Nasolacrimal Duct Obstruction: An Unusual Presentation of Sarcoidosis.

Lacrimal drainage system disorders leading to epiphora are a common ophthalmologic complaint. When such a patient is identified, the ophthalmologist frequently collaborates with the otolaryngologist to perform a dacryocystorhinostomy (DCR). In rare cases, sinonasal sarcoidosis may lead to nasolacrimal duct obstruction (NLD) and dacryocystitis. A 48-year-old Caucasian female was referred to the Otolaryngology clinic for evaluation of a 6-month history of persistent right-sided nasal obstruction and epiphora. After physical examination and computerized tomography (CT) scan, she was diagnosed with right NLD with dacryocystitis. The patient underwent right endoscopic DCR. Pathology from the lacrimal bone and nasal tissue demonstrated noncaseating granulomas suggestive of sarcoidosis. Postoperative evaluation including lung CT scan confirmed systemic sarcoidosis. Nasolacrimal duct obstruction very rarely is the presenting symptom in patients with sarcoidosis. Imaging is necessary to rule out other causes of NLD, and histopathology is essential for diagnosis. Noncaseating granulomas are found along the nasal tissue and lacrimal sac, specifically in the subepithelial layer. Treatment consists of DCR, either endoscopic or external. Both approaches achieve long-lasting resolution of symptoms but may require revision from inflammation and scarring. There is no consensus on the use of intraoperative or postoperative steroids.

Endoscopic Approach for Excision of Venous Malformation of the Orbital Apex.

INTRODUCTION: Venous malformation is a common tumor of the orbit, presenting with visual impairment and proptosis. These lesions can be excised via an external or transcranial approach, but recent advances in minimally invasive surgery have led to increased popularity of endoscopic approach. PATIENT: The authors report a 62-year-old female presenting with diplopia and proptosis, found to have a 1.7-cm venous malformation of the orbital apex. An endoscopic trans-nasal approach was undertaken for surgical resection. RESULTS: The tumor was successfully removed in a single specimen, without injury to the nearby orbital anatomy. The patient experienced resolution of her presenting symptoms 3 weeks after the procedure, with no adverse effects. A review of the literature demonstrates increasing reports of similar successful cases. CONCLUSION: A minimally invasive, endoscopic resection of orbital venous malformation is possible and provides a reasonably safe and effective approach. Further large-scale studies are needed to fully explore its outcomes relative to traditional approaches.

Postoperative radiographs after ACL reconstruction are not cost-effective.

Postoperative radiographs have become standard after anterior cruciate ligament (ACL) reconstruction, even though few findings in the literature substantiate their efficacy. The goal of this study was to determine whether routine postoperative radiographs were cost-effective in patients undergoing ACL reconstruction. In addition, the authors sought to determine whether these radiographs provided meaningful clinical information that changed postoperative management. Between January and December 2010, the authors retrospectively reviewed all patients who underwent ACL reconstruction at their institution. The clinical course of all patients was reviewed to determine whether the results of the radiograph at the time of interpretation changed the plan of care. All radiographs were then scrutinized for abnormal findings that could have changed the plan of care if noted at the time of follow-up. Of 624 patients who underwent ACL reconstruction, 340 (54.4%) had a postoperative radiograph within 30 days. No radiograph showed a complication as interpreted by the surgeon at the time the radiograph was obtained, and no changes were made in routine postoperative care. On final review of each radiograph, none showed findings that would have changed management. The cost of performing and interpreting radiographs was $42.62 per patient, with a combined cost of $14,490.80. The findings of the study showed that postoperative radiographs after ACL reconstruction should not be considered "routine" practice. In addition, because these studies provided little clinical information, they are recommended only when symptoms suggest a mechanical complication and in cases of unforeseen postoperative trauma.

Approach to the active patient with chronic anterior knee pain.

The diagnosis and management of chronic anterior knee pain in the active individual can be frustrating for both the patient and physician. Pain may be a result of a single traumatic event or, more commonly, repetitive overuse. "Anterior knee pain," "patellofemoral pain syndrome," and "chondromalacia" are terms that are often used interchangeably to describe multiple conditions that occur in the same anatomic region but that can have significantly different etiologies. Potential pain sources include connective or soft tissue irritation, intra-articular cartilage damage, mechanical irritation, nerve-mediated abnormalities, systemic conditions, or psychosocial issues. Patients with anterior knee pain often report pain during weightbearing activities that involve significant knee flexion, such as squatting, running, jumping, and walking up stairs. A detailed history and thorough physical examination can improve the differential diagnosis. Plain radiographs (anteroposterior, anteroposterior flexion, lateral, and axial views) can be ordered in severe or recalcitrant cases. Treatment is typically nonoperative and includes activity modification, nonsteroidal anti-inflammatory drugs, supervised physical therapy, orthotics, and footwear adjustment. Patients should be informed that it may take several months for symptoms to resolve. It is important for patients to be aware of and avoid aggravating activities that can cause symptom recurrence. Patients who are unresponsive to conservative treatment, or those who have an underlying systemic condition, should be referred to an orthopedic surgeon or an appropriate medical specialist.