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.     

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.     

Endoscopic “retrograde” dacryocystorhinostomy: A fast route to the lacrimal sac

Endoscopic Dacryocystorhinostomy (DCR) is an established surgical technique for the management of peripheral nasolacrimal duct (NLD) obstruction. Its main points are the correct identification of the lacrimal sac and the execution of surgical procedures that allow a rapid and accurate healing of the surgical field. The main endoscopic landmarks used for the identification of the lacrimal sac are the middle turbinate and the maxillary line.However, in some cases, this procedure can be difficult due to several factors (e.g. anatomical variations, former surgery).In the present study, a variation of “classic” endoscopic DCR, named “retrograde” endoscopic endonasal DCR (rDCR), is described. rDCR is performed through the quick identification of the NLD at the level of the most anterior insertion of the inferior turbinate in the lateral nasal wall. In most cases, at this level only a very thin shell of bone is present (crack point), easily fractured by using blunt angled dissector. The duct is then followed upward along its course by removing the overlying bone in order to correctly identify the lacrimal sac and unequivocally drill along the lacrimal pathway. This technique proved to be a safe, quick and effective procedure, even in patients with difficult anatomy.     

泪囊鼻腔吻合术中泪骨的定位测量

目的:探讨泪骨在泪囊鼻腔吻合术中的重要意义。方法:测量10具(男5具,女5具)成人尸头鼻腔外侧壁上泪骨的长、宽、厚,观察钩突、上颌线和M点(上颌线的中点)的解剖位置。结果:泪骨在鼻腔外侧壁位于钩突的前方,骨质菲薄,所测量的长、宽、厚的平均值分别为9.23、3.63和0.06 mm。结论:使用咬钳可以咬除泪骨,进一步开放泪囊内壁骨质,同时避免使用电钻,减小创伤。钩突、上颌线及M点可作为术中可靠的定位标志。     

鼻内鼻窦手术损伤泪道的解剖学分析

为了减少或避免易内鼻窦手术损伤泥道，在20具成人尸头标本上，观测泪道与鼻腔外侧壁的毗邻关系。发现前筛气房与泪囊窝关系密切，气房侵及泪骨占87．5％；鼻泪管与钩突上端游离线之间距离为6.74±1．72mm，距离筛漏斗前界3．44±0．75mm，距上颌窦鼻内开口为5．50±3．73mm。鼻泪管开四位于下鼻道前端鼻甲附着处。研究表明，前筛房、钩突切除和上颌窦鼻内开窗手术范围，如果过于向前，容易损伤泪道。     

Die Technik der Tränensackoperation nach Falk bei saecalen und präsaccalen Stenosen

Summary The lacrimal sac as saccular structure is totally sacrificed in the extranasal dacryocytorhinostomy introduced by Falk. The sac is opened over its total extent and implanted in toto in to the lateral nasal wall. This procedure proved to be successful in almost all kinds of lacrimal duct stenoses in our clinic (for example following fractures of maxilla and nasal skeleton as well as after unsuccessful previous operations according to one of the conventional methods). Indication for this operation is now being extended also to such cases where there is an obliteration of lacrimal ductules or where the lacrimal sac is obliterated. In this case following a typical lacrimal sac operation the stenosis is revised, a thin venous catheter is introduced via the lacrimal point into the inferior lacrimal duct and drained into the nose. The catheter is removed after an average of some 6 weeks.     

Outcomes of posterior lacrimal sac approach in endoscopic dacryocystorhinostomy: review of 35 cases

BACKGROUND: The purpose of this study was to describe the posterior lacrimal sac approach in endoscopic dacryocystorhinostomy (DCR) performed at our institute and report perioperative results achieved with this procedure. METHODS: A prospective clinical study was performed of 35 adult patients with nasolacrimal duct obstruction who underwent posterior lacrimal sac approach DCR from March 1998 to May 2005. Follow-up period ranged from 13 to 30 months (average, 17.5 months; SD, 6.8 months). "Surgical success" was defined as complete relief of epiphora and patent surgical ostium on endoscopic assessment. RESULTS: Surgical success was achieved in 30/35 (85.7%) patients after the primary surgery. Of 5 unsuccessful patients who complained of occasional epiphora, 4 patients had formed stenosis and 1 patient had granulation around the surgical opening, and all had revision surgery. Four of 5 (80.0%) patients achieved surgical success. Thus, including the result of revision surgery, 34/35 (97.1%) patients were successful. CONCLUSION: Posterior lacrimal sac approach in endoscopic DCR has several advantages: good sac accessibility, a low complication rate, and a relatively high success rate. Therefore, the posterior lacrimal sac approach appears to offer a useful alternative approach for the surgical treatment of nasolacrimal duct obstruction.     

No thermal tool using methods in endoscopic dacryocystorhinostomy: no cautery, no drill, no illuminator, no more tears

The purpose of this study was to evaluate the surgical outcome of the endoscopic dacryocystorhinostomy (DCR) without thermal tools such as cautery, drill and illuminator. The study is a retrospective analysis of patients in a tertiary care unit for oculoplastic surgery. The participants enrolled into the study are a retrospective series of 127 consecutive endonasal DCRs performed between January 2008 and March 2011. The surgical procedure in this conventional endoscopic transnasal DCR involved a manual osteotomy of the frontal process of the maxilla and removal of the lacrimal bone by punch without illuminator, cauterization and drill. We evaluated the result of the manual Endo-DCR technique without cauterization or drilling-assisted technique. Data of 127 eyes were reviewed. Full success was achieved in 90.5 % (115/127) of manual Endo-DCR technique with an average follow-up period of 6 months. Our study appears to show favorable results compared to other previously published outcomes including Endo-DCR surgery with thermal equipments. No thermal tool methods in endonasal DCR can achieve a good surgical success rate. Therefore, the newest tools, cauterization, drilling or illumination, are generally not necessary for endoscopic dacrycystorhinostomy.     

Powered endoscopic dacryocystorhinostomy with radiowave instruments: surgical outcome according to obstruction level

Endoscopic endonasal dacryocystorhinostomy (EDCR) is an accepted alternative to external dacryocystorhinostomy (DCR) for relieving obstruction of the lacrimal drainage system. Powered and radiowave instruments are useful for the control of bleeding and for wide exposure of the lacrimal sac and canaliculus. In this study, we evaluated the surgical outcome of powered EDCR with radiowave instruments at five obstruction levels: (1) upper and/or lower canaliculi (obstruction was located less than 8 mm from puncta); (2) common canaliculus (obstruction was less than 10 mm from puncta); (3) lacrimal sac; (4) duct-sac junction; and (5) nasolacrimal duct. The overall success rate was 93.6 % (104/111), with 60.0 % (3/5) success for upper and lower canalicular stenosis, 85.0 % (17/20) for common canalicular stenosis, 92.0 % (23/25) for obstruction at the lacrimal sac, 100 % (41/41) for obstruction at the duct-sac junction, and 100 % (20/20) for nasolacrimal duct obstruction. EDCR resulted in a good overall surgical outcome for any obstruction of the lacrimal drainage pathway compared with external DCR. Powered EDCR using radiowave instruments is useful for not only obstruction of the lacrimal sac and duct-sac junction, but also for that of the upper/lower and common canaliculi.     

Endoscopic dacryocystorhinostomy in patients with postsaccal stenosis of lacrimal duct

Dynamic development of the endoscopic treatment of the lacrimal duct obstruction has been observed for the last 20 years. Various causes of the tear outflow disorders, different levels of lacrlmal duct blockage may require different surgical approach and sometimes additional modern equipment. THE AIM of the study was to present the results of treatment of possibly uniform group of patients with lacrimal duct obstruction in whom the same method of endoscopic surgery was applied. Material and method: 16 patients with postsuccal level of obstruction were qualified for the study. All of them were treated endoscopically with mucosal flap formation. Patients in whom synechiae in the upper part of the sac or at the orifice of common canalicullus were found during the procedure were excluded from the study, as well as the patients with Wagener's granulomatosis and posttraumatic form of lacrimal obstruction. RESULTS: Release of epiphora and proper patency of lacrimal system corroborated by irrigation test was achieved in 14 (87,5%) patients of the studied group. In 2 (12,5%) patients recurrence of symptoms was observed. In both cases too small osteotomy and lack of surgical technique precision were the cause of failure. No major complications in the studied group were observed. CONCLUSIONS: Endoscopic dcryocystorhinostomy Is low traumatic and effective procedure of surgical treatment of lacrimal duct obstruction. The success is determined by high precision of surgical technique.     

Modified Lynch procedure for chronic frontal sinus diseases: rationale, technique, and long-term results

The modified Lynch operation (Neel-Lake) differs in several ways from the operation described by Lynch. The operation begins with an intranasal anterior ethmoidectomy. The agger nasi cells are removed by curetting forward between the frontal process of the maxilla and the septum. The middle turbinate, normal-appearing mucosa of the frontal-ethmoid complex, and frontal process of the superior maxilla are preserved. Bone removal is limited in most cases to the anterior floor of the frontal sinus, a portion of the lacrimal bone, and the bone over the anterior ethmoid cells. Another important difference is the use of soft, nonreactive material (thin Silastic sheeting) to stent the nasal-frontal passageway. Removal of all the mucosa of the frontal-ethmoid-sphenoid complex is unnecessary for a good postoperative result, and the remaining normal mucosa hastens the process of reepithelialization of the nasal-frontal duct. The patients in our original study group have been observed for a period of 5 to 20 years (mean, 13.5 years) after the surgical procedure. This is the longest period of follow-up for any group of patients reported in the literature. The incidence of failures increased from 7% (one duct) to 20% (3 of 15 ducts) after an additional 7 years of follow-up.     

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.     

Endoscopic laser dacryocystorhinostomy

Endoscopic laser dacryocystorhinostomy (DCR) enables an obstructed lacrimal sac to be opened through an intranasal approach, avoiding the need for a skin incision. The holmiumtyttrium aluminum garnet (holmium:YAG) laser is well-suited for this procedure because of its properties of fiberoptic delivery, effective bone cutting, and precise soft-tissue coagulation. Efficient bone ablation is particularly important for primary DCR which requires removal of relatively thick bone along the lateral nasal wall to expose the lacrimal sac. Forty-six endoscopic laser DCRs were performed on 40 patients. There were no intraoperative or postoperative complications. The surgery successfully relieved lacrimal obstruction in 85% of patients. Endoscopic instrumentation allowed for the rapid identification and correction of intranasal causes of DCR failure, including ethmoid sinus disease and middle turbinate hypertrophy. Endoscopic laser DCR appears to be a safe and effective procedure which should be considered as an alternative to external DCR for the surgical treatment of nasolacrimal duct obstruction.     

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.     

Anatomical and computed tomographic analysis of the interaction between the uncinate process and the agger nasi cell

CONCLUSIONS: The agger nasi cell, together with the postosuperior portion of the uncinate process, was the key that unlocked the frontal recess. OBJECTIVES: To investigate the anatomical interaction between the upper portion of the uncinate process and the agger nasi cell. MATERIALS AND METHODS: Twenty-one skeletal skulls (42 sides) were studied by spiral computed tomography (CT) and endoscopy, and one cadaver head (2 sides) was studied by collodion-embedded sectioning in the coronal plane. RESULTS: The endoscopic view of the entrance of the middle meatus showed the middle part of the uncinate process and the middle part of the middle turbinate fused together as the axilla of the middle meatus. The middle portion of the uncinate process attached to the frontal process of the maxilla in all of the skeletal nasal cavities, as well as the lacrimal bone in 33 sides of the skeletal nasal cavities. On CT scans, the agger nasi cell was present in 38 sides of the skeletal nasal cavities. The agger nasi cell was medially, superiorly and inferiorly bounded by the uncinate process. The superior portion of the uncinate extended into the frontal recess and may insert into the lamina papyracea (33%), skull base (10%), middle turbinate, and a combination of these (57%).     

The mucoperiosteal flap in frontal sinus surgery. (The Sewall-Boyden-McNaught operation.)

The problem with the Lynch operation for frontal sinus disease is the high incidence of failures (30 percent) due to the closure of the nasofrontal communication. It seems to us that the use of permanent (Dacron, described as recently as 1972) or temporary (Portex) indwelling tubes to preserve this communication is unreasonable when there is available an operation that requires no gadgets. This is the mucoperiosteal flap operation. This has several advantages over the osteoplastic flap-fat obliteration procedure. It is performed through a Killian-type incision through which surgical treatment of the ethmoid and sphenoid sinuses can also be done (not possible with the osteoplastic approach). It is less formidable and not deforming, and there is no concern about the possibility of developing secondary mucoceles. The incidence of failures is extremely low. The probable reason that it is not used more is that it is not well known. It was demonstrated by Sewall and McNaught that an operative nasofrontal duct remains open if one side is epithelized. Sewall, in 1935, described a medially based mucoperiosteal flap to provide this epithelium. He described a Lynch type approach with a Killian incision. The lateral bony wall of the nose is removed carefully to the underlying mucoperiosteum. When a large enough area of the membrane is exposed, two cuts are made vertically and one horizontally, thus forming a flap, based on the septum, that eventually will be turned up into the frontal sinus after the proper surgery on the frontal sinus, the glabella, the anterior ethmoids and posterior ethmoids and sphenoid sinus, if necessary, is done. The flap is held in place with a Portex tube which is removed in seven days. McNaught, in 1936, described a laterally based mucoperiosteal flap for use in cases with large frontal sinuses with narrow nasal vaults, and particularly those with bilateral involvement. He used Lothrop's operation for removing the interfrontal septum, all the nasal portion of the floor of both frontal sinuses, and the upper part of the anterior portion of the bony nasal septum, thus making a large opening into the nose. The opening is lined unilaterally or bilaterally with mucoperiosteal flaps based from the mucosa under the nasal process of the maxilla and cut from the nasal septum and then turned into the frontal sinus over the periosteum of the orbit after the frontoethmoidal surgery has been completed. We believe that the mucoperiosteal flap operation is the best available for external surgery of the frontal sinus. The exception is in the large osteoma for which the osteoplastic flap operation is better.     

Endonasal, endoscopic-microscopic control of the decompression of the optic nerve. An anatomic endoscopic presentation of the operation

The indication for decompression of the optic nerve after indirect trauma is made both by the ophthalmologist and the ENT-surgeon. The ENT-surgeon usually reaches and decompresses the optic canal by a transethmoidal-transsphenoidal route. The majority of authors prefer the transfacial approach to the ethmoid including resection of the crossing plane comprising the frontal process of the maxilla, the ethmoid, the lacrimal and the frontal bone. Hitherto we have knowledge of only one author utilising an endonasal approach to decompress the optic nerve. At the university hospital of G?ttingen, the ENT-surgeons gathered experience with the endonasal, endoscopically and microscopically controlled operation method, which is less traumatic to the patient and avoids postoperative mucoceles of the frontal sinus. This surgical procedure is described by surgical-anatomical specimens.     

泪囊窝的应用解剖研究

目的 :明确泪囊窝的解剖学特点 ,为鼻内镜下鼻腔泪囊造孔术提供参考。方法 :对 2 3具 (4 6侧 )成人尸头泪囊窝的骨性结构构成及骨壁的厚度和倾斜角度进行测量。结果 :泪囊窝中部的骨性构成中上颌骨额突所占比例略大于泪骨 ,且变异较大 ;泪囊窝后壁与冠状面呈大约 2 0°的倾角。结论 :在鼻内镜鼻腔泪囊造孔术中 ,应对眶壁行CT检查 ,以明确不同类型泪囊窝骨性构成情况下手术可能遇到的问题 ,防止术中眶内并发症或由于造孔过小导致术后鼻泪管阻塞 ,症状不能缓解     

钩突上端和鼻丘气房的解剖学和影像学观察

目的 通过观察钩突上端和鼻丘气房的解剖关系，进一步阐明鼻丘径路鼻内镜下额窦开放手术的解剖学基础。方法 鼻内解剖标志完整的成人颅骨21个（42侧）和成人尸头1个，①鼻内镜观察颅骨钩突前上端与中鼻甲和鼻腔外侧壁的毗邻关系；②16排螺旋CT扫描（层距0．300mm，层厚0．625mm）结合三维重建技术（层厚0．625mm），观察颅骨钩突前上端与鼻丘气房的关系，以及钩突上端的附着点，同时测量鼻丘气房的前后径、横径和高度；③火棉胶包埋后冠状位薄层（100μm）断层经苏木精伊红染色后，观察成人尸头钩突前上端的毗邻关系。结果 ①鼻内镜下中鼻甲垂直板前缘中部与钩突前缘上部相互融合，在中鼻道前端顶部与鼻腔外侧壁间形成骨性穹隆；钩突前上缘除附着于上颌骨额突（42侧，100％）外，多数还同时附着于上颌骨额突后方的泪骨（33侧，78．6％）。②冠状位CT显示钩突上端的附着点可位于眶内壁、颅底或中鼻甲（垂直板）上，单一钩突上端附着点的位置，多数位于眶内壁上（33．3％），额窦在该平面经钩突上端内侧引流人中鼻道；其余附着于颅底（9．5％），额窦在该平面经钩突上端外侧引流入筛漏斗。2个附着点的钩突，多数附着于眶内壁和颅底（31．0％）；少数附着于眶内壁和中鼻甲（21．4％）。③多数鼻丘（90．5％）含1～2个气房，钩突参与组成鼻丘气房的内、下和上壁，左侧和右侧钩突的横径、高度以及前后径均无显著性差异。④尸头冠状位连续断层的观察结果与鼻内镜下和CT观察结果一致。结论 钩突上端参与组成鼻丘气房，并与中鼻甲前端形成骨性连接。通过开放鼻丘气房可从前下部疏通额窦引流通道。