Nasolacrimal duct obstruction prevalence is 0.3% among alpacas evaluated with ophthalmic disease at a veterinary teaching hospital between 2000 and 2023

OBJECTIVE

To examine the prevalence of nasolacrimal duct (NLD) obstruction in hospital populations and assess signalment, diagnostics, and clinical approaches for alpacas and llamas diagnosed with NLD atresia or obstruction.

ANIMALS

29 alpacas and 2 llamas.

CLINICAL PRESENTATION

Medical records were reviewed to identify camelids with NLD evaluated between 2000 and 2023. Signalment, history, physical examination data, diagnosis, and treatments were recorded. Follow-up information was gathered via phone and email questionnaire. Data were evaluated to determine prevalence and describe signalment and treatments for NLD disease.

RESULTS

31 camelids met the inclusion criteria. A total of 8,027 alpacas and 1,998 llamas were seen within the study period at 1 teaching institution. The prevalence of NLD obstruction for this population of alpacas was 0.3% (26/8,027). Nineteen of 31 (61%) camelids presented at 1 year of age or younger. The most common physical exam finding was ocular discharge (68%). The most common diagnosis was NLD atresia (16/31 [51%]). Patency was established by surgical opening or lavage of the NLD. Long-term follow-up was available for 13 alpacas and 2 llamas, of which 11 (73%) had successful outcomes.

CLINICAL RELEVANCE

Results indicate that NLD obstruction is a condition that most commonly affects alpacas < 1 year of age and is associated with a good prognosis for treatment success.

A transconjunctival surgical technique for dacryocystotomy in dogs with foreign body-induced dacryocystitis

PURPOSE

The purpose of this study is to describe a simplified, less invasive dacryocystotomy technique that allows for complete inspection of the canine lacrimal sac and to retrospectively evaluate this surgical technique in a larger series of dogs. The anatomical background of the canine nasolacrimal system is described as a basis for the surgical technique.

METHODS

Records of dogs from 2003 to 2023 which were diagnosed with dacryocystitis due to presumed foreign body and underwent surgical exploration and removal of foreign bodies within the lacrimal sac using this technique were reviewed. Postoperative treatment and outcome were evaluated.

RESULTS

Records of 48 dogs were included. A foreign body was discovered during the surgery or upon retrieval of the catheter in 85% of cases (41/48). An indwelling catheter was placed in 83% of cases (40/48) for a median of 21 days. At the last recheck, the nasolacrimal duct was patent in 87% of the cases (41/47). The median follow-up time was 34 days (3-1255 days). The most commonly affected breeds were Golden retrievers (11) and dachshunds (8). The following complications occurred: two dogs removed or partly removed the catheter themselves (day 7, day 14), and one dog showed marked irritation at the catheter site which had to be removed by day 10.

CONCLUSIONS

The transconjunctival dacryocystotomy technique is simple and less invasive than other described techniques with a successful long-term outcome in the majority of cases.

CT-Measured Angulation Between the Frontal Bone and Bony Nasolacrimal Duct: Variations in Obstructed and Healthy Lacrimal Ducts

PURPOSE

The aim of this study was to analyze the characteristics of CT-measured intersection angle (FB-BNLD) between the frontal bone and bony nasolacrimal duct and to provide suggestions for treating primary acquired nasolacrimal duct obstruction (PANDO) patients in West China.

METHODS

Three hundred and nine participants' CT were, respectively, evaluated with RadiAnt DICOM Viewer. We defined the FB-BNLD angle >0° as the anterior type and the FB-BNLD angle ≤0° as the posterior type.

RESULTS

The mean FB-BNLD was -2.52° (95% CI, -3.16° to -1.88°) across all participants, of whom 37.2% were of the anterior type and 62.8% of the posterior type. Approximately 65.0% of the female patients had a posterior FB-BNLD type, and 54.2% of the male patients had an anterior FB-BNLD type (p = .002). Posterior FB-BNLD was the dominant type in the PANDO and control groups (p = .011), and the angle of FB-BNLD was statistically different in both groups (PANDO group, -2.54° to -0.71°; control group, -4.42° to -2.67°; p < .001). Among the male participants, the type of FB-BNLD differed between the two groups (p = .036), with differences in the angle of FB-BNLD (PANDO group, 0.59° to 5.13°; control group, -4.08° to 1.89°; p = .034). There was no difference in the type of FB-BNLD in female participants between the two groups (p = .051).

CONCLUSION

The present study revealed individual differences in the type of FB-BNLD, with anterior-type majority in males and posterior-type dominance in females. Evaluating the FB-BNLD type on CT can provide a fast method for knowing the nasolacrimal duct condition during planning for lacrimal manipulation.

A rare case of lacrimal sac angioleiomyoma managed with dacryocystectomy and turbinectomy

We report a rare case of a lacrimal sac angioleiomyoma. A 56-year-old woman complained of pain in the right medial canthal region over a period of 2 years. There were no complaints of epiphora or ocular infection, and no visible or palpable masses in the medial canthal region. Computed tomography scan revealed a solid tumor of the lacrimal sac expanding to the nasolacrimal duct and protruding under the inferior turbinate. The tumor was removed by external dacryocystectomy combined with endonasal, endoscopic anterior turbinectomy, and nasal mucosal resection. Histological and immunohistological findings were consistent with an angioleiomyoma of the venous type. There was no recurrence of the tumor at the three-year follow-up. Angioleiomyomas should be included in the differential diagnosis of lacrimal sac tumors. The definitive diagnoses rely on histology and immunohistological reactions. The treatment is complete surgical resection.

Large B-cell Lymphoma with IRF4 Rearrangement in the Nasolacrimal Duct: A Clinicopathological Study of One Case and Literature Review

BACKGROUND

Large B-cell lymphoma (LBCL) with interferon regulatory factor 4 (IRF4) rearrangement (LBCL-IRF4) is a rare subtype of LBCL, with a high prevalence in Waldeyer's ring as well as the neck, head and gastrointestinal lymph nodes.

MATERIALS AND METHODS

A patient with 2-month clinical symptoms of nasal obstruction and facial swelling was reported in this short review. A nasal endoscopy examination revealed a neoplasm in the inferior nasal meatus. Both CT and enhanced MRI showed that a soft tissue occupied the nasolacrimal duct, with bone destruction, and extended into the left nasal cavity and left lacrimal gland area. Then, a biopsy of the neoplasm in the inferior nasal meatus was performed.

RESULTS

HE staining results showed that neoplastic cells presented diffuse growth patterns, abundant cytoplasm, vacuole shape, lightly stained nuclei, and irregular nuclear membrane. Immunohistochemistry staining results revealed MUM1(+), Bcl6(+), CD20(+), CD79α(+), and CD10(+). FISH analyses detected positive IRF4 rearrangement. LBCL-IRF4 was diagnosed in the patient. The patient received treatment with four cycles of R-CHOP and two times of rituximab, followed up for 2 years, and finally got complete remission.

CONCLUSION

For the first time, we summarize the imaging and pathological features, drug treatment, and curative effect of LBCL-IRF4 in the nasolacrimal duct.

Epstein-Barr Virus-Associated Acute Dacryocystic Retention

Epstein-Barr virus (EBV) associated dacryocystic retention presents with an acute swelling in the lacrimal sac area with epiphora and lymphadenopathy. The patient would usually have a preceding history of infectious mononucleosis with clinical features of fever, pharyngitis, preauricular and cervical lymphadenopathy, hepatosplenomegaly, subclinical hepatitis, nausea, and palatine petechiae. The present case is of a 3-year-old child who presented with a sudden painless swelling in the lacrimal sac region with epiphora. Investigations and a biopsy helped in establishing the diagnosis of EBV-associated dacryocystic retention which resolved completely with conservative management.

[Anatomical structure and morphometric parameters of the distal segment of the lacrimal drainage system]

The article analyzes the literature data concerning the anatomical structure of the tear ducts with a focus on morphometric studies of individual structures. It is noted that, despite the high information content of cadaveric studies, most of the information to date has been obtained with the use of intravital radiation visualization methods. It is shown that the lacrimal drainage system has age, gender, and racial characteristics. Most studies focus on features of the bone nasolacrimal canal, while there is a relative shortage of research devoted to soft-tissue nasolacrimal duct. The analysis showed that most of the studies are devoted to particular morphometric indicators, which makes it difficult to obtain a complete objective picture of the size of the tear duct. Information about its volume can be found only in a couple of studies. The numerical values of the obtained data vary, which can be explained by a different approach to the selection of research subjects, sample sizes, anatomical criteria and the calculation method of morphometric parameters. There are only a few studies on morphometric parameters of the nasolacrimal duct in healthy humans, which is extremely important for determining the pathogenesis of disorders of the patency of the lacrimal drainage system.

Cytological Diagnosis Suggesting Candidal Infection of the Nasolacrimal Duct in an Uncontrolled Diabetic Patient With Gingival Abscess

In this unique cytology case of a 64-year-old diabetic male who presented with left-sided facial swelling between the ala and lateral canthus of the left eye, conventional fine-needle aspiration cytology (FNAC) was done. FNAC of the swelling showed desquamated epithelial cells from the nasolacrimal duct and abundant proteinaceous material admixed with fungal organisms like that of budding yeast forms, morphologically resembling Candida on May-Grunwald-Giemsa stain. Special stain with periodic acid-Schiff revealed positivity for budding yeast forms. In this case report, we discuss the causes and clinical effects of nasolacrimal duct obstruction, cytological diagnostic features, and microscopic recognition of fungal organisms on routine staining as well as on special fungal stains.

Effect of Maxillary Sinus Pneumatization on the Ease of Access to Prelacrimal Recess

OBJECTIVE

Prelacrimal recess approach can be used to access lesions of the anterior wall of the maxillary sinus (MS). Moreover, the longer the prelacrimal recess window distance (PLRWD), the easier it is to access the anterior wall. This study aimed to define the correlation between maxillary sinus pneumatization (MSP) and PLRWD, a previously defined anatomic factor predictive of the ease of prelacrimal recess approach (PLRA).

METHODS

In total, 506 sides of 253 participants were studied. In the axial image, the PLRWD, the distance between the anterior wall of the MS and the lacrimal duct, was measured through radioanatomical analysis and classified as type I (<3 mm), type II (3-7 mm), or type III (>7 mm). On the coronal image, the distance between the nasal floor and the lower end of the MS was measured. When MSP did not reach the nasal floor, it was classified as grade I, as grade II when MSP reached the nasal floor, and grade III when the MS was pneumatized below the nasal floor.

RESULTS

Type I included 115 sides (22.7%); type II, 277 sides (54.7%); and type III, 114 sides (22.5%). Grade I was observed in 58 sides (11.5%), grade II in 38 sides (7.5%), and grade III in 410 sides (81.0%). The mean PLRWD of grade I was 2.35 ± 2.41 mm, II was 3.37 ± 2.46 mm, and III was 5.55 ± 2.54 mm, showing a significant difference (P < .001). Post hoc analysis showed significant differences in the mean PLRWD among grades I, II, and III. Two anatomical factors, the MSP and PLRWD, were positively correlated (r = .507, P < .001).

CONCLUSIONS

This study demonstrates a correlation between the feasibility of MSP and PLRA. Both MSP and PLRWD are essential diagnostic parameters for preoperative planning and better surgical outcomes.

Accuracy of the Lacrimal Syringing Test in Relation to Dacryocystography and Dacryoendoscopy

Purpose

This study aimed to evaluate the accuracy of the lacrimal syringing test (syringing) in relation to dacryocystography (DCG) and dacryoendoscopy (DE) in lacrimal pathway (LP) obstruction.

Methods

We retrospectively reviewed 101 patients (188 LPs) who underwent syringing, cone-beam computed tomography (CBCT)-DCG, and DE to diagnose the degree and site of LP obstruction. The degree of obstruction was classified into patent, partial obstruction, and complete obstruction. The degree of LP obstruction was determined by combining the findings of DE and CBCT-DCG and was designated as DCG+DE. When differentiating complete or partial obstruction on DE was uncertain, complete or partial obstruction was assigned if the DCG showed evidence of contrast media obstruction or passage, respectively. The consistency between syringing and DCG+DE was evaluated by calculating the weighted kappa coefficient.

Results

The sensitivity and specificity of syringing were 94% and 89%, respectively. The weighted Cohen's kappa value of agreement between syringing and DCG+DE was κ = 0.73 (SE = 0.04, 95% confidence interval [CI]: 0.66-0.80, p < 0.01). When divided into presaccal and postsaccal obstruction categories, the kappa values were κ = 0.40 (SE = 0.11, 95% CI: 0.19-0.62, p < 0.01) and 0.55 (SE = 0.09, 95% CI: 0.37-0.73, p < 0.01), respectively. Furthermore, when limited to common canaliculus obstruction (stenoses), which accounted for 78% (46 LPs) of the total presaccal obstructions, the kappa value was κ = 0.29 (SE = 0.12, 95% CI: 0.05-0.54, p = 0.021), which demonstrated the lowest consistency between syringing and DCG+DE.

Conclusion

Syringing was "substantially" in agreement with DCG+DE in detecting the degree of LP obstruction. Moreover, syringing was a sufficiently sensitive and specific test when performed by an experienced clinician. However, distinguishing between complete and partial obstructions by syringing was sometimes difficult, particularly in the common canaliculus obstruction (stenosis).

[Dynamic pathomorphological characteristics of the nasolacrimal duct in its stenosis]

OBJECTIVE

Pathological description of the process of stenosis of the nasolacrimal duct at its various stages.

MATERIAL AND METHODS

The material for the study was obtained from the wall of the nasolacrimal duct during surgery in 50 patients whose condition was attributed to the 1st, 2nd or 3rd clinical stage of dacryostenosis. The material was fixed in formalin and sent for pathohistological and immunohistochemical (IHC) studies.

RESULTS

In the 1st stage, the integrity of the epithelium of the nasolacrimal duct was preserved, the density of goblet cells was reduced. Seromucinous glands were single in the lamina propria in the area of stenosis. Diffuse lymphoid-plasmacytic infiltration was observed along the periphery of the terminal sections of the glands and in the subepithelial zone. The infiltrate includes CD68+ tissue macrophages and CD20+ and CD3+ lymphocytes, with a predominance of B-lymphocytes over T-lymphocytes. In the 2nd stage, changes in the epithelial layer in the stenosis zone were detected. In the IHC study, only individual leukocytes were observed in these zones, and T cells were found mainly in the subepithelial zone, B cells - deeper, monocytes - evenly in all layers. In the adjacent zones, the picture of the infiltrate corresponded to the 1st stage. In the 3rd stage, fragments of the nasolacrimal duct wall were represented by dense fibrous connective tissue with pronounced atrophic changes, areas of squamous metaplasia or proliferation of the basal layer, goblet cells were not detected. There was no infiltrate in the area of stenosis during IHC study. In the cellular elements of the infiltrate in areas adjacent to the stenosis zone, CD20+ and CD3+ lymphocytes were present in equal proportions, the arrangement in layers corresponded to that of the 2nd stage.

CONCLUSION

The results of the study showed that dacryostenosis is a progressive pathological process associated with the progredient development of chronic productive inflammation in the lacrimal ducts.

[Biometric characteristics of the lacrimal passages in healthy individuals and in patients with nasolacrimal duct obstruction]

Despite an obvious interest in the processes occurring in the lacrimal passages in their obstruction, there is few articles analyzing their biometric parameters.

PURPOSE

The study investigates the biometric characteristics of the lacrimal passages in healthy individuals and in patients with nasolacrimal duct obstruction.

MATERIAL AND METHODS

The study included 81 cases of partial nasolacrimal duct obstruction and 38 cases without tear drainage insufficiency. All patients underwent computed tomography with dacryocystography. Analysis of the biometric parameters involved calculation of the length, volume, and average sectional area of the nasolacrimal duct and the nasolacrimal bony canal. The ratio R4/16l was calculated (where R is the radius of the nasolacrimal duct; l is the length of the nasolacrimal duct). The normality of values was assessed using the Shapiro-Wilk test. Intergroup differences were assessed using the Mann-Whitney test and t-statistics for independent samples. Correlation analysis was performed according to the Spearman method. ROC analysis was carried out. Differences were considered significant at p≤0.05.

RESULTS

There were significant differences in the volume (p=0.004) and the average sectional area of the nasolacrimal duct (p=0.014), as well as in the length of the nasolacrimal canal (p=0.034). Relationships were established between the age of patients without tear drainage insufficiency and the length of the nasolacrimal canal (p=0.042); the length of the nasolacrimal canal and the volume of the nasolacrimal duct (p=0.034), as well as the volume of the nasolacrimal duct and the nasolacrimal canal in partial nasolacrimal duct obstruction (p=0.017). The AUC of the R4/16l ratio in the ROC analysis was 0.653 (p=0.007).

CONCLUSION

In addition to the obvious differences, it was found that the length of the nasolacrimal bony canal significantly differed in the subjects of both study groups. We considered the tear ducts as a hydrodynamic system obeying Poiseuille's law, so we calculated the ratio R4/16l. The value of this ratio varied (p=0.016), and the ROC analysis showed high sensitivity and specificity of the criterion. This makes it possible to use this ratio as a diagnostic criterion for partial nasolacrimal duct obstruction.

Lacrimal imaging findings in fellow asymptomatic eyes of unilateral epiphora

AIMS

To investigate the prevalence of subclinical anatomical and functional abnormalities of lacrimal drainage in fellow asymptomatic eyes of unilateral epiphora using dacryocystography and dacryoscintigraphy.

METHODS

Retrospective case note review of lacrimal imaging of adult patients presenting to a hospital Oculoplastic clinic with unilateral epiphora over 10 years.

RESULTS

A total of 172 patients with unilateral epiphora were included. The median age was 67 (range 18-96 years). A dacryoscintigraphy (DSG) abnormality was present in 54 (42%) asymptomatic eyes, and dacryocystography (DCG) abnormality in 10 (10%). The most common finding on DSG was no delay in 76 eyes (58%), and most common DSG abnormality was post sac delay in 51 (39%) eyes. The most common finding on DCG was no obstruction in 88 (90%) eyes, and the most common DCG abnormality was post sac stenosis (7.1%). Of the 92 asymptomatic eyes with both DCG and DSG, 53 (57%) showed neither an obstruction on DCG or delay on DSG, and 28 (30%) showed a post sac delay on DSG and no abnormality on DCG.

CONCLUSION

Greater than a third of asymptomatic eyes displayed post sac delay on DSG, frequently without accompanying anatomical obstruction on DCG. Subclinical DSG delay in asymptomatic eyes may represent physiological variation in tear transit time, subclinical lacrimal drainage dysfunction or anatomical stenosis undetected by DCG. Furthermore, the DSG results of fellow asymptomatic eyes in unilateral epiphora may not represent a normal standard that can be utilised for comparison. Further investigation with dacroyendoscopy, the use of control eyes, and long term follow up is required.

Lacrimal drainage anomalies in Pierre Robin sequence

Pierre-Robin sequence consists of a classical triad of micrognathia, glossoptosis, and upper airway obstruction. The common ocular manifestations include congenital glaucoma, high myopia, maculopathy, and retinal detachment. Except for a mention of a nasolacrimal duct obstruction without many details, lacrimal drainage anomalies have not been reported earlier to the best of the authors' knowledge. The present case describes several lacrimal drainage anomalies including supernumerary puncta, canalicular wall hypoplasia, grossly dilated nasolacrimal duct, and complex congenital nasolacrimal duct obstruction in a patient of Pierre Robin sequence. The patient was successfully managed with endoscopic guided probing and marsupialization of the large intranasal cyst resulting in a complete resolution of epiphora.

Investigation of the morphometry of the pre-lacrimal recess of the maxillary sinus for the pre-lacrimal approach of the maxillary sinus and paramedian skull base. A computed-tomography study

The pre-lacrimal recess approach is modernly used for lesions of the anterior maxillary wall and for reaching paramedian cranial base regions. In this computed-tomography study, we assessed the pre-lacrimal recess types as well as the angles between the anterior and medial maxillary walls and between the anterior maxillary wall and the lateral margin of the nasolacrimal canal to show the feasibility of the pre-lacrimal recess approach in reaching lesions of the infratemporal and pterygopalatine fossae, using 30 computed-tomography studies (60 sides). A type I pre-lacrimal recess was identified in 22 cases (35%), type II was identified in 31 cases (53.30%), and type III in 7 cases (11.66%). We found that angle 1 (the angle between the anterior maxillary wall and the medial maxillary wall) had a mean value of 80.8° (minimum 75.5°, maximum 85.8°), while angle 2 (the angle between the anterior maxillary wall and the lateral margin of the nasolacrimal canal) had a mean value of 59.1° (minimum 57.6°, maximum 60.1°). We consider the pre-lacrimal recess approach a very good option for the anterior maxillary wall, the alveolar recess, and in reaching the infratemporal fossa and lateral part of the pterygopalatine fossa. In cases where direct visualization of the medial part of the pterygopalatine fossa is needed, the pre-lacrimal recess approach could not be the perfect option.

Case series: Computed tomography (CT) demonstrates lacrimal canal involvement in koalas (Phascolarctos cinereus) with maxillary incisor dental disease

Dental disease is common in wild and captive koalas. Effective treatments are limited and dental disease may not be recognised until it is quite severe. We describe the appearance of varying severities of dental disease on computed tomography (CT) images in a case series of six koalas. This case series demonstrates the use of CT to detect both mild and severe dental disease in koalas. The study also documents the normal CT appearance of the nasolacrimal duct in the koala. The only clinical abnormality in koalas with the mildest dental disease was ocular discharge. Computed tomography findings associated with ocular discharge were periapical lysis of first maxillary incisors, lacrimal canal remodelling and subsequent nasolacrimal duct obstruction. Dental disease should be a differential diagnosis for ocular discharge in koalas and CT examination enables visualisation of early stages of dental disease.

Anatomy of the nasolacrimal duct in Persian cats determined by computed tomographic dacryocystography

OBJECTIVE

This study sought to describe the anatomical characteristics of the nasolacrimal duct of Persian cats as observed by computed tomographic dacryocystography.

ANIMAL STUDIED

Ten cats weighing 3-6 kg (three live cats and seven cadaveric specimens).

PROCEDURES

The animals were submitted to bilateral computed tomographic dacryocystography, totaling 20 nasolacrimal ducts. Dorsal, sagittal, and transverse planes were studied. Two additional skulls were also dissected following latex injection into the nasolacrimal duct. The length and width of the nasolacrimal duct and lacrimal canaliculi, and the distance between the nasolacrimal duct and the root of the upper canine tooth at the point of closest proximity were measured.

RESULTS

The nasolacrimal duct followed a convoluted course, particularly in the middle and rostral portions. Duct stenosis (width reduction equal to or >75%) and dilations (width increase equal to or >50%) were also detected, particularly in the rostral portion. Nasolacrimal duct length and width ranged from 1.3 to 1.5 cm and 1.5 to 2.3 mm, respectively. Mean lacrimal canaliculus length and width corresponded to 3.1 mm and 0.4 mm, respectively. Mean distance from the nasolacrimal duct to the canine tooth was 2.4 mm. The root of this tooth interfered with the course of the nasolacrimal duct.

CONCLUSION

This study provided anatomical information for clinical assessment of the nasolacrimal drainage system in Persian cats.

Primary balloon dacryoplasty for nasolacrimal duct obstruction in adults: a systematic review

Introduction: Acquired nasolacrimal duct obstruction (NLDO) is a major cause of epiphora. Balloon dacryoplasty (BD) is a minimally invasive procedure effectively used for congenital NLDO which has also been used in adults, instead of dacryocystorhinostomy (DCR), the current gold standard technique. The main objectives were to assess the results of BD with and without silicone tube insertion (STI) in NLDO in adults.Materiel and Method: A systematic review of literature was conducted on PubMed, SCOPUS and Cochrane databases. The articles were scanned to identify all studies that evaluated the outcomes of primary BD for NLDO in adults. The mean success rates were calculated and compared using the multiple comparisons Sidak's T-testResults: Sixty-seven articles were identified but only 13 publications matched the inclusion criteria. For partial NLDO, BD had a mean, success rate of 73.29% (64.86% with STI) with a mean follow-up of 16 months. For complete NLDO, BD had a success rate of 36.67% (52.50% with STI) with a mean follow-up of 15.5 months. Altogether the success rate of BD was significantly higher for partial NLDO compared to complete stenosis (p = 0,002).Conclusion: BD is significantly more successful for partial NLDO, without significant additional benefit from subsequent STI. The main complication would be the high recurrence rate. BD is not effective for complete NLDO with very low success rates. However, BD could be proposed for partial NLDO, as it is a safe procedure, with minimal invasiveness in comparison to DCR. Further prospective and controlled studies are required to confirm these encouraging results.

Treatment of congenital nasolacrimal duct cyst: the role of endoscopic marsupialisation

Objective

Congenital nasolacrimal duct cyst (NLDC) is a rare disorder, which can present with ophthalmological and nasal signs and symptoms. The authors analyse their personal experience to identify diagnostic criteria for NLDC, which were treated by endoscopic transnasal procedure.

Methods

Clinical records of patients with a diagnosis of NLDC were retrospectively reviewed. All patients underwent rhinoscopy and ophthalmologist evaluation before surgery, whereas imaging was performed in selected cases. All neonates underwent transnasal endoscopic marsupialisation after failure of conservative medical therapy.

Results

Five patients were included in the study. One patient presented bilateral NLDC. In 3 cases, CT scan of the sinus was carried out. A total of 6 marsupialisation procedures were performed and a bi-canalicular lacrimal stent was positioned in 1 case. Complete remission of symptoms was observed in all cases.

Conclusions

Nasal endoscopy is mandatory to diagnose NLDCs, and, in some cases, it can be complemented by radiological procedures. When symptoms persist after systemic and topical therapy, nasal endoscopic marsupialisation is the treatment of choice. This surgical procedure is effective, safe and can be repeated if needed.

Multidisciplinary approach to lacrimal system diseases

Pathologies of the lacrimal drainage system range from benign to malignant lesions. However, independently of the etiological origin, the most common presenting symptom is represented by epiphora due to the dysfunction of the lacrimal system. Different diagnostic tools are now available, but for the most the first diagnostic approach is characterized by an ophthalmological visit, associated with nasal endoscopy, usually performed by an otolaryngologist. Frequently the diagnostic work-up is completed with a radiological exam (e.g. maxilla-facial CT or dacryocystography), whose role is still to be determined. Once a diagnosis has been made, different treatments are available in relation to the type of the disease, and commonly need close cooperation between an ENT and ophthalmic surgeon given the close anatomical structures involved. Taking into account all these aspects, the aim of this review is to highlight how a multidisciplinary approach to lacrimal pathologies is mandatory from diagnosis to treatment in order to offer the best clinical approach.

[The effect of endoscopic dacryocystorhinostomy on different lacrimal duct obstruction]

Objective:To observe the effect of endoscopic dacryocystorhinostomy on different lacrimal duct obstruction. Methods:Eighty eyes with the lacrimal passage obstruction were collected, and treated with endoscopic dacryocystorhinostomy. Meanwhile, the abnormal structures of the nasal cavity were corrected and the pathological changes of the nasal cavity and sinuses were treated. The patients were followed up and the curative effect was observed. Follow-up period ranged from 10 months to 8 years. Results:The first operation cure rate was 78.8%, the effective rate was 17.5%, the ineffective rate was 3.8%, and the success rate was 96.2%. Two of the 3 eyes failed in first operation were cured by reoperation. The total success rate was 98.8%. Conclusion:Endoscopic dacryocystorhinostomy can be used as a routine operation in the treatment of different lacrimal duct obstruction. The structural abnormalities and pathological changes of the nasal cavity and paranasal sinuses can be treated simultaneously. Combined with postoperative treatment and follow-up, long-term curative effect can be obtained.

Extended Anterior Inferior Approach to Endoscopic Medial Maxillectomy for Maxillary Sinus Lesions

BACKGROUND

Myriad open and endoscopic approaches are employed to resect maxillary sinus lesions, each with associated advantages and disadvantages. The inferior and anterior portion of the sinus remains a challenging space to access.

OBJECTIVES

To describe the extended anterior inferior approach to endoscopic medial maxillectomy (EAMM) as a novel and valuable addition to a stepwise approach for minimizing surgical morbidity without compromising tumor outcomes. To report the outcomes of patients treated with this approach.

METHODS

A retrospective case series study of 9 patients who underwent EAMM between 2016 and 2019 at a tertiary care referral center was performed. The endoscopic technique is described. The duration of follow-up ranged from 1 to 53 months. Intraoperative steps, including transection of the nasolacrimal duct and execution of an intraoperative dacryocystorhinostomy, were reviewed. Postoperative outcomes, including patient symptoms at follow-up and tumor recurrence, were recorded.

RESULTS

Adequate exposure with gross total tumor resection or margin-negative tumor resection was achieved in all cases. Sparing of the nasolacrimal duct was achieved in 2 patients. No patients reported persistent epiphora, empty nose syndrome, or changes in cosmesis such as alar or nasal tip collapse. One patient reported unilateral V2 hypoesthesia at 6 months postoperatively that had resolved by his next follow-up 18 months after surgery. Postoperative tumor surveillance was achieved by endoscopic examinations in all patients and there was no evidence of tumor recurrence at a median follow-up of 22 months.

CONCLUSIONS

The EAMM provides improved access to the inferior-posterior-medial maxillary sinus. This approach minimizes the risk of hypoesthesia and change in cosmesis present in other approaches, and obviates division of the nasolacrimal duct for inferior, posterior-medial attached lesions. This progressive escalation of approach for maxillary sinus lesions minimizes injury to nasal and nasolacrimal structures without compromising tumor outcomes.

Angioleiomyoma of the nasolacrimal duct: case report and literature review

Angioleiomyomas are benign tumors composed of smooth muscle and vascular endothelium. While infrequent in overall prevalence, they are exceptionally rare in the head and neck. Herein, we describe the case of a 65-year-old female who was found to have an angioleiomyoma of the right nasolacrimal duct. Endoscopic excision of the lesion along with medial maxillectomy and dacryocystorhinostomy was performed without complication. The current report is one of the few reported cases of angioleiomyoma of the lacrimal drainage system.

Clinical profile and management outcomes of lacrimal drainage system malignancies

Purpose: To report the clinical profile and management outcomes of a series of cases of malignant tumors of the lacrimal drainage system (LDS).Materials and Methods: A retrospective analysis of all cases diagnosed with LDS malignancy over the past 24 years (1995-2019) was done. Patient characteristics, tumor types, management, and outcomes were analyzed.Results: A total of 14 patients were included. Thirteen cases were of primary malignancy, while one was a secondary lesion. The mean age was 42.5 years, with males and females being equally affected. A medial canthal mass was the most common (9, 64.2%) presentation. Six patients (42.8%) had undergone one or more dacryocystorhinostomy surgeries for nasolacrimal duct obstruction before presentation. Seven patients underwent wide local excision (50%) while 3 (21.4%) each underwent dacryocystectomy and exenteration. Adjuvant radiation was administered to 4 (28.5%) patients. Thirteen (92.8%) patients were diagnosed with epithelial malignancy while one (7.1%) was a case of small B cell lymphoma. Transitional cell carcinoma was the most common epithelial malignancy (4, 28.5%). Three (21.4%) patients had metastatic disease (2 lymph nodes and one angle of jaw). There was no mortality after a mean follow up of 40.7+_25.1 months (Median 26; Range 4-131).Conclusion: LDS malignancy is rare, with the epithelial variant being far more common than non-epithelial. Wide local excision with adjuvant radiotherapy is the preferred management. Long-term follow-up is essential to manage recurrences and to increase survival.

Usefulness of high definition sialoendoscope for evaluation of lacrimal drainage system in congenital nasolacrimal duct obstruction

PURPOSE

Sialoendoscope was used as a dacryoendoscope, high- definition images of the lacrimal drainage system (LDS) were captured and its performance in congenital nasolacrimal duct obstruction (CNLDO) is reported.

METHODS

Nasal endoscopy was done as the first in all the cases using a 0°, 2.7 mm nasal endoscope (Karl Stroz Tutlingan Germany). This was followed by Dacryoendoscopy (DEN) of the lacrimal drainage system from puncta till the valve of Hasner. DEN was performed under general anaesthesia in 26 children (including 17 primary and 9 failed probing cases). All cases were examined using 0.8 mm sialoendoscope (Karl Storz, Tuttlingen, Germany) with fibreoptic light transmission with a side port for irrigation.

RESULTS

We were able to obtain high-definition images of canaliculi, lacrimal sac, sac duct junction, proximal, mid and distal segments of nasolacrimal duct in all the children with CNLDO.In 17 primary cases 16 had distal membranous obstruction and I case had proximal canalicular obstruction. In nine children with history of failed probing, five had membranous obstruction, two had dacryoliths, two had NLD malformation at different levels. An overall success rate of 88.4% was achieved.

CONCLUSION

Sialoendoscope can be used as high-definition dacryoendoscope for diagnostic and therapeutic use in CNLDO. Useful information can be obtained on dacryoendoscopy in complex CNLDO cases.

3D morphological classification of the nasolacrimal duct: Anatomical study for planning treatment of tear drainage obstruction

BACKGROUND

The purpose of this study is to analyze and classify morphological features of the nasolacrimal duct (NLD) through 3D reconstruction to help understand the causes and treatment of NLD obstruction.

METHODS

In this study, we included 63 males and 55 females who underwent autopsy without NLD obstruction with ages ranging from 20 to 78 years. The NLD was defined from the lacrimal fossa to the opening of the BNLD to the inferior meatus, and all continuous CT images showing the NLD were selected. Segmentation was performed semi-automatically, and the reconstruction and measurement of NLD was performed using the Mimics program.

RESULTS

Overall NLD length, bony nasolacrimal duct (BNLD) length, anteroposterior and transverse diameters at the entrance to the BNLD, anteroposterior and transverse smallest diameters of the BNLD, BNLD volume, and lacrimal sac BNLD angle were significantly higher in males than females (p < .05). BNLD direction in the coronal plane was slightly more likely to be inward. The most common type in both sexes was cylinder type (42.0%), males were more likely to have lower-thicker types (34.1%), and females more likely to have upper-thicker types (22.7%).

CONCLUSION

There were sex differences in NLD measurements, and females had significantly smaller NLDs. These results may partially explain the increased prevalence of primary acquired NLD obstruction in females. The BNLD tends toward the midline, and inclines posteriorly.

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.

Nasolacrimal duct stenosis-Surgery with a novel robotic endoscope positioning system

BACKGROUND

Distal nasolacrimal duct stenosis is usually treated by head and neck surgeons with transnasal endoscopic dacryocystorhinostomy (DCR). The presented clinical study discusses advantages and drawbacks of a robot-assisted endoscope positioning system, which allows for hands-free visualization of the surgical field.

MATERIAL AND METHODS

Two patients were treated by surgical DCR. The endoscopic positioning system (Medineering^® ) features a mechatronic holding arm with four segments and seven degrees of freedom. It is driven by using a foot pedal.

RESULTS

Visualization and instrumentation of the surgical field including the relevant anatomical landmarks were feasible. The endoscope position could be controlled with sufficient precision. The surgeon was able to maintain bimanual instrumentation.

CONCLUSION

The endoscope positioning system allows for two-handed surgery, which facilitates the essential steps of the surgical procedure. If the benefit of the system is sufficient for the use in clinical routine, it has to be evaluated in repeated applications.

Outcomes and comparison of nasolacrimal probing for patients older than 12 months

Objective:

In this study, we report the results of probing done in our clinic. We also want investigate role of late probing on outcome, especially in children older than 24 and 48 months.

Methods:

We retrospectively evaluated records of patients who underwent probing under general anaesthesia due to congenital nasolacrimal duct obstruction between 2013 and 2017 in Nigde Ömer Halisdemir University Faculty of Medicine in Nigde, Turkey. Success rates of probing for different age groups were compared.

Results:

143 eyes of 123 patients were included in the study. Overall success rate was 93.7% (134 eyes out of 143). We found the success rate as 95.5 in 12–18 months age group, 93.3% in 18–24 months age group, 93.8% in the 24–48 months age group, 86.6% in the 48 months and older age group. Overall success rate in 24 months and older age group was 91.5%. The second operation was performed on seven of the nine patients where the initial surgery failed, and successful results were achieved in six patients. Success rate was 100% after the second surgery in patients older than 48 months.

Conclusion:

The success rate of probing is high in patients with congenital nasolacrimal duct obstruction from 12 to 84 months. In patients with congenital nasolacrimal duct obstruction who are older than 48 months probing is effective and should be first-choice in this age group in management of congenital nasolacrimal duct obstruction. Probing may be used even in older patients who had previous unsuccessful probing.

COVID-19 pandemic and lacrimal practice: Multipronged resumption strategies and getting back on our feet

The aim of this review was to propose multi-pronged resumption strategies for lacrimal practice in an effort to plan a sustainable recommencement of elective surgeries after we emerge from the peak of COVID-19 pandemic. The strategies for lacrimal practice were classified into 7 subtypes, and each of the blueprints were reassessed based on existing information on resumption strategies of elective surgeries from other specialties in COVID-19 era. The specific needs of lacrimal practice were then added to construct algorithms summarizing the resumption strategies. The basic principle of 'primum non nocere' needs to be followed. The overall proposed plan advocates the transition to a more sustainable health care reality in a world where we would still co-exist with COVID-19. A comprehensive effort involving screening, laboratory testing, appropriate triage, effective personal protection and specific precautionary measures for lacrimal clinics and operating room are needed to be able to safely resume elective surgery when the pandemic peak declines. To predict the timing of the resumption of elective surgeries is quite complex and influenced by several geographic, political and economic factors. It is equally important to remember that COVID-19 crisis is a dynamic situation and constantly evolving, hence the strategies provided are subject to change. Strict adherence to standard COVID-19 guidelines combined with effective testing and personal protection strategies can ensure slow yet smooth and safe return to full lacrimal practice after the COVID-19 pandemic calms down. The local government directives, individual and institutional discretion are advised.

Primary Malignant Epithelial Tumors of the Lacrimal Drainage System: A Major Review

Purpose: To perform a literature review on the primary malignant epithelial tumors (PMET) involving the lacrimal drainage system (LDS).Methods: The authors performed a PubMed search of all articles published in English on primary malignant epithelial tumors of the lacrimal sac and the nasolacrimal duct. Data analyzed include prevalence, demographics, clinical presentation, histopathological subtypes, management modalities, outcomes, and recurrence rates.Results: Malignant epithelial tumors of the lacrimal sac are commonly diagnosed in the fifth to seventh decades of life (mean age: 58 years) and have no gender predilection. Typical clinical presentation includes epiphora (84%) and lacrimal fossa mass lesion (78%). Pain (9%) and blood-stained epiphora (4%) were inconsistent findings. Among the PMET, squamous cell carcinomas (SCCs) were the most common (61%) followed by transitional cell carcinomas (TCC; 15%), and mucoepidermoid carcinoma (MEC; 7%). Complete surgical excision followed by radiotherapy (59%) was the preferred modality of management, and only 18% required orbital exenteration. Of the 331 tumors with available treatment details, 85% survived at a mean follow-up of 33 months. The overall recurrence rate following treatment was 20% (65/331). MECs of the lacrimal sac had the best while adenoid cystic carcinoma had the worst prognosis.Conclusion: Blood-stained epiphora was not the classical presentation for primary epithelial malignancies of the LDS. No validated staging system exists for lacrimal drainage tumors. There is a need for consistent and detailed reporting in the literature, more so on the histological subtypes and their management.

Lacrimal drainage system anomalies in Williams-Beuren syndrome

Williams-Beuren syndrome is a rare multi-system disorder affecting 1:10000 to 1:20000 live-births. The cause is de novo contiguous gene deletion on the long arm of chromosome 7 (7q11.23). It typically manifests with dysmorphic facies and predominantly involves the connective tissues, cardiovascular and nervous systems. The published literature reveals that lacrimal drainage anomalies are exceptionally rare and not much is known of those reported. The present case describes multiple lacrimal drainage anomalies in a child with Williams-Beuren syndrome.

Carcinomas of the lacrimal drainage system

Malignant tumors of epithelial origin are the most frequent neoplasms of the lacrimal drainage system (LDS). A total of 539 cases are reported in the literature from 1960 to 2019. LDS carcinoma is a disease of the middle-aged and elderly population, with a median age at diagnosis of 57 years. Overall, there is a slight male predominance. Reported risk factors are chronic inflammation, LDS papilloma, and infection with oncogenic viruses. Symptoms of an LDS carcinoma resemble those of benign, inflammatory diseases, with epiphora from obstruction of the LDS as the most frequently encountered symptom. The median time from symptoms to diagnosis is 12 months and even longer for patients reporting epiphora as the only initial symptom. This diagnostic delay leads to a substantial fraction of patients with locally advanced tumors and lymph node spread at the time of diagnosis. Surgery with adjuvant radiotherapy is the treatment of choice for most patients; however, the extension and aggressiveness of the disease and the patient's general health and preferences determine the definite treatment. Five-year overall survival is reported to range from 61 to 87.6%. A large tumor size and positive lymph node status correlate with a decreased overall and disease-free survival.

Sinonasal Anatomical Variations and Primary Acquired Nasolacrimal Duct Obstruction: A Single Centre, Case-Control Investigation

Objective

Primary acquired nasolacrimal duct obstruction (PANDO) is an idiopathic narrowing of the nasolacrimal duct caused by chronic inflammation and consecutive stenosis of the nasal tissue. In the current investigation, we aimed to study the etiopathogenic role of sinonasal anatomical abnormalities and paranasal inflammatory pathologies in PANDO.

Materials and Methods

Computed tomography (CT) findings of 459 patients who were diagnosed with unilateral PANDO between April 2009 and March 2017 were compared with that of a control group, which comprised 200 subjects without nasolacrimal duct obstruction who had been referred to the ear nose throat (ENT) clinic with the complaint of vertigo and headache. A radiologist (R. S.) masked to the clinical situation of participants retrospectively examined their CT findings.

Results

The prevalence of deviated nasal septum was found to be strongly associated with PANDO incidence (55.3% on PANDO side of patients vs. 28.3% among controls; p<0.001). Significant increases, albeit of smaller magnitude, were also observed in the relative frequency of Agger nasi cells and maxillary sinusitis on the PANDO side of the subjects (14.6% and 27.0%, respectively) compared to controls (9.5% and 20.6%, respectively) (p=0.023 and p=0.038, respectively). Unilateral PANDO was also found to be robustly associated with an ipsilateral deviated nasal septum (p<0.001). The odds of septal deviation occurrence were 3.037 times (95% Confidence Interval (CI): 2.303-3.990; p<0.001) more on the PANDO than the non-PANDO side of the studied cases.

Conclusion

Ipsilaterally deviated nasal septum appears to have a role in the development of unilateral primary acquired obstructive disease of the lacrimal drainage system. The incidence of PANDO might also be affected by Agger nasi cells and maxillary sinusitis. Multicenter studies are essential to further elucidate the interaction between type, severity, extent, and dimensions of different pathologies with nasolacrimal duct obstruction.

Reversible Endoscopic Medial Maxillectomy: Endonasal Approach to Diseases of the Maxillary Sinus

Introduction  The endoscopic access has reduced the morbidity associated with external approaches in diseases of the maxillary sinus. A reversible endoscopic medial maxillectomy (REMM) is presented as an alternative for treatment of benign maxillary diseases.

Objective  To describe the REMM technique and report four cases of patients with benign maxillary sinus conditions treated through this approach.

Methods  The present study was divided into two parts: anatomical and case series. Two cadaveric dissections confirmed the feasibility of the REMM approach. The same technique was performed on four consecutive patients with benign maxillary sinus disease.

Results  The cadaveric dissections confirmed wide exposure to the maxillary cavity, preserving the anatomy of the maxillary sinus. In the patient series, one patient presented with an antrochoanal polyp, one had a silent sinus syndrome, one had a chronic maxillary sinusitis secondary to a gunshot, and the last one had an inverted papilloma in the maxillary sinus. In all of the cases, the REMM approach provided excellent access and adequate resection, as well as preservation of the inferior turbinate, nasolacrimal duct, and lateral wall of the nose (including its osteomucosal component). Finally, all of the patients had an uneventful postoperative course.

Conclusion  The REMM technique is an excellent surgical approach to benign conditions of the maxillary sinus. It has few limitations and appears to be associated with less morbidity than conventional techniques.

Inverted Papilloma of the Lacrimal Sac and Nasolacrimal Duct: A Case Report and Review of the Literature

Inverted papillomas of the lacrimal sac and nasolacrimal duct are exceedingly rare. Though histologically benign, these tumors are locally aggressive, have propensity for recurrence and are associated with a chance of malignant transformation. These tumors can present in an innocuous manner, masquerading as more common conditions such as primary acquired nasolacrimal duct obstruction. We present our experience with one such case and a review of the literature to emphasize the importance of pre-operative assessment and intra-operative vigilance, so as to aid in accurate diagnosis and early treatment.

Acute dacryocystitis in pediatric patients and frequency of nasolacrimal duct patency

Purpose: To study acute dacryocystitis in a pediatric age group, focusing on patients' demographic profiles, clinical presentation, and management outcome. Methods: A retrospective case series of all acute dacryocystitis in pediatric patients (0-17 years) from two tertiary-care eye centres in Riyadh, Saudi Arabia was conducted. Demographic profile, risk factors, initial clinical presentation, management regimens, and final outcome were analysed. Results: A total of 51 patients were included in the study. The mean age of presentation was 3.9 ± 4 years (1 month-13 years). Thirty-eight patients (74.5%) reported symptoms of congenital nasolacrimal duct obstruction (NLDO) prior to presentation, four patients (7.8%) had congenital dacryocystocele, two (3.9%) had a history of traumatic NLDO, and ten (19.6%) had an attack of acute dacryocystitis in the absence of NLDO or any other known risk factors. Four patients (7.8%) progressed to orbital cellulitis while another three (5.8%) had lacrimal sac fistula secondary to acute dacryocystitis. Systemic antibiotics were the initial management in all 51 patients. Twenty-five (49%) underwent probing after the resolution of the acute attack while 12 (23.5%) patients underwent dacryocystorhinostomy (DCR). Conclusions: Early recognition and urgent management for acute dacryocystitis are required to prevent further potential complications and achieve excellent outcomes. Congenital NLDO is the main risk factor for the development of acute dacryocystitis in the pediatric age group. In a small set of patients, acute dacryocystitis can develop despite the presence of a patent lacrimal drainage system on clinical evaluation with lack of tearing and discharge before and after the attack of acute dacryocystitis.

Prevalence and Treatment Outcome of Nasolacrimal Duct Obstruction in Saudi Children with Down Syndrome

Introduction

Congenital nasolacrimal duct obstruction (CNLDO) is one of the most common congenital abnormalities encountered by pediatric ophthalmologists, occurring in 20-30% of all neonates (range: 6-84%). The majority of the cases (up to 90%) resolve within the first year of birth. Many syndromes, such as Down syndrome, are associated with congenital lacrimal anomalies. The prevalence of nasolacrimal anomalies in Down syndrome has been reported to be 22%.

Methods

This was a retrospective study of all children diagnosed with Down syndrome at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia between 2010 and 2015.

Result

The total sample size was 175 patients; 15 patients were diagnosed with CNLDO with a prevalence of 8.57%. The prevalence among the gender was 53.3% male and 46.7% female, with a median age of eight years. Regarding ocular disorders, 20.0% cases were diagnosed with refractive error, 13.3% with nystagmus, and 13.3% with blepharitis. Myopia, strabismus, conjunctivitis, and cataract were observed in four different patients, and the remaining four cases reported no other ocular disorders. Tearing, alone or associated with other symptoms, was the main presentation of CNLDO (86.7%). Bilateral CNLDO was the most commonly observed abnormality, alone or associated with others. The median age at diagnosis was one year. Of the cases, 53.3% were treated medically, 26.7% by surgical correction, and 13.3% required both.

Conclusion

Bilateral CNLDO is the most observed disease pattern among children with Down syndrome. In our study, tearing was the most common clinical presentation and most cases were treated medically. Down syndrome patients should be carefully examined for nasolacrimal duct obstructions and treated medically.

Three-Dimensional Analysis of the Nasolacrimal Duct and Nasal Cavity and Arrangement of Mucosal Tissue in Chickens

The nasal mucosa plays an important role in the immune system, with nasal mucous cells secreting mucin that, along with pili, exclude foreign substances from intervening. Nasal mucosal-associated lymphoid tissue (NALT), present in the nasal lamina propria, acts as a local immune system. In birds, the Harderian gland in the orbit also plays an important role in the local immune system. In this study, we analyzed the pathway from the nasolacrimal duct to the nasal cavity in chickens and the distribution of the nasal mucous cells responsible for defense mechanisms against pathogens. To determine the three-dimensional structure of the pathway from the nasolacrimal duct to the nasal cavity, we made casts of the anatomy by injecting an acrylic resin into the area. We then prepared paraffin sections to determine the distribution of the NALT and mucous cells. The mucous gland was clearly seen in the mucosal epithelium of the nasal cavity, suggesting that the pathway along the nasal cavity develops a nonspecific immune system to deal with large foreign substances, such as bacteria, using mucins that are secreted from the mucous glands. Hence, there is not only a physical barrier but also an antibacterial activity. Unlike in other animals, morphologically, the nasolacrimal duct in chicken becomes the ventral nasal meatus and opens into the choanae in the caudal portion of the nasal cavity. NALT was prominently present in the lamina propria of the ventral nasal meatus, suggesting the presence of a specific immune system protecting against avian viruses. Thus, responses to vaccine stimulation could be developed from tissues along the pathway of the ventral nasal meatus via the nasolacrimal duct running from the punctum. These morphological studies suggest that the instillation of eye drops could be used as an efficient vaccination method for avoiding respiratory diseases.

Refined Sphenopalatine Ganglion Stimulator Placement and Intensity Setting to Augment Blood Flow and Neurologic Function

Background and Purpose- Two large, randomized trials indicated that sphenopalatine ganglion (SPG) stimulation improves final disability outcome in acute anterior circulation patients with ischemic stroke with confirmed cortical involvement. This study evaluated 2 refinements in SPG stimulation treatment technique: (1) SPG electrode placement with real-time optical tracking guidance; and (2) stimulation intensity comfortable tolerance level selection using non-noxious facial physiological markers. Methods- This study was a single, active arm trial at 4 centers, enrolling patients with anterior circulation ischemic stroke, National Institutes of Health Stroke Scale 1 to 6 including arm weakness subitem score ≥1, not receiving recanalization therapies, and within 24 hours of onset. Stimulation level was set based on ipsilateral facial tingling sensation or lacrimation. SPG stimulation effects were assessed by measuring volumetric blood flow in the ipsilateral common carotid artery by ultrasound and grasp and pinch strength in the affected hand before and during stimulation, and by change in National Institutes of Health Stroke Scale from day 1 to 7. Results- Among 50 enrolled patients, age was median 66 years (interquartile range, 60-74), 44% were female, National Institutes of Health Stroke Scale median was 5 (interquartile range, 4-5), and median onset-to-screening time was 18 hours (interquartile range, 9-20). Median implantation skin-to-skin time was 4 minutes (interquartile range, 3-7), and all 50 implants were placed correctly. Comfortable tolerance level was found based on physiological biomarkers in 96% of patients, including 86% in the optimal, low-medium intensity range. SPG stimulation significantly increased common carotid artery peak systolic and end-diastolic blood flow (44%, P<0.0001; and 52%, P<0.0001) and improved pinch strength (42%, P<0.0001) and grasp strength (26%, P<0.0001). Degree of National Institutes of Health Stroke Scale recovery by day 7 was greater than in matched historic controls, median 75% versus 50%, P=0.0003. Conclusions- SPG stimulator placement with real-time optical tracking guidance was fast and accurate, and selection of stimulation intensity levels based on non-noxious facial tingling and lacrimation was feasible in nearly all patients. SPG stimulation led to cervico-cranial blood flow augmentation and improved hand motor function. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT03551093.

A rare association of blepharophimosis-ptosis-epicanthus inversus case with congenital nasolacrimal duct obstruction

PURPOSE

The aim of reporting this case is to describe a rare combination of blepharophimosis-ptosis-epicanthus inversus syndrome with congenital nasolacrimal duct obstruction. A variety of lacrimal anomalies have been seen in blepharophimosis-ptosis-epicanthus inversus syndrome but the occurrence of nasolacrimal duct obstruction is rare.

METHOD

The blepharophimosis-ptosis-epicanthus inversus syndrome is an autosomal dominant rare genetic defect with clinical manifestation of dysplasia of the eyelids, palpebral fissures, flat nasal bridge, and ptosis. A 20-month-old boy was referred with the complaints of watering and discharge from his right eyes since birth. On examination, the child had all the features of blepharophimosis-ptosis-epicanthus inversus syndrome with right congenital nasolacrimal duct obstruction in line with the published reports.

RESULT

On endoscopic probing and irrigation, the probe could not be visualized into the inferior meatus. On dacryoendoscopy, the membranous part of the nasolacrimal duct was found to be completely obliterated with no light transmission into the nose indicating a malformed nasolacrimal duct. The child was managed by endoscopic dacryocystorhinostomy. We could find only one case report published so far on the combination of congenital nasolacrimal duct obstruction with blepharophimosis-ptosis-epicanthus inversus syndrome. This study adds one more case of blepharophimosis-ptosis-epicanthus inversus syndrome with congenital nasolacrimal duct obstruction and adjuvant use of dacryoendoscopy.

Poorly differentiated primary adenocarcinoma of the lacrimal sac and the nasolacrimal duct

Primary adenocarcinoma of the lacrimal drainage system is a rare malignancy. Poorly differentiated subtypes of this tumor demonstrate aggressive behaviors, and metastasis is not uncommon. We present a patient with poorly differentiated adenocarcinoma of the lacrimal sac and nasolacrimal duct with an orbital extension. The case was managed by a combined external and endoscopic approach excision followed by adjuvant radiotherapy.

Epiphora after nasolacrimal duct fracture in patients with midfacial trauma: A retrospective study

The aim of this study was to identify the factors related to occurrence of epiphora or requirement of dacryocystorhinostomy (DCR) in patients with midfacial trauma.We performed a retrospective analysis of the medical records of 1038 patients with midfacial trauma from January 2005 to December 2015. Fifty-one patients (55 cases) diagnosed with nasolacrimal duct (NLD) fracture using facial bone computed tomography were enrolled. Correlation analysis was performed of patient- and injury-related factors, including age, sex, facial trauma etiology, accompanying injury, type and level of the NLD fracture, and time from injury to initial surgery, with the occurrence of epiphora and requirement for DCR.Epiphora occurred in 14.5% and DCR was performed in 5.5% of the patients with NLD fracture. The correlation analysis revealed no significant relationship among the factors with the occurrence of epiphora and requirement for DCR.In patients with midfacial trauma and NLD fracture, epiphora occurred in 14.5% and endoscopic DCR was performed due to persistent epiphora in 5.5% and its result was all successful.

Lacrimal Diversion Devices (Sinopsys Lacrimal Stent): Sharing our Experience with Patients with Chronic Rhinosinusitis without Polyposis

Introduction  Chronic rhinosinusitis (CRS) is a highly prevalent pathology in our society. Due to the prevalence of this condition and to the persisting symptoms despite an appropriate medical treatment, surgical techniques are often required. Lately, minimal invasive techniques have been described, such as lacrimal diversion devices (LDDs). This technique offers a fast and convenient choice for delivery of sinus irrigation and topical medication. Objective  We aimed to describe our experience with LDDs and evaluate the safety and effectiveness of the procedure in patients with moderate to severe CRS without nasal polyposis (CRSsNP) and persistent symptomatology despite medical therapy. Methods  A total of 7 patients underwent bilateral lacrimal stents placement in the operating room. A retrospective observational study was conducted. The Sino-Nasal Outcome Test-20 (SNOT-20) survey was performed and the score obtained was compared before and 1 month after the procedure. Results  The LDDs were used for an average of 80 days. During the follow-up, only three patients had a mild complication with the device (granuloma in the punctum, obstruction, and early extrusion). The mean baseline SNOT-20 score dropped significantly ( p  = 0.015) from 25.85 to 11.57 (mean: - 14.29) 1 month after the procedure. Conclusion  According to our experience and results, the use of LDD is a novel, feasible, and less invasive technique to treat refractory CRS. It reduces the risk of mucosal stripping, provides short-term outcomes, and the surgical procedure does not require advanced training in endoscopic sinus surgery. Moreover, it can be performed in-office under local anesthesia or sedation.

Postoperative Bioresorbable Chitosan-Based Dressing for Endoscopic Middle Meatal Dacryocystorhinostomy With Balloon Dilation

PURPOSE

To evaluate the improvement in epiphora and need for surgical revision in patients with acquired nasolacrimal duct obstruction following balloon-assisted, middle meatal endoscopic dacryocystorhinostomy with chitosan-based dressing versus bioresorbable polyurethane packing versus no packing.

PATIENTS AND METHODS

This was a retrospective study of consecutive adult patients seen from 2015 to 2018 with follow-up evaluation of epiphora at least 3 months after balloon-assisted, middle meatal endoscopic dacryocystorhinostomy. Patients with a history of prior punctoplasty, septoplasty, sinus surgery, or dacryocystorhinostomy of any kind were excluded. Those meeting criteria were stratified by postoperative hemostatic intervention: no packing, bioresorbable packing, and chitosan-based dressing (groups 1, 2, and 3, respectively). Procedural outcomes were graded as successes or failures based on subjective report and anatomical findings at most recent visit within an 18-month postoperative window. Instances of recommendation for revision surgery were also recorded.

RESULTS

Forty-three cases (36 patients) met the abovementioned criteria. Groups 1, 2, and 3 comprised 12, 17, and 14 cases each, respectively. Average patient age was 55.3 years old, and average duration of follow-up was 6.7 months. Significant variation in outcomes was detected across the 3 groups (P = .0495), particularly between groups 1 and 3 (P = .033). Use of chitosan-based dressing trended toward reduced rates of recommendation for surgical revision (P = .203, P = .113).

CONCLUSIONS

Use of chitosan-based dressing after endoscopic dacryocystorhinostomy was associated with improved subjective and anatomical outcomes. It may also contribute to less frequent need for revision surgery. Further study in a larger prospective trial is recommended.

A Comprehensive Review of Cross-Sectional Imaging of the Nasolacrimal Drainage Apparatus: What Radiologists Need to Know

OBJECTIVE. The purpose of this study is to provide a comprehensive review of the radiographic anatomy and cross-sectional imaging findings of the full gamut of nasolacrimal drainage apparatus diseases, highlighting imaging findings from the different nasolacrimal drainage apparatus surgeries, posttreatment complications, and potential imaging pitfalls. CONCLUSION. Radiologists play a critical role in guiding the management of nasolacrimal drainage apparatus diseases and should be familiar with the anatomy and characteristic imaging findings of commonly encountered nasolacrimal drainage apparatus abnormalities and surgeries.

Computed Tomography Versus Dacryocystography for the Evaluation of the Nasolacrimal Duct-A Study With 72 Patients

Objectives

In patients with epiphora, imaging of the nasolacrimal duct is essential not only for differential diagnosis, but also for preoperative planning. Advances in imaging technology and introduction of cone beam computed tomography (CB‐CT) enable the combination of contrast agent‐based imaging with a three dimensional tomography with low radiation exposure. However, the value of CT/CB‐CT as an alternative to conventional dynamic dacryocystography (DCG) has not been evaluated yet.

Study Design

Retrospective study.

Methods

Conventional DCG was performed preoperatively in 72 consecutive patients treated for epiphora between 01/2013 and 04/2015 in our department. CB‐CT or conventional CT was performed afterward with the contrast media still in place. Three separate experts (two radiologists and one otorhinolaryngologist) analyzed the radiographic images without any information about the respective clinical or surgical findings. The presence of further findings in the CT/CB‐CT (eg, septal deviation, sinusitis) that were not detected in DCG and the overall visibility of the lacrimal duct system in both modalities were evaluated.

Results

Good delineations of bone, soft tissue, and contrast agent in the lacrimal system were achieved with both methods. No side effects were noted. Beside the pathology of the lacrimal duct, CT/CB‐CT scans enabled the additional diagnosis of pathologies in the nose and the sinus system in 65.7% of the patients. Accordance in the identified level of obstruction between the two modalities was achieved in 71.4% of the patients.

Conclusion

Thus, CT/CB‐CT should be used in conjunction with contrast agent to reliably identify the level of obstruction as preoperative standard and can be used as diagnostic tool in addition to or even instead of conventional DCG.

Level of Evidence

4

Magnetic resonance dacryocystography in the horse: A feasibility study

OBJECTIVE

To provide a comprehensive anatomical description of the normal equine nasolacrimal duct using magnetic resonance imaging, and to develop a practical protocol for performing magnetic resonance dacryocystography (MRD) in horses.

ANIMAL STUDIED

The heads of ten fresh horse cadavers with no history of sinonasal or ophthalmologic disorders were used for this study.

PROCEDURE

An MRD technique was developed in this study, which consisted of two parts. In the first part, olive oil and gadolinium were compared as contrast medium, using five horses. Two concentrations of gadolinium were used: 0.25 mmol/mL and 0.5 mmol/mL. In the second part, the influence of different head recumbencies using olive oil as the sole contrast medium was studied in the remaining five horses.

RESULTS

Injection with olive oil resulted in better distention and a complete filling of the nasolacrimal duct (ND) in all horses. Injection of 0.25 mmol/mL of gadolinium resulted in incomplete filling of the ND, whereas injection of 0.5 mmol/mL of gadolinium resulted in slightly better filling of the duct. The nondependent duct showed better distention compared to the dependent duct when scanning in lateral recumbency. No differences were observed between ducts in a dorsal recumbency. The degree of distention in dorsal recumbency was slightly less than the degree of distention observed in the nondependent ND in lateral recumbency.

CONCLUSIONS

Magnetic resonance dacryocystography is a suitable technique for evaluating the nasolacrimal duct and can be performed during a normal magnetic resonance examination.

Swinging inferior turbinate approach to the nasolacrimal duct

Purpose: To report a case of a lacrimal sac tumour identified at the time of endoscopic dacryocystorhinostomy and describe a swinging inferior turbinate approach to the nasolacrimal duct (NLD) to facilitate an en-bloc excision of the lacrimal drainage apparatus.Methods: An 88-year-old male presented with a 6-month history of epiphora and mucocele. Endonasal DCR was performed for nasolacrimal duct obstruction (NLDO). Intraoperatively, a biopsy was performed of abnormal appearing lacrimal sac mucosa, following opening of the lacrimal sac. Subsequent definitive management was performed via a combined external and endoscopic approach using a swinging inferior turbinate approach to the NLD to facilitate an en-bloc excision of the lacrimal drainage apparatus, without removal of the bony medial wall of the maxillary sinus.Results: The excised lacrimal drainage showed insitu and invasive squamous cell carcinoma of the canaliculi and lacrimal sac with focal divergent neuroendocrine and sebaceous differentiation. There was no local tumour recurrence or metastatic spread at 3 months of follow-up.Conclusions: We describe a swinging inferior turbinate approach to the NLD to facilitate an en-bloc excision of the lacrimal drainage apparatus, without entering the maxillary sinus. We believe this modified technique is a useful option to consider in the management of tumours of the lacrimal drainage apparatus.

Fluoroscopically guided neocanalization for treatment of nasolacrimal atresia in two horses

CASE DESCRIPTION

A yearling Thoroughbred stallion and an 8-year-old Saddlebred mare were evaluated for persistent mucoid ocular discharge.

CLINICAL FINDINGS

Examination of both horses revealed copious yellow-tan mucoid ocular discharge with a negative Jones I test, absent nasal punctum, and unsuccessful anterograde nasolacrimal duct (NLD) irrigation. Clinical abnormalities were present on the right side only in one horse and bilaterally in the other. Computed tomography (CT) with contrast confirmed nasolacrimal duct atresia in both horses.

TREATMENT AND OUTCOME

Under general anesthesia, the affected NLD was catheterized anterograde and contrast injected. Using fluoroscopic guidance, retrograde access to the distal NLD was obtained for through-and-through wire access. Over the wire, the stoma was dilated and a temporary stent placed for 4-8 weeks. After the procedure, both horses were comfortable and free of ocular discharge at the minimum time of last follow-up, 9 months postoperatively.

CLINICAL RELEVANCE

Fluoroscopically guided neocanalization is a viable alternative to traditional surgical approaches for NLD atresia, especially when access to the site of obstruction is limited.