Comparison of oxymetazoline and lidocaine versus cocaine for outpatient dacryocystorhinostomy

Topical combined tranexamic acid and epinephrine versus topical epinephrine in control of intraoperative bleeding of external dacryocystorhinostomy

PURPOSE

To compare the efficacy of gauze soaked with combined tranexamic acid (TXA) (100 mg/ml) epinephrine 1:200,000 versus gauze soaked with only epinephrine 1:200,000 used to guard against intraoperative bleeding in external Dacryocystorhinostomy (DCR).

PATIENTS AND METHODS

The study included 33 patients; only 30 patients fulfilled the inclusion criteria and were divided randomly into 2 groups using the random numbers table, with 15 patients in each group. The first group (Group A) was operated upon using gauze soaked with combined TXA (100 mg/ml) and epinephrine 1:200,000, while the second group (Group B) was operated upon using gauze soaked only with epinephrine 1:200,000.

RESULTS

The amount of bleeding was significantly lower in group A (29.4 ± 17.1 ml) compared to group B (49.1 ± 18.1 ml), with a P value = 0.005. In addition, the number of used gauzes and total surgical time was significantly lower in group A compared to group B, with P value = 0.008 and 0.01 respectively.

CONCLUSION

External DCR using gauze soaked with combined TXA (100 mg/ml) and epinephrine 1:200,000 showed a significant reduction in the amount of intraoperative bleeding compared to gauze soaked with epinephrine 1:200,000 only. The reduction in the amount of bleeding with the addition of TXA resulted in clearer surgical field, shorter surgical time and more surgeon satisfaction.Query.

Dacryocystectomy as a treatment of chronic dacryocystitis in the elderly

To evaluate the dacryocystectomy (DCT) outcomes for chronic dacryocystitis in an elderly population over 70 years old. A retrospective chart review was performed for patients over 70 years old who were diagnosed with chronic dacryocystitis and underwent DCT at the Botucatu School of Medicine, UNESP, Brazil, from 2007 to July 2014. Data were collected about patient demographics, age, gender, previous nasal, or ophthalmic diseases, symptoms related to the lacrimal drainage system preoperatively and postoperatively, signs of enlargement of the lacrimal sac (regurgitation of secretion), and histopathologic evaluation. The study sample was comprised of 17 patients with an average age of 76.5 ± 8.5 years. The major complaint for all patients was tearing and 17.6% patients had an additional complaint of discharge. Regurgitation of secretion with lacrimal sac expression was present in 76.5% of patients. Postoperatively, 76.5% of the patients reported improvement of the initial complaint, likely due to the total excision of the lacrimal sac which removed the focal site of chronic infection. Epiphora persisted in 23.5% of patients, of whom 11.7% underwent successful lacrimal stent intubation. DCT for chronic dacryocystitis should be considered a primary procedure in individuals over 70 years old. This procedure has a much lower risk to these patients who often have associated comorbidities.

Improving Results in Closed Nasal Reduction: A Protocol for Reducing Secondary Deformity

BACKGROUND

Nasal fractures are the most common facial fracture. Improper reduction is a common occurrence, resulting in a residual deformity that requires secondary surgery. A treatment protocol for nasal fracture management is presented with the aim of reducing secondary deformities requiring corrective surgery.

METHODS

After institutional review board approval, a retrospective review of all closed nasal reductions performed by a single surgeon between 2006 and 2015 was conducted. Patient age, sex, presence of secondary deformity, and need for a correctional operation were recorded. Clinical records were analyzed for evidence of postoperative deformity and need for subsequent manipulation or surgery.

RESULTS

A total of 90 patients with nasal bone fractures who underwent closed nasal reduction were identified. The mean age of patients was 24.9 years. The male-to-female ratio was 2.2:1. Postoperative deformity was reported in 14 patients (15.6 percent). Four of the 90 patients (4.4 percent) were found to have avulsion of their upper lateral cartilage from the nasal bone. Nine of the 14 subjects (64.3 percent) presenting with secondary deformity were managed with external manipulation, avoiding a secondary operation. Five patients (5.5 percent) from the original cohort of 90 underwent revision surgery.

CONCLUSIONS

By using the described protocol to treat nasal fractures, we have seen a low rate of postreduction deformity and a small percentage of need for secondary operation. The overall success rate of closed nasal reduction with postoperative manipulation (when necessary) was identified to be 94.5 percent. Using this protocol, surgeons may see a decrease in secondary deformities following closed nasal reduction procedures.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Awake Laryngoscopy in the Emergency Department

BACKGROUND

Many emergency physicians gain familiarity with the laryngeal anatomy only during the brief view achieved during rapid sequence induction and intubation. Awake laryngoscopy in the emergency department (ED) is an important and clinically underutilized procedure.

DISCUSSION

Providing benefit to the emergency physician through a slow, controlled, and deliberate examination of the airway, awake laryngoscopy facilitates confidence in the high-risk airway and eases the evolution to intubation, should it be required. Emergency physicians possess all the tools and skills required to effectively perform this procedure, through either the flexible endoscopic or rigid approaches. The procedure can be conducted utilizing local anesthesia with or without mild sedation, such that patients protect their airway.

CONCLUSION

We discuss two clinical scenarios, indications/contraindications, patient selection, and steps to performing two approaches to awake laryngoscopy in the ED.

Assisted local anesthesia for powered endoscopic dacryocystorhinostomy

PURPOSE

The role of assisted local anaesthetic (aLA) for both endoscopic and external dacryocystorhinostomy is a well-tolerated and established approach. However the tolerability of aLA is unclear with powered burrs used in powered endoscopic DCR (PEDCR). We aim to evaluate the acceptability of aLA for PEDCR.

METHODS

This is a prospective, interventional, non-randomized, non-comparative, single surgeon study. Consecutive series of patients that underwent PEDCR performed under aLA were included in the study. Tolerability was assessed by intra-operative pain score on 100 point visual analogue scale (VAS) and if patients were willing to have aLA-PEDCR again.

RESULTS

A total of 44 PEDCR was performed on 42 patients.56% of patients reported 0 on 100 point VAS, 65.9% (29/44) reported <10, 88.6% (39/44) reported <20 and no patients had score of >30/100. 97.7% (43/44) of patients are happy to have PEDCR performed again under aLA. The one patient unwilling to have a repeat aLA-PEDCR was not because of pain but intolerance to the sound of drilling.

CONCLUSION

PEDCR with assisted local anaesthetic is well tolerated and accepted by patients.

Topical cocaine vs adrenaline in endoscopic sinus surgery: a blinded randomized controlled study

BACKGROUND

Adequate surgical field visualization is among the most important factors in preventing complications in functional endoscopic sinus surgery (FESS). The aim of this study was to assess the effect of topical cocaine vs adrenaline on surgical field visualization and intraoperative bleeding during FESS.

METHODS

A randomized controlled trial was conducted. A total of 37 patients that underwent FESS for chronic rhinosinusitis were randomized to the side of the nose that received adrenaline or cocaine-soaked patties, and the side that was operated first. The surgeon evaluating the bleeding was blinded to the vasoconstrictor allocation. At the commencement of surgery and at regular 15-minute intervals, the operating surgeon evaluated the extent of bleeding in the operative field according to a validated scale. At each assessment, mean arterial pressure (MAP), heart rate, and end tidal CO2 were also recorded. At the end of each side, total blood loss was measured.

RESULTS

There was no difference in the mean surgical field scores between the adrenaline and cocaine sides (2.04 ± 0.75 vs 2.17 ± 0.7, p = 0.24), nor the total blood loss (p = 0.43). On the cocaine side, there was a correlation between surgical field grade and duration of surgery (p < 0.05) as well as blood loss (p < 0.05) and MAP (p < 0.05).

CONCLUSION

There is no difference in the quality of the surgical field achieved through the use of topical cocaine or adrenaline during FESS. Either of these agents can be effectively used for topical decongestion at the onset of surgery.

[Comparison between topical anaesthesia with cocaine versus lidocaine plus adrenaline for outpatient laser dacryocystorhinostomy]

OBJECTIVE

To evaluate the effectiveness of topical anaesthesia with cocaine versus lidocaine plus adrenaline for outpatient transcanalicular and endonasal dacryocystorhinostomy (TCLDCR) with diode laser under sedation.

METHODS

A double blind randomised clinical trial was designed using topical anaesthesia for outpatient TCLDCR in the treatment of adult epiphora. A total of 92 patients were enrolled, and randomly allocated to be operated on under sedation and topical anaesthesia with cocaine 4% pledgets versus sedation and topical anaesthesia with lidocaine 2% plus 1/100.000 adrenaline pledgets. Main outcome measures were postoperative comfort, evaluated by a visual analogue scale, presence of secondary effects (blood pressure, heart rate), and resolution of epiphora, evaluated by Munk's scale and endoscopic control.

RESULTS

Patients in both groups reported being comfortable during and immediately after TCLDCR. Visualization of the operative field was adequate, and surgery was successfully completed in all cases. Complications were more common in the cocaine group: Sixteen patients from the cocaine group had high blood pressures, versus 2 patients from the lidocaine group (RR=8). Mean blood loss was 6.09 ml in cocaine group, versus 2.05 ml in lidocaine group (RR=6). Both parameters were statistically significant (p=1,1×10(-9)). There were no cases of postoperative epistaxis requiring nasal packing or hospital admission in any group. Success rate was similar in the 2 groups (86.96% group 1 and 89.13% group 2), after 6 months of follow-up.

CONCLUSIONS

The combination of topical lidocaine and adrenaline is more effective for outpatient transcanalicular and endonasal dacryocystorhinostomy than topical cocaine. Patient comfort was adequate in both groups, but high blood pressure and blood loss more common after cocaine.

Simplified local anesthesia technique for external dacryocystorhinostomy without nasal packing: a new technique and pilot study outcome

BACKGROUND

The purpose of this paper is to describe a simplified local anesthesia technique for external dacryocystorhinostomy (EXT-DCR).

METHODS

In this pilot, retrospective, noncomparative, interventional case series, 448 patients (480 eyes) underwent EXT-DCR using a simplified local anesthesia technique. Nasal mucosal anesthesia was achieved using combined application of 6 mL of oxymetazoline 0.025% nasal spray and lidocaine 1% in the same spray bottle, without any packing of the nose with either pledgets or ribbon gauze. Local infiltration anesthesia consisted of subcutaneous injection of a 7 mL mixture of 2% lidocaine with 1:100,000 epinephrine injected on the flat side of the nose beneath the incision site, in addition to a second medial peribulbar injection (3 mL, 2% lidocaine without epinephrine).

RESULTS

Successful unilateral or bilateral EXT-DCR was achieved in 432/448 patients (96.4%). Four patients could not tolerate the procedure under local anesthesia and were converted to general anesthesia. Four patients required additional local anesthetic injections because of intolerable pain. Heavy sedation was essential in eight uncooperative patients because surgical manipulation was impossible. The remaining patients tolerated the procedure well. The intraoperative bleeding rate was very low except in one patient. Mean operative time was 16 minutes. Severe postoperative epistaxis was observed in four patients. Temporary anosmia developed in one patient.

CONCLUSION

Our simplified local anesthesia approach of EXT-DCR is convenient for the patient because it avoids unnecessary nasal packing. It is also safe and effective, as evidenced by the high rate of successful completion of the procedure without conversion to general anesthesia or the need for supplemental local anesthesia.

Pain during external dacryocystorhinostomy with local anesthesia

Background

External dacryocystorhinostomy (DCR) is often performed under local anesthesia (LA) without adequate knowledge of the pain experienced by the patient.

Material/Methods

We subdivided our surgical technique into stages easily understood by the patients (introducing cotton tipped applicators, performing parabulbar injection, creating the incision, bone cracking (opening the ostium), manipulating the nose, intubating, closing the wound, and packing with gauze). A total of 50 patients ranging in age from 31 to 83 years of age (63.64±9.64) underwent external DCR. Each patient was asked 30 minutes after surgery to indicate the intensity of pain experienced at each stage of the surgery and during intramuscular (IM) injection of an antibiotic using a visual analog scale (VAS).

Results

Analysis of the VAS-based pain scores indicated 3 statistically equal occurrences of pain coinciding with the opening of the ostium, and receiving both parabulbar anesthetic and IM antibiotic injections.

Conclusions

The level of pain experienced during the most unpleasant stage of external DCR (ostium opening) was similar to the pain experienced from an IM injection. Patients can be informed that pain during external DCR with local anesthesia is comparable to receiving an IM gluteal injection.

Xylometazoline pretreatment reduces nasotracheal intubation-related epistaxis in paediatric dental surgery

BACKGROUND

Epistaxis is the most common complication encountered during nasotracheal intubation (NTI) in children. The aim of this study was to test the efficacy of prophylactic intranasal admixture of xylometazoline and local anaesthetic gel in reducing epistaxis after NTI in children.

METHODS

Children presenting for dental procedures requiring NTI were randomly allocated into two groups: Group 1 (xylometazoline group, n=53) and Group 2 (control group, n=51). After sevoflurane inhalation induction, the more patent nostril in each subject was lubricated with lidocaine 2% (1 ml) jelly, followed by 0.6 ml of either xylometazoline hydrochloride 0.1% nasal drops (Group 1) or sodium chloride 0.9% (Group 2). The presence and extent of bleeding occurring during intubation, extubation, or both and navigability through the nasal passage were assessed.

RESULTS

The incidence and severity of bleeding were significantly reduced between the study group (7.5%) compared with the control group (27.5%; P<0.01). Navigability was similar in both groups.

CONCLUSIONS

Admixture of intranasal xylometazoline 0.1% drops and lidocaine 2% jelly reduced the incidence and severity of epistaxis after NTI in preschool children.

Single-prick infiltration anesthesia for external dacryocystorhinostomy

PURPOSE

To determine the effectiveness, complications and patient acceptance of single-prick local anesthesia for external dacryocystorhinostomy (DCR).

METHODS

Data were prospectively collected from January 2004 to March 2006 on 463 patients undergoing external DCR operated by a single surgeon. All surgeries were performed under single-prick local infiltration anesthesia. Replies to the Verbal Rating Scale (VRS) were recorded to measure pain intraoperatively at various steps of the surgery. Patients were specifically asked about discomfort during the surgery and whether they would undergo surgery under the same anesthesia if needed for the other eye.

RESULTS

The mean operative duration was 15.50 minutes (range 14-18 minutes). There were 298 females and 165 males. The mean age was 46.5 years (range 17-81 years). The patients reported being comfortable during and immediately after surgery. The VRS was 3-4 (mild pain) for the degree of pain during bone removal and flaps formation. The VRS was 0-2 (no pain) during skin incision and wound closure. None of the patients required additional anesthesia during surgery. None of the patients complained of nausea or vomiting intraoperatively or in the immediate postoperative period. The majority of the patients preferred the same anesthetic technique for surgery in the other eye if required.

CONCLUSIONS

Single-prick local infiltration anesthesia for external DCR is safe, effective and has good patient acceptance.

Assisted local anaesthesia for endoscopic dacryocystorhinostomy

BACKGROUND

Endoscopic dacryocystorhinostomy is traditionally performed under general anaesthesia. However, there are reports in the literature of various local anaesthetic techniques with or without sedation for this procedure. An effective and acceptable local anaesthetic technique enables the avoidance of the risks associated with general anaesthesia, particularly for elderly patients, with the added benefit of reduced bleeding, reduced nausea and vomiting, and reduced length of hospital stay and thus health care cost savings. This study aims to evaluate the safety and patient acceptance of a minimally invasive assisted local anaesthetic technique for endoscopic dacryocystorhinostomy.

METHODS

A prospective questionnaire-based study is presented of 24 consecutive adult patients who underwent 26 endoscopic dacryocystorhinostomies in a day surgery including 22 primary and four revision procedures performed by one surgeon under local anaesthesia and sedation over a 4-month period.

RESULTS

Apart from persistent postoperative vomiting in one patient there were no anaesthetic complications. There were no instances of epistaxis. The mean pain score on a visual analogue scale of 0-10 was 1.56 and 56% reported no pain. Ninety-two per cent would recommend the procedure to others.

CONCLUSION

This assisted local anaesthetic technique for endoscopic dacryocystorhinostomy is safe and acceptable to patients.

Simultaneous bilateral external dacryocystorhinostomy

PURPOSE

To assess the outcome and complications of simultaneous bilateral external dacryocystorhinostomy (DCR) surgery.

METHODS

The records of all patients who underwent bilateral external DCR in a single session between November 1999 and October 2005 were reviewed.

RESULTS

The study cohort comprised 59 patients (50 females, nine males; age range: 6-72 years; mean age: 49 years). Nasolacrimal duct obstruction was acquired primarily in 54 patients, congenitally in three and secondary to sinonasal surgery in two. Thirteen eyes of eight patients had a history of unsuccessful lacrimal surgery. The operation was performed under local anaesthesia plus sedation in 54 patients (92%). Total intraoperative haemorrhage varied from 3 mL to 200 mL (median: 17 mL; mean: 37 mL). Excessive intraoperative haemorrhage (= 100 mL) occurred in five patients (9%). Total duration of surgery varied between 70 and 140 min, with an average of 89 min. Postoperatively, early bleeding requiring intranasal tamponade developed in one patient (2%) and bilateral wound infection in one patient (2%). Surgical success rate was 95%. Mean follow-up time was 8.8 months (range: 3-38 months).

CONCLUSION

This study supports that the simultaneous bilateral external DCR surgery may not adversely affect surgical success and complication rates.

Oxymetazoline solutions inhibit middle ear pathogens and are not ototoxic

OBJECTIVES

This study was performed to explore the antimicrobial activity of two commercially available oxymetazoline hydrochloride preparations against the common pathogens of otitis media and to demonstrate the lack of ototoxicity of these agents and of United States Pharmacopeia (USP) oxymetazoline in a standard animal model.

METHODS

Disc diffusion assays and minimum inhibitory concentration studies against American Type Culture Collection reference strains of common middle ear pathogens were used to evaluate the antimicrobial activity of oxymetazoline solutions and fluoroquinolone drops, and outer hair cell counts were performed on scanning electron micrographs of guinea pig basal cochlear segments after chronic exposure to oxymetazoline solutions and positive and negative controls.

RESULTS

Oxymetazoline nasal spray and eyedrops had activity against all species tested except Haemophilus influenzae and Pseudomonas aeruginosa. The USP oxymetazoline had limited antimicrobial activity. Oxymetazoline nasal spray, oxymetazoline eyedrops, and USP oxymetazoline had ototoxicity profiles indistinguishable from that of the saline solution control.

CONCLUSIONS

Commercially available oxymetazoline solutions are active against several of the common pathogens of otitis media. This antimicrobial activity is not due to oxymetazoline, and is more likely due to preservatives present in the solutions. The solutions tested are not ototoxic to guinea pig outer hair cells. Oxymetazoline solutions are potential substitutes for broad-spectrum antibiotic drops after tympanostomy tube placement.

Local versus general anesthesia for external dacryocystorhinostomy in young patients

PURPOSE

To compare the effectiveness, complications, and patient acceptance of local anesthesia with general anesthesia in young patients for external dacryocystorhinostomy (DCR).

METHODS

Data were prospectively collected over an 8-year period (1996-2004) on young patients (mean age: 22.64+/-1.71) undergoing external DCR in Gulhane Military Medical Academy. Patients were randomly allocated in two groups: general anesthesia (GA) and local anesthesia (LA). Of the 480 DCR procedures, 182 were performed with general anesthesia (44 bilateral), 298 were performed with local anesthesia (32 bilateral). Visual analogue scales were recorded in the postoperative 2-hour period. Postoperative nausea and vomiting (PONV), epistaxis, length of hospital stay, and intraoperative bleeding were noted.

RESULTS

Patients in both groups reported being comfortable during and immediately after surgery. Only 2 patients in the LA group required additional local anesthetic because of pain. Intraoperative bleeding was lower in the LA group. Analgesic requirement and signs of nausea and vomiting in the GA group were higher in the early postoperative period (p<0.05). The incidence of PONV was higher (p<0.05) in the GA group. Postoperative epistaxis was observed in 12 patients in the GA group and just 2 patients in the LA group. Length of hospital stay was 2.29+/-0.46 days in the GA group, and 1.23+/-0.42 days in the LA group (p<0.01).

CONCLUSIONS

Local anesthesia in DCR is safe and comfortable when proper anatomical approach to nerve blocks is performed correctly. Local anesthesia in young patients undergoing external DCR is a good alternative because it is cost-effective and it eliminates the complications of general anesthesia.

External dacryocystorhinostomy and local anesthesia: technique to measure minimized blood loss

PURPOSE

To describe the techniques required to minimize blood loss in external dacryocystorhinostomy (DCR) under local anesthesia and to accurately measure the intraoperative blood loss through application of these techniques.

METHODS

Prospective single-surgeon series to include the first 20 sequential external DCRs from June 2002. Hemostasis was maximized at each stage of the procedure. Blood loss was measured by attaching a collection pot to the first link in the vacuum tubing. Patient demographics and operative duration were recorded.

RESULTS

The mean blood loss was 4.5 mL (range, 1 to 14 mL). The mean operative duration was 36 minutes (range, 25 to 65 minutes). Seventy-five percent of patients were female and 25% were male. The mean age was 57 years (range, 48 to 76 years).

CONCLUSIONS

Intraoperative blood loss in external DCR can be reduced to a negligible level through careful patient preparation and operative technique. Minimal blood loss allows for patient comfort with DCR under local anesthesia.

Obstruction of the lacrimal drainage system

This review covers evolving concepts in lacrimal outflow obstruction. Recent studies have increased our understanding of the surgical anatomy and pathophysiology of the lacrimal drainage system through radiologic, clinical, and microbiologic techniques. While external dacryocystorhinostomy remains an important treatment for nasolacrimal duct obstruction, there have been a number of therapeutic developments worthy of review, including advances in endoscopic and transcanalicular dacryocystorhinostomy, conjunctivodacryocystorhinostomy, and the use of mitomycin C in these procedures. In addition, we summarize recent advances in minimally invasive techniques for lacrimal outflow obstruction, including balloon dacryocystoplasty, lacrimal stents, and conjunctivoplasty. Finally, the roles of probing versus irrigation, nasal endoscopy, and endoscopic dacryocystorhinostomy in children are discussed.

Selective antibiotic use to prevent postoperative wound infection after external dacryocystorhinostomy

PURPOSE

The use of systemic antibiotic prophylaxis in lacrimal drainage surgery is controversial. Some studies have reported high rates of postoperative infection and surgical failure after lacrimal drainage surgery when systemic antibiotic prophylaxis was not routinely administered. Many ophthalmologists have traditionally used antibiotics only in selected patients undergoing dacryocystorhinostomy (DCR), and this study evaluates the success of this strategy.

METHODS

This was a retrospective interventional case series of 138 consecutive patients who underwent 163 external DCR procedures. Antibiotics were given only when inflammatory signs were present in the medial canthal region or when purulent material was noted during surgery. Patients with persistent external medial canthal inflammatory signs received amoxicillin/clavulanate or cephalexin orally 3 to 7 days before and 1 week after surgery. Patients in whom purulent lacrimal sac material was noted during surgery received cefazolin intravenously.

RESULTS

Postoperative results were evaluated in terms of wound infection and related complications and surgical success. Systemic antibiotics were given in 15 of 163 (9%) cases. Nine (6%) cases received intraoperative (intravenous) antibiotics; 5 (3%) cases received perioperative (oral) antibiotics; and 1 (1%) case received both. None of the patients had postoperative deep soft tissue infection (cellulitis). Skin changes compatible with superficial wound infection occurred in 2 (1%) cases and responded well to topical treatment. Surgery was successful in 157 of 163 (96%) cases. Of 6 failures, none were associated with postoperative wound infection.

CONCLUSIONS

Selective use of antibiotics limited to patients with signs of lacrimal sac inflammation appears sufficient to prevent soft tissue infection after DCR.

Effectiveness of local anaesthesia for external dacryocystorhinostomy

PURPOSE

To establish the effectiveness, complications and patient acceptance of local anaesthesia (LA) with intra-venous sedation, for external dacryocystorhinostomy (DCR).

METHODS

Data were prospectively collected over a 4-year period (1997-2000) on all patients undergoing external DCR under LA with intravenous sedation by one surgeon and one anaesthetist, using a standardized technique.

RESULTS

Of 183 DCR procedures, 145 (76.5%) were performed using LA in 123 patients aged 24-84 years (median 64 years). Eleven simultaneous bilateral DCR procedures were performed under LA. Another 11 patients had a contralateral DCR at a later date. In only three DCR (2.1%) was supplementation of LA required during the procedure because of pain. The only complication of the technique was one retrobulbar haemorrhage from the medial peribulbar injection. In this patient, the procedure was completed satisfactorily without further sequelae. All patients found the technique acceptable and all 11 patients who returned for surgery on the opposite side at a later date elected to have surgery under LA again.

CONCLUSIONS

External DCR can be satisfactorily and safely performed under LA with a high level of patient acceptance.

Diseases of the lacrimal drainage system

We will refer to lacrimal system pathologies involving the outflow pathways, as well as to the recent advances in the management of canalicular and lacrimonasal duct anomalies, including modifications to dacrycystorhinostomy technique, treatment for congenital obstructions, and lacrimal intubations. Special emphasis will be placed on the usefulness of nasal and canalicular endoscopy for the examination and treatment of congenital obstructions and endonasal pathologies, as an aid for intubations and lacrimal surgery, as well as on reasons for failed procedures.

Endoscopic conjunctivodacryocystorhinostomy with Jones tube placement

OBJECTIVE

Conjunctivodacryocystorhinostomy (CDCR) with Jones tube placement as described by Jones has traditionally been performed as an "open" or external procedure by means of medial canthal incision. Application of endoscopic technique for CDCR with Jones tube placement has not been well described in the peer-reviewed literature.

DESIGN

Retrospective nonrandomized comparative trial.

PARTICIPANTS

Ten patients with epiphora secondary to canalicular stenosis.

METHODS

A total of 13 consecutive CDCR with Jones tube procedures were reviewed. Five procedures (performed predominantly in the early study period) were done by means of a traditional external approach with a medial canthal incision. Eight procedures were performed with an intranasal endoscopic approach and instrumentation with Jones tube placement under direct endoscopic visualization.

MAIN OUTCOME MEASURES

Total operative time, estimated blood lost, intraoperative, and postoperative complications and need for secondary surgery were evaluated.

RESULTS

All procedures were successfully completed with no intraoperative complications. Average operative time was 59 minutes in the endoscopic group and 74 minutes in the external group. Average blood loss was 3.5 ml and 4.4 ml in the endoscopic and external groups, respectively. Postoperative adjustment of tube size or position (performed as an office procedure with topical/local anesthesia) was common: five of eight endoscopic and three of five external approach. Two patients in the endoscopic group required secondary surgery for anatomic reasons. Ultimately, all cases in both groups demonstrated patent, retained Jones tubes and relief of epiphora.

CONCLUSION

Endoscopic technique appears to be a reasonable approach for CDCR with Jones tube placement. Operative time and blood loss were comparable in the two groups, with the endoscopic group being slightly lower for each variable. Endoscopic Jones tube placement can be accomplished with readily available instrumentation. In this series, we did not find it necessary to use laser, radiofrequency, or monopolar devices for intranasal hemostasis.