Endonasal carbon-dioxide laser assisted dacryocystorhinostomy verses external dacryocystorhinostomy

This is a prospective, non-randomized study to evaluate and compare the results, morbidity and surgical time for endonasal carbon-dioxide laser assisted dacryocystorhinostomy and external dacryocystorhinostomy. 70 consecutive patients of chronic dacryocystitis with nasolacrimal duct obstruction were selected for the study. 36 patients under went endonasal CO2 laser assisted dacryocystorhinostomy and 34 had external dacryocystorhinostomy. Selection of the type of operation was left to the patient's choice. All the patients had preoperative counseling and both the procedures were explained in detail with their advantages and disadvantages. Patients not willing for the external incision were selected for endonasal laser assisted dacryocystorhinostomy and others were operated via external approach. Silicone tubes were put in all the patients for three months after surgery. The final follow up was 12 months after the removal of silicone tubes. The patency of the lacrimal passage was confirmed by irrigation, and patients were questioned about their symptoms. The success rates, 12 months after removal of silicone tubes were 100% in endonasal CO2 laser assisted dacryocystorhinostomy and 88.24% in external dacryocystorhinostomy. The surgical time of endonasal laser assisted dacryocystorhinostomy was 38 minutes as compared to 62 in external dacryocystorhinostomy. Complication rate in both groups was almost equal. Thus, we came to the conclusion that Endonasal CO2 laser assisted dacryocystorhinostomy is a better surgical option to external dacryocystorhinostomy in cases of chronic dacryocystitis with nasolacrimal duct obstruction, with shorter surgical time.     

Management of Traumatic Dacryocystitis and Failed Dacryocystorhinostomy Using Silicone Lacrimal Intubation Set

The aim of this work is to study the management and success rate of traumatic dacryocystitis and failed dacryocystorhinostomy (DCR) using Silicone lacrimal intubation set. A prospective study was conducted at a tertiary eye care hospital, India from February 2006 to January 2008. This study material comprised 50 patients of traumatic dacryocystitis and failed dacryocystorhinostomy. Anterior single flap external dacryocystorhinostomy with Silicon intubation was performed in all the patients. The patients were followed up at weekly intervals for 1 month and thereafter every 2 months for 1 year post operatively. Criteria determining success were based on resolution of epiphora and patency on syringing. In traumatic dacryocystitis, 21(91.3%) cases fulfilled these criteria while 23(85.2%) cases of failed DCR were successful. The overall success rate (88%) was determined with an average follow-up of 1 year. Globally, the technique was effective in 85% of cases. The results were comparable with other similar studies. This study concludes that performing a DCR in traumatic dacryocystitis and failed DCR taking into consideration the complications and chances of failure is a challenge for the surgeon. We opine that External dacryocystorhinostomy with Silicon Intubation is one of the most effective modality in dealing with such cases.     

Conventional dacryocystorhinostomy versus endonasal dacryocystorhinostomy-a comparative study

The objective of present study was to compare the results of endonasal endoscopic dacryocystorhinostomy and external dacryocystorhinostomy. It was a prospective non-randomized study. Forty consecutive patients having complaints of watering with complete naso lacrimal duct obstruction were selected for the study. Dacryocystography was done in all the cases. Selection of type of operation was left to the patient’s choice. All patients had preoperative counseling and both the procedures were explained in detail with their advantages and disadvantages. Twenty patients underwent endonasal dacryocystorhinostomy and twenty had external dacryocystorhinostomy. Silicon intubation was done in all cases of endonasal dacryocystorhinostomy for three months after surgery. The final follow-up was done at 12 months after surgery. The patency of lacrimal passage was confirmed by syringing and patients were questioned about their symptoms. There was no significant difference in the results of both surgeries. The complication rate in both groups was almost equal. Thus we came to the conclusion that these two different dacryocystorhinostomy techniques are acceptable alternatives.     

Powered Endoscopic Endonasal Dacryocystorhinostomy with Mucosal Flaps and Trimming of Anterior End of Middle Turbinate

Endoscopic endonasal dacryocystorhinostomy (DCR), when compared to external techniques, has always had guarded acceptance primarily due to inconsistent success rates. The most common cause of surgical failure in endoscopic DCR is very high/very low mucosal incision, obstruction of neo-ostium by granulation tissue, infolding of flap or formation of synechiae between middle turbinate and the neo-ostium site post-operatively. Several techniques and modifications have been suggested by various authors over the years since the first introduction of endoscopic endonasal DCR. With the newer techniques and advancements, the success rates have become comparable or even higher than external DCR. The aim of our study was to determine the success of endoscopic endonasal DCR using the classical Wormald technique with a few modifications. A total of 37 cases of epiphora secondary to nasolacrimal duct obstruction were operated using endoscopic endonasal DCR technique. The surgical technique included classical Wormald principle of mucosal flap, removal of the overlying bone using Kerrisons punch & chisel-hammer followed by vertical incision on the sac. The medial wall of lacrimal sac was then trimmed using microdebrider, thus apposing it to the nasal mucosal flaps. The anterior end of middle turbinate was also trimmed prophylactically to prevent synechiae formation. The outcome and long term patency of the cases were evaluated. Of the 37 cases, 35 cases (94.6 %) had complete resolution of the epiphora at the end of 1 year follow up period. The two cases of failure were due to canaliculitis in one patient and extensive granulation around the neo-ostium in another. Thus the above method has very good success rate comparable to previous studies and very less chances of granulation tissue formation and blockage of neo-ostium by synechiae/flap infolding.     

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.     

Analysis of 104 Cases of Endonasal Dacryocystorhinostomy in a Tertiary Care Hospital: A Prospective Study

To evaluate the results of endoscopic endonasal dacryocystorhinostomy performed in a tertiary care hospital. Prospective, nonrandomized, interventional clinical study. A prospective interventional study was performed on 104 patients presenting with epiphora between January 2006 and January 2010. All patients were operated by one surgeon. Out of 104 cases, 08 cases were of revision endonasal dacryocystorhinostomy (DCR). Bicanalicular silicon intubation was performed in all cases of revision endonasal DCR. Twelve patients had concomitant sinonasal disease for which septoplasty or FESS was done. The patency of nasolacrimal duct was assessed by doing syringing of lacrimal passage weekly for 1 month, monthly for 3 month, then at 6 month and 1 year. Out of 104 patients 10 patients lost follow up after surgery. Ninety four patients were followed for 1 year. On syringing, rhinostomy site was found patent in 80 patients (85.10 %), therefore they were fully satisfied. In 6 cases (6.38 %) minimal block was seen with clear fluid regurgitation, were to some extent symptomatically relieved and were found to be satisfied, whereas in 08 cases (8.51 %) syringing showed complete block. They required further management. Success rate of our study is comparable to other studies on endonasal DCR as well as external DCR, with advantages of less intra-operative bleeding, shorter operative time, better cosmesis, preservation of lacrimal pump mechanism. Other nasal pathology can be treated at the same time. Our results are clinically as well as statistically highly significant (P value < 0.0001).     

Polypropylene in Endoscopic Dacryocystorhinostomy: A Novel Stent

Endoscopic dacryocystorhinostomy (DCR) is usually done in cases of lacrimal apparatus obstruction. The common causes of failure are that of obstruction in the common canaliculus and closure of the rhinostomy site. To overcome these problems we use stents. Stents most commonly used are that of silicon which are expensive and not readily available. As an alternative, polypropylene (Prolene; Ethicon) is used as a stent which is cheaper and readily available. This study is done to evaluate the clinical efficacy and results of stenting with polypropylene suture material in endoscopic dacryocystorhinostomy. Fifty one endoscopic DCR operations were performed between July 2013 to December 2014. After creating an aperture in the medial wall of the lacrimal sac, 3/0 prolene was inserted from lower punctum to neo ostium. The prolene was left in the lacrimal sac for 3 weeks. The patients were followed up for 3 months. In our study, most of the patients belonged to the age group of 41–60 years (47%). There was female preponderance as 64.7% were females. 47 patients (92.2%) showed very good results. Two patients (3.9%) developed granuloma for which revision surgery was done. We lost 2 patients during follow up. This modification enables an easy, safe, effective and low-cost form of DCR. Prolene is cheaper and readily available. It might be used successfully in endoscopic dacryocystorhinostomy and is promising alternative to silicone stent intubations, especially in settings with limited resources.     

A 7-year prospective study of routine histopathological evaluation of the lacrimal sac wall incisional biopsy specimens obtained during external dacryocystorhinostomy in adults and a review of the literature

The most common lacrimal sac pathology is chronic inflammation with or without occlusive fibrosis. However, a substantial number of lacrimal sac-specific pathologies were reported throughout the literature which may mimic chronic inflammation and be misdiagnosed. From a tertiary ophthalmic care centre in Serbia, in a single ophthalmic pathology laboratory, during a 7-year period (January 2004 to October 2010), a 599 consecutive lacrimal sac wall biopsy samples routinely obtained during external dacryocystorhinostomy in adult patients with clinically presumed primary acquired lacrimal drainage system obstruction were analysed. Although non-specific lacrimal sac pathology was present in the vast majority of cases (578 biopsy specimens; 96.49%), this report also reveals a relatively substantial number (21 biopsy specimens; 3.51%) of clinically non-suspected or intraoperatively unexpected primary lacrimal sac-specific pathology—among them, six lesions with malignant biological behaviour were identified: one microinvasive squamous cell carcinoma and five malignant lymhoproliferative lesions. Usefulness of routine lacrimal sac wall biopsy during surgery for primary acquired lacrimal drainage system obstruction is undoubtful and commensurate with the constant need for better understanding of the pathological processes that involve lacrimal drainage system.     

Endoscopic DCR: How To Improve The Results

Since Toti described the initial dacryocystorhinostomy (DCR) operation in 1904 many technical modifications have evolved (Becker in Ophthalmic Surg 19:419–427, 1988). Overall, three groups of procedures are currently practised; external DCR, endoscopic DCR with contact laser, and surgical endoscopic DCR without laser (Woog et al. in Am J Ophthalmol 116:1–10, 1993; Jokinen and Karja in Arch Otolaryngol 100:41–44, 1974. Many factors influence the outcome of these different approaches. The purpose of this study was to improve the long term surgical outcome in endonasal DCR. A retrospective analysis of more than 1,500 patients, who underwent primary endoscopic DCR, was done and specific small modifications were identified and applied in the next 108 cases showing an improvement in the results.     

Double Posterior Based Flap Technique in Primary Endoscopic Dacryocystorhinostomy With and Without Using Powered Instrument

To demonstrate the surgical technique and outcomes of double posterior based flap technique in primary endoscopic dacryocystorhinostomy (DCR) with and without use of powered instrument. 28 patients of nasolacrimal duct obstruction were included in the study from September 2012 to February 2015. All underwent endoscopic dacryocystorhinostomy with double posterior based nasal and lacrimal flap technique. In patients of group A (14 patients), bone removal was done with the help of Smith–Kerrison punch forceps and in patients of group B (14 patients), powered drill has been used for the same. Patients were visited the endoscopic clinic at 1, 3, 6 months and 1 year after the surgery for post operative evaluation. Of 28 patients, 26(92.85%) were found free of symptoms at the end of 1, 3 and at 6 months. One from each group had recurrence of symptoms. At the end of 12 months of 25 patients, 3(12%) patients were found to have recurrence of symptoms of which 1(8.33%) patients was from group A and 2(15.38%) were from group B and failures were because of granulation tissue and stomal stenosis. Patients assisted with powered drill had more postoperative complications compared to cold instrument. Double posterior based flap technique in primary endoscopic DCR without the assistance of powered drill could be an effective surgical option for the patients of chronic nasolacrimal duct obstruction enabling early epithelisation by preventing peristomal granulation tissue resulting in encouraging surgical outcome with least postoperative complication.     

Rhiinosporidiosis — unusual presentations

Rhinosporidiosis is an infection caused by Rhinosporidium seeberi that frequently presents as polypoidal nasal lesions. Here, we report two cases of rhinosporidiosis with unusual presentations. The first case presented in our department with chronic dacryocystitis of left side for endoscopic dacryocystorhinostomy (endoscopic DCR) operation. The second case presented as a long hanging mass arising from the right side of nasal septum. The diagnosis was established on the morphological basis by the identification of endospores and sporangia. The clinicopathological and immunologic features were discussed and the literature was reviewed.     

胫骨严重性大段骨缺损的治疗体会

目的 探讨胫骨严重感染合并大块骨缺损有效治疗方法。方法 总结1992—2003年38例胫骨严重感染性大段骨缺损的治疗方法。所有病例均采用病灶彻底清除，半环槽式或环开槽式外固定器加压固定骨断端，同期或一期行干骺小切口截骨延长术，在骨断端加压固定的同时或骨不连愈合后，重建肢体长度。结果 38例胫骨严重感染合并大块骨缺损与骨不连伤口感染得到有效控制，最终均达到骨性愈合。骨愈合时间3—8个月，平均4、9个月，拆除外固定架时间3—10个月，平均5．8个月。25例同期、13例二期重建了肢体长度，达到了肢体长度均衡，平均延长4．2cm，愈合指数36d／cm。结论采用改进外固定器技术治疗严重感染合并大块骨缺损与骨不连，能有效促进感染与骨缺损的愈合，同期或二期干骺端小切口截骨延长有效重建了肢体长度，达到肢体长度的均衡。     

Intracavitary irradiation of endometrial carcinoma using a high-intensity 60Co afterloading method

Intracavitary irradiation of endometrial carcinoma with an afterloading technique, employing Cathetron equipment, was used preoperatively and in patients with inoperable disease as a single therapy or together with external pelvic irradiation. In clinical stages I and II, the survival rates of patients treated preoperatively with afterloading techniques and with the manual Heyman method were quite similar, and the radiation induced complications were less frequent with the afterloading technique. In cases with a large uterine cavity, the one-source tandem method was replaced with a specific two-phase intracavitary irradiation technique. In this method the treatment catheter was positioned against one lateral uterine wall in the first phase, and against the opposite lateral uterine wall in the second phase of irradiation. In experimental studies the shape of the dose distribution curves resembled the uterine shape, and the measured doses were quite similar to those calculated from the radiograms. The treatment results of 32 patients irradiated by this method confirmed its clinical usefulness. Our results show that the afterloading technique is a practical alternative to the manual packing method in the preoperative irradiation of endometrial cancer. With specific instrument modifications the new technique is also useful in cases with a large uterine cavity, whereas the details in the treatment strategies using remote intracavitary irradiation alone or in combination with external radiotherapy need further development.     

Intracavitary radiation treatment of nasopharyngeal carcinoma by the high dose rate afterloading technique

Sixty-four patients with nasopharyngeal carcinoma were treated by various combinations of external irradiation with intracavitary radiotherapy using the high dose rate afterloading technique. The afterloading intracavitary radiation (AIR) was given as a routine boost or for residual or recurrent disease. The external irradiation dose varied from 45 to 70 Gy, whereas the AIR dose ranged from 10-50 Gy, depending on the nature of the primary nasopharyngeal lesion. The results were quite encouraging, although the longest follow-up so far has only been just over 4 years. Of 13 such cases that received external radiotherapy plus AIR as primary treatment, 12 have survived. However, of the 9 cases who received AIR for local recurrence after external radiotherapy, only 5 survived. Of the total of 64 cases treated by AIR from June 1981 to May 1986, 54 are alive. No serious radiation sequelae have been observed. It can be concluded that AIR for nasopharyngeal carcinoma is indicated for boosting the dose to the nasopharyngeal cavity with appropriate reduction in external irradiation dose, and for residual or recurrent disease after primary external radiotherapy.     

Brachytherapy for head and neck cancers (nasopharynx excluded)

Brachytherapy is one of the standard treatments of head and neck cancers. The main indications are: the oral cavity, the oropharynx, the lips, the peri-orificial skin carcinomas on the face, the postoperative treatments for T1-2/N0 cancers of the oral cavity with close or positive margins, the second cancers in previously irradiated areas, the intra-operative brachytherapy for recurrent cervical lymph node metastases from previously irradiated tissues after maximal surgical debulking. The major prognostic factors published allowed to improve the technique: using a leaded protection of the mandible, the intersource spacing (1,2-1,4 cm), the volume treated (30 cm3, i.e. three loops), the safety margin (5 mm), the dose rate (0,5 Gy/h), the total dose (65 Gy in case of exclusive brachytherapy, 25 Gy in case of a combination of external beam irradiation [50 Gy] and brachytherapy in the oropharyngeal carcinomas, 35 Gy in case of a combination of external beam irradiation [40 Gy] and brachytherapy in the oral cavity carcinomas, 60 Gy in case of a second cancer in previous irradiated tissues), the delay between external irradiation and brachytherapy (< 20 days). The pulse dose rate brachytherapy should improve results with the control of the dose rate and the optimization of the dose distribution. For high dose rate brachytherapy, more results are needed to recommend this technique for routine use.     

早中期鼻咽癌外照射联合腔内放疗长期疗效的前瞻性研究

[目的]探讨Ⅰ、Ⅱ期鼻咽癌患者采用单纯外照射放疗与外照射加腔内联合放疗的长期疗效。[方法]前瞻性研究453例Ⅰ、Ⅱ期鼻咽癌患者,随机分为单纯外照射组297例,联合照射组156例;单纯外照射组采用低熔点铅挡块不规则野照射,常规照射,常规分割,总剂量为66～74Gy;联合照射组采用同样的外照射方法,总剂量给予58～62Gy,并给予15～20Gy腔内近距离放疗。[结果]单纯外照射组和联合照射组的5年鼻咽局控率分别为Ⅰ期92.86%、96.43%（P=0.35）,Ⅱ期89.02%、94.53%（P=0.01）;5年总生存率分别为Ⅰ期88.10%、92.86%（P=0.27）,Ⅱ期81.18%、90.63%（P=0.03）。口干和张口困难的毒副反应联合照射组比单纯外照射组轻。[结论]Ⅰ、Ⅱ期鼻咽癌患者采用常规外照射联合腔内放疗相对单纯常规放疗有较好的疗效,并可减轻毒副反应。     

Endobronchial brachytherapy: a preliminary experience.

Fourteen patients with malignant airway obstruction were treated with a placement of a flexible nylon catheter for low dose rate manual afterloading Iridium 192 endobronchial brachytherapy using a flexible fibreoptic bronchoscope. Eight patients had obstructive pneumonitis at initial presentation, while 6 cases were recurrences after previous external irradiation. Six evaluable patients of the former group had complete or partial reinflation of lung and were followed by external radiotherapy. Of the latter group, 3 were evaluable and had moderate to good palliation of their symptoms. No complication was observed. The technique is simple and safe with good patient compliance. Further evaluation is indicated to assess its role in the locoregional management of lung cancer.     

Treatment of bladder tumors by iridium 192 implantation. The Créteil technique

The technique and results of a treatment protocol for bladder cancer combining low dose pre-operative external beam irradiation followed by external iliac nodal dissection, limited partial cystectomy and curietherapy with iridium 192 are described. In 55 patients treated from 1971 to 1979, 37/45 (67%) are alive NED at 5 years--23/31 pT1, 10/14 pT2, 4/10 pT3--with 9/55 bladder recurrences at 5 years--7/31 pT1, 1/14 pT2, 1/10 pT3. Only two patients (total cystectomy) have not retained a functional bladder. These favorable results have been obtained in a carefully selected population; our indications for the technique being T1, T2, T3a tumors with a total surface area not exceeding 5 cm, not involving the bladder neck and unifocal or in some cases plurifocal, but closely grouped. The advantages and precise details of each stage of the technique will be described and compared with large series in which radium 226 is utilized and results of curietherapy will be compared with other modalities of treatment employed under similar circumstances for similar patient groups. We feel that curietherapy has certain advantages over other methods in the treatment of bladder cancer and that an afterloading technique employing iridium 192 wires permits the curietherapy to proceed under optimal conditions, allowing combination with partial cystectomy, optimal placement of sources, precise radiographic control and dosimetry, dose reduction in many cases, optimal conditions of radioprotection and widening of the indications for the technique.     

Experience in the treatment of carcinoma of the cervix using a rotational technique

The radiation technique described is an unconventional method of treatment for carcinoma cervix patients and is essentially external beam therapy alone, using a ⁶⁰Cobalt rotation plan. This is in contrast to the more conventional series of 2 or 3 intracavitary radium insertions, either preceded and/or followed by fixed field external beam therapy. An advantage to the patient from this treatment scheme is the avoidance of the trauma associated with the repeated anaesthetics required for uterine and vaginal radium applications. Dosage levels have also been determined to ensure minimal post-radiation complications, and the 5- and 10-year survival rates for stage II and stage III cases are comparable with the survival results published by other centres. The series was treated during 1957-64 and consisted of all stage II and III cases referred to the Westminster Radiotherapy Department during this period, together with 13 stage I cases which were considered to be poor anaesthetic risks, and 4 stage IV cases. The 5- and 10-year survival rates for 69 stage II cases were 44% and 36% respectively, and for 81 stage III cases were 38% and 23% respectively.     

关节镜下缝线桥技术与双排技术治疗肩袖撕裂的Meta分析

目的 通过Meta分析评估关节镜下缝线桥(suture bridge,SB)技术与双排(double-row,DR)技术治疗肩袖撕裂的临床疗效.方法 系统检索PubMed、Embase、Web of Science、Cochrane Library、中国知网、维普和万方数据库,搜集关于关节镜下SB与DR治疗肩袖撕裂的对...