A Case of Epiphora and Recurrent Basal Cell Carcinoma of the Nasal Tip and Review of Acquired Nasolacrimal System Obstruction

Abstract

A case of a 67-year-old man with recurrent basal cell carcinoma of the nasal tip and an incidental symptom of epiphora (volunteered by the patient) is presented. Epiphora is an abnormal overflow of tears that fail to drain into the inferior nasal meatus via the nasolacrimal system. Within the differential diagnosis of epiphora and nasolacrimal obstruction is neoplasm – primary, secondary or metastatic. On further investigation, including computed tomography imaging, he was subsequently found to have invasive disease extending along the left embryological cleavage plane superiorly to the medial canthal tendon. An excision attempt using Mohs technique by the dermatological surgeon was unsuccessful in adequately clearing the margins, and revealed a diagnosis of morphea-like basal cell cancer. This failure, taken together with the extent of disease identified by computed tomography scan, resulted in significant alteration of the operative approach. The patient underwent extensive tumour extirpation and nasal reconstruction using a forehead flap.

The present case alerts surgeons involved in the management of skin cancers to the importance of the anatomical relationship of the nasolacrimal apparatus to embryological soft tissue cleavage planes when dealing with recurrent and aggressive lesions. In addition, it serves as a reminder to inquire about the signs and symptoms associated with nasolacrimal obstruction. Moreover, when preparing for surgical excision of recurrent aggressive basal cell carcinoma, high-quality imaging is essential to tailor the operative plan.