Bony nasolacrimal duct dehiscence in functional endoscopic sinus surgery: radiological study and discussion of surgical implications

The role of CT-DCG in hardware - associated secondary acquired lacrimal duct obstruction: SALDO update study - (SUP) - Paper III

Purpose

To study cases of hardware-associated secondary acquired lacrimal duct obstructions (SALDO) and the role of computed tomography dacryocystography (CT-DCG) scans in its diagnosis and management.

Observations

Retrospective, interventional case review of four patients diagnosed as Hardware-associated SALDO, with primary maxillofacial repair performed elsewhere, were analyzed. The mean age was 36.5 years (range: 22-74 years), three of them being males. Left and right lacrimal systems were equally involved. Epiphora, swelling and discharge were the main presenting features. Three lacrimal sacs and nasolacrimal ducts on CT-DCG showed the screws of the orbital fracture plate directly piercing their walls, whereas a single case showed the sac displaced and pierced by the medial side of the orbital floor implant. Two cases underwent dacryocystorhinostomy with intubation, and the remaining two had to undergo dacryocystectomy due to extensive damage. Post-operatively all four cases were doing well at a mean follow-up of 2 months.

Conclusions

The present series highlights the role of CT-DCG in delineating spatial relationship of lacrimal drainage system with the surrounding structures, facilitating planning as well as choice of surgery, and anticipating the intraoperative challenges. It also signifies importance of interdisciplinary coordination between oculoplastic and maxillofacial surgeons to avoid iatrogenic trauma to the lacrimal drainage system.

Early trends of secondary acquired nasolacrimal duct obstruction in COVID-19 associated sino-orbital mucormycosis: SALDO update study (SUP) - Paper IV

Purpose

To study the emerging trend of development of secondary acquired nasolacrimal duct obstruction (SALDO) in the cases treated for rhino-orbito-cerebral mucormycosis (ROCM).

Observations

Prospective, interventional case series of five patients who developed SALDO post-surgical and medical management of ROCM. The mean age was 45.4 years (range: 40-62 years), all five being males. Right lacrimal drainage pathways was involved slightly more than the left (right:left = 3:2). Epiphora and discharge were the main presenting features. All five patients were treated with extensive debridement of the nose, sinuses, orbit and cerebral involvement as needed followed by medical management for ROCM. CT- Dacryocystography for all 5 patients showed obstruction at the lower end of the nasolacrimal duct. The patients underwent external dacryocystorhinostomy with mitomycin-C with or without intubation with good anatomical and functional outcomes at 6 months follow-up.

Conclusions and importance

The present series highlights the possible etiology of development of SALDO in cases treated for ROCM, its management and discusses the role of Computed Tomography Dacryocystography (CT-DCG) in understanding the pathophysiology of the development of SALDO along with delineating the spatial relationship of the lacrimal drainage system with the surrounding structures.

Lacrimal Sac Reconstruction Using a Nasal Mucosal Graft

Iatrogenic lacrimal drainage trauma during surgery is not common. It has been reported during orbital surgeries, medial maxillectomies, post-trauma repairs, excision of adherent lesions in the vicinity, and facial reconstructive procedures. The present case reports a focal loss of the lacrimal sac wall during the excision of an intricate dermoid cyst. The defect was sealed by a nasal mucosal graft harvested from the floor of the ipsilateral nasal cavity. Postoperatively, the epiphora was resolved, and a CT-dacryocystography confirmed the anatomical integrity of the reconstructed lacrimal sac.

Relationship of the anterior ethmoid sinus to the lacrimal sac: a computed tomography study

OBJECTIVE

To analyze the anatomical relationship between the lacrimal sac and the agger nasi cell on Computed Tomography (CT); to correlate the right and left sides on each scan.

METHODS

CT scans of adult patients were reviewed for pneumatization of the agger nasi and its relationship to the lacrimal sac. The degree of agreement between the right and left sides was also evaluated.

RESULTS

A total of 130 CT scans were examined. An agger nasi cell was found medial to the lacrimal sac in 59.23% of scans. On 86.15% of scans, pneumatization was similar on both sides.

CONCLUSION

The agger nasi air cell is located medial to the lacrimal sac in more than half of individuals. The right and left sides exhibit the same pneumatization pattern in approximately 80% of cases.

LEVEL OF EVIDENCE: 4

Radiological evaluation of lacrimal apparatus injury after functional endoscopic sinus surgery

OBJECTIVE

To determine the incidence of nasolacrimal duct injury after functional endoscopic sinus surgery radiologically, using computed tomography.

METHODS

Fifty patients of either sex who underwent functional endoscopic sinus surgery were evaluated for nasolacrimal duct injury by computed tomography. Computed tomography was conducted pre-operatively, and post-operatively at the end of four weeks, and nasolacrimal duct injury was analysed.

RESULTS

The prevalence of nasolacrimal duct injury dehiscence was 1.16 per cent, with a similar incidence of 1.16 per cent for nasolacrimal duct injury post-operatively. However, no cases of symptomatic nasolacrimal duct injury were recorded.

CONCLUSION

Computed tomography scan is an effective, non-invasive method to evaluate nasolacrimal duct injury following functional endoscopic sinus surgery, in accordance with evidence-based medicine.

Patency of the nasolacrimal drainage system after power‐assisted medial flap turbinoplasty

Objective

Turbinoplasty is a common procedure for the management of nasal blockage resulting from inferior turbinate hypertrophy. There are many ways to perform turbinoplasty; however, power‐assisted medial flap turbinoplasty provides reliable reduction and long‐lasting results compared to other techniques. The aim of this study was to assess the patency of the nasolacrimal drainage system after power‐assisted medial flap turbinoplasty and to investigate the safety of this procedure with regard to drainage of the nasolacrimal ducts.

Methods

This prospective study included 31 patients (62 turbinates) who underwent power‐assisted medial flap turbinoplasty in the period between January 2017 and December 2017 and had a normal nasolacrimal drainage system as confirmed by endoscopic fluorescein dye test preoperatively. The test was repeated 3 months postoperatively to test for patency.

Results

All the patients showed normal drainage of the fluorescein dye from the inferior meatus preoperatively and postoperatively as well. No other major complications resulting from the power‐assisted medial flap turbinoplasty procedure were reported.

Conclusion

Power‐assisted medial flap turbinoplasty is a safe and effective procedure. There was no nasolacrimal duct injury among our patients and we did not observe any major complications.

Level of Evidence

IIb

Evaluation of the effect of inferior turbinate outfracture on nasolacrimal transit time by saccharin test

AIM

To evaluate the effect of inferior turbinate outfracture on nasolacrimal transit time by saccharin test.

MATERIALS AND METHODS

Twenty patients who underwent septoplasty + unilateral radiofrequency ablation and outfracture of inferior turbinate were enrolled into study. They had no complaints about their eyes and denied previous ocular surgery. Their nasolacrimal saccharin transit times (NSTTs) were estimated preoperatively and postoperatively in the 1st and 2nd months. The non-fractured side eye was measured only once preoperatively. The fractured-side eye was measured three times. These times were compared statistically.

RESULTS

There were 8 men and 12 women. Mean age was 29.04. Killian incision was used in 14 and hemitransfixion incision was used in 6 patients. Median NSTT was 484, 461, 490 and 446 s for the non-fracture side, preoperatively and postoperatively in the 1st and 2nd months, respectively. There was no statistically significant difference between the two eyes preoperatively, and in the fractured side preoperatively and postoperatively in the 2nd month. There were significant differences between median NSTT in postoperative 1st month and median NSTT in the preoperative measure, and between postoperative 1st and 2nd months (p < 0.05). Median NSST in the 1st month was longer than the others.

CONCLUSION

Outfracture of inferior turbinate had no permanent effect on NSTT 2 months after surgery in patients that had a healthy nasolacrimal system.

Entire lacrimal sac within the ethmoid sinus: outcomes of powered endoscopic dacryocystorhinostomy

BACKGROUND

The aim of this study was to report the outcomes of powered endoscopic dacryocystorhinostomy (PEnDCR) in patients with lacrimal sac within the sinus.

MATERIALS AND METHODS

Retrospective analysis was performed on all patients who underwent PEnDCR and were intraoperatively documented to have complete lacrimal sac in sinus. Data collected included demographics, clinical presentations, associated lacrimal and nasal anomalies, intraoperative findings, intraoperative guidance, complications, postoperative ostium behavior, and anatomical and functional success. A minimum follow-up of 6 months postsurgery was considered for final analysis.

RESULTS

A total of 17 eyes of 15 patients underwent PEnDCR using standard protocols, but with additional intraoperative guidance where required and careful maneuvering in the ethmoid sinus. The mean age of the patients was 37.2 (range 17-60) years. Of the unilateral cases, 69% (nine of 13) showed left-side predisposition; 80% of patients showed regurgitation on pressure over the lacrimal sac area. Associated lacrimal and nasal anomalies were observed in 13.3% (two of 15) and 40% (six of 15), respectively. At a mean follow-up of 6.6 months, anatomical and functional success were observed in 93.3% (14 of 15). One patient showed failure secondary to cicatricial closure of the ostium.

CONCLUSION

An entire sac within an ethmoid sinus poses a surgical challenge. Good sinus-surgery training, thorough knowledge of endoscopic anatomy, careful maneuvering, and use of intraoperative navigation guidance result in good outcomes with PEnDCR.