Endoscopic inferior dacryocystorhinostomy

Conventional dacryocystorhinostomy (DCR) usually involves extensive removal of bone at the lacrimal fossa and hence risks disruption of the lacrimal pump mechanism. A physiological operation for nasal lacrimal blockage is described whereby only the inferior portion of the lacrimal sac and the adjacent duct are marsupialized into the nose. The operation is safe, quick and does not involve sophisticated instruments. Result of 81 consecutive endoscopic inferior DCRs reveals a success rate of over 90% which is maintained with time. Most patients had a wide lacrimal window with preserved lacrimal pump movement at the superior sac remnant.     

Manometric Measurement of Lacrimal Sac Pressure after Endoscopic and External Dacryocystorhinostomy

Objective—To evaluate endoscopic and external dacryocystorhinostomy (DCR) using a quantitative, objective functional tool. Material and methods—This study comprised 58 cases divided into 4 groups: healthy controls; patients suffering from epiphora due to nasolacrimal duct (NLD) obstruction; patients who had undergone endoscopic DCR; and patients who had undergone external DCR. The lacrimal sac pressure was measured during blinking, forced blinking and the Valsalva maneuver using a polygraph. Results—Negative pressure was detected during blinking and forced blinking in all normal subjects and in most patients who had successfully undergone DCR. In contrast, positive pressure was detected in cases with epiphora and patients in whom DCR had failed. Negative pressure was higher after endoscopic than external DCR. During the Valsalva maneuver there were no pressure changes in normal cases and patients with epiphora. In contrast, positive pressure was detected after all of the successful procedures (being higher after external than endoscopic DCR) and in most of the patients in whom external DCR failed. Conclusions—In normal subjects, negative pressure is created during blinking. In cases with epiphora due to NLD obstruction, the lacrimal pump is affected but its function is restored after successful DCR. The suction power of the pump mechanism is more effective after endoscopic than external DCR.     

泪囊造影CT在创伤性泪道损伤中的作用

目的：探讨泪囊造影CT在创伤性泪道损伤中的诊断价值，为鼻内镜下泪囊鼻腔吻合术提供指导。方法：对28例创伤性泪道损伤患者行泪囊造影薄层CT扫描，在同步工作站进行容积成像、最大密度投影、曲面重建、三维重建等以显示泪囊的形态、泪囊窝骨折移位情况及泪道阻塞部位，并观察钩突与泪囊窝的关系，测量泪囊窝前上部上颌骨额突与后下部泪骨的厚度，中鼻甲腋分别至泪囊顶、泪囊底之间的距离。结果：泪囊造影CT能显示泪囊的形态、泪囊窝骨折移位情况、泪道阻塞部位以及钩突与泪囊窝的关系，发现泪小管堵塞6例，泪囊阻塞14例，鼻泪管阻塞8例；泪囊窝前上部及后下部骨质的平均厚度分别为（2．96±0．30）mm和（0．02±0．005）mm，中鼻甲腋至泪囊顶、泪囊底之间的距离分别为（6．80±1．50）mm、（4．00±1．80）mm（P〈0．05）。结论：泪囊造影CT结合容积成像、最大密度投影、曲面重建、三维重建等均能清晰显示泪囊形态、泪囊窝骨折移位情况及泪道阻塞部位，分析钩突与泪囊窝的关系，为鼻内镜下泪囊鼻腔吻合术提供临床指导。     

Pediatric endonasal dacryocystorhinostomy: a report of 34 cases

OBJECTIVES: To present experience with the endoscopic dacryocystorhinostomies (EDCR) at the pediatric age. STUDY DESIGN: Case series, clinical study. METHODS: The operative and postoperative data have been collected in 34 pediatric EDCRs (mean age 4.5 years; range 4 months to 13 years). The total of 34 primary and 5 revision procedures have been performed by the same surgeon using a standardized surgical technique. The follow-up evaluations include symptom evaluations and the endoscopic assessment of the newly created ostium with fluorescein testing. RESULTS: The 28 of 34 primary EDCRs (82.3%) were patent after a mean follow-up of 12 to 36 months: 24 of 27 (88.9%) procedures with subsaccal obstructions, 3 of 5 (60.0%) with combined subsaccal and suprasaccal obstructions, and 1 of 2 (50.0%) with suprasaccal obstructions. Intubation was used in 30 primary EDCRs. We found no differences in the success rate between the group with operative intranasal debridement and the group without it in the follow-up period. EDCRs failed in six patients, five of whom were revised endoscopically with success. CONCLUSIONS: EDCRs in children appear to provide a safe and successful procedure with the success rate comparable with those achieved with external DCRs and those in adults.     

Lacrimal fossa block: an audit of a minimally invasive regional anaesthetic technique for endoscopic dacryocystorhinostomy (DCR)

The lacrimal fossa block (LFB), a new development to provide regional anaesthesia for endoscopic dacryocystorhinostomy, is reported. Cadaveric study showed that the block needle, inserted as described, made direct contact with the periosteum of the frontal process of the maxilla within the lacrimal fossa. This technique enables both relevant divisions of the trigeminal nerve to be anaesthetized through a single entry site and, as this injection is confined to the anterior part of the orbit, ocular complications are minimized. An audit of 66 patients has shown that this technique, combined with standard intranasal local anaesthesia, provides good intraoperative analgesia, causes minimal diplopia and has a high level of patient acceptability.     

Endonasal laser dacryocystorhinostomy: its role in anticoagulated patients

OBJECTIVE: To report the results of endoscopic laser-assisted dacryocystorhinostomy in anticoagulated patients. STUDY DESIGN: A retrospective study of 16 consecutive anticoagulated patients with distal nasolacrimal duct obstruction treated by endoscopic laser-assisted dacryocystorhinostomy. METHODS: A case note review was made of all patients treated with endoscopic laser-assisted dacryocystorhinostomy who were taking coumadin in two centers between 1993 and 2000. The parameters of age, gender, indications for surgery, surgical findings, complications, and outcome were analyzed. The mean follow-up time was 14 months (range, 9-26 mo). RESULTS: Fifteen of the 16 patients who were treated had an eventual successful outcome, but 6 patients required revision surgery. The patient whose symptoms were not improved was shown to have functional epiphora. No patient had a problem with primary or secondary epistaxis, and no patient required admission. A major benefit was the lack of disruption of anticoagulant therapy. CONCLUSIONS: Endoscopic laser-assisted dacryocystorhinostomy is a safe, efficient technique for the relief of distal nasolacrimal duct obstruction in anticoagulated patients. Not only does it avoid any disruption to their anticoagulant therapy, but it also can be performed as an outpatient procedure.     

The anatomy of the lacrimal bone at the lateral wall of the nose: its significance to the lacrimal surgeon

The position, dimension and thickness of the exposed lacrimal bone at the lateral nasal wall in 10 cadaveric half-heads were examined. In all cases, the lacrimal bone at the lateral nasal wall was found to be just anterior to the mid-third of the uncinate process. The average length and width was 7.4 mm and 2.5 mm, respectively. In nine of the 10 half-heads, the lacrimal bone was very thin with an average thickness of 57 mm. In all the cases, the position of the lacrimal passage covered by the lacrimal bone corresponded to the postero-medial aspect of the upper lacrimal duct and the lower lacrimal sac. This study shows that the uncinate process is a reliable landmark for the lacrimal bone in endoscopic nasal surgery. The paper-thin lacrimal bone allows a bone rongeur to infracture through and nibble away the bony covering of the lacrimal sac in a dacryocystorhinostomy.     

Eosinophilic fungal rhinosinusitis of the lacrimal sac

OBJECTIVES/HYPOTHESIS: Chronic sinusitis is a condition affecting millions of individuals each year. Recent findings indicate that chronic rhinosinusitis is a response to fungi mediated by the eosinophil in some of these individuals. We report a case of eosinophilic fungal rhinosinusitis of the lacrimal sac, an entity not previously reported. STUDY DESIGN: Case report. METHODS: A 69-year-old man presented with a 1-cm cystic lesion in the right-side medial canthal region. This lesion was fluctuant, and mucoid material was freely expressed from the medial canthal area. Endoscopic examination revealed bilateral nasal polyps anteriorly and superiorly with mucopurulent drainage from both maxillary sinuses. He had undergone three prior sinus surgeries and two prior lacrimal cannulations elsewhere. A computed tomography scan showed opacification of both maxillary sinuses, ethmoid sinuses, and the left sphenoid sinus and moderate thickening in the frontal sinuses. There was significant soft tissue prominence in the area of both lacrimal fossae with erosion into the medial orbit. The patient underwent bilateral endoscopic revision ethmoidectomies, middle meatal antrostomies, sphenoidotomies, frontal sinusotomies, and endoscopic right-side dacryocystorhinostomy at the Department of Otorhinolaryngology, Mayo Clinic (Rochester, MN). RESULTS: At the time of surgery, massive amounts of thick mucoid material were aspirated from both lacrimal regions. The aspiration of the lacrimal duct on the left side was sufficient treatment, whereas the dacryocystorhinostomy was necessary to decompress the cyst of the face on the right side. The material aspirated was allergic mucin, and the patient met the criteria for diagnosing eosinophilic fungal rhinosinusitis. The patient was started on a regimen of antifungal nasal irrigations postoperatively and has done well in follow-up. CONCLUSIONS: Although never previously reported, eosinophilic fungal rhinosinusitis can occur in the lacrimal sac. It is important to recognize this so that the underlying disease process can be treated appropriately.     

Endoscopic dacryocystorhinostomy

The endonasal surgical approach of the lacrymal sac assisted by video-endoscopy is carried out today with high success rates. Despite the satisfactory results reached with the traditional external approach, it has the disadvantage of requiring a skin incision and a consequent local scar. With the development and enhancement of the endonasal techniques, the endoscopic approach is increasingly preferred by surgeons.ObjectiveThis paper reviews the lacrymal system anatomy, the preoperative assessment and the technical details of the endoscopic assisted approach which may provide better surgical outcomes for patients. We will also briefly discuss complications and causes for surgical failure.MethodologyThis is a review of the experience of the authors in the past 10 years of employing the endoscopic technique for the lacrymal sac surgery.ConclusionOutcomes regarding the endoscopic dacryocystorhinostomy are, at leas, equal to those from the traditional external approach. Notwithstanding, the joint work between the otorhinolaryngologist and the ophthalmologist is of great benefit to patients with epiphora.     

复发的外伤性泪囊炎的治疗经验

外伤性泪囊炎指由外伤引起的鼻泪管阻塞伴局部解剖结构改变,组织层次不清和瘢痕形成,致溢泪、流脓。由于组织粘连泪囊往往移位,术中寻找泪囊困难且易出血。传统的泪囊吻合术疗效不佳,复发率高。我们采用鼻内镜鼻腔泪囊吻合术加低温等离子治疗,术中泪道置管,疗效较好,现报告如下。1资料与方法1.1临床资料选取2005-03-2012-05期间因外伤导致的泪囊炎首次手术失败、第2次在我科接受治疗的11例（11眼）泪囊炎患者为研究对象,男8例（8眼）,女3例（3眼）;年龄6~51岁,平均25岁。     

Lacrimal sac diverticulum due to Rhinosporidiosis

Rhinosporidiosis is a disease affecting primarily the mucosa of nose, conjunctiva and urethra. Larynx, trachea, skin and lungs are less frequently involved. It is endemic in some Asiatic regions, affecting people of any age and sex. Its manifestation is a polypoid mass growing inside the affected nasal cavity and the treatment is surgical excision, with adjuvant radiotherapy and chemotherapy. Rhinosporidium seeberi is the aetiological agent. The lesion may recur and sometimes cause osteolytic bone lesions. A case of Rhinosporidiosis with an unusual feature of spread to the nasopharyngeal area and chronicity of 2 years is presented.     

Endoscopic dacryocystorhinostomy with conventional instruments: results and advantages over external dacryocystorhinostomy

Background  The aim of study is to evaluate the Endoscopic dacryocystorhinostomy (DCR) with conventional instruments, its results and advantage over external dacryocystorhinostomy (DCR). Methods  The study group comprised of 127 patients who underwent consecutive endoscopic dacryocystorhinostomy. The cases operated by one team were included in the study to make the uniform analysis and its result. There were 48 males and 79 female in this study and male female ratio was 1:1.6. The mean age of the patient was 37 years (range from 16 years to 58 years). There were wide variety of cases like epiphora, lacrimal sac abscess, lacrimal sac fistula, acute dacryocystitis and road vehicular accident. All the patients had undergone non-laser, non-powered conventional instruments surgery under local anesthesia. The lighted probe was not used in any case for sac identification. The free flow of saline through newly created stoma during sac syringing was considered as successful criteria. The stent was used in two cases of road vehicular accident and in remaining 125 cases no stent was used. There were 66 cases of epiphora, 30 cases of lacrimal sac abscess, 26 cases of acute dacryocystitis, 3 cases of lacrimal fistula and 2 case of road traffic accident with multiple fractures. The average follow up period was 17 months (maximum follow up 3 years and minimum 4 months.) Results  The success rate was 96 %. Conclusion  The endoscopic DCR with conventional instruments is safe with very high success rate without any complications. It can be done in acute cases and very much suited for lacrimal sac abscess and lacrimal sac fistula.     

Otologic T-tube in endonasal dacryocystorhinostomy: a new approach

Conclusion. Otologic T-tubes had a success rate of 73% if implanted during endoscopic dacryocystorhinostomy (DCR). We suggest that they can be used successfully in endoscopic DCR, and are promising as an alternative to silicone stent intubations. Objective. To evaluate the efficacy of endoscopic DCR using otologic T-tube. Materials and methods. Twenty patients (22 eyes) with nasolacrimal duct obstruction underwent endoscopic DCR. After creating an aperture in the medial wall of the lacrimal sac, the otologic T-tube (1.15 mm diameter, Invotec, Jacksonville, FL, USA) was inserted into the sac transnasally. The T-tube was left in the lacrimal sac for between 3 and 6 months. The patients were followed up for between 6 and 24 months (mean 12.4 months). The improvement in patients’ epiphora complaint was grouped as very good, good, or no change. Results. Eleven eyes (50%) proved to be ‘very good’, whereas five eyes (23%) were good, and six eyes (27%) had no change. Of six eyes that were reported to have no change after the operation, three experienced spontaneous tube loss in the early period, one eye was a recurrent case, and the other two were primary cases.     

External and endoscopic dacryocystorhinostomy in chronic dacryocystitis: comparison of results

To compare external and endoscopic dacryocystorhinostomy outcomes in patients with chronic dacryocystitis, a total of 103 patients with the complaint of epiphora and diagnosed as chronic dacryocystitis were included in the study. We performed external dacryocystorhinostomy on 55 patients under local anesthesia and endoscopic dacryocystorhinostomy on 48 patients under general anesthesia by means of drill and placed silicon stents to all the patients. The patients were examined endoscopically, at postoperative intervals of 1 week, first month, third month, sixth month and the first year. The patency of the tubes and nasolacrimal ducts were evaluated by irrigation and complaints of the patients were noted. Silicon stents were harvested at the sixth week postoperatively. Outcomes were classified as successful when epiphora diminished, no recurrent infection was noted and minimal or no reflux from the canaliculis during or after lacrimal irrigation was seen. A prospective endoscopic surgery group was compared to a prospective control group (external dacryocystorhinostomy). Full success was achieved in 69.9% of the patients with external dacryocystorhinostomy group whereas the full success rate of endoscopic dacryocystorhinostomy was 89.7%. Recently popularized endoscopic dacryocystorhinostomy is a safe and reliable procedure with high success rates.     

Adenocarcinoma ex-pleomorphic adenoma of the lacrimal sac and nasolacrimal duct: a case report

OBJECTIVES: To present the clinical presentation, workup, surgical approach, and pathological findings of the first case report of a patient with adenocarcinoma ex-pleomorphic adenoma of the lacrimal sac and nasolacrimal duct. STUDY DESIGN: Retrospective review of the records of a case of adenocarcinoma ex-pleomorphic adenoma of the lacrimal sac and nasolacrimal duct. METHODS: The clinical presentation, workup, surgical approach, and pathological findings were reviewed. RESULTS: A 51-year-old man presented with a 10-year history of recurrent epiphora of the right eye. At dacryocystorhinostomy a small lesion was visualized within the lumen of the lacrimal sac. A biopsy specimen was consistent with adenocarcinoma. En bloc resection was accomplished using a lateral rhinotomy and medial maxillectomy. The final specimen showed adenocarcinoma ex-pleomorphic adenoma. The patient was given postoperative radiation therapy. He was free of disease 16 months after treatment. CONCLUSIONS: Lacrimal sac tumors should be considered in the differential diagnosis of chronic epiphora. Management of nasolacrimal adenocarcinoma requires complete surgical resection. Radiation treatment in and of itself is not curative but may be useful as adjuvant therapy. Carcinoma ex-pleomorphic adenoma can develop in the lacrimal sac and nasolacrimal duct.     

Endonasal dacryocystorhinostomy: a prospective study

Objective  The objectives of this study are to report the results of Endonasal Dacryocystorhinostomy (EnDCR) and the role of silicon intubation in EnDCR in Indian population. Study design  The authors conducted a prospective case series. Methods  290 patients underwent EnDCR between January 2002 and July 2007 — 240 cases without silicon intubation and 50 cases with silicon intubation. Patients were followed up for an average of 18.6 months in first group and 5.2 months in second group. Outcome was evaluated subjectively and objectively. Results  In EnDCR without silicon intubation, the procedure was successful in 93.3% of cases. In EnDCR with silicon intubation, the procedure was successful in 96% of cases. Conclusion  EnDCR is a safe procedure with good success rate and has potential advantages in chronic dacryocystitis cases. The use of silicon intubation in nasolacrimal pathway helps in maintaining the patency of rhinostomy.     

A new approach to endoscopic DCR

AimTo compare a composite technique of Endoscopic Dacrocystorhinostomy with the conventional technique.MethodsA randomised prospective study was carried in the department of Otolaryngology Maulana Azad Medical College. Thirty patient selected for Endoscopic DCR were divided into two groups, one of which underwent conventional Endoscopic DCR and the other group were treated with a newer technique using cautery, cold instrumentation and laser at different steps of Endoscopic DCR. The patients were followed up for Nine months.Results/ConclusionBy using cautery, cold instrumentation and laser at different steps of Endoscopic DCR we were able to achieve a success rate of around 94% with this composite technique as compared to 83.3% in conventional Endoscopic DCR surgery.     

Endoscopic dacryocystorhinostomy vs KTP 532 laser-assisted endoscopic dacryocystorhinostomy

Objectives  Advances in endoscopy and lasers have improved surgical management of chronic nasolacrimal duct obstruction. This is a preliminary comparison between standard and laser assisted endoscopic dacryocystorhinostomy (DCR). Study Design  Combined retrospective and prospective study. Setting  Tertiary referral hospital. Patients and Methods  Thirty-eight cases of chronic nasolacrimal duct obstruction underwent endoscopic DCR (26 standard and 12, laser-assisted) and were assessed at 3 and at 6 months postoperatively by nasal endoscopy. Results  Three months postoperatively (n=38), total relief of epiphora among the nonlaser group was 80.76 vs 75% in the laser group (P=0.982). At 6 months (n=19), the laser group had recorded 100% symptomatic relief compared to 85.71% in the nonlaser group (P=0.964). The laser group suffered fewer complications (33.33 vs 46.15% for nonlaser group). Conclusion  Lasers show promise in long-term management of duct obstruction and are associated with fewer complications. A larger study is required before and generalization is made.