Nasolacrimal Obstruction Following the Placement of Maxillofacial Hardware

Computed Tomography - Dacryocystography Guided Management of Traumatic Secondary Acquired Lacrimal Duct Obstruction: SALDO Update Study (SUP) - Paper V

PURPOSE

To evaluate the role of computed tomography-dacryocystography (CT-DCG) in the management of traumatic secondary acquired lacrimal duct obstruction (SALDO) and study its correlation with the intra-operative findings.

METHODS

Retrospective interventional case series. Eighty-five lacrimal drainage systems (LDS) of 79 patients diagnosed with traumatic SALDO, who underwent pre-operative CT-DCG, between January 2019 and June 2023, were analyzed. The lacrimal intervention included endoscopic dacryocystorhinostomy (En-DCR), external DCR(Ex-DCR), or dacryocystectomy (DCT) based on the clinical presentation, CT-DCG findings, local and systemic factors. Anatomical and functional outcomes were assessed.

RESULTS

Eighty-five LDS of 79 patients with a mean age of 32 years and male predominance (n = 70, 89%) were studied. The median time of trauma to clinical presentation was 12 months and the duration of epiphora was 8 months. Naso-orbito-ethmoid fractures were seen in 56 (66%) cases and cribriform plate fracture in 5 (6%) patients. CT-DCG revealed a dilated sac in 60 (71%) LDS, shrunken in 13 (15%), while the sac could not be visualized in 3 (4%) LDS. Relative lacrimal sac displacement was seen in 51 (64%) LDS of which 21 (41%) were displaced posteriorly, 18 (35%) superiorly, 5 (10%) inferiorly, and 8 (16%) into the anterior orbit. Sac - duct junction was the most common location of obstruction (n = 78, 92%). At a mean follow up period of 3.5 months, 62 of the 63 LDS surgeries performed (98%) demonstrated anatomical and functional success. Of the 63 operated LDS, CT-DCG findings corroborated with intra-operative findings in 60 (95%) LDS.

CONCLUSION

CT-DCG helps decide the surgical approach, possible complications, intra-operative course and hence has the potential to influence the outcomes. A thorough understanding of CT-DCG, therefore, should be a part of a Dacryologist's armamentarium for managing complex SALDO.

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.

Evaluation of nasolacrimal canal morphology in different facial skeletal relationships

BACKGROUND

Abnormal morphological variations of nasolacrimal canal (NLC) and its lack of understanding contributes to acquired injuries during craniomaxillofacial surgical procedures which leads untoward postoperative complications like nasolacrimal obstruction (NLO) and epiphora.

PURPOSE

The purpose of this study was to determine dimensional and volumetric morphological variations of nasolacrimal canal in various facial skeletal relationships which aid in performing a precise and safe surgery.

MATERIALS AND METHODS

This retrospective cohort study involved dimensional and volumetric analysis of nasolacrimal canal procured from computed tomography scans of 47 individuals grouped as ClassI, Class II and Class III, and unilateral cleft lip and palate (UCLP) groups. The outcome variables included length of NLC, volume of NLC, distance between the inferior orifice of the NLC to nasal floor, distance between inferior orifice of NLC to canine apex and distance between inferior orifice of NLC to central incisor apex. The objectives were to analyse morphological variation of NLC in different facial skeletal relationships and to evaluate the variation with change in facial sides and its relationship with surrounding structures.

RESULTS

Volume of the NLC was found significant in Class I and UCLP population (p < 0.05) with the greatest volume in the UCLP group. The mean linear and volumetric measurements between the right and left sides were found insignificant among all groups. Inferior orifice of NLC from canine apex were farthest in Class III and nearest in the UCLP group (p < 0.05). There was no significant association between outcome variables and skeletal base configuration.

CONCLUSION

NLC demonstrates dimensional and anthropometric variations between different skeletal relationships and this study is inevitable in understanding the probability of NLC injury during maxillofacial surgeries.

Endoscopic Dacryocystorhinostomy Following Nasolacrimal Drainage System Trauma and Medial Orbital Wall Reconstruction

Study Design

Case series.

Objective

To describe the assessment and surgical approach to dacryocystorhinostomy (DCR) for patients with nasolacrimal duct obstruction (NLDO) in the presence of orbital wall hardware.

Methods

The pre-operative assessment, management and outcomes of two patients with secondary acquired NLDO following medial orbital wall fracture repair treated by nasal endoscopic DCR.

Results

Anatomical and functional success was achieved in both cases at 6 weeks post operatively without disruption of the orbital plate. There was persistent success at 1 and 3 years' post-operatively.

Conclusions

Endoscopic DCR is a good option for the treatment of NLDO in patients with previous medial orbital wall fracture repair where the location of the plate may complicate the external approach.

Two cases of nasolacrimal duct obstruction operated by endoscopic dacryocystorhinostomy after orbital fracture reconstruction with an implant

Purpose

To report two cases of nasolacrimal duct obstruction (NLDO) caused by orbital fracture reconstruction with an implant successfully treated with endoscopic dacryocystorhinostomy (EnDCR).

Observations

Two patients presented with NLDO after orbital fracture reconstruction with an implant. Case 1 was a 67-year-old female. She became aware of epiphora in her left eye after undergoing orbital fracture reconstruction with an implant for a left orbital floor fracture 14 years previously. Dacryocystitis was diagnosed based on a lacrimal syringing test because of pus reflux. Computed tomography (CT) showed that the implant was inserted on the left orbital floor, crossing into the lacrimal sac; dacryoendoscopy showed that the implant blocked the nasolacrimal duct. EnDCR was performed without implant removal. The symptoms resolved postoperatively. Case 2 involved a 6-year-old male who had been aware of epiphora in his left eye since undergoing orbital fracture reconstruction with an implant for a left orbital floor fracture one month prior. Dacryocystitis was diagnosed based on a lacrimal syringing test because of pus reflux. CT showed an unclear implant location, but dacryoendoscopy showed that the implant blocked the nasolacrimal duct. The implant was removed. However, EnDCR was performed because there was no improvement in NLDO. The symptoms resolved after EnDCR.

Conclusions and importance

One previous report of NLDO after orbital floor fracture reconstruction was performed with external dacryocystorhinostomy with implant removal. Dacryoendoscopy and CT are useful for confirming the location of the implant and obstruction. Depending on the implant's location, it may be possible to perform EnDCR without removing the implant.

Lacrimal Drainage Systems Injured During Repair of Orbital Fractures

Implant placement for inferomedial orbital fractures through a lower fornix approach requires wide access, with the incision extended in the retrocaruncular line; the lacrimal drainage system is at risk of injury with both the incision and implant. The authors describe the radiologic and surgical findings for 5 patients in whom maxillofacial repair of periorbital fractures was associated with immediate postoperative epiphora; 1 patient also had a fistula between the implant and lower fornix. All patients had marked and early improvement of lacrimal drainage symptoms where uncomplicated open dacryocystorhinostomy or canaliculidacryocystorhinostomy was combined with removal of the offending orbital implants and neighboring screws. All implants were incorrectly positioned (projecting into the ethmoid sinus or inferior orbital fissure) and/or comprised materials of unnecessary size and rigidity for the underlying fracture. Fractures involving the orbital walls (but not rims) can usually be addressed with thin and pliable implants and without screw fixation.

Influence of Indwelling Lacrimal Drainage Tube on the Curative Effect of Endonasal Endoscopic Dacryocystorhinostomy

Endonasal endoscopic dacryocystorhinostomy (EES-DCR) has gradually become the main surgical method for treating chronic dacryocystitis. Whether the placement of the lacrimal drainage tube during the operation can improve the operation’s success rate is an issue. This study observes the effect of an indwelling lacrimal drainage tube on the curative effect of EES-DCR in patients with chronic dacryocystitis. The cure rate of the Lacrimal duct drainage tube non-indwelling group A was 93.8% (46/49). The 3 cases failed because of the nasal cavity’s inflammation, which resulted in the adhesion of the anastomotic stoma and the middle turbinate. The cure rate of the Lacrimal drainage tube indwelling group B was 85.7% (42/49). The 7 cases failed because of the excessive proliferation of the tissue around the anastomosis, the hyperplasia of granulation tissue, the shedding of the lacrimal duct drainage tube, the crack of the lacrimal duct, and the premature removal of the lacrimal duct drainage tube caused the contraction of the mucosa around the anastomosis, resulting in the anastomosis obstruction. There was no obvious difference between the two groups (P > 0.05). At 6 months, 46 cases of the EES-DCR group A had gradually epithelialized anastomoses without granulation tissue growth with the follow up time extension. In the EES-DCR group B, 42 cases of anastomoses were gradually epithelialized without granulation tissue growth. Nasal endoscopic dacryocystorhinostomy combined with an indwelling lacrimal duct drainage tube can be used to treat chronic dacryocystitis, but an indwelling lacrimal duct drainage tube has no significant effect on the efficacy of chronic dacryocystitis.