Different Modalities for Management of Pediatric Epiphora

Objective

This study assessed the efficacy and safety of different modalities for managing nasolacrimal duct obstruction and epiphora in children over one year.

Methods

We performed a non-randomized prospective study on 98 children (149 eyes) with epiphora and no history of lacrimal operation. The selected candidates attended the ENT and ophthalmology outpatient clinics of Minia University Hospital, seeking to treat epiphora that may or may not be associated with sinonasal pathology. Nasolacrimal operations involved a joint approach involving an otorhinolaryngologist and an ophthalmologist.

Results

Ninety-eight children (149 eyes) were identified. Ages varied from 1 to 12 years old. Conservative measures were successful in 32.6% of children. Silicone stents were used in 27.5% of the interventions with a mean time to removal of 3-6 months. The success rate for dacryocystorhinostomy (DCR) was 85.7%. Revision surgery was performed in 10% of probing cases, 8% of intubation cases, and 14.3% of DCR patients. The concomitant chronic sinonasal problems were evident in 62.2% of patients.

Conclusion

Conservative measures, probing, endonasal nasolacrimal intubation, endoscopic DCR, and external DCR are safe and effective procedures for epiphora in children. Also, correcting concomitant nasopharyngeal or sinonasal diseases in epiphora patients is crucial for successful management, overcoming recurrence, and minimizing morbidity.

Ocular manifestations of RT-PCR-confirmed COVID-19 cases in a large database cross-sectional study

OBJECTIVE

To evaluate ocular manifestations of reverse transcriptase (RT)-PCR-confirmed SARS-CoV-2-infected patients in a validated comparative model, and additionally to evaluate the correlation between severity of COVID-19 and ocular manifestations.

METHODS AND ANALYSIS

In a prospective cross-sectional study, a total of 2400 subjects were enrolled over a period of 8 months. To eliminate bias of identical ocular symptom profile in other non-COVID-19 respiratory infections and to acquire a comparative model, 1200 COVID-19 RT-PCR-positive patients (group 1) and 1200 RT-PCR-negative patients (group 2) were included. Data collection included use of a prestructured tool and 'Google-forms', along with stratification of patients into 'mild, moderate, and severe' categories. Study subjects were evaluated for ocular manifestations by clinical examination and laboratory work-up. Univariate and multivariate logistic regression analyses were performed.

RESULTS

144 (12%) patients in group 1 had ocular symptoms as compared with 24 (2%) patients in group 2 (p<0.001). Ocular manifestations (symptoms and signs) comprising burning sensation (6.7%, p<0.001), foreign body sensation and irritation (7.0%, p<0.001), and conjunctival signs (2.7%, p<0.001) were found statistically significant in group 1 as compared with group 2. Ocular involvement increased in proportion to severity of COVID-19: mild (5.3%), moderate (24.6%) and severe (58.8%) (p=0.0006).

CONCLUSION

The frequency of occurrence of ocular manifestations was higher in group 1 as opposed to group 2. Furthermore, the presence of ocular manifestations carried a direct correlation with severity of systemic disease and presence of comorbidities.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

The Management of Rhinitis in Patients with Functional Epiphora: A Randomized Controlled Crossover Trial

Background

Nasolacrimal duct obstruction, secondary to inflammation of the nasal mucosa, can result in epiphora. This can be treated successfully with topical corticosteroids, avoiding the need for surgery. This study tests the hypothesis that treating clinically significant rhinitis improves the symptoms of epiphora.

Methods

A randomized controlled crossover trial (pilot study) was performed at the Cumberland Infirmary, Carlisle. Patients were assessed in an epiphora clinic by a consultant ophthalmologist and were included in the trial if they had bilateral functional epiphora, i.e., the nasolacrimal duct was patent on syringing. Twenty-three patients were then referred to a consultant otolaryngologist, where the severity of rhinitis and epiphora were assessed using visual analogue scales, subjective scoring, and clinical assessment. The 11 patients suitable for the study were randomized into two groups. The treatment group received nasal corticosteroids and the control group received no treatment, both groups changing treatment arms at a specified point. Subjective and objective scores were assessed at the beginning, midpoint, and end of each treatment period.

Results

Seven of 11 patients showed an improvement in epiphora scores with topical therapy. Six patients documented a symptomatic improvement. Eight patients showed an improvement in symptoms and signs of rhinitis, with two patients continuing on nasal corticosteroids for nasal symptoms only. There was a statistically significant improvement in both epiphora symptom scores and clinical findings of rhinitis in patients treated with nasal steroids (p = 0.021 and 0.019, respectively).

Conclusion

Epiphora secondary to rhinitis can be treated successfully with intranasal steroids. Patients with epiphora should be asked about symptoms of rhinitis and should always have their nose examined for evidence of intranasal pathology.

Culture of olfactory ensheathing cells for central nerve repair: the limitations and potential of endoscopic olfactory mucosal biopsy

BACKGROUND

Autotransplantation of olfactory ensheathing cells (OECs) into the damaged central nervous system is a potential therapeutic strategy for spinal cord and root cord injuries. One limiting factor has been the poor OEC yields from human mucosal biopsies. Previous studies have only commented on their success in obtaining mucosal specimens containing olfactory mucosa, but have not commented on the yield of OECs from those specimens.

OBJECTIVE

To describe a reproducible and safe surgical technique for obtaining human olfactory mucosa and identify patient factors that possibly affect the yield of OEC cultures from the human olfactory mucosa.

METHODS

We obtained mucosal biopsies from 43 consecutive patients by using a novel reproducible surgical technique and our laboratory culture protocol. The Spearman rank correlation coefficient was used to assess the relationship between OECs and fibroblast yield with patient characteristics and specimen factors.

RESULTS

A greater yield of OECs was obtained from patients of younger age. In addition, patients with worse mucosal disease yielded poorer cell cultures. Greatest yields were found in patients with absence of mucosal disease. Furthermore, a higher yield of OECs was obtained from specimens harvested from the more caudal portions of the superior turbinate, and OEC yield did not correlate with the ventroposterior location of the biopsy.

CONCLUSION

We have provided evidence that biopsies closer to the cribriform plate can produce larger yields of OECs, and that patient factors like age and mucosal disease adversely affect the culture yield.

What is the role of partial middle turbinectomy in endocanalicular laser-assisted endonasal dacryocystorhinostomy?

BACKGROUND

This study was designed to compare outcomes of endocanalicular laser-assisted endonasal dacryocystorhinostomy (DCR) with and without partial anterior middle turbinectomy.

METHODS

A prospective randomized comparative study was conducted on 91 subjects with primary acquired nasolacrimal duct obstruction, undergoing endocanalicular (ECL) procedures. Group 1 was composed of 44 (7 bilateral) patients undergoing ECL diode laser-assisted endonasal DCR without partial anterior middle turbinectomy and group 2 was composed of 47 (7 bilateral) patients undergoing partial anterior middle turbinectomy and ECL diode laser-assisted endonasal DCR. Follow-up period was 11.0 (6.0-14.5 months) months for group 1 and 9.2 (5.0-14.2 months) months for group 2. Functional success was defined as absence of epiphora and anatomic success was defined as ability to irrigate the lacrimal system. Anatomic and functional success at the 1st week, 3rd month, and final postoperative examinations of two groups were compared using chi-square tests.

RESULTS

Final anatomic successes were 39/51 (76%) cases for group 1 and 51/54 (94%) cases for group 2. Final functional successes were 36/51 (%71) patients in group 1 and 48/54 (88%) patients in group 2. Group 2 had higher success at the final examination and the difference was statistically significant.

CONCLUSION

We recommend partial anterior middle turbinectomy in all laser ECL laser-assisted endonasal DCR, but further studies with larger sample sizes are needed to strengthen our hypothesis.

Pseudodacryocystitis and nasolacrimal duct obstruction secondary to ethmoiditis

A 23-year-old woman presented with clinical symptoms suggestive of acute dacryocystitis. She had no history of epiphora, and her lacrimal drainage system was patent on irrigation. CT findings were consistent with anterior ethmoiditis and maxillary sinusitis. Although the symptoms responded to antibiotic treatment, they recurred 2 times within the following 5 months. During the last episode, a complete obstruction of the nasolacrimal duct developed. The condition did not recur after external dacryocystorhinostomy and anterior ethmoidectomy during a follow-up of 21 months. Ethmoiditis may rarely cause a localized infection in the lacrimal sac region mimicking dacryocystitis. Recurrent infections may progress to complete obstruction of the nasolacrimal duct.

Epiphora: an evidence based approach to the 12 minute consultation

BACKGROUND

Epiphora is the presence of a watering eye which may be due to reflex tearing or defective drainage of tears. Whilst most cases present to the ophthalmologist the otolaryngologist has a key role to play in both assessment and management of these patients.

METHODS

This review was based on a literature search last performed on 21st October 2009. MEDLINE and Cochrane databases were searched using the subject headings 'epiphora' or 'functional epiphora' in combination with diagnosis, investigation, management, treatment, intervention and surgery. Results were limited to English language articles. The personal biographies of the senior authors were also used.

CONCLUSION

An accurate assessment of the site and degree of obstruction is important to ensure the correct management is undertaken. Medical treatment with nasal steroid spray may be effective but the majority of obstructed cases will require surgical intervention in the form of dacryocystorhinostomy (DCR). There is increasing evidence that powered endoscopic DCR has outcomes comparable with the 'gold standard' procedure of external DCR.

Nasal endoscopy in congenital dacryocystitis

PURPOSE

Controversy exists regarding the relationship between nasal pathology and congenital dacryocystitis. The recent advent of nasal endoscopes has greatly improved visualization of deep and hidden areas of nasal anatomy and has led to the elaboration of nasal anatomical variants and pathologies that were previously unknown. The current study aimed to evaluate for associations, if any, between anatomical abnormalities or variations in the lateral nasal wall and the presence and resolution of congenital dacryocystitis.

PATIENTS AND METHODS

Phase I was a case-control study that compared the incidence of a predefined set of nasal endoscopic variations in infants with congenital dacryocystitis versus normal infants. Phase II was a cohort study that evaluated the impact of nasal endoscopic variations on the effectiveness of conservative treatment for congenital dacryocystitis. "Failure" to respond to conservative treatment measures was defined as the persistence of symptoms at the first birthday.

RESULTS

Inferior turbinate hypertrophy and inferior meatal narrowing were significantly more frequent in the case group than in the control group. Conservative treatment measures resulted in 70 of 83 resolved cases on subsequent follow-up. The occurrence of inferior turbinate hypertrophy or inferior meatal narrowing at final examination was associated with non-resolution. The relative risk of non-resolution with inferior turbinate hypertrophy or inferior meatal narrowing was 7.7 (confidence interval, 2.32 to 25.72) and 12 (confidence interval, 3.7 to 39.2), respectively.

CONCLUSION

Inferior turbinate hypertrophy and inferior meatal narrowing are more frequent in cases of congenital dacryocystitis. They are predictive of a poor outcome when congenital dacryocystitis is treated with conservative measures. This information should be considered when making clinical decisions for patients with congenital dacryocystitis.

Understanding the symptoms of the common cold and influenza

The common cold and influenza (flu) are the most common syndromes of infection in human beings. These diseases are diagnosed on symptomatology, and treatments are mainly symptomatic, yet our understanding of the mechanisms that generate the familiar symptoms is poor compared with the amount of knowledge available on the molecular biology of the viruses involved. New knowledge of the effects of cytokines in human beings now helps to explain some of the symptoms of colds and flu that were previously in the realm of folklore rather than medicine-eg, fever, anorexia, malaise, chilliness, headache, and muscle aches and pains. The mechanisms of symptoms of sore throat, rhinorrhoea, sneezing, nasal congestion, cough, watery eyes, and sinus pain are discussed, since these mechanisms are not dealt with in any detail in standard medical textbooks.