Complex Stenoses and CT Features of the Nasolacrimal Canal in Congenital Nasolacrimal Duct Obstruction.

PURPOSE: To study the CT appearance of the nasolacrimal canal (NLC) in cases of congenital nasolacrimal duct obstruction (CNLDO) where there is a tactile sensation of a hard contact (HC) stop in the duct preventing stent intubation. METHODS: The authors retrospectively reviewed all consecutive cases of chronic CNLDO observed between 2003 and 2018 in which an apparent HC obstruction prevented nasolacrimal intubation. CT scans were reviewed to determine the cause of probing failure: distal stenosis, loss of parallelism of the NLC walls, abnormal angulations or an adjacent obstacle blocking tear outflow. RESULTS: Nine patients (12 sides) met the following criteria: CNLDO + HC + probing failure. The mean age at the time of the first HC was 3.9 years (range: 0.8-8.1 years) and at the time of a second confirmation of HC with subsequent dacryocystorhinostomy was 7.8 years (range: 4.1-9.2 years). Nasolacrimal duct opacification was noted in 33% of cases (4/12). Abnormalities of the NLC occurred in 8 of the 12 cases of CNLDO (8/12 = 66.6%) and on the asymptomatic side in 1 case (1/6 = 16.6%). A canine tooth bud situated in the same plane as the NLC was observed in 9 cases of CNLDO (9/12 = 75%) and on the asymptomatic side in 2 cases (2/6 = 33.3%). CONCLUSIONS: HC noted during probing is a sensitive but relatively nonspecific sign which, nevertheless, does indicate either a complex obstruction or at least potential intubation difficulties. As confirmed by CT imaging, a significant anatomical variant is not necessarily predictive of epiphora, but nevertheless may complicate the intubation procedure.The authors describe hard contact palpation during probing for CLNDO and its relationship to anatomic location and etiologies of obstruction in the nasolacrimal canal by CT imaging.

Complex Bony Congenital Nasolacrimal Duct Obstruction Caused by an Adjacent Canine Tooth Bud.

The authors report the case of a 7-year old child with failed probing with stent intubation, who was found to have an unusual curvature of the nasolacrimal duct on the symptomatic side. CT imaging revealed a permanent maxillary canine tooth adjacent to the duct. It appeared that the relationship of the tooth bud to the curved nasolacrimal duct was most likely responsible for the symptoms of epiphora on this anomalous side.

Endoscopic dacryocystorhinostomy: the keys to surgical success.

PURPOSE: To describe a surgical technique for endoscopic endonasal dacryocystorhinostomy. METHODS: A consecutive case series of adult endoscopic dacryocystorhinostomy surgery was reviewed. The specific surgical approach of uncinectomy with or without septoplasty and anterior middle turbinectomy was noted. Postoperative follow up including endoscopic examination and results were documented. RESULTS: A total of 300 cases were included (271 patients) with average age of 66 (range 24-94). An uncinectomy was performed in 285 of 300 (95%) cases, a septoplasty in 82 of 300 (27%) cases and an anterior middle turbinectomy performed in 225 of 300 (75%) cases. Postoperative bleeding that required nasal packing occurred in 2 of 300 (0.6%) cases. Persistent nasolacrimal symptoms after surgery occurred in 18 of 300 (6.0%) cases with an average follow up of 28 months (range 1-70). Postoperative nasolacrimal symptoms were attributed to a persistent lacrimal sac (sump syndrome) in 1 of 300 (0.3%) cases, a mucocele recurrence in 2 of 300 (0.6%) cases, and scarring at the rhinostomy in 15 of 300 (5.0%) cases. CONCLUSIONS: Endoscopic endonasal dacryocystorhinostomy is an effective treatment for nasolacrimal duct obstruction. An uncinectomy, septoplasty, and anterior middle turbinectomy contribute to the optimal clearance of the common canaliculus and ultimate surgical success.

Pushed monocanalicular intubation: an alternative stenting system for the management of congenital nasolacrimal duct obstructions.

PURPOSE: To present our experience with a "pushed" monocanalicular nasolacrimal intubation device in the management of nasolacrimal duct obstruction in children. METHODS: The cases of consecutive patients with nasolacrimal duct obstruction who were treated with primary probing and intubation with the Masterka were reviewed retrospectively. The Masterka includes a metal guide placed inside a silicone tube for "pushed" intubation as opposed to material attached at the distal end of the silicone for intranasal retrieval ("pulled" intubations). All procedures were accomplished with the patients receiving masked airway anesthesia; neither laryngeal mask airway nor endotracheal intubation was necessary. Only patients noted to have a membranous (mucosal) obstruction were considered for treatment with the Masterka. The duration of operation, duration of stent intubation, and severity of symptoms on follow-up were noted. Success was defined as absence of symptoms after stent removal or loss. RESULTS: A total of 110 eyes of 88 patients were included (average age, 2.4 years; range, 1-8 years). The average operating time was 3 minutes (range, 2-9 minutes). Persistent tearing on follow-up with the stent in place was noted in 26 eyes (24%); tearing resolved after stent removal in 19 eyes (73%). Success was achieved in 94 eyes (85%). with an average follow-up of 33.7 weeks (range, 4-139). Keratitis was noted in 2 eyes (2%). Early stent loss occurred in 17 ducts (15%). CONCLUSIONS: The Masterka was an effective primary treatment for nasolacrimal duct obstruction associated with mucosal obstructions in this small series of patients.

Surgical anatomy of the lacrimal fossa a prospective computed tomodensitometry scan analysis.

PURPOSE: To establish the accurate surgical anatomy of endonasal dacryocystorhinostomy (DCR) based on the radiological analysis of underlying bony structures. DESIGN: Prospective noncomparative observational case series study. PARTICIPANTS: Fifty-nine patients with complete nasolacrimal stenosis underwent a computed tomodensitometry (CT) scan before endonasal DCR. METHODS: High-resolution CT scanning with contrast injection of the lacrimal sac was performed. Image reconstruction was performed to obtain continuous 1.0-mm axial and coronal sections for review. MAIN OUTCOME MEASURES: Relationship of the lacrimal fossa (LF) to the operculum of the middle turbinate (OMT), the uncinate process (UP), and the frontal recess (FR); symmetry of the right and left anatomies; location of the OMT; position of the most anterior insertion of the UP with respect to 2 main references (the posterior lacrimal crest and the junction between the maxillary and lacrimal bones) on axial sections at 3 different levels (upper, intermediate, and lower of the LF); height of the LF; and distance of the OMT from the lower limit of the LF. RESULTS: The OMT, the UP, and the FR were adjacent to the LF in 41 (53.2%), 73 (94.8%), and 23 cases (29.9%), respectively. There was a right-left symmetry in 10 of 18 patients (55%). The OMT was always anterior to the junction between the maxillary bone and the lacrimal bone. The UP was more frequently posterior (32.5%) or adjacent (45.5%) to the LF at the lower level, adjacent to the maxillary bone (55.8%) at the intermediate level, and adjacent to the middle turbinate (61%) at the upper level. The height of the LF was 12.06+/-1.93 mm. The OMT was located 5.96+/-2.05 mm upward from the lower limit of the LF. CONCLUSION: The almost constant overlapping of the UP onto the LF at the level of the common canaliculus indicates that the most effective approach for successful DCR osteotomy is via a submucosal cleavage and resection of the anterior part of the UP. The management of these landmark structures should be an integral part of the endonasal DCR method.

Complications of standardized endonasal dacryocystorhinostomy with unciformectomy.

PURPOSE: To report the nature and frequency of complications occurring with endonasal dacryocystorhinostomy (DCR) based on routine unciformectomy. DESIGN: Prospective, noncomparative interventional consecutive case series study. PARTICIPANTS: Endonasal DCR was performed on 300 patients with complete nasolacrimal stenosis. METHODS: The uncinate process was resected (unciformian endonasal DCR), except when the lacrimal fossa was anterior to its insertion (23 cases [7.7%]). Preoperative clinical assessment and computed tomography scans, intraoperative endoscopic video recording, and postoperative clinical and endoscopic follow-ups were analyzed for reported endonasal DCR failure and complications. The mean follow-up was 13+/-12.6 months (range, 1-57). MAIN OUTCOME MEASURES: Failure rate, nature, frequency, and time of intraoperative and postoperative complications. RESULTS: Of the 300 patients treated, 39 (13%) suffered from residual epiphora and no passage upon irrigation; there was secondary canalicular stenosis in 2 cases (0.6%), sump syndrome in 4 cases (1.2%), a distal stenosis from progressive healing closure of the ostium in 21 cases (7.0%), a recurrence of lacrimal mucocele in 5 cases (1.7%), and adhesions between the ostium and septum in 2 cases (0.6%). Access to the surgical site required an anterior middle turbinectomy in 103 cases (34.3%) and a septoplasty in 1 case (0.3%). Intraoperative bleeding was minor in 183 (60.6%), moderate in 82 (27.3%), and severe in 35 cases (11.6%). Postoperative bleeding occurred in 4 cases, and was controlled by packing. Transient frontal sinusitis (n = 1), nasal mucosa burn (n = 1), cacosmia (n = 8), phlebitis (n = 1), and maxillary pain (n = 8) also occurred. Orbital fat prolapse, cerebrospinal fluid leaking, cutaneous scarring, diplopia, and loss of vision did not occur. CONCLUSION: Complications from unciformian endonasal DCR may be less frequent or severe than with maxillary endonasal DCR, and comparable to or less frequent than those for external DCR.

Systematic unciformectomy for a standardized endonasal dacryocystorhinostomy.

PURPOSE: To describe a standardized osteotomy method for endonasal dacryocystorhinostomy (en-DCR) and the results obtained. DESIGN: Prospective nonrandomized, noncomparative, interventional case series study. PARTICIPANTS: One hundred consecutive adult patients (81 females, 19 males) underwent en-DCR performed by the same team of oculoplastic and rhinologic surgeons. METHODS: A standardized procedure was used in all cases. This included endoscopic assessment of the surgical site from the nasal aspect, diaphanoscopy of the common canaliculus, and endonasal osteotomy. Anterior unciformectomy was followed by resection of the lacrimal bone and protected drilling of the maxillary bone of the lacrimal fossa to expose the entire medial aspect of the lacrimal sac. The middle turbinate was preserved whenever atraumatic dissection of the nasal mucosa was possible or when it was resected partially before osteotomy. MAIN OUTCOME MEASURES: Rate of direct localization of the lacrimal fossa, rate of turbinectomy/septoplasty, rate of residual postoperative tearing, rate and nature of complications RESULTS: Transillumination of the common canaliculus was obtained directly in 94% of cases; transillumination, required the opening of an ethmoidal cell in 2%, partial resection of the middle turbinate in 3%, and unciformectomy in 1%. Access to the surgical site required partial resection of the middle turbinate in 21% of cases, but no septoplasty. Osteotomy was initiated in 90% of cases by cleavage of the anterior insertion of the uncinate process, and in 5% by cleavage of the first, overdeveloped ethmoidal cell. The cleavage opened directly to the medial aspect of the lacrimal fossa in these 95 cases. Osteotomy was achieved by drilling alone in only five cases. Perioperative complications were limited to significant bleeding in six cases. Postoperative complications included one case of resolved frontal sinusitis on day 3, and one case of inferior lid hematoma with emphysema. CONCLUSIONS: The authors suggest that anterior resection of the uncinate process is the most important surgical step to expose the medial aspect of the lacrimal fossa during endonasal DCR, whereas partial resection of the middle turbinate can be considered optional.