下鼻甲肥大对功能性溢泪影响的分析

目的探讨下鼻甲肥大与功能性溢泪的关系及临床治疗价值。方法 11例下鼻甲肥大伴溢泪患者中,7例同时伴鼻中隔偏曲,术前完善检查,并利用CT泪囊造影术和三维重建,排除溢泪的眼部疾病,行下鼻甲减容术伴或不伴鼻中隔偏曲矫正术,观察疗效。术后随访12个月。结果 11例患者中8例(72.7%)溢泪症状消失,3例(27.3%)溢泪症状好转。7例患者术后鼻中隔均居中,下鼻甲明显缩小。其中鼻塞痊愈10例(90.9%),好转1例(9.1%)。结论下鼻甲肥大为功能性溢泪的一个重要的原因,对其进行治疗可治愈或改善功能性溢泪。     

Endoscopic dacryocystorhinostomy without stents

OBJECTIVE: The aim of this study is to present our endoscopic DCR operation method without the use of silicone tubing and our results on the patients suffering from chronic epiphora with postsaccal stenosis. METHODS: Endoscopic dacryocystorhinostomy operations were performed to 21 sides of 18 patients who had chronic epiphora. No silicone tubing was used in any of the cases. In the postoperative healing period, the rhinostomy opening was maintained with frequent removal of nasal debris and using eyedrops. The patients were evaluated by fluoresceine test and endoscopic controls. RESULTS: Symptomatic improvement was achieved in 19 out of 21 sides of the patients (90.5%) and the results were confirmed by the fluoresceine test under endoscopic control. CONCLUSION: Our results of 21 sides of 18 cases underwent primary DCR without stents are as successful as those reported in the literature and the technique seems to be promising.     

The management of rhinitis in patients with functional epiphora: a randomized controlled crossover trial

BACKGROUND: Nasolacrimal duct obstruction, secondary to inflammation of the nasal mucosa, can result in epiphora. This can be treated successfully with topical corticosteroids, avoiding the need for surgery. This study tests the hypothesis that treating clinically significant rhinitis improves the symptoms of epiphora. METHODS: A randomized controlled crossover trial (pilot study) was performed at the Cumberland Infirmary, Carlisle. Patients were assessed in an epiphora clinic by a consultant ophthalmologist and were included in the trial if they had bilateral functional epiphora, i.e., the nasolacrimal duct was patent on syringing. Twenty-three patients were then referred to a consultant otolaryngologist, where the severity of rhinitis and epiphora were assessed using visual analogue scales, subjective scoring, and clinical assessment. The 11 patients suitable for the study were randomized into two groups. The treatment group received nasal corticosteroids and the control group received no treatment, both groups changing treatment arms at a specified point. Subjective and objective scores were assessed at the beginning, midpoint, and end of each treatment period. RESULTS: Seven of 11 patients showed an improvement in epiphora scores with topical therapy. Six patients documented a symptomatic improvement. Eight patients showed an improvement in symptoms and signs of rhinitis, with two patients continuing on nasal corticosteroids for nasal symptoms only. There was a statistically significant improvement in both epiphora symptom scores and clinical findings of rhinitis in patients treated with nasal steroids (p = 0.021 and 0.019, respectively). CONCLUSION: Epiphora secondary to rhinitis can be treated successfully with intranasal steroids. Patients with epiphora should be asked about symptoms of rhinitis and should always have their nose examined for evidence of intranasal pathology.     

An association between acquired epiphora and the signs and symptoms of chronic rhinosinusitis: a prospective case-control study

BACKGROUND: It has been suggested that chronic rhinosinusitis may lead to epiphora because of inflammatory edema at the nasal end of the nasolacrimal duct and that treatment of the underlying nasal disease may obviate the need for dacryocystorhinostomy. The aim of this study was to establish whether or not there is an association between the signs and symptoms of chronic rhinosinusitis and a complaint of epiphora in a blinded, prospective case-control study. METHODS: A consecutive series of 15 adult patients presenting to the ophthalmology department with acquired epiphora were compared with 29 patients presenting with chronic open-angle glaucoma over the same study period. Nasal symptoms and the findings on nasal endoscopy were recorded by a single otolaryngologist blinded to the diagnosis and using a standardized staging system RESULTS: The age and sex distributions of the two groups were similar. Scores for headache and altered smell were significantly higher in the epiphora cases than in controls (p = 0.05 and 0.03, respectively). Trends for higher scores for congestion and discharge were not statistically significant (p = 0.06 and 0.07, respectively). Mucosal edema and discharge were significantly more common on endoscopy in the epiphora cases than in the control cases (p < 0.02). CONCLUSION: We have shown an association between rhinosinusitis and acquired epiphora, and this would be consistent with chronic rhinosinusitis being the cause of the epiphora in some cases.     

Nasolacrimal duct orifice cysts in adults: a previously unrecognized, easily treatable cause of epiphora

BACKGROUND: Epiphora is a common problem evaluated by ophthalmologists and otolaryngologists. It is typically the result of obstruction at some level of the nasolacrimal system, either the canaliculi, sac, or duct. Multiple etiologies exist, including scarring from infection or trauma, tumors, or masses. Cysts of the nasolacrimal duct orifice (dacryocystoceles) in the inferior meatus have been described in neonates, usually presenting as obstructive nasal masses shortly after birth. Nasolacrimal duct orifice cysts have not been described in the adult population in the medical literature. PATIENTS: Three patients were identified with epiphora as a result of cysts in the inferior meatus at the opening of the nasolacrimal duct. All patients presented with constant epiphora and were referred for dacryocystorhinostomy by an ophthalmologist or an otolaryngologist. None of the patients had a previous history of nasolacrimal duct (NLD) surgery. One patient had previous endoscopic sinus surgery for nasal polyps. Cysts were identified by nasal endoscopy of the inferior meatus in all patients. RESULTS: All patients underwent endoscopic resection of the inferior meatus cyst to relieve the obstruction of the NLD. Two procedures were performed under general anesthesia and one under intravenous sedation. All patients had complete relief of epiphora and have had no evidence of recurrence of the symptoms or the cyst in 4 to 10 months follow-up. CONCLUSIONS: NLD orifice cysts are easily correctable causes of epiphora. Routine inferior meatus endoscopy should be routinely performed in patients with epiphora to identify whether on not this pathology is present prior to performing dacryocystorhinostomy.     

Endonasal and transcanalicular Er:YAG laser dacryocystorhinostomy

In the last 10 years different types of lasers were used for dacryocystorhinostomy (DCR). Between April 1998 and August 1999, a fibreoptic erbium laser DCR was performed on 12 patients. Eight cases were for a presaccal stenosis and 4 cases for a postsaccal stenosis. An erbium laser with a specially designed handpiece was used endonasaly and transcanaliculary. Preoperative epiphora was present in all patients. Double bicanalicular nasal silicone tubes were placed during surgery in all cases. The 3 cases of postoperative failure included 2 cases of presaccal stenosis and 1 case of the postsaccal group; failure manifested with recurrent epiphora/dacryocystitis; the onset of symptom recurrence varied from 9 weeks to 11 weeks postoperatively. Laser-assisted DCR includes the avoidance of a cutaneous incision, excessive tissue injury, the advantage of short operation time and precision. Suitable indications for the erbium laser are stenoses in the canaliculi, in the sac, but also for bone lacrimal bone cutting.     

Endoscopic medial maxillectomy with preservation of inferior turbinate: how do we do it?

The aim of this study was to describe the endoscopic medial maxillectomy technique with preservation of the inferior turbinate in patients affected by maxillary sinonasal inverted papilloma. We retrospectively reviewed the clinical charts and surgical technique in six patients with paranasal sinus inverted papilloma. There were five males and one female, whose mean age at diagnosis was 60?years ranging between 57 and 65?years. No recurrences were diagnosed, and no nasal crusting was evidenced postoperatively. Nasal breathing was satisfying in all cases. Postoperative epistaxis was not observed, and none of the patients refereed to have epiphora after the surgery. This technique has been successfully performed, showing no recurrence to the present and allowing the preservation of a functional inferior turbinate.     

Endoscopic laser dacryocystorhinostomy. An unusual post-operative finding: re-opening of the nasolacrimal duct.

Endoscopic laser dacryocystorhinostomy (DCR) is a recognized technique for the surgical treatment of epiphora. Nasolacrimal duct obstruction is surgically bypassed by creating a passage from the lacrimal sac to the nasal cavity (rhinostomy). Some patients have undergone endonasal laser-assisted DCR, and were found to have an obstructed rhinostomy at follow-up. However, they reported a subjective improvement in their symptoms. Five such patients, at six months follow-up, were found to have a non-functioning rhinostomy with fluorescein dye emerging from under the inferior turbinate. These five patients along with four controls had post-operative macrodacryocystograms (MDCG) to delineate the anatomical passage by which tears were entering the nasal cavity. In the control group, clear passage of contrast into the middle meatus was demonstrated in three of the four subjects. In the study group, passage of dye to the inferior meatus, via the nasolacrimal duct was demonstrated in four of the five subjects. It is well recognized that a proportion of patients suffering from epiphora will have a natural resolution of their symptoms. Our results demonstrate that the resolution of epiphora in some operated patients was due to a re-opening of the nasolacrimal duct, and not because of a patent rhinostomy.     

鼻中隔偏曲矫正术后贯穿连续缝合技术的应用与效果分析

目的　评价鼻腔填塞法和鼻中隔贯穿连续缝合技术在鼻中隔偏曲矫正术后应用的疗效及效果分析。方法  选取行鼻中隔偏曲矫正术患者158例,随机分成2组。填塞组：术后以高分子止血海绵填塞鼻腔;缝合组：术后以可吸收缝线立即行贯穿连续缝合鼻中隔黏膜。术后对患者主观不适感以视觉模拟评分法（visual analogue scale,VAS）进行评分,观察术后鼻腔黏膜水肿程度和鼻中隔血肿、粘连、术后治愈率等临床指标。结果　术后48 h内两组患者在鼻部疼痛、头部疼痛、溢泪、耳鸣/耳闷、睡眠困难、吞咽困难 6个方面的VAS评分均值比较,差异均有统计学意义。两组在术后出血量、鼻中隔血肿、鼻腔粘连、穿孔、感染等方面比较差异无统计学意义。结论　鼻中隔偏曲矫正术后缝合法较填塞法能减轻患者痛苦,不增加术后并发症的发生机率。     

鼻中隔连续贯穿缝合技术在鼻中隔偏曲矫正术中的应用

目的 评价鼻中隔连续贯穿缝合技术在鼻中隔偏曲矫正术中的应用及效果。 方法 选取2016年4月至2017年3月因鼻中隔偏曲接受手术治疗的患者39例,随机分成填塞组与缝合组。填塞组于术后用高分子膨胀海绵填塞双侧鼻腔,缝合组于术后行鼻中隔连续贯穿缝合,不进行鼻腔填塞。术后对两组患者主观不适感以视觉模拟评分法(VAS)进行症状评分,比较两组患者术后鼻塞、鼻部疼痛、头痛、睡眠困难、流泪的VAS评分,观察术后鼻出血量、鼻中隔血肿、鼻中隔穿孔发生率等临床指标。 结果 术后48 h内填塞组患者鼻部疼痛、头痛、睡眠困难、流泪等方面VAS评分明显高于缝合组,差异有统计学意义(P均<0.05)。两组患者术后鼻塞VAS评分、鼻出血量、鼻中隔血肿、鼻中隔穿孔发生率等差异无统计学意义(P均>0.05)。 结论 鼻中隔连续贯穿缝合技术能明显减轻鼻中隔偏曲患者术后的痛苦,并不增加术后并发症的发生概率。     

内镜鼻窦手术后Rhino凝胶填塞效果的观察

目的 前瞻性比较新型鼻腔填塞材料Rhino凝胶与传统填塞物用于内镜鼻窦手术后填塞的效果.方法 对双侧病变基本对称,手术范围基本相同的24例慢性鼻窦炎患者行内镜鼻窦手术,术后右侧鼻腔以Rhino凝胶填塞(观察组),左侧鼻腔以藻酸钙+油纱条填塞(对照组).术后1日抽取对照侧填充物,观察侧凝胶保留至术后1周第1次内镜复查时清理,鼻腔冲洗、鼻喷糖皮质激素等其他局部处理双侧鼻腔相同.采用视觉模拟量表(visual analog scale,VAS)记录两侧鼻腔术后当天(填塞期)、术后第1天(抽取左侧填充物时)、术后第2天(抽取左侧填充物后)患者鼻痛、鼻堵程度,分泌物、渗血、流泪量,以及术后内镜复查术腔恢复情况(干痂、分泌物、反应膜、黏膜水肿、囊泡、窦口阻塞),并对两组上述11项观察项目评分和上皮化时间进行比较.结果 苏醒时因血压过高,凝胶侧鼻腔出血改用纱条填塞1例;外地患者失访2例.余21例完成2～20个月的随访.术后当天、术后第1天鼻痛,术后当天流泪评分,Rhino组<对照组(Z值分别为-3.575、-3.546、-2.736,P值均<0.05);术后第1天渗血评分,Rhino组<对照组(Z=-3.075,P<0.05);术后1周术腔干痂评分,Rhino组<对照组(Z=-2.103,P<0.05);其余各项评分差异无统计学意义;凝胶侧术腔平均上皮化时间为(10.7±2.6)周,对照侧为(10.6±2.9)周,两组差异无统计学意义(t=-0.146,P=0.886).结论 Rhino凝胶可减轻患者鼻腔填塞期的不适,并可避免专门撤除填充物造成的痛苦和出血,较传统方法有明显的优越性.在促进术腔恢复方面与传统方式相当.     

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.     

A novel stenting technique in endoscopic dacryocystorhinostomy

The objective of our study was to evaluate in a prospective noncomparative case series, the clinical efficacy and the results of modified T-tube insertion instead of silicone tube in endoscopic dacryocystorhinostomy (EDCR). Following ophthalmologic examinations, 22 patients (16 female, 6 male) suffering from recurrent chronic epiphora with postsaccal stenosis for whom DCR was indicated, underwent EDCR at Dumlupinar University Hospital by an otorhinolaryngologist and an ophthalmologist between the years 2006 and 2007. Instead of inserting a classic silicone tube passed through canaliculi and knotted inside the nose, a modified T-tube was used, without passing it through punctum, and was placed to stoma with a less traumatic endonasal endoscopic technique. The medial wall of the sac was incised vertically and the T-tube was placed horizontal to the incision. Postoperatively, the patients were evaluated by endoscopic controls in the first, third, sixth, and twelfth months to evaluate T-tube localization and rhinostomy opening site. The success was defined as resolution of epiphora with patent ostium after evaluation by irrigation and nasal endoscopy. Eighteen patients (82%) showed complete resolution of epiphora at 12-months of follow-up. Re-stenosis was observed only in four cases, one in the sixth and the other in the ninth postoperative months. Granulation tissue formation near the rhinostomy site was seen in one patient, which did not cause any functional problem. The success rate was calculated as 82%. We conclude that modified T-tube placement in EDCR seems to be a practical and less traumatic technique. This is also a cheaper method besides being less traumatic and easier to perform than canalicular stenting. It can be considered as a useful alternative to the classic silicon tubes in cases of epiphora resulting from the postsaccal stenosis.     

Anastomosis of nasal mucosal and lacrimal sac flaps in endoscopic dacryocystorhinostomy

Endoscopic dacryocystorhinostomy (DCR) is a well-established alternative to external approaches in the treatment of nasolacrimal canal obstruction. From July 2004 to December 2008, 92 endoscopic DCRs were performed on 88 patients at the Department of Otorhinolaryngology, San Raffaele Hospital, Milan. All patients were affected by chronic dacryocystitis with epiphora. Preoperative work-up included Jones tests, lacrimal pathways irrigation, nasal endoscopy, and imaging evaluation by computed tomography. The technique involved anastomosis of nasal mucosal, lacrimal sac flaps and a large bony ostium. A silicone tube was inserted in all patients that remained for a period of 3 months. The first endoscopic intervention was successful in 91.30% of patients. After a second revision endoscopic DCR, the overall success rate raised to 95.65%. Anastomosis of nasal mucosal between lacrimal sac flaps plays a key role in endoscopic DCR with a high success rate both in primary nasolacrimal obstructions and in revision cases.     

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.     

不同手术入路治疗上颌窦真菌性鼻窦炎94例的临床分析

目的探讨不同手术入路治疗上颌窦真菌性鼻窦炎的临床疗效。方法回顾性分析94例上颌窦真菌性鼻窦炎患者的临床资料,分别采用3种手术径路,即柯一陆手术入路31例、鼻内镜上颌窦窦口开放入路33例、鼻内镜上颌窦窦口开放联合下鼻道开窗入路30例;比较不同术式的临床疗效。结果所有患者术后均随访12个月。其中采用柯-陆手术入路患者治愈率74．2％（23／31）,5例出现面部麻木,无溢泪及鼻腔粘连等并发症;采用鼻内镜上颌窦窦口开放人路患者治愈率81．8％（27／33）,7例患者出现鼻腔粘连,鼻内镜下直接分开后好转,无溢泪及面部麻木等症状;采用鼻内镜上颌窦窦口开放联合下鼻道开窗入路患者治愈率100％,5例患者出现鼻腔粘连,鼻内镜下直接分开后好转,无溢泪及面部麻木等并发症。结论鼻内镜上颌窦窦口开放联合下鼻道开窗入路是一种微创、安全、有效的治疗上颌窦真菌性鼻窦炎的手术方式。     

Paranasal mucoceles in children with cystic fibrosis

Sinus mucocele is rare in the paediatric age, and so far no prevalence data have been reported in children with Cystic Fibrosis (CF). Moreover, safety and efficacy of endoscopic management of sinus mucoceles has been widely proven but only in the adult population. The aim of our study was to evaluate the prevalence of this complication and the efficacy of endoscopic sinus surgery in CF patients during the initial years of life. Among the 242 CF patients born in the period between 1990 and 2001 and in regular follow up at our CF Centre, 90 patients with possible symptoms of chronic upper airways disease (CUAD) underwent a comprehensive ENT examination including rhinofibroscopy. In selected cases a CT scan of the paranasal sinuses was also performed. CUAD was diagnosed in 55/90 because of the consistent presence of nasal obstruction, combined with at least two other nasal symptoms such as chronic nasal discharge, snoring, epiphora. Diagnosis of mucoceles (five maxillary bilateral mucoceles, one maxillary unilateral, three maxillary and etmoidal mucoceles) was done by means of CT scan in 9/15 who performed the examination. Median age at the diagnosis was 4+/-0.5 years, ranging from 0.5+/-7 years, showing a prevalence of 16.4% (9/55) among patients with symptoms. Endoscopic sinus surgery was performed in all the cases. The follow-up period ranged from 3 months to 6 years with no recurrence observed. Sinus mucocele in CF population is less unusual than expected and a high degree of suspicion is needed. Endoscopic sinus surgery seems to be a safe and efficient treatment of this complication also in a paediatric population at a high risk as for the CF patients.     

The disappeared disease: tuberculosis of the nasal septum

Recent advances in chemotherapy have reduced the incidence of upper respiratory tract tuberculosis. Tuberculosis of the nose is mainly by secondary infection to pulmonary tuberculosis via contagious, hematogenous or lymphatic routes. Primary infection of the nose is rare but possible when self-cleansing mechanism and lysosomal activity, of the nose is lost. A 45-year-old Korean woman with the chief complaints of nasal obstruction, crusting, and recurrent episodes of epistaxis is presented. Physical examination of the nose revealed friable, easily bleeding masses with crusts on both sides of the septum. The appearance and consistency of the lesions were different from those of nasal polyps. Chest and sinu X-rays revealed no active lesions. Tuberculin skin test was positive and the biopsied specimen proved to be consistent with tuberculosis. Her condition improved after anti-tuberculous medication for about 6 months.     

鼻外泪囊鼻腔吻合术后并发症的鼻内镜鼻腔进路的治疗

目的探讨鼻外泪囊鼻腔吻合术后泪道不通的鼻内镜下治疗方法。方法对18例经鼻外泪囊鼻腔吻合术后再次出现溢泪的病人,在鼻内镜下对吻合口进行检查,针对不同时期和具体情况进行相应治疗。结果所有病人术后随访6个月至3年,除1例因泪囊鼻腔间置入的扩张管脱落而再次出现溢泪,经重新置管后症状消失外,其余病人均未再出现溢泪。结论对经鼻外泪囊鼻腔吻合术后泪道不通病例,鼻内镜下对吻合口进行检查,针对不同情况进行相应处理,常能使病人再次康复。     

Epiphora: an evidence based approach to the 12 minute consultation

Clin. Otolaryngol. 2010, 35 , 210–214 Background: Epiphora is the presence of a watering eye which may be due to reflex tearing or defective drainage of tears. Whilst most cases present to the ophthalmologist the otolaryngologist has a key role to play in both assessment and management of these patients. Methods: This review was based on a literature search last performed on 21st October 2009. MEDLINE and Cochrane databases were searched using the subject headings ‘epiphora’ or ‘functional epiphora’ in combination with diagnosis, investigation, management, treatment, intervention and surgery. Results were limited to English language articles. The personal biographies of the senior authors were also used. Conclusion: An accurate assessment of the site and degree of obstruction is important to ensure the correct management is undertaken. Medical treatment with nasal steroid spray may be effective but the majority of obstructed cases will require surgical intervention in the form of dacryocystorhinostomy (DCR). There is increasing evidence that powered endoscopic DCR has outcomes comparable with the ‘gold standard’ procedure of external DCR.