Distal Nasolacrimal Duct Research Articles

A REPERTOIRE OF ACUTE DACRYOCYSTITIS

Background: Clinical features of acute dacryocystitis comprise of three stages- stage of cellulitis, lacrimal abscess and fistula formation. Infective odontogenic focus is one of the known etiologies for acute dacryocystitis. Pre-septal cellulitis is the most common presentation associated with epiphora. Tenacious inflammation of sac or distal nasolacrimal duct obstruction can result in a lacrimal abscess. Unattended abscess may consequently form a fistula. Acute dacryocystitis rarely can get complicated to cause orbital cellulitis overstriding the anatomic barriers. Case Presentation: Case1: A 72/F complained of toothache since a week, followed by diffuse swelling below lower eyelid, pain and discharge near medial canthus. The case was diagnosed as acute dacryocystitis with pre-septal cellulitis due to apical abscess of right maxillary molar which was visualised on orthopantomogram. Case2: A 36/M presented with mild pre-septal cellulitis and lacrimal abscess. Case3: A 79/M presented with diminution of vision, pain and inability to move the right eye. He had history of watering for8 years. He was diagnosed to have orbital cellulitis with fistula secondary to acute on chronic dacryocystitis. Discussion: Case 1: Symptoms resolved spontaneously with emergency access opening of right first maxillary molar and systemic intravenous broad-spectrum antibiotics. She further underwent dacryocystectomy with fistulectomy. Case 2: Lacrimal abscess was managed with incision and drainage followed by dacryocystorhinostomy. Case 3: Orbital cellulitis was managed with broad-spectrum intravenous antibiotics. Dacryocystectomy with fistulectomy was performed after the eye was quiet. Conclusion: Presentation of dacryocystitis can have variable causes hence proper history and addressing underlying cause at the earliest can help in early resolution. Aggressive management of complications can help in steady subsidence without progression.

Does Bicanalicular Intubation Improve the Outcome of Endoscopic Dacryocystorhinostomy?

The aim of this study was to compare the success of endoscopic dacryocystorinostomy with and without bicanalicular intubation in the treatment of distal nasolacrimal duct obstruction. Methods: In a prospective, randomized, comparative study, endoscopic dacryocystorinostomy without bicanalicular silicone intubation (Group I) and endoscopic dacryocystorinostomy with intubation (Group II) were performed in patients with distal nasolacrimal duct obstructions. The tubes were removed 3 months after surgery in Group II, and the patients were followed up for 6 months after surgery. Therapeutic success was defined as the fluorescein dye disappearance test grade 0–1 corresponding with a complete resolution of symptoms. Results: Thirty patients, aged 23–86 years, were included in the study. The success rate was 13/15 (86.67%) in Group I and in 14/15 (93.33%) in Group II. The difference between the two groups was not statistically significant (p = 0.483). Most common complications were granulations that occurred in 1/15 (6.67%) patient in Group I and in 2/15 (13.33%) patients in Group II. Adhesions in rhinostomy with epiphora and persistent secretion were observed in 1/15 (6.67%) patient in Group II. Conclusions: Bicanalicular intubation does not significantly increase the success rate of EDCR in distal nasolacrimal obstruction in adults.

Endoscopic Findings of a Cosmetic-Associated Distal Nasolacrimal Duct Pigmentation.

Endoscopic Findings of a Cosmetic-Associated Distal Nasolacrimal Duct Pigmentation.

A study of clinical profile of patients undergoing endonasal endoscopic dacryocystorhinostomy without stenting in a teaching hospital of Western Gujarat

<p class="abstract"><strong>Background:</strong> Chronic dacryocystitis is commonly treated with dacryocystorhinostomy (DCR). The aim of the study was to analyzed the clinical profile of patients suffering from distal Nasolacrimal duct (NLD) blockage and outcomes of EnDCR without stenting in patients with chronic dacryocystitis. </p><p class="abstract"><strong>Methods:</strong> This prospective observational study consisted of 50 patients who underwent EnDCR without stenting at ENT department of Gujarat Adani Institute of Medical Sciences during the period of October 2019 to September 2021, after taking IEC consent. All patients with distal NLD blockage were included in study. Pre-operative, intra-operative and post-operative details were recorded as per pre-validated proforma and data was analyzed using Microsoft excel sheets.</p><p class="abstract"><strong>Results:</strong> Watery discharge from eye was most common chief complaint (76%) during presentation followed by watery discharge and swelling over medial end of eye both (20%) and swelling over medial end of one eye (4%). Most common duration of chief complaint was between 3 to 12 months. In our study, out of 50 patients, 31 cases were operated under local anesthesia and 19 were operated under general anesthesia. Out of 50 operated cases, only 3 patients had stenosis of ostium at 3-month follow-up. Overall success rate of endoscopic endonasal DCR without stenting was 94%.</p><p><strong>Conclusions:</strong> The success rate of endonasal dacryocystorhinostomy without stenting is as high as that of external dacryocystorhinostomy and endonasal DCR with stenting without the disadvantages of either one. </p>

Endoscopic dacryocystorhinostomy (EDCR) – A single group experience in an evolving technique and a review of literature

Introduction: Endoscopic dacrocystorhinostomy (EDCR) is increasingly becoming a popular method of treating distal nasolacrimal duct obstruction (NLDO) in the modern era. In this article, through literature review and personal experience, we plan to recommend a management protocol mainly concentrating on surgical technique. Secondarily, we would also like to make the case for EDCR over traditional DCR as both techniques have comparable success rates. Objective: To detail surgical technique with emphasis on evolution of surgical steps citing the literature pertaining to various methods. Methods: A literature review was carried out using keywords endoscopic DCR and dacryocystorhinostomy techniques. In a retrospective study, EDCR case data was collected concentrating on surgical methods used. The data was then analysed using the Microsoft excel statistical analysis package. Results: Details of 136 cases were assessed from the period between 2008 to 2021. 9 key surgical steps of the procedure were identified. Discussion: Highlights of recommendations include performing a ‘first look’ endoscopy before starting the surgical procedure, optional usage of the ‘light pipe’ during sac exposure, complete removal of the sac and sending it for histology, duct stenting is useful particularly in younger patients and post-operative local application of triamcinolone in prevention of granulations at the surgical site.

Nasolacrimal duct stenosis-Surgery with a novel robotic endoscope positioning system.

Distal nasolacrimal duct stenosis is usually treated by head and neck surgeons with transnasal endoscopic dacryocystorhinostomy (DCR). The presented clinical study discusses advantages and drawbacks of a robot-assisted endoscope positioning system, which allows for hands-free visualization of the surgical field. Two patients were treated by surgical DCR. The endoscopic positioning system (Medineering® ) features a mechatronic holding arm with four segments and seven degrees of freedom. It is driven by using a foot pedal. Visualization and instrumentation of the surgical field including the relevant anatomical landmarks were feasible. The endoscope position could be controlled with sufficient precision. The surgeon was able to maintain bimanual instrumentation. The endoscope positioning system allows for two-handed surgery, which facilitates the essential steps of the surgical procedure. If the benefit of the system is sufficient for the use in clinical routine, it has to be evaluated in repeated applications.

Outcome of Primary Probing for Simple Membraneous Congenital Nasolacrimal Duct Obstruction in Children Older Than 4 Years.

To report outcomes of nasolacrimal duct (NLD) probing in children 4 years and older with simple membranous NLD obstruction. The records of all patients 4 years and older with congenital NLD obstruction who underwent surgery from 1997 to 2015 at Washington University School of Medicine were retrospectively reviewed. Of 47 patients reviewed, 18 (38.3%) were found to have simple membranous obstructions and were included in this study. Simple membranous obstruction was present at the distal duct and was relieved with passage of the probes in all patients. Children with canalicular or diffuse distal NLD stenosis (as defined by a tight, gritty feeling or multiple obstructions when passing the probe through the bony portion of the NLD), trisomy 21, lacrimal trauma, or craniofacial abnormalities were excluded. A successful outcome was determined by resolution of epiphora and periocular crusting. Eighteen patients with ages ranging from 4.1 to 10.6 years with simple membranous NLD obstruction were treated. Sixteen of 18 (88.9%) patients had good outcomes following NLD probing. Two patients had persistent symptoms that resolved following balloon dilation and stent placement. This study found that the success rate of probing in older patients with simple membranous NLD obstruction was comparable to that of younger patients. NLD probing alone is a good treatment option for older children with simple membranous NLD obstruction. Additional procedures such as balloon catheter dilation or stent placement may not be necessary at the time of initial probing. [J Pediatr Ophthalmol Strabismus. 2020;57(1):44-47.].

Primary fistulectomy of congenital lacrimal fistula: A case report

A 13-month-old male patient presenting with epiphora and discharge in his left eye present since birth was assessed in our clinic. Epiphora and an orifice of fistulae next to the left nasal root were identified via physical examination. Punctual mucoid discharge was observed following a massage of the left lacrimal sac. Chronic lacrimal fistulae were diagnosed in terms of stain outflow from the fistula orifice following a trypan blue injection to the lacrimal sac under general anesthesia. The patency of the distal nasolacrimal duct was confirmed by performing lavage following the fistulectomy procedure. The epiphora disappeared and the nasolacrimal passage was open in post-operative care.

Probing for congenital nasolacrimal duct obstruction.

Probing for congenital nasolacrimal duct obstruction.

Distal Nasolacrimal Duct Showing the Valve of Hasner

Recognition of the location of the nasolacrimal duct opening is important to prevent its damage while performing an intranasal inferior meatal antrostomy or creating a window transantrally in the inferior meatal wall during a Caldwell-Luc procedure.

Inferior meatus surgery for distal nasolacrimal duct obstructions: long-term outcomes and treatment paradigm.

Epiphora is a symptom resulting from obstruction of the nasolacrimal system. Classically, dacryocystorhinostomy has been performed to relieve epiphora. However, this does not address distal obstruction. Inferior meatus (IM) surgery at or near Hasner's valve has been shown to have a 92.8% short-term success rate in treating distal nasolacrimal duct (NLD) obstruction. In addition, IM surgery for proximal obstruction has shown poor success rates. Differentiation between distal and proximal obstruction would allow for more appropriate treatment and improved patient outcomes. To date, no study has addressed long-term outcomes or the workup for distal and proximal NLD obstructions. To report long-term outcomes in a subset of patients with epiphora due to distal NLD obstruction who underwent IM surgery and to present a treatment paradigm to differentiate distal from proximal NLD obstruction. This retrospective medical record review with follow-up telephone survey was conducted at a tertiary referral center. Participants were patients surgically treated for epiphora from July 2006 to March 2010. Inferior meatus surgery was performed to relieve epiphora in patients with distal NLD obstruction. Improvement or resolution of epiphora. Seventeen patients were contacted for follow-up; 13 patients responded, representing 18 nasolacrimal systems. One patient (2 sides) was excluded owing to the surgical specimen showing leukemic infiltrates. Mean time of follow-up was 6.2 years. Ten sides had distal NLD obstruction. Of the nasolacrimal systems with distal obstruction, 9 had long-term subjective improvement of symptoms (90%). No patient had nasal complications. Directed IM endoscopic surgery resulted in long-term improvement of epiphora in 90% of nasolacrimal systems when performed for distal NLD obstruction. A treatment paradigm was developed and is detailed herein.

English

Endonasal dacrocystohinostomy (DCR) is the surgery used for chronic dacrocystitis, where the patient has epiphora caused by blocking of nasolacrimal duct, leading to collection of lacrimal fluid in the sac which ends in inflammation of the lacrimal sac. As the success rate of endonasal DCR varies from 50---97%, various different methods are used to have high success rate. It is very important to make the ostium at the level of the common canaliculus. If the exposure of lacrimal sac is not sufficient then even though Mitomycin is applied the rate of failure remains high. INTRODUCTION: Epiphora is the most bothersome complication of lacrimal system obstruction. Other than it relapsing dacrocystitis, dacryocele and dacryolithiasis, latter being quite rare, are the other indications of dacrocystorhinostomy. DCR is a surgical procedure in management of obstructive epiphora. Obstructive epiphora finds today his best solution with a surgical procedure Dacrocystorhinostomy by nasal endoscope. The lacrimal flow is diverted into nasal cavity through an artificial opening made at the level of lacrimal sac. DCR can also be performed by an external approach. It is called external DCR. In comparison of both, endonasal DCR has certainly many advantages; minimally invasive procedure, better aesthetic results with no cutaneous scar, preserves lacrimal pump system, faster resumption to daily activities, any intranasal pathology that might have caused obstruction can be addressed at the same time, active infection of the lacrimal system is not a contraindication to the surgery, it is much less bloody than the external approach, the per-operative time is shorter. If the obstruction is in puncta or canaliculus, endonasal; DCR will not help. Mitomycin—C is an alkaline agent used as anticancer, isolated from streptomyces Caespitosus. It inhibits the synthesis of DNA, cellular RNA and proteins in the rapidly growing cells. It has the ability to suppress fibrosis and vascular growth hence can reduce possibility of stenosis of the newly created ostium. We used Mitomycin –C (0.5 mg/ml) for 5 minutes over osteotomy site. MATERIAL AND METHODS: Three hundred patients (300), who presented with epiphora, were selected and operated for Endonasal DCR. The patients ranged from 5 years to 85 years of age. One hundred and thirty nine (139) were males and one hundred and sixty one (161) were females. All of them had epiphora which was not responding to medical line of treatment. Some of them had relapsing dacrocystitis, some had persistent purulent, sticky discharge from eye, and some had lacrimal abscess or fistula. All the patients were examined by ophthalmologist prior to surgery. The clinical evaluation included probing of nasolacrimal system and lacrimal irrigation. The nasal cavity had an adequate examination using 0 degree Endoscope and intranasal pathology that might have caused the obstruction was determined preoperatively. The indication for endonasal approach included distal nasolacrimal duct obstruction. All the patients were examined by an ophthalmologist prior to the surgery. DOI: 10.14260/jemds/2014/2641

Diode laser photoablation to correct distal nasolacrimal duct atresia in an adult horse

An 8-year-old Hanoverian mare was presented for chronic mucopurulent discharge in the left eye, which was responsive to topical antibiotic therapy. The nasolacrimal orifice was absent in the left nasal meatum, and anterograde irrigation of left nasolacrimal duct was not possible. Dacryocystorhinography was performed and revealed about 4-6 cm of distal nasolacrimal duct atresia. A novel technique was attempted with the horse under standing sedation using an urinary catheter and a 980 nm diode laser with a 600 μm diameter flexible bare quartz fiber. A nasolacrimal orifice was successfully created by ablating the nasal mucosa directly over the tip of the urinary catheter, and patency was maintained with a soft catheter sutured in place for 4 weeks. At 3 months re-evaluation, the left nasolacrimal duct was patent and functional. This case report describes a successful novel surgical technique used to correct congenital distal nasolacrimal duct atresia in an adult horse under standing sedation. Advantages over conventional surgical techniques are shorter operating time and limited hemorrhage.

Iatrogenic Nasolacrimal Duct Obstruction following Tooth Extraction in a Cat

A 10-year-old DSH cat was referred for a dental evaluation and extraction procedure. Subsequently, the animal developed an acute onset of ocular discharge. Ophthalmologic examination revealed presence of unilateral ocular mucoid discharge leading to a diagnosis of epiphora secondary to nasolacrimal duct obstruction. Dacryocystorhinography was performed and confirmed the presence of a nasolacrimal duct obstruction, presumably acquired after an invasive dental procedure. Additionally, a vinyl cast in situ study of the nasolacrymal apparatus was performed to demonstrate the route of the nasolacrimal duct in the cat and its relationship to oral dental structures. This report documents an unusual case in which excessive inflammation/edema following tooth extraction caused acute epiphora secondary to extraluminal compression of the distal nasolacrimal duct.

The Results of Pediatric External Dacryocystorhinostomy

Aim: To present our results of external dacryocystorhinostomy (DCR) operations in pediatric patients with distal nasolacrimal duct obstruction. Material and Methods: This study included 6 pediatric patients (3 boys, 3 girls) with distal nasolacrimal duct obstruction underwent external DCR. The median age was 9.0 years (range 4-14). All patients had a large hydrops lacrimal sac in lipiodol dacryocysrography. The patients underwent U-flap DCR and only anterior mucosal flaps were formed. Surgical success was accepted as the absence of epiphora and open lacrimal passage with irrigation. Results: The patients were examined at 1st week and 1, 3, 6. and 12 months. The cases were followed for a minimum of 6 months and a maximum of 24 months (mean follow up was 13.8 months). All nasolacrimal ducts were open with irrigation at all control. Surgical success was 100% (6/6). No severe intraoperative or postoperative complication occurred in any case. Conclusion: DCR was concluded as a successful surgical procedure for the pediatric age group in appropriate cases. Key Words: Pediatric Nasolacrimal Duct Obstruction; External Dacryocystorhinostomy.

Congenital Nasolacrimal Duct Obstruction

To characterize anatomical abnormalities of the distal nasolacrimal duct (NLD) in children with congenital obstruction using high-resolution computed tomographic imaging. The anatomy of the bone and soft tissue of the NLD and the postductal anatomy of the inferior meatus in 6 children with a wide spectrum of NLD obstructions were imaged by computed tomographic scans and then reconstructed in a 3-dimensional viewer. Images were taken from prior axial (5 children) or coronal (1 child) computed tomographic facial scans at 0.625- or 1.25-mm mm resolution, respectively. The axial computed tomographic images and 3-dimensional reconstructions showed bony obstructions of the distal NLD in 3 children, membranous obstructions of the distal NLD in 1 child, and a postductal obstruction in the inferior meatus in 1 child. One child had a combined soft tissue obstruction of the NLD and post-NLD obstruction. This study provides anatomic evidence of a bony or membranous obstruction at the distal portion of the NLD or of a postductal obstruction at the inferior meatus in children with congenital NLD obstruction.

Eksternal Dakriyosistorinostomide Mukozal Flep Tekniğinin Cerrahi Başarı Üzerine Etkisi: H Flep mi? U Flep mi?

Purpose: To compare the effects “H” and “U” flap technique on surgical success in external dacryocystorhinostomy (DCR). Method: This study included 50 eyes of 50 patients (36 women, 14 men) with the diagnosis of distal nasolacrimal duct obstruction. All cases underwent external dacryocystorhinostomy (DCR). The patients were divided into 2 groups according to their order of operation. The first 25 cases were included in Group 1 and the next 25 cases were included in Group 2. In the first group, qHq shaped incision was made in the sac and nasal mucosa then patients assigned to anterior and posterior flap anastomosis. In the second group only anterior flap was prepared by qUq shaped incision was made in the sac and nasal mucosa and the patients assigned to only anterior flap anastomosis. All surgical steps were performed in the same way in all cases, except for the flap technique. Silicone intubation was not performed in any patient. Results: The mean ages were 42.7p14.3 (range: 18-60) and 44.2p13.4 (range: 22-65) in group 1 and 2, respectively. The mean follow-up period was 10.5p3.6 (range: 7-14 mo.) and 11.4p4.2 (range: 5-13 mo.) months in group 1 and 2, respectively. Lacrimal drainage pathway was open in twenty one patients (%84) in Group 1 and 25 patients (%100) in Group 2, at last post-operative examination and all preoperative complaints were disappeared. Conclusion: The rate of surgical success may increase with U-flap technique in DCR surgery. Prepearing of large enough flaps is possible with this technique in the patients with small sacs as well as the patients with big sacs. Key words: External Dacryocystorhinostomy; Mucosal Flap Technique; U-Flap; H-Flap.

Endoscopic Endonasal Retrieval of a Nasolacrimal Duct Stone via the Valve of Hasner in the Inferior Meatus

A 37 year old man presented with a 6 month history of a right epiphora with associated mucus discharge. Lacrimal irrigation demonstrated right unilateral partial nasolacrimal duct obstruction, confirmed with lacrimal scintigraphy. Nasal endoscopy showed a pale elevation in the right inferior meatus. Endoscopic endonasal examination revealed a yellow-white nasolacrimal duct stone emerging from the valve of Hasner in the inferior meatus. The distal nasolacrimal duct in the lateral wall of the inferior meatus was marsupialised and the stone removed. At 12 months follow-up the patient maintained complete resolution of symptoms.

Dacryocystitis: Systematic Approach to Diagnosis and Therapy.

The objective of this paper is to review the main findings of the largest studies on the etiopathogenesis and microbiology of the development of dacryocystitis and to formulate clinical and surgical guidelines based on said studies and on our experience at Cruces Hospital, the Basque Country, Spain. The most common sign of this entity is the distal nasolacrimal duct obstruction, and this should be treated to prevent clinical relapse. The time when surgery should be indicated mainly depends on the clinical signs and symptoms, age and general status of a patient. Given the germs isolated in cases of dacryocystitis, antibiotic therapy against Gram positive (S. aureus, S. pneumoniae, S. epidermidis) and Gram negative bacteria (H. influenzae, P. aeruginosa) should be administered, orally in adults and intravenously in pediatric patients, prior to surgery. Gentamicin and amoxicillin-clavulanic acid have been found to be effective against the bacteria commonly implicated in the etiopathogenesis of this entity.

The Nasolabial Cyst: A Nonodontogenic Oral Cyst Related to Nasolacrimal Duct Epithelium

Nasolabial cysts are interesting, relatively uncommon benign extraosseous maxillary lesions. We review current knowledge about epidemiology, symptoms, imaging modalities, pathogenesis, histopathologic and ultrastructural features, treatment options, and prognosis. Nasolabial cyst lining epithelium is characteristically composed of a basal layer of cuboidal cells and a luminal layer of columnar secretory cells with interspersed mucous goblet cells. In addition, areas of multilayered epithelium and squamous metaplasia may be seen. The cyst stroma is characterized by collagen-rich fibrovascular tissue with variably admixed chronic inflammatory cells. Furthermore, to our knowledge, we report the first example of immunohistochemical protein expression profiling of nasolabial cyst lining epithelium, discovering that basal layer cells express p63 and cytokeratin 5/6, while goblet cells express MUC-2 and MUC-5AC mucins, supporting the notion that nasolabial cysts can be understood as hamartomatous, locally expansile remnants of distal nasolacrimal duct development.