Medial ectropion: association with lower lacrimal obstruction and combined management

Nine consecutive patients who presented with a medial ectropion (12 eyelids) and epiphora were prospectively evaluated and surgically managed. Medial ectropion was successfully corrected in all 12 eyelids (mean follow-up 12.2 months). A lateral tarsal strip procedure (Anderson procedure) was used to correct the horizontal lid laxity. Resecting the retractors of the lower lid subjacent to the punctal area corrected the punctal eversion. Prior to medial ectropion repair, three of the 12 eyes demonstrated evidence of complete obstruction at or below the level of the lacrimal sac. These patients required concurrent dacryocystorhinostomy (DCR) in addition to repair of the medial ectropion. DCR with silicone intubation obviated the need for anastomosis of lacrimal sac and nasal mucosal flaps, and it corrected the punctal stenosis. Histopathologic examination of the sac specimens confirmed chronic inflammation. One of six patients without complete obstruction required DCR after medial ectropion repair and punctoplasty. Medial ectropion may predispose to lower lacrimal obstruction. In turn, the epiphora may lead to aggravation of the medial ectropion as a result of wiping of tears.     

A method for combined dacryocystorhinostomy with external ethmoidectomy

Severe polypoid rhinosinusitis requiring external ethmoid surgery may be seen in conjunction with partial or complete nasolacrimal obstruction. When this obstruction is associated with persistent, unresolved lacrimal symptoms, it is sometimes appropriate to combine surgical procedures, thereby avoiding separate lacrimal surgery. A method combining dacryocystorhinostomy (DCR) with external ethmoidectomy is described. The anatomy involved in this procedure and the indications for it are discussed.     

Comparative external versus endoscopic dacryocystorhinostomy: results in 115 patients (130 eyes).

BACKGROUND: Epiphora is an annoying symptom, embarrassing the patient both socially and functionally. The two widely accepted treatment modalities of epiphora resulting from obstruction of the nasolacrimal ductus are external and endoscopic dacryocystorhinostomy (DCR). OBJECTIVE: The aim was to compare the results, operative time, and complications of external and videoendoscopic endonasal DCR performed between December 1994 and December 1998. METHODS: In group 1, conventional primary external DCR with or without silicone tube intubation was performed in 79 patients (66 women and 13 men) with unilateral dacryocystitis. In group 2, endoscopic primary endonasal DCR with hammer-chisel removal of bone located over the lacrimal sac was performed in 51 eyes of 36 patients, 33 women and 3 men (15 bilateral procedures). RESULTS: The follow-up period was 6 to 48 months (mean 25 months) after surgery. The age range was from 4 to 76 years (mean 38.5 years). The success rates of external and endoscopic hammer-chisel DCR were found to be 89.8% and 88.2%, respectively. A lower complication rate was observed in the endoscopic group, with minimal morbidity and shorter operative time compared with the external approach. CONCLUSIONS: Hammer-chisel endoscopic DCR is practical, less traumatic, less time-consuming, and cosmetically more convenient than the external approach. The success rate of the endoscopic DCR procedure is comparable with that of traditional external DCR, and it also allows simultaneous correction of any intranasal pathology.     

An alternative method of canalicular stent tube placement in lacrimal drainage surgery

Certain situations in lacrimal drainage surgery require stent tubing: in a dacryocystorhinostomy (DCR) when flap anastomosis or clearance of the common internal punctum is problematic; when a common canalicular obstruction indicates a DCR and common internal punctoplasty; when a lateral common canalicular or individual canalicular obstruction indicates a canaliculodacryocystorhinostomy (CDCR); in cases involving a totally obliterated canaliculus and when intubating the patent canaliculus in conjunction with a DCR or CDCR. We describe a simple and effective technique of tube placement, using silastic tubing which involves placing a silastic sleeve under direct visualization for precise tube fixation. This method has been employed successfully in 379 cases from a 5-year series of over 1,000 lacrimal drainage operations.     

Surgical treatment of obstruction of the nasolacrimal ducts in patients with anatomical endonasal variants

The presence of anatomical endonasal variants (concha bullosa, nasal septal deviation, or hypertrophic turbinates) may cause more complications in patients with epiphora who have external dacryocystorhinostomy (DCR). The purpose of this study was to assess the results of surgical placement of a stent in 28 patients. They were randomised into two groups and had either DCR or placement of a Song's polyurethane stent. They were followed up for 18 months. Twenty-six patients had a good result. The success rate was 13/14 for those who had DCR and 13/14 for those who had a stent. Operating time was significantly less for placing a stent (mean (SD) 15 (2) minutes) compared with 40 (3) minutes for DCR (p<0.01). Placement of a polyurethane stent is an effective and short procedure for nasolacrimal obstruction, which is suitable for patients with unusual intranasal conditions.     

Surgical treatment of obstruction of the nasolacrimal ducts in patients with anatomical endonasal variants.

The presence of anatomical endonasal variants (concha bullosa, nasal septal deviation, or hypertrophic turbinates) may cause more complications in patients with epiphora who have external dacryocystorhinostomy (DCR). The purpose of this study was to assess the results of surgical placement of a stent in 28 patients. They were randomised into two groups and had either DCR or placement of a Song's polyurethane stent. They were followed up for 18 months. Twenty-six patients had a good result. The success rate was 13/14 for those who had DCR and 13/14 for those who had a stent. Operating time was significantly less for placing a stent (mean (SD) 15 (2) minutes) compared with 40 (3) minutes for DCR (p <0.01). Placement of a polyurethane stent is an effective and short procedure for nasolacrimal obstruction, which is suitable for patients with unusual intranasal conditions.     

Endoscopic dacryocystorhinostomy with double posteriorly based nasal and lacrimal flaps: a prospective randomized controlled trial

Objectives To conduct the first prospective randomized controlled trial assessing and comparing the safety and efficacy of endoscopic dacryocystorhinostomy (DCR) with double posteriorly based nasal and lacrimal flaps to conventional endoscopic DCR in adult patients with acquired complete nasolacrimal obstruction. Study Design A prospective randomized controlled study. Setting General hospital. Subjects and Methods Seventy-four adult patients with a total of 80 procedures were recruited to undergo endoscopic DCR. They were prospectively equally randomized into 2 groups: endoscopic DCR with flaps (group I) and conventional endoscopic DCR (group II). Regular follow-up settings were done to document the patient's subjective improvement, judge ostium patency on irrigation, and record any complications. Results Endoscopic DCR with flaps had a higher (92.1%) but nonsignificant difference in success rate when compared with conventional endoscopic DCR (87.4%). There was no significant difference between the 2 techniques in operative time, adverse events, and tolerability of the technique to be done under local anesthesia with minimal sedation. Group I demonstrated a significantly lower number of debridement sessions than did group II. Conclusion Endoscopic DCR with double posteriorly based nasal and lacrimal flaps provides a viable alternative to conventional endoscopic DCR in managing acquired nasolacrimal duct obstructions in adults. It has a comparable success rate, operative time, and safety profile, with a suggestion of a better healing profile in terms of mucosal recovery, wound healing, and less need for debridement sessions.     

Dacryocystorhinostomy failure: association with nasolacrimal silicone intubation

A retrospective review of 242 consecutive dacryocystorhinostomies (DCRs) revealed no association between failure and either age, gender, or etiology of the nasolacrimal obstruction. However, silicone intubation of the nasolacrimal system was associated with a statistically significant increase in the failure rate of primary DCR. We postulate that silicone tubing by inciting granuloma formation in the nose and lacrimal fossa, predisposes to DCR failure. Routine use of silicone tubing in DCR should be avoided unless there is canalicular scarring, a large valve of Rosenmueller occluding the common canaliculus, or a small contracted or scarred lacrimal sac.     

Endoscopic revision of external dacryocystorhinostomy.

OBJECTIVES: To observe the benefit of endoscopic surgery for the treatment of lacrimal duct obstruction in revisional surgeries after external dacryocystorhinostomy. STUDY DESIGN AND SETTING: Retrospective nonrandomized study. Eleven cases of recurrent lacrimal duct obstruction after external dacryocystorhinostomy were submitted to endoscopic dacryocystorhinostomy. RESULTS: The rate of success after revisional surgery was 90.9%. The major causes of failure of the external approach were the presence of granulation tissue, septal deviations and synechiae near the opening of the fistula, inadequate removal of the bony wall adjuvant the lacrimal sac, technical error in the localization of the lacrimal sac, and excessive perioperative bleeding that impaired the surgical field. CONCLUSION: Endoscopic dacryocystorhinostomy in revisional cases proved to be a safe technique of low morbidity, permitting effective resolution of the lacrimal obstructions. SIGNIFICANCE: Endoscopic surgery allows greater visibility of the lacrimal sac and its neighbor anatomic alterations and leads to better results.     

Intranasal Z-plasty for internal nasal valve collapse

OBJECTIVE: To describe the technique of intranasal Z-plasty and early results for this minimally invasive method to repair internal nasal valve collapse. Intranasal Z-plasty has been well described for nasal valve stenosis and cleft nasal deformities but poorly described for idiopathic nasal valve collapse, the most common indication for nasal valve surgery. DESIGN: A retrospective medical record review was performed for 12 patients undergoing intranasal Z-plasty for nasal valve collapse. Medical records were evaluated for age, sex, indication for surgery, prior surgical procedures, complications, results, and length of follow-up. A visual analog scale was used to rate nasal obstruction preoperatively and postoperatively. RESULTS: A total of 8 men and 4 women underwent surgery, and the procedure was bilateral in 10 of the 12 patients, for a total of 22 nasal valves. Eleven patients noted subjective improvement in airflow on both sides, with the remaining patient noting improvement on one side and no change in the opposite side. Mean follow-up was 16.8 months (range, 5-32 months). The mean preoperative nasal obstruction score was 7.2, and the mean postoperative nasal obstruction score was 3.3 (on a scale of 0 to 10, with 10 being total obstruction). No complications were reported, and no patients complained about postoperative nasal appearance. CONCLUSION: Intranasal Z-plasty appears to be a safe, effective, and relatively noninvasive technique to repair internal nasal valve collapse.     

An Interim Report on Parietal Cell Vagotomy Versus Selective Vagotomy and Antrectomy for Treatment of Duodenal Ulcer

This is an interim report of a prospective, randomized study involving 194 consecutive patients who underwent elective operation for treatment of duodenal ulcer. The results of parietal cell vagotomy without drainage (PCV) and selective vagotomy-antrectomy and Billroth I anastomosis (SV-A-B I) were compared. There was no mortality. Postoperatively patients were examined at two, six, 12 months and every 12 months thereafter. The two operations showed no statistical difference in the frequency of diarrhea. Dumping was less (p < .01) after PCV than after SV-A-B I. Weight loss was less (p < .01) after PCV than after SV-A-B I. There were no recurrent ulcers after SV-A-B I and five after PCV. In each instance but one the recurrent ulcer healed on withdrawal of an ulcerogenic drug. One patient required reoperation. Reoperations in the PCV group consisted of one for recurrent ulcer, one for gastric outlet obstruction and three for intestinal obstruction. The reoperations after SV-A-B I consisted of four for gastric outlet obstruction, three for intestinal obstruction, one for ruptured spleen and two for incisional hernia. PCV was technically feasible and practical to perform except in the occasional patient with severe pyloric stenosis. Obesity was never a deterrent. After PCV it is reasonable to assume that a recurrent ulcer rate in the range of 5-10% can be expected by surgeons who have been properly trained. This recurrence rate is higher than that after SV-A-B I but no higher than that encountered with TV-P. The recurrence rate is acceptable and is a fair exchange for the avoidance of dumping and weight loss that accompany SV-A-B I with significantly greater frequency and which on occasion can produce gastric crippling, although this did not occur in this study. All recurrent ulcers after PCV do not require reoperation but when operative treatment is required the patient has all the options that he had prior to PCV.     

UK survey of the present role of ear, nose and throat surgeons in lacrimal surgery

INTRODUCTION

The objective of this study was to evaluate the current involvement of ear, nose and throat (ENT) surgeons in lacrimal surgery.

SUBJECTS AND METHODS

A postal survey was distributed to 796 practicing UK consultant otorhinolaryngologists listed at the drfoster website.

RESULTS

Overall, 531 questionnaires were returned, giving a response rate of 66.7%. Of these, 108 (20.6%) respondents indicated they were involved in lacrimal surgery. The majority of otolaryngologists seem to work in collaboration with ophthalmologists. In our survey, 98% (106) perform endoscopic dacryocystorhinostomy (DCR). Most respondents believed lacrimal intubation and dilation to have limited success, endoscopic DCR to have moderate success and external DCR to have high success.

CONCLUSIONS

Lacrimal surgery is carried out in a spirit of collaboration with ophthalmologists rather than competition. Endoscopic DCR is the favoured surgical procedure of otolaryngologists. The perceived success rate for endoscopic DCR reported in this survey coincides with that reported in the literature.     

Lacrimal obstruction after medial maxillectomy.

Medial maxillectomy can result in lacrimal obstruction and the need for subsequent dacryocystorhinostomy. Computed tomographic dacryocystography is a technique in which radiopaque dye is instilled in the lacrimal sac and computed tomography is subsequently performed. Computed tomographic dacryocystography facilitated the management of a patient with lacrimal obstruction after medial maxillectomy by helping to exclude recurrent tumor and sinusitis, and by providing a surgical "roadmap" in the presence of altered anatomy.     

Metastatic melanoma of the lacrimal sac

The case history of a patient with metastatic melanoma obstructing the lacrimal sac is presented. To our knowledge, this case represents a unique metastatic pattern that has not been previously reported. The patient was first treated for a melanoma of the left arm, which was excised in continuity with the axillary lymph glands. She was free of disease for 3 years until she developed metastatic disease causing obstruction of the ipsilateral lacrimal sac. Anatomical details of the metastasis were provided by computed axial tomography. Treatment consisted of excision of the metastatic lesion with reconstruction using forehead and intranasal mucosal flaps, followed by irradiation, hyperthermia, and multiple-drug chemotherapy. Emphasis is placed here on the differential diagnosis of orbital adnexal tumors.     

Asymptomatic Lacrimal Flow Abnormalities in Patients with Septal Deviations and Turbinate Hypertrophy

Background: This study aimed to investigate the lacrimal flow in patients affected by septal deviations and turbinate hypertrophy and to evaluate changes after rhinoseptoplasty with dacryocystography (DCT) and computed tomographic dacryocystography (CT-DCT). Methods: The study prospectively recruited patients having septal deviations with or without turbinate hypertrophy who underwent surgical evaluation for correction of their respiratory symptoms and were not referred for epiphora. Patients were excluded if they had undergone surgery for cranial vault defects or had experienced septal deviations after traumatic accidents. All patients were studied with DCT and CT-DCT preoperatively and postoperatively. Results: A total of 24 patients (10 men and 14 women) were recruited for the study. Of these patients, 11 (45.8%) had a reduced flow of the medium contrast due to a partial obstruction at the level of the internal ostium. All 11 patients had septal deviations and turbinate hypertrophy, whereas 8 patients had a unilateral obstruction (72.7%), and 3 patients had a bilateral obstruction (27.3%). All flows were corrected after surgery. Conclusions: The safe and well-tolerated radiologic techniques performed in this study provided detailed imaging of the lacrimal outflow system. A high incidence of partial obstruction to the internal ostium was found in patients with septal deviations, turbinate hypertrophy, and no lacrimal symptoms, suggesting a frequent presymptomatic condition.     

A new method using epidural catheters in the reconstruction of lacrimal drainage.

Lacrimal outflow obstruction after severance of the duct is a common problem in facial trauma. Conventional treatments include external dacryocystorhinostomy, endoscopic-assisted dacryocystorhinostomy, conjunctivorhinostomy, and a Jones tube bypass. However, the disadvantages of these methods are that the procedures are complicated and there is a high rate of recurrence. From April 2000 to March 2003, seven patients with epiphora after facial trauma had their lacrimal ducts drained with epidural catheters. The V-M shape incision was used with an epidural catheter placed as a stent for six months. After removal of the tube, all patients recovered fully from the epiphora during the follow-up period, and there were no complications.     

Distal intestinal obstruction syndrome in cystic fibrosis treated by oral intestinal lavage, and a case of recurrent obstruction despite normal pancreatic function.

An oral intestinal lavage solution has been successfully used in the treatment of six patients with chronic distal intestinal obstruction syndrome (previously referred to as meconium ileus equivalent) complicating cystic fibrosis and a further case of recurrent small bowel obstruction. The patient with recurrent obstruction is unusual in having no evidence of pancreatic maldigestion, which previously has been considered a prerequisite for the syndrome.     

Three different types of congenital lacrimal sac fistulas

Three different symptoms in 4 patients with congenital lacrimal sac fistulas are presented. The first symptom was epiphora since birth, the second symptom was infection of the lower eyelid, and the third symptom was tearing from the eye in a 76-year-old patient. This patient had nasolacrimal obstruction at the canal level and no symptoms of congenital lacrimal sac fistula. She had undergone excision, including dacryocystorhinostomy. Three of the 4 patients underwent excision of the fistulous tract. The fistula originated from the lacrimal sac in all patients. Symptomatic congenital lacrimal sac fistulas can be treated successfully with excision alone or with excision and dacryocystorhinostomy in cases of nasolacrimal obstruction.     

Treatment of tracheomalacia: eight years' experience

Between 1978 and 1985, 21 patients were treated for tracheomalacia, (group I) and 4 for tracheobronchomalacia (group II). The median age at treatment was 7 months (range 1 to 96 months). Indications for surgery in group I were, "dying spells" (n = 12), recurrent pneumonia (n = 4), intermittent respiratory obstruction (n = 3) and inability to extubate airway (n = 2). 18 had esophageal atresia repair. Treatment in group I was aortopexy (n = 19), three of whom also required an external airway splint; two had an airway splint only. Airway obstruction was relieved in all. Group II patients required surgery because they could not be extubated; none had esophageal atresia. Aortopexy in all and splinting in one failed in 3 of 4 patients. Aortopexy is the primary treatment of tracheomalacia. External airway splinting may be used where aortopexy is inadequate. A satisfactory treatment for tracheobronchomalacia has not yet been devised.