Lacrimal sac primary squamous cell carcinoma with synchronous tonsillar primary squamous cell carcinoma

A gentleman with recurrent epiphora after two failed endonasal dacryocystorhinostomies was found to have a squamous cell carcinoma of the lacrimal sac at his third operation via an external approach. CT showed contralateral nodal involvement; however, biopsy of the node found it to be histologically distinct from the lacrimal sac lesion. A PET-CT revealed a second primary lesion located at the contralateral palatine tonsil. We discuss the histological features of squamous cell carcinomas and the impact on prognosis. This case highlights the importance of nasoendoscopy prior to lacrimal surgery. There should be a low threshold for lacrimal sac biopsy, and any anatomical or histological inconsistency should prompt further investigation.