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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

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

11. 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

12. 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

13. 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

14. 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

15. 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

16. Day 4 of Life Decreased intensity of jaundiceTB DB IB
12/7/ thHOL
15.81
0.46
15.61
HIRZ
12/9/ th HOL
11.84
0.47
11.56
LRZ
Decreased intensity of jaundice
Continue double phototherapy

17. 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

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

19. 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

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

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

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

24. 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

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

26. Diagnosis
Imaging
UTZ – can be done perinatally
MRI

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

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

30. Management
Wong, et. al. 2008

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