A Case of Successful Endoscopic Dacryocystorhinostomy in Nasolacrimal Duct Obstruction with Wegener Granulomatosis

PURPOSE: To report a case of nasolacrimal duct obstruction occurring in a patient with Wegener granulomatosis treated successfully with endoscopic dacryocystorhinostomy. CASE SUMMARY: A 36-year-old female diagnosed with Wegener's granulomatosis 3 years prior and treated with rituximab and currently taking azathioprine 100 mg presented with a 1-year history of left epiphora and mucus in the left eye. Her left tear meniscus was higher than the right and was a hard stop with lacrimal probe when a lacrimal probing test was performed. Mucus was regurgitated during lacrimal irrigation and middle turbinate was not observed due to granuloma in the nasal cavity. Dacryocystography showed proximal nasolacrimal duct obstruction and a well-defined dacryocystocele 6 x 5 x 6 mm in size was observed on the left lacrimal fossa on facial 3D computed tomography. After synechiolysis for a granuloma in the nasal cavity, endoscopic dacryocystorhinostomy was performed and silastic sheet sutured on the nasal septum to prevent resynechia. After 2 weeks and 4 months, the silastic sheet and silicon tube were removed, respectively. The patient was asymptomatic following surgery and there was no regurgitation during lacrimal irrigation test. The ostium was patent at 5 months after surgery using the endoscopic dye test. CONCLUSIONS: Nasolacrimal duct obstruction occurring in a patient with Wegener's granulomatosis can be treated effectively with endoscopic dacryocystorhinostomy even if the nasal cavity is narrow due to granuloma.

The Effect of Nasal Packing with Rolled Silastic Sheet after Closed Reduction of Nasal Bone Fracture

PURPOSE: Nasal bone fracture is the most common type of facial bone fracture and most of nasal bone fracture is combined with septal fracture frequently. Nasal septum is important to support the distal nose and to maintain the nasal airway. But nasal septal fractures are usually unrecognized and untreated at the time of operation. Recently, various materials were using for nasal packing after closed reduction, however these materials are not focused on the correction of nasal bone and nasal septal fracture and many patients are suffered from nasal packing materials. Thus, the purpose of this study is to compare routine packing materials and rolled silastic sheet with respect to postoperative effect of correction of nasal bone fracture and discomfort of nasal packing materials. METHODS: We examined 320 patients treated nasal bone fracture from January 2008 to December 2010. For Group I(n=92), Merocel(R) was used for nasal packing, for Group II(n=152) vaseline gauze was used, and Rolled silastic sheet(RSS) with vaseline gauze packing(VGP) was used for Group III(n=76). Under the general anesthesia, all patients were operated by closed reduction and nasal packing was done using three kinds of packing materials. At the time of postoperative 7 days, packing material was removed and studied for pt's satisfaction and postop. complications. RESULTS: In patients with RSS with VGP, the complaints (nasal obstruction, foreign compressive sensation and discomfort during food ingestion) of keeping the nasal packing were decreased(p0.05). CONCLUSION: Postoperative nasal packing with RSS with VGP was more comfortable to the patients and it was more effective method to correct the nasal bone fracture and nasal septal fracture.

Comparison of Clinical Efficacy Between Tie Methods of Silicone Tube Intubation in Nasolacrimal Duct Obstruction

PURPOSE: To compare the clinical outcome of silicone tube intubation according to the tie methods. METHODS: Eighty-eight eyes of 87 patients who underwent silicone tube intubation were divided into two groups based on the tie method: a silicone silastic sheet group (Group 1, n=59) and a nylon 6-0 suture knot group (Group 2, n=29). The two groups were compared according to their success rates, recurrence rates and complications. RESULTS: No significant difference was found in the success rate between the two groups (83.0% in Group 1 and 82.7% in Group 2). However, Group 2 showed a significantly higher rate of postoperative complications than Group 1. In Group 1, 5/59 (8.4%) eyes had ocular irritation, 2/59 (3.4%) eyes exhibited tube prolapse, conjunctivitis, corneal erosion, and dacryocystitis and 1/69 (1.6%) eyes had a punctal slit after intubation. In Group 2, 3/29 (10.3%) eyes had ocular irritation, 2/29 (6.9%) eyes exhibited tube prolapse, conjunctivitis, a punctal slit, and dacryocystitis, and 1/29 (3.4%) eyes showed corneal erosion, or a granuloma after intubation. A recurrence of symptomatic tearing was found in 6/59 (10%) eyes in Group 1 and 3/29 (10%) in Group 2. CONCLUSIONS: In silicone tube intubation of incomplete NLD obstruction, the usage of silicone silastic sheets to tie both ends of the silicone tube produced a lower complication rate and a higher success rate than that of the suture knot group. Lower tension on the nasolacrimal passage in the silicone silastic sheet group allows for a significantly lower rate of punctal slit development. Therefore, the method of using silicone silasitic sheets can be considered useful in the treatment of NLD obstruction.

Prevention of Lateral Synechia Formation with Silastic Sheet in the Endoscopic Sinus Surgery / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Lateral synechia formation between the middle turbinate and the lateral nasal wall is one of the most common complications in endoscopic sinus surgery. Unstable and floppy middle turbinate occurs not infrequently and it may make meticulous postoperative dressing difficult during healing period, and consequently increases the risk of synechia and recurrence of sinusitis. The aim of this study was to investigate whether insertion of the silastic sheet in the middle meatus can effectively prevent the synechia formation. SUBJECTS AND METHOD: Twenty eight patients (31 sides including 3 bilateral cases) with unstable and floppy middle turbinate occurred during endoscopic sinus surgery were enrolled in this study. The silastic sheet was designed in fan-shape and inserted between the middle turbinate and the lateral nasal wall. The silastic sheet was secured to the caudal septum and removed 2 to 3 weeks after the operation. We performed a follow-up study for 5 months and investigated the occurrence rate of synechia. RESULTS: The success rate of our method was 90.3% and synechia in the middle meatus developed in 3 of 31 sides (9.7%). Although synechia between the middle turbinate and nasal septum occurred in 4 sides, the patients did not complain of olfactory disturbance. CONCLUSION: The results of this study suggest that insertion of the silastic sheet in the middle meatus can be a useful method in the prevention of lateral synechia formation when unstable and floppy middle turbinate has developed during endoscopic sinus surgery.

A Silastic Sheet found during Endoscopic Transnasal Dacryocystorhinostomy for Acute Dacryocystitis

PURPOSE: To report the case of a silastic sheet that was found during an endoscopic transnasal dacryocystorhinostomy for treatment of acute dacryocystitis with necrosis of the lacrimal sac. METHODS: A thirty-two year old male presented with painful swelling on the nasal side of his left lower lid two weeks prior to visiting this clinic. Fourteen years ago, the patient was involved in a traffic accident and underwent surgery to reconstruct the ethmoidal sinus. Lacrimal sac massage showed a regurgitation of a purulent discharge from the left lower punctum. Therefore, the patient was diagnosed with acute dacryocystitis and an endoscopic transnasal dacryocystostomy was performed the next day. RESULTS: The surgical finding showed severe necrosis around the lacrimal sac and a 20 x 15-mm sized silastic sheet was found crumpled within the purulent discharge. The sheet was removed, the lacrimal sac was irrigated with an antibiotic solution, and a silicone tube was intubated into the lacrimal pathway. After surgery, the painful swelling on the nasal side of left lower lid resolved gradually, and there were no symptomatic complications three months later. CONCLUSIONS: We report the first case where a silastic sheet applied during a facial reconstruction had migrated adjacent to the lacrimal sac resulting in severe inflammation.

Clip Reinforcement Technique by Circumferential Wrapping with Silastic Sheet for Treatment of Cerebral Aneurysms and Its Follow-Up Outcome / 대한뇌혈관외과학회지

OBJECTIVE: To describe the clip reinforcement technique by circumferential wrapping with silastic sheet for the treatment of unclippable cerebral aneurysms and evaluate its long term follow-up results. METHODS: The nature of 26 unclippable aneurysms were as follow:12 blister-like superior wall aneurysm of internal carotid artery (ICA), 6 microaneurysms (<2 mm), 4 fusiform aneurysms, 4 broad-based aneurysms. After aneurysm and the parent artery are circumferentially wrapped by silastic sheet, aneurysm clips are positioned on the sheet with parallel to the parent artery. The mean follow-up period was 37 months (range, 3-140 months). RESULTS: 25 of 26 patients had a favorable outcome and one patient had a severe disabled due to severe vasospasm at 3 months after operation. Of the 21 patients who underwent immediate angiographic examination, stenosis of parent artery was detected in 6 patients and remnant of aneurysm in 4 patients. Asymptomatic occlusion of parent artery was observed in one patient on follow-up angiographic examination. 22 of 24 patients followed-up for a long time had a favorable outcome and 2 patients had a severe disabled (one patient was due to previous severe disabled and the other was due to thalamic intracerebral hematoma developed during the follow-up period). CONCLUSION: In our study, there was no clip reinforcement technique-related clinical complications such as rebleeding of aneurysm or ischemic event during follow-up period. Clip reinforcement technique by circumferential wrapping with silastic sheet is simple and useful method for the unclippable cerebral aneurysm.

Surgical Consideration for Internal Carotid Superior Wall Aneurysm

Seven cases of aneurysm arising from the superior wall of the internal carotid artery were operated on from January 1993 through December 1997. They consist of 3.7% among 191 operated cases of the internal carotid artery aneurysms and 1.2% among 590 operated cases of total intracranial aneurysms. Aneurysmal adhesion to the optic nerve was observed in five cases and the arteriosclerotic change in two cases. Four aneurysms were blister-like and thin-walled, and the other two aneurysms were covered with thick hematoma. Premature rupture occurred in three cases, two cases during aneurysmal clipping and one case during aneurysmal dissection. In three cases the aneurysms were clipped, and in the other four cases the aneurysms were wrapped circumferentially with the dacron mesh silastic sheet and clipped. Among the four wrap-clipping cases, two cases were associated with very fragile aneurysmal walls. There were neither clip sliding nor the regrowth of aneurysms on the following angiograms. The Glasgow Outcome Scale at discharge showed good recovery in five cases, moderately disabled in one case, and severely disabled in one case. In conclusion, wrap-clipping with the silastic sheet is helpful for the superior wall aneurysms of internal carotid artery with very fragile and thin walls or avulsion of aneurysmal neck.

Treatment of Blow-out Fracture Located in the Posterior Portion of the Orbital Floor

Until now, there has been many papers about orbital blow-out fracture, but reports regarding the treatment and the prognosis of fractures located in the posterior portion of the orbital floor have been limited. The most common fracture site of the orbital floor is the medial portion of the infraorbital groove and repairing of the floor fracture located in the anterior portion of the floor is relative easy and has minimal complications. But when the fracture is located in the posterior portion of the floor, the possibility of the optic nerve injury is anticipated by surgical manipulation itself and the implanted silastic sheet Authors reconstructed posterior portion of the orbital floor fracture through conjunctival approach combined with Caldwell-Luc procedure in 5 patients, confirmed posterior orbital floor fracture on CT scan from July 1993 to November 1994. The results were satisfactory with no residual diplopia. Complications including prolonged maxillary sinusitis and lateral canthal deformity were encountered in each patient, but cured with ENT treatment and lateral canthoplasty. In reconstruction of orbital floor fracture, Caldwell-Luc approach was seldom used because of several reasons including the poor predictability, bleeding problrm, and the high incidence of sinus infection. But recently, Caldwell-Luc approach is reanimated by some endoscopic surgeons because of good visualization and less traumatic. In case of posterior floor fracture, our surgical method can reduce the possibility of injury to optic nerve and vital tissues around the orbital apex in spite of enlarging surgical field.