Phototherapy discontinued IV removed For discharge

Final Diagnosis Term Baby Boy delivered via stat CS to a 29yo G1P1 (1001) at 37 1/7 weeks AOG, BW 3085g, BL 51cm, AS 9,9, MT 37AGA Dacryocystocoele, Right s/p probing and eye examination

Discussion Reference: Wong et. al. Presentation and Management of Congenital Dacryocystocele. Pediatrics 2008. 122 (5)

Congenital Dacryocystoceles Aka congenital mucocele or amniotocele Rare variant of nasoclarcrimal duct obstruction (NLDO) Wong, et. al. 2008

Congenital Dacryocystoceles Pathophysiology Mesoderm fails to canalize distally  obstruction  distention of lacrimal sac

Congenital Dacryocystoceles Presentation Usually at first week of life Seen as a bluish, cystic, firm mass below the medial canthus May also have excessive tearing or eye discharge Differentials Encephaloceles, hemangiomas, gliomas Wong, et. al. 2008

Congenital Dacryocystoceles Complications Infection of the cyst  sepsis Difficulty breathing Difficulty feeding Wong, et. al. 2008

Diagnosis Imaging UTZ – can be done perinatally MRI

Management Conservative approach Gentle pressure over the lacrimal sac  decompression Antibiotic drops as prophylaxis Warm compress Resolution rate is 76% Wong, et. al. 2008

Management Surgical Probing to establish patency (Bowman probe #00-0000) Can be done as outpatient If infection of the cyst occurs – need for systemic antibiotics for 24-48 hours prior to probing May need marsupialization if with intranasal extension Wong, et. al. 2008

Management Wong, et. al. 2008

Thank You! Reference: Wong et. al. Presentation and Management of Congenital Dacryocystocele. Pediatrics 2008. 122 (5)