In our study, when we analyzed the monthly distribution of the patients admitted to our hospital with acute dacryocystitis symptoms for five years, we obtained data indicating that the development of acute dacryocystitis may have a seasonal relationship. In our series, the average age was younger than in western countries. The patients who have dacryocystitis are diagnosedgenerally at the age of 40 and over. However, acquired nasolacrimal duct obstruction has been diagnosed in the advanced age group (mean between 55.0 and 66.3 years) in developed countries (8). In our study, the mean age of the patients was 54.70 ± 16.80 years.
In the study conducted by Chung et al., the age of the cases was found to be 55.4 years, similar to our study. The number of female patients is higher than that of men. In this study, S.Aeuris was found to be the most frequently isolated microbiological agent in the culture results (9).When dacryocystitis cases are examined in terms of gender, while the distribution between genders is equal in congenital dacryocystitis cases, dacryocystitis seen in adulthood is more common in women. This ratio is observed as 80% women and 20% men. It has been reported in various studies that hormonal irregularities in women may cause narrowing of the nasolacrimal canal, causing dacryocystitis to be observed more frequently. In addition, the lower lacrimal passage is more irregular in women (10, 11). In our study, the rate of female patients in a series of 60 patients included in the study was 75%. Studies conducted in our country have reported the rate of women between 71.2% and 89.3% (12, 13).
Despite the differences in various economic and environmental factors, the fact that nasolacrimal obstruction occurs more frequently in women and in the postmenopausal period suggests that anatomical and hormonal factors play an important role (14, 15). When nasolacrimal duct obstruction develops, patients usually develop a low-grade chronic dacryocystitis, which exacerbates from time to time. Patients usually live with these symptoms of chronic dacryocystitis until they undergo surgery for nasolarimal duct obstruction. The patients have symptoms of permanent epiphora, purulent discharge due to recurrent conjunctivitis from time to time. These cases develop acute dacryocystitis due to acute inflammation of the lacrimal sac at a certain time of the year. When acute dacryocystitis develops, a very disturbing clinical picture with subacute onset of pain, tense swelling at medial chantus and mild to intense preseptal cellulitis develops in these patients and systemic antibiotic treatment is often required. Some patients are persuaded to undergo surgery after experiencing acute dacryocystitis. It is very difficult to predict when a picture of acute dacryocystitis will develop in these patients. A seasonal relationship with the time of onset of acute dacryocystitis may indicate the influence of other environmental factors. Whether there is a seasonal relationship with acute dacryocystitis has rarely been investigated in the literature.
In an epidemiological study on acute dacryocystitis, the seasonal variation analysis of acute dacryocystitis cases showed that dacryocystitis was relatively more common during warm periods, but it was not statistically significant. Seasonal distribution analysis was not performed between the genders (16).
In our study, it was observed that there was an increase in the frequency of acute dacryocystitis during the hot season among all patients. This difference was statistically significant among women (p < 0.05). No significant difference was found between the male patients in terms of seasonal distribution by months of the year (p > 0.05).
Badhu et al. showed that dacryocystitis was observed at a higher rate in patients with nasolacrimal duct obstruction living in the plains compared to those living in the mountainous region from their sociodemographic data(17). This geographic data may show that temperature is a risk factor and is consistent with the results of our study. In a retrospective study on the sociodemographic data by Nemet et al, it was found that 36.3% of the patients with nasolacrimal obstruction had a low socioeconomic level, but this rate was not found to be significantly different from the control group (18). In our study, no evaluation could be made regarding the socioeconomic level or geographical place.
Our study has some limitations. The small number of patients is one of them. Second limitation may be the lack of microbiological culture data to analyze microbiological factors causing dacryocystitis according to seasons. Third, anatomical variations of the patients were not examined by endoscopic examination. In our study, it was not attempted to reach these data accurately retrospectively, but rather we exerted afford to find data about when the patients developed symptoms. More detailed results can be obtained by examining these features in larger case series.
The seasonal relationship between the time of occurrence of acute dacryocystitis cases and the fact that there is an increase in the warm seasons especially in female patients but the absence of seasonal relationship in male patients suggests that different factors may play a role in the etiology of acute dacryocystitis. Our study should be investigated with further studies, especially considering the small sample size of male patients. If this relationship is validated by further studies, patients with chronic epiphora or chronic dacryocystitis can be informed and warned about the seasonal risk factor of this very disturbing clinical picture, and thus disease management can be done more accurately.
In conclusion, we considered that the increase in frequency of acute dacryocystitis cases in summer seasons of the year may be due to the change in lacrimal sac flora or increase in infectious agents in these seasons. Further studies are warranted to demonstrate the seasonal relationship of development of acute dacryocystitis.