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Purpose The COVID‐19 pandemic gave rise to renewed concerns of the transmission risks posed by surgeries on sites of high viral colonization such as the nasopharynx. Endoscopic dacryocystorhinostomy (DCR) involves the creation of a new tear duct from the lacrimal sac to the nasal cavity. The purpose of this project is to determine if endoscopic DCR is an aerosol generating procedure (AGP). Methods An optical particle sizer (OPS) was used to intraoperatively quantify aerosol concentrations during four cases of endoscopic DCR. The OPS sampled the air once every 60 seconds throughout the operations. The time of important operative steps were documented and correlated with OPS readings. Particle concentrations during each major surgical step were compared to baseline readings by the Mann Whitney U Test. Results There were statistically significant increases in median particle concentrations during laryngeal mask airway intubations for both particles 0.3 to 5.0 μm and >5.0 μm (P, An optical particle sizer quantified aerosols during key steps of endoscopic 42 dacryocystorhinostomy, showing increases in 0.3‐5.0 μm and >5.0 μm particles during 43 intubation, but no increases in particles associated with any of the surgical steps.

Importance: This is the first retrospective study of the effect of computed tomography (CT) in diagnosis and surgical correction of recurrent pediatric acute dacryocystitis (PAD). Objective: To explore the pathogenesis of recurrent PAD and the impact of CT in guidance of surgical planning. Methods: Medical histories, clinical manifestations, and CT results of 10 patients with recurrent PAD were reviewed. Etiologies and treatment effectiveness were recorded for all patients. Results: CT revealed that three patients had congenital dacryocystocele with lacrimal sac cyst, enlargement of the nasolacrimal canal, and intranasal cyst of affected sides. After regression of local inflammation, marsupialization was performed. CT showed that four patients had PAD secondary to congenital nasolacrimal canal dysplasia; these patients exhibited normal upper portions of the nasolacrimal canals, but had stenotic or atretic middle and terminal segments. After improvement of local inflammation, endonasal dacryocystorhinostomy was performed. Three patients had PAD secondary to congenital lacrimal sac diverticulum; after contrast injection, CT showed that the cysts at the lacrimal sac area were filled with contrast, and were connected to the normal lacrimal sac. After the topical infection was controlled, transcutaneous dacryocystorhinostomy was performed in combination with excision of the lacrimal sac diverticulum. No recurrence of PAD was detected at 6-month follow-up. Interpretation: Causes of PAD include congenital dacryocystocele, congenital lacrimal sac diverticulum, or congenital nasolacrimal canal dysplasia. Marsupialization with endoscope, endonasal dacryocystorhinostomy, and transcutaneous dacryocystorhinostomy constitute distinct surgeries for PAD treatment. CT provides an important diagnostic function and facilitates selection of specific surgical approaches for recurrent PAD. Key words: Acute dacryocystitis; Nasolacrimal canal; Computed tomography

Solitary fibrous tumor (SFT) is a fibroblastic tumor of the pleura, and subcutaneous and deep soft tissues of the extremities, abdomen, pelvis, and retroperitoneum. In the head and neck region, the sinonasal tract and soft tissues of the orbit are involved most frequently. However, the lacrimal sac is an extremely unusual location for this tumor, with occasional case reports in literature. Being superficially located and palpable, lacrimal sac masses are easily amenable to FNAC. Despite cytological features of SFT being well-documented, they are often underdiagnosed on FNAC. Immunocytochemistry for STAT6 is a sensitive and specific marker that can aid in accurate diagnosis, as is required for planning appropriate management. We describe the case of a 45-year-old lady who presented with a mass at the medial canthus of the right eye, and was diagnosed as SFT on FNAC, based on cytomorphological features and immunopositivity for STAT6. The diagnosis was subsequently confirmed on histological examination.

Objectives To study the clinical profile and the route of spread of lacrimal sac rhinosporidiosis. To device a standard transnasal endoscopic surgical procedure in the treatment of lacrimal sac rhinosporidiosis. Methods This is a retrospective analysis of a case series on lacrimal sac rhinosporidiosis. Thirteen cases of lacrimal sac rhinosporidiosis reported in our institution from July 2003 to July 2016 were included. Workup included diagnostic nasal endoscopy and lacrimal syringing. All patients underwent transnasal endoscopic excision of rhinosporidiosis. Results Lacrimal sac rhinosporidiosis was more prevalent among males and in the 31 to 40 years age group. All patients had a history of bathing in stagnant water bodies. The most common clinical presentation was a doughy swelling medial to the medial canthus. Lacrimal sac rhinosporidiosis invariably presented with involvement of the nasolacrimal duct. Following the endoscopic excision of lacrimal sac rhinosporidiosis, all patients were followed up for a mean period of 16 months, and only one patient had recurrence. Conclusion A unique aspect of our case series is that patients presented with features pertaining to isolated lacrimal system involvement rather than sinonasal involvement. Involvement of the nasolacrimal duct and nasal cavity without involvement of the eyes in all cases confirms the retrograde spread of rhinosporidiosis from the nasal cavity into the lacrimal sac via the nasolacrimal duct as the most common route of spread of infection. We recommend that endoscopic dacryocystorhinostomy, along with nasolacrimal duct excision used for surgical management in our case series with superior results, must become the standard of care in treatment of this condition. Level of evidence 4 Laryngoscope, 128:2693-2696, 2018.

Background Although the efficacy of Draf type II and III procedures for frontal sinus diseases is well recognized, a certain amount of postoperative stenosis of the frontal neo-ostium occurs. Exposed bone induces inflammation and leads to osteoneogenesis. To prevent stenosis, we developed a surgical technique designed to minimize bone exposure while maximizing the frontal neo-ostium area created with Draf type II and III procedures. We fully exposed the lacrimal sac and used a superior lateral anterior pedicle flap to cover the exposed bone during the Draf procedure. We aimed to describe our technique. Methods We reviewed 19 patients who underwent a Draf type II or III procedure with our technique. Endoscopic views from the follow-ups and complications were evaluated. Results Overall, the neo-ostium remained patent in all patients. No complications, such as synechiae or orbital injury, were seen in any of the patients. Conclusion Draf type II and III procedures with lacrimal sac exposure and a superior lateral anterior pedicle flap are convenient and seem to be effective. However, further studies with larger numbers of patients are needed to verify our technique.

Objective Obstruction of the nasolacrimal duct is a relatively common condition that affects patients of all ages, races, and sexes. The surgical gold standard for complete nasolacrimal duct obstruction and dacryocystitis is dacryocystorhinostomy (DCR). The purpose of this study was to describe a novel, bipedicled interlacing mucosal sparing flap technique for endoscopic DCR (eDCR). Methods A posteriorly based mucosal flap over the fundus is combined with a novel, anteriorly based mucosal flap over the intraosseus portion of the nasolacrimal duct (NLD). This exposes a wide area of the maxillary bone, allowing for exposure and identification of the NLD/sac complex in a safer, more inferior position. The interlacing mucosal flaps may be replaced at the conclusion of the procedure, thereby minimizing bone exposure and maintaining excellent long-term patency. Results The authors have utilized this technique in 55 procedures with 100% positive identification of the NLD and lacrimal sac, 0% complication rate, 100% anatomical patency rate, and 96.4% success rate after a minimal follow-up of 6 months. Discussion The bipedicled interlacing flap technique for eDCR provides for safe and reproducible identification of the NLD and lacrimal sac while minimizing bone exposure and restenosis rate. Conclusion The bipedicled interlacing flap technique for eDCR provides for safe and reproducible identification of the NLD and lacrimal sac while minimizing bone exposure and restenosis rate. Level of evidence NA. Laryngoscope, 128:794-797, 2018.

Background Oncocytomas and oncocytic carcinomas are rare tumors of the sinonasal cavity with the propensity for local invasion. This report and systematic review details a case of a nasal oncocytoma involving the lacrimal sac and provides an update of the current literature. Methods A systematic literature review was performed using PubMed and Ovid databases. The data obtained from published articles with sinonasal oncocytoma/oncocytic carcinoma as the primary diagnosis included patient demographics, presentation, radiographic and histologic findings, management, and recurrence rates. Results Twenty cases were identified. The most common symptoms were epistaxis (n = 11) and nasal obstruction (n = 11). Involvement of the nasal cavity was most common (n = 17), followed by the paranasal sinuses (n = 13) and nasolacrimal apparatus (n = 4). Recurrence occurred in 55% of cases. Recurrence was associated with invasion or infiltration found on histology or the presence of both invasion/infiltration and mitotic figures/pleomorphism (p < 0.05), with no significant relationship between recurrence and age at diagnosis (p = 0.42), sex (p = 0.65), and location of tumor (p = 0.14). The authors present the case of a 73-year-old woman with a 5-month history of worsening epistaxis and biopsy-proven oncocytoma. Complete surgical resection of the tumor using combined endonasal endoscopic and anterior orbitotomy approach is described. Conclusion Oncocytomas and oncocytic carcinomas are rare tumors of the sinonasal cavity with a high rate of local recurrence and orbital involvement. Surgical resection is the treatment of choice and complete resection can be achieved with an endoscopic endonasal approach.

Objective To describe canaliculosinostomy performed to resolve epiphora caused by nasolacrimal duct obstruction and to report the outcome of horses undergoing this procedure. Study Design Case series. Animals Seven horses with uni- or bilateral nasolacrimal duct obstruction. Methods The ventral lacrimal punctum and canaliculus were expanded with catheters of increasing diameter until a 14 gauge, Jamshedi needle could be passed into and through the lacrimal sac into the caudal maxillary sinus. One end of a plastic tube was inserted through the needle into the sinus, and the needle was withdrawn over the tubing. Using a hubless needle, the other end of the tube was passed through the lower eyelid leaving a segment of tubing exposed ventral to the eyelid. The end of the tubing within the sinus was exteriorized through a trephine hole in the frontal sinus and then tunneled beneath the skin adjacent to the osteotomy using a hubless needle, leaving a segment of tubing exposed on the forehead. Exposed tubing was sutured to the skin. The tubing was removed at 5–6 weeks. Results Canaliculosinostomy was easily performed with the horses sedated. Five horses had resolution of epiphora, and 2 had improvement. Conclusion Canaliculosinostomy to divert lacrimal secretions into the sinuses resolves or improves epiphora caused by nasolacrimal duct obstruction and provides a good functional and cosmetic outcome. Canaliculosinostomy can be performed in the sedated horse.

To describe a case of a nasolacrimal canaliculocele with intranasal extension in a dog. A 6-year-old neutered female Jack Russell Terrier was referred to the Centre Hospitalier Veterinaire des Cordeliers for a slowly enlarging mass adjacent to the medial canthus of the right eye of 5 months duration. Ophthalmic exam, ultrasound, fine needle aspiration, dacryocystorhinography and computerized tomography examinations were performed. Rhinoendoscopic treatment with marsupialisation of the endonasal canaliculocele was performed. Physical examination revealed a 3 cm diameter, subcutaneous mass beneath the medial canthus of the right eye, with a defect in the maxillary bone below. Dacryocystorhinography demonstrated blockage at the level of the nasolacrimal duct. Fine needle aspiration confirmed the cavitary nature of the lesion. During rhinoendoscopy, a mass containing watery fluid was found. Following marsupialisation with a large mass wall resection, the lacrimal drainage system irrigated freely in the nasal chamber. The communication of the lumen of the diverticulum with the lumen of the superior but not the inferior canaliculus was clearly demonstrated during endoscopy. Given negative immunohistochemical staining for smooth muscle actin and desmin, nasolacrimal dacryocele appears to be the most likely diagnosis. Histological examination confirmed that no goblet cells were present in the wall of the diverticulum, which is consistent with the canaliculus rather than the lacrimal sac. Complete resolution was observed without recurrence one year after surgery. Despite its rarity, a canaliculocele should be considered in adult dogs with nasolacrimal duct obstruction. Marsupialisation seems to be the appropriate therapy.

The creation of an alternative pathway from the lacrimal sac into the nose has been practised for over two millennia. Early historical figures who pioneered lacrimal surgery were Celsus and Galen, treating dacryocystitis by plunging a red-hot cautery iron through the lacrimal bone into the nose. Better understanding of lacrimal physiology and anatomy led to the introduction of more sophisticated techniques in the 18th century. However, despite these approaches, the technique of Celsus continued to be practised well into the eighteenth and nineteenth centuries. Modern lacrimal surgery began when the Italian otolaryngologist, Toti, described his external dacryocystorhinostomy procedure in 1904. Dupuy-Dutemps and Bourget refined Toti's procedure, and introduced the technique of anastomosing lacrimal and nasal mucosal flaps which remains the foundation of the external dacryocystorhinostomy performed today. The endonasal dacryocystorhinostomy was described before the external approach, but its popularity and success grew only in recent times.

Diffuse large B-cell lymphoma (DLBCL) and mantle cell lymphoma (MCL) constitute two distinct subtypes of non-Hodgkin lymphoma (NHL) associated with considerable morbidity and mortality. Marked diversities with regard to molecular biology and clinical features are recognized in different subsets of the two lymphomas. Because these differences could be related to the location of the lymphoma, it is of interest to investigate the clinical and histopathological features of DLBCL and MCL involving the ocular adnexal region (i.e. the orbit, eyelids, conjunctiva, lacrimal gland and lacrimal sac). Similarly, the lacrimal gland is the only glandular structure within the orbit. Because the lacrimal gland represents an important part of the immunological system, it is of interest to investigate lymphomas involving this location with regard to clinical and histological characteristics. Purpose: To characterize the clinical and histopathological features of Danish patients with DLBCL of the ocular adnexal region between 1980 and 2009 and of Danish ocular adnexal MCL patients from 1980 to 2005. Furthermore, the aim of this PhD was to review all specimens from patients with lymphoma of the lacrimal gland in Denmark between 1975 and 2009 to determine the distribution of lymphoma subtypes of the lacrimal gland and to describe the clinicopathological features of these patients. Results: A total of 34 patients with DLBCL and 21 with MCL of the ocular adnexal region were identified. Twenty-seven patients had lacrimal gland lymphoma, including four DLBCLs and three MCLs from studies I and II. Elderly patients predominated in all three groups, with median ages of 78, 75 and 69 years in the DLBCL, the MCL and the lacrimal gland lymphoma groups, respectively. MCL patients had a preponderance of males, whereas females prevailed among lacrimal gland lymphoma patients. The orbit was the most common site of involvement in DLBCL and MCL. Most DLBCL patients had unilateral involvement, while MCL patients had a high frequency of bilateral involvement. Similarly, localized lymphoma was relatively frequently seen in DLBCL patients in contrast to the predominance of disseminated lymphoma in the MCL group. The majority of lacrimal gland lymphomas were low grade, and the distribution of subtypes was as follows: extranodal marginal zone lymphoma, 10 (37%); follicular lymphoma, 5 (19%); DLBCL, 4 (15%); MCL, 3 (11%); chronic lymphocytic leukaemia/small lymphatic lymphoma, 2 (7%); and unclassified B-cell lymphoma, 3 (11%). The overall survival rates at 3 and 5 years for the entire study group of DLBCL were 42% and 20%, whereas 58% and 22% of MCL patients were alive 3 and 5 years after the time of diagnosis. The 5-year overall survival rate of lacrimal gland lymphoma patients was 70%. Concordant bone marrow involvement and the International Prognostic Index score were predictive factors for the overall survival in the DLBCL group in Cox regression analysis. Rituximab-containing chemotherapy was associated with an improved survival rate in MCL patients. Conclusions: Diffuse large B-cell lymphoma and MCL involving the ocular adnexal region and lymphoma of the lacrimal gland are prevalent among elderly patients. The overall prognosis in DLBCL and MCL was poor, whereas the prognosis for lacrimal gland lymphoma patients was relatively good. Concordant bone marrow involvement and the International Prognostic Index score were independent predictive factors for mortality in the DLBCL group. Chemotherapy containing rituximab significantly improved survival in the MCL group.

Purpose To describe a minimal invasive technique for nasolacrimal duct reconstitution with radiofrequency in a case of lacrimal flow restriction. Methods Case report of a 23 years-old female, with previous history of tearing, swelling, redness and pain over the innermost aspect of the lower eyelid of her right eye (RE). The symptoms started four years ago and sometimes relapses and discharge. The patient denies any other comorbilities, systemic or local complaints or any medication. External examination RE: Milder test +++, BUT inferior to 3’’. LE: Milder test +, BUT inferior to 3’’. Both eyes present inferior punctate keratopathy. It was diagnosed low nasolacrimal obstruction in RE, confirmed with dacriocistography. Treatment option was nasolacrimal duct reconstitution with radiofrequency under sedation and local anesthesia. Results The patient was followed for at least one year. She was evaluated for the presence of secretion, epiphora, reflux at compression of the lacrimal sac, placement of silicone tube and Milder test. At postoperative visits, the patient presented positive irrigation with clearance of lacrimal duct. Conclusions Reconstitution with radio frequency seems to be a solution to be considered. The presented technique was effective in the treatment of nasolacrimal duct obstruction with a good safety profile, being less invasive when compared with the classic DCR. Prospective, comparative, multicentric studies and larger follow up are still needed.

Background: A prospective observational study in a university hospital setting to study the immunohistochemical (IHC) characteristics of non-neoplastic human lacrimal sac epithelium. Methods: Twenty paraffin-embedded specimens of human lacrimal sac were studied using monospecific monoclonal antibodies to 34 beta E12, cell adhesion molecule (CAM 5.2), epithelial membrane antigen (EMA), cytokeratins (CK) 7 and 20, estrogen receptor and progesterone receptor. The distribution and histologic location of IHC staining were examined qualitatively, and the IHC stains scored as positive (+) or negative (−). Results: The haematoxylin–eosin stains were reviewed for tissue morphology. All 20 specimens were positive for 34 beta E12, CAM 5.2, EMA and CK 7 and negative for CK 20, estrogen receptor and progesterone receptor. Conclusion: To our knowledge, this is the first study to characterize the IHC properties of human lacrimal sac epithelium. This epithelium appears to possess consistent IHC properties as it stains for 34 beta E12, CAM 5.2, EMA and CK 7 and this information would be potentially useful in differentiating tumours arising in the region of the lacrimal sac.

The aims of the study were (1) to quantify the influence of selected imaging parameters on the image quality (slice thickness, mAs, and beam orientation) defining optimal conditions for scan protocols and (2) to evaluate the benefits of the 3D reconstruction techniques for visualization of NDS structures in dogs. CT-DCG was performed bilaterally in 32 heads of dogs. CT transverse images were obtained using a combination of two slice thickness values (0.8 mm and 2 mm) and two mAs values (50 mAs and 300 mAs). Two beam projection orientations were also tested: transverse plane (perpendicular to the hard palate) and oblique to the hard palate. Three-dimensional images were obtained using Volume Rendering (VR). Transverse beam projection proved to be superior for the assessment of the inferior and superior lacrimal canaliculi and lacrimal sac. In this study, there was no statistical difference regarding mAs values (50 mAs and 300 mAs) and slice thickness values (0.8 mm and 2 mm). Three-dimensional images were helpful for the assessment of topographic relationship between nasolacrimal structures and cranial landmarks.

Summary Reasons for performing study: No endoscopic examination of the nasolacrimal duct has been described before. In contrast with other imaging techniques, endoscopy provides a direct inspection of the intralumen and ductal mucosa in standing sedation. Objectives: To provide a reference against which the endoscopic and clinical features of obstructive nasolacrimal disease in the horse may be compared. Methods: Endoscopic examination of the nasolacrimal duct was performed in 10 French Thoroughbred bay mares with a 3 mm shaft diameter flexible fibrescope. The duct was divided into 3 zones (1, 2 and 3) from the nostril to the lacrimal sac. Results: Endoscopic examination of the nasolacrimal duct appeared to be quite easy to perform in Zones 1 and 2, while the ease or difficulty of examining Zone 3 depended on the weight and size of the horse for the position of the endoscope in the lacrimal canal. Conclusions: Endoscopic inspection has provided the possibility of a novel diagnostic approach to conditions of the nasolacrimal duct in horses. Potential relevance: Endoscopic examination of the nasolacrimal duct could help to diagnose and treat nasolacrimal diseases by performing sample withdrawal and duct irrigation.

Purpose: Dacryocystorhinostomy (DCR) is an effective and safe procedure for patients with post-saccal obstruction of the nasolacrimal pathway. The aim of DCR is to relieve symptoms by creating a bypass between the lacrimal sac and the nasal cavity. The most common reason for failure is stenosis caused by a fibrotic process at the rhinostomy site. In this prospective study we assessed the expression of heat shock protein 47 (HSP47), a regulator of fibrosis, in the biopsies of nasal mucosa isolated from patients undergoing primary endoscopic DCR (EN-DCR). Methods: Thirty consecutive primary EN-DCR procedures in 30 patients were performed using the powered instrumentation technique. The nasal mucosa specimens over the rhinostomy site were collected for histological analysis at the beginning of the operation and the expression of HSP47 was evaluated by immunohistochemistry. The outcome of EN-DCR was estimated in follow-up visits at 1 week, 2 months and 6 months after surgery. Results: At the 6-month follow-up, the overall success rate after primary EN-DCR was 83%. A metaplastic change and strong expression of HSP47 in nasal mucosa were associated with EN-DCR failure (p = 0.009). Conclusions: HSP47 may be regarded as a novel marker to predict impaired EN-DCR outcome.

Objectives: Access to the medial orbit traditionally has been gained transcutaneously, with potential for associated soft tissue and lacrimal disruption. Endoscopic transnasal approaches to the medial orbit may be limited in certain scenarios by tumor presence or patient-specific factors. The medial transconjunctival approach, or transcaruncular approach, has been recently described for access to the medial orbit in orbital decompression and repair of medial blowout fractures. The aim of this study is to determine the utility of this minimally invasive external approach in the endoscopic management of advanced sino-orbital disease. Methods: This is a cadaver study with additional clinical correlations. The transcaruncular approach was combined with a transnasal endoscopic approach in cadaver dissections performed on eight sides. Five cases are described in which the transcaruncular approach was used as an adjunctive technique in advanced endoscopic sinus surgery. Results: In cadaver dissection, the transcaruncular approach is a simple, reliable method to ligate the ethmoid arteries and place bony cuts along the medial orbital wall. In certain anatomic configurations, supraorbital dissection into the frontal sinus or anterior fossa may be achieved. In the cases examined, exposure of the medial orbital subperiosteal plane allowed for ligation of ethmoid arteries, assessment of periorbital invasion of disease, assistance in tumor dissection, and placement of a malleable retractor for protection of orbital contents. Conclusions: The transcaruncular approach to the medial orbit has certain advantages over the traditional open approach. Ligation of the ethmoid arteries, assessment of the lacrimal sac and periorbita for tumor invasion, protection of orbital contents, and en bloc resection of the periorbita and lamina papyrecea are possible through this route.

BACKGROUND: Malignant epithelial neoplasms of the lacrimal apparatus are rare and are typically treated with surgery and occasionally adjuvant radiation therapy (RT). The purpose of this study was to assess treatment outcomes by type of surgery (orbital exenteration vs eye-sparing surgery) and clarify the role of adjuvant RT for this rare disease. METHODS: Forty-six patients with malignant epithelial neoplasms of the lacrimal apparatus were treated at a single institution from 1945 through 2008. Twenty-seven patients (59%) were treated with orbital exenteration and 19 (41%) with eye-sparing surgery; 64% of the orbital exenteration group and 83% of the eye-sparing surgery group also received adjuvant RT (median dose, 60 grays). Median follow-up time for all patients was 38 months (range, 3-460 months). RESULTS: For the orbital exenteration and eye-sparing surgery groups, the 5-year overall survival (OS) rates were 59% and 62%, and the 5-year disease-free survival (DFS) rates were 49% and 39%, respectively (P = .56, P = .35). Tumor status (T1-2 vs T3-4) was associated with OS (P = .02), and tumor size ( 3.5 cm) with DFS (P = .015). Median time to locoregional recurrence was 85 months for orbital exenteration, and 123 months for eye-sparing surgery. All patients who did not receive RT experienced local recurrence, and RT extended time to locoregional recurrence (median 460 vs 30 months, P = .009). Seven grade ≥3 complications were experienced after adjuvant RT. CONCLUSIONS: For appropriately selected patients, an eye-sparing surgery for lacrimal apparatus tumors can achieve similar survival outcomes to those in patients treated with an orbital exenteration. Adjuvant RT should be considered for all patients presenting with these rare tumors. Cancer 2011. © 2011 American Cancer Society.

A case report of a primary malignant melanoma of the lacrimal sac is presented. After excision a local recurrence appeared one year later. Wide, but incomplete excision and postoperative irradiation resulted in local tumour control for 4 years. The patient succumbed to a uremic death caused by a rectal cancer removed 3 years before the occurrence of the malignant melanoma.

Background: To determine the correlation between the anthropometric facial features and the anatomy of the nasolacrimal drainage system. Methods: Forty-six mid-sagittal halves of 23 cadavers were studied. The inclination of the lacrimal sac (LS) and nasolacrimal duct (NLD), and the LS-NLD angle were measured in both the sagittal and coronal planes. For the facial features, the height, length and depth of the nose, the intercanthal distance, nasal breadth, nasofacial angle, distance between the external naris, and the inferior aperture of the NLD were measured. The correlations between the angles and the facial features were calculated. Results: The LS-NLD angle was classified into three anatomical types according to the inclination of the LS and the NLD in the sagittal and coronal planes; the anterior-inward type (43.5%), anterior-outward type (37.0%), and posterior-outward type (19.5%). The nasal depth was correlated with the sagittal LS-NLD angle, and the nasal height and length were correlated with the coronal LS-NLD angle. Conclusions: There is a large variation in the LS-NLD angle, and nasal depth, height and length can be used to predict the direction of this angle.

Purpose: To evaluate whether silicone tube insertion is always necessary in external dacryocystorhinostomy (DCR). Methods: During external DCR for primary nasolacrimal duct obstruction carried out between January 2001 and October 2004, silicone intubation was not performed selectively if the lacrimal sac was large and the nasal cavity was not severely narrowed. Results: Of a total of 166 DCR cases in 153 patients, no silicone tube was placed in 74 eyes of 69 patients (44.6%). Anatomic patency of rhinostomy was achieved in all non-intubation group eyes. However, four (6.7%) of these 69 eyes showed persistent epiphora even with anatomic patency. Conclusions: Silicone tubing can be avoided in about 50% of cases of external DCR without detrimentally affecting the success rate. Cases in which intubation was avoided had a large lacrimal sac and a wide nasal cavity.

Computed tomography (CT) of the nasolacrimal drainage system with and without contrast medium (barium sulfate) was used to create an anatomic basis for clinical evaluation in domestic cats. To evaluate and compare the anatomical findings, three casts were carried out and were followed by CT examinations. These CT series were also used for a three-dimensional (3D) reconstruction of the nasolacrimal drainage system within surrounding structures. In noncontrast CT images, osseous structures limiting the nasolacrimal drainage system are easily recognizable. In most cats, this allows the identification of the nasolacrimal drainage system even without contrast enhancement. A distal part of the lacrimal sac adjoins directly to the respiratory mucosa of the nasal cavity without an osseous protection. Thus, this may represent a predilection site for infiltration of adjacent pathologic processes from the nasal cavity onto the lacrimal sac. The nasolacrimal duct begins on level with the maxillary third premolar tooth. The apex of the root of the canine tooth is situated very close to the nasolacrimal duct. This close topographic relation may lead to problems with the nasolacrimal drainage system. In domestic cats the nasolacrimal drainage system consists of a descending and a horizontal part, which form an angle of approximately 90 degrees for unhindered drainage of the lacrimal fluid.

Purpose: To determine the frequency of histologically verified lesions of the lacrimal drainage system in Denmark between the years 1910 and 1999. Furthermore, to correlate the clinical diagnosis with the pathology diagnosis. Methods: Retrospective review of all pathology reports from 1910 to 1999 in the files of the Eye Pathology Institute, University of Copenhagen, describing a lesion of the lacrimal drainage system. In addition, a retrospective review of all reports describing a lesion of the lacrimal drainage system from the Danish Pathology Database. All specimens were re-evaluated, except in cases with a primary diagnosis of dacryocystitis. In these cases a sample of 25% was re-evaluated. Results: A total of 643 lesions were collected. Dacryocystitis was the most frequent lesion, constituting 508 cases (79%). The remaining cases were diagnosed as dacryolithiasis (62 cases; 7.9%), tumour (29 cases; 4.5%), trauma (19 cases; 3.0%), congenital malformation (nine cases; 1.4%), canaliculitis (eight cases; 1.2%) and granulomatous inflammation (eight cases; 1.2%). Seventeen tumours were malignant, of which B-cell lymphoma was the most common (six cases). In 0.6% of cases with a clinical diagnosis of dacryocystitis/lithiasis a nonsuspected malignant tumour was diagnosed. Micro-organisms were uncommon in dacryocystitis (9%) but frequent in cases of dacryolithiasis (87%). Conclusion: Dacryocystitis was by far the most frequent lesion of the lacrimal drainage system referred for histopathological evaluation. Dacryolithiasis was often associated with micro-organisms, especially Gram positive rods. Histopathology is necessary to confirm suspected tumours, more than half of which were inflammatory lesions, and to detect tumours that sometimes masquerade as inflammation.

The aim of this study was to describe the nature of active skill-based errors occurring in endoscopic dacrocystorhinostomy (DCR) surgery. A human reliability analysis methodology was used to assess surgical error from observational capture data. Twelve endoscopic DCR operations performed by three different surgical trainees were video recorded. The steps (subtasks) of each operation were carefully analysed and common errors were documented. Specific errors that resulted in trauma to the nasal mucosa were noted. Execution errors were common, with errors of grasping being most frequent (67% of all execution errors). Most of these involved the Blakesley forceps. In total, there were 69 mucosal trauma hits. Inserting instruments into or withdrawing them from the nasal cavity with too much force or speed caused more than half of these. Incising with too much force resulting in 'overshoot' caused 34% of mucosal trauma. Trainee ENT surgeons should take particular care when inserting or withdrawing instruments from the nasal cavity and also when performing lacrimal sac or nasal mucosa incisions. Performance of these tasks with too much force was identified as a common and potentially avoidable cause of mucosal trauma. Further research is needed into the design and use of endoscopic sinus surgery instruments with the aim of avoiding the errors that were encountered.

This is a case series with chart review from 1997 to 2010 to determine results of endoscopic dacryocystorhinostomy in children. Thirty-seven children underwent removal of the medial wall (RMW) of the lacrimal sac (LS) and 2 had lacrimal stents inserted because they had external fistulae and small cicatrized LS. Parameters of success were (1) resolution of epiphora, (2) no further attacks of dacryocystitis, and (3) patency of neofistula. Of the 37 (95%) children who had RMW of the LS, 34 (92%) were patent after 12 weeks and were considered successful. Three (8%) neofistulae obstructed within 2 weeks and needed revision, and 2 (5%) patients had small cicatrized LS along with fistula and were stented. The fistulae closed down in 4 weeks. However, when the stents were removed 6 weeks later, epiphora returned. The authors' experience reveals that removal of the medial wall of the LS is effective in stopping chronic epiphora.

To describe powered endoscopic dacryocystorhinostomy (DCR) with full sac exposure and primary mucosal anastomosis and report perioperative and follow-up results achieved with this procedure.Prospective, nonrandomized cohort study.Operative and postoperative data were prospectively collected on 36 unselected patients (15 men and 21 women; mean age, 62.4 y; range 14-91 y) who presented to a lacrimal clinic with epiphora and obstruction of the drainage of the nasolacrimal system and who consecutively underwent either primary or revision powered endoscopic DCR. A total of 47 procedures were performed; all were done by the same surgeon, who used a standardized surgical technique. Follow-up evaluations included symptom evaluation and endoscopic assessment of the newly created ostium with fluorescein testing at each postoperative visit.The only surgical complication was one case of orbital fat exposure. Forty-five of the 47 DCRs were patent after a mean follow-up of 11 months (standard deviation = 5 mo), yielding a success rate of 95.7%. Patency was assessed by endoscopic visualization of the ostium and fluorescein (initially placed on the conjunctiva) in the ostium. One of the 47 DCRs was a failure and one patient had O'Donaghue tubes in place with symptoms. Two patients with a patent ostium and positive results on fluorescein testing continued to have some symptoms.Powered endoscopic DCR with full sac exposure and primary mucosal apposition has a success rate comparable to that achieved with external DCR.

Background Malignancy of the lacrimal sac is rare, and primary malignant melanoma in this region is extremely rare. Methods We report two cases of malignant melanoma of the lacrimal sac presented with epiphora and a palpable mass in the medial canthal area. We performed radical surgery and radiation therapy. Results The light microscopic, immunohistochemical, and electron microscopic studies confirmed the diagnosis. One of the patients, a 65-year-old-woman, has no evidence of recurrence or distant metastasis 3 years after surgery and radiotherapy, whereas another patient, a 56-year-old man, died of distant metastasis 6 months after surgery and radiotherapy. Conclusions We present two cases of malignant melanoma of the lacrimal sac that masqueraded as chronic dacryocystitis. Head and neck surgeons should be aware of this disease entity when encountered with patients with epiphora and mass in the medial canthal area. © 2001 John Wiley & Sons, Inc. Head Neck 23: 809–813, 2001

Aims: To determine the current bacteriology of mucopurulent discharge in congenital nasolacrimal duct obstruction (CNDO), the in vitro response to different antibiotics and clinical effectiveness of the antibiotics used to relieve babies from mucopurulent discharge. Methods: A clinical study evaluated the effectiveness of local antibiotic agents clinically and in vitro. 50 samples were obtained from the lacrimal sac in 47 young children with CNDO. The patients' mean age was 21.45±17.09 months. The cultures were incubated and the infectious agents isolated. Sensitivity testing was performed in each case, testing 10 different local antibiotics. A control group of 10 babies expected for cataract surgery was constituted. Results: Cultures were positive for bacteria from 72.64% of the samples. 73 isolates were recovered from the 50 samples. The bacterial species most frequently cultured was Streptococcus pneumoniae, representing 35.4% of the isolates, followed by Haemophilus influencae (19.6%). The sensitivity testing revealed ofloxacin and tetracycline to be the most effective drugs as monotherapy. Clinically the combination of bacitracin and neomycin, primarily used in half of the patients as initial therapy, was successful in curing the dacryocystitis in 82.5% of all patients. Conclusion: Chronic dacryocystitis due to CNDO is associated with an equal proportion of Gram positive and negative bacteria, which can be treated with a high effectiveness by a combination drug of bacitracin and neomycin.

Objective Traditional endoscopic dacryocystorhinostomy (DCR) involves creation of a lacrimal sac side hole that may close down in the presence of a partially patent lower lacrimal drainage system. Endoscopic terminal DCR is a modified DCR procedure designed to prevent this problem. Methods From September 1996 to June 1999, 16 patients (17 sides) had endoscopic terminal DCR that involved resection of the lacrimal sac-duct junction to achieve total separation of the lacrimal sac from the nasolarcrimal duct and creation of a terminal DCR opening. Results Ten of the 17 DCRs were primary and 7 were revisions. The follow-up ranged from 3 to 36 months. There were two failures. One failure was due to canalicular obstruction and the other was due to prolapse of orbital fat hindering proper fashioning of the mucosal flap. The overall success rate was 88%. Conclusions Instead of creating a side hole in the lacrimal sac as proposed by most endoscopic DCR studies, we advocate total diversion of tear flow by performing a terminal DCR opening that would further improve the success rate of endoscopic DCR, particularly in cases of idiopathic and partial obstruction.

Nasopharyngeal carcinoma (NPC) is treated primarily by radiotherapy. Marginal miss after radiotherapy is a potential cause for treatment failure in NPC. Anterior marginal miss after irradiation results in recurrent tumors in the nasal cavity outside the nasopharynx. From 1991 to January 1997, 6 recurrent NPCs arising in the anterior marginal miss zone after radiotherapy were confirmed by pathologic and radiologic evaluation. One patient had infiltrating growth of the original NPC tumor into the anterior part of nasal septum, and the other 5 had microscopic extensions from the original NPC tumors into the nasal cavity that were beyond detection by endoscopy or CT scan. In some cases the tumors extended further to include the hard palate or the lacrimal sac. Medial maxillectomy and partial maxillectomy with or without resection of the hard palate were necessary to encompass the extent of the tumors. Surgical margins were free of cancer cells in 5 patients. No further treatment was given in these 5 patients. Another patient with tumor extending to the lacrimal sac received postoperative radiotherapy. Five of the 6 patients survived with no evidence of disease for 8 to 65 months. One patient had distant metastasis 14 months after surgery but was free from tumor at the primary site. Radical surgery can result in good and sustained local control for anterior marginal miss of NPC after radiotherapy. (Otolaryngol Head Neck Surg 1999;121:622-6.)

Purpose Obstruction of the naso-lacrimal duct has traditionally been treated by dacryocystorhinostomy. This pilot project aimed to evaluate the use of stents as an alternative approach to the treatment of naso-lacrimal duct obstruction. Methods Six patients with naso-lacrimal duct obstruction underwent a pre-procedural dacryocystogram to confirm the site of obstruction. Under local anaesthesia, they subsequently underwent dilatation of the naso-lacrimal duct using a guide wire and a plastic dilator aided by fluoroscopy and digital subtraction imaging. The stent was then placed with its head in the lacrimal sac and tail protruding out of the naso-lacrimal duct into the inferior meatus. Dacryocystography was repeated to confirm patency. Patients were followed up for a minimum of 12 months. Results The procedure was successfully completed in four of the six patients. In one patient, we failed to negotiate the guide wire and in one, a false passage was created. All four successful cases were rendered asymptomatic and their lacrimal passages remained patent at 12 months. Conclusion Naso-lacrimal duct dilatation and stenting is a viable alternative to conventional dacryocystorhinostomy in the treatment of naso-lacrimal duct obstruction and merits a larger trial.

The position, dimension and thickness of the exposed lacrimal bone at the lateral nasal wall in 10 cadaveric half-heads were examined. In all cases, the lacrimal bone at the lateral nasal wall was found to be just anterior to the mid-third of the uncinate process. The average length and width was 7.4 mm and 2.5 mm, respectively. In nine of the 10 half-heads, the lacrimal bone was very thin with an average thickness of 57 mm. In all the cases, the position of the lacrimal passage covered by the lacrimal bone corresponded to the postero-medial aspect of the upper lacrimal duct and the lower lacrimal sac. This study shows that the uncinate process is a reliable landmark for the lacrimal bone in endoscopic nasal surgery. The paper-thin lacrimal bone allows a bone rongeur to infracture through and nibble away the bony covering of the lacrimal sac in a dacryocystorhinostomy.

Objectives To observe the benefit of endoscopic surgery for the treatment of lacrimal duct obstruction in revisional surgeries after external dacryocystorhinostomy. Study Design and Setting Retrospective nonrandomized study. Eleven cases of recurrent lacrimal duct obstruction after external dacryocystorhinostomy were submitted to endoscopic dacryocystorhinostomy. Results The rate of success after revisional surgery was 90.9%. The major causes of failure of the external approach were the presence of granulation tissue, septal deviations and synechiae near the opening of the fistula, inadequate removal of the bony wall adjuvant the lacrimal sac, technical error in the localization of the lacrimal sac, and excessive perioperative bleeding that impaired the surgical field. Conclusion Endoscopic dacryocystorhinostomy in revisional cases proved to be a safe technique of low morbidity, permitting effective resolution of the lacrimal obstructions. Significance Endoscopic surgery allows greater visibility of the lacrimal sac and its neighbor anatomic alterations and leads to better results.

Conventional dacryocystorhinostomy (DCR) usually involves extensive removal of bone at the lacrimal fossa and hence risks disruption of the lacrimal pump mechanism. A physiological operation for nasal lacrimal blockage is described whereby only the inferior portion of the lacrimal sac and the adjacent duct are marsupialized into the nose. The operation is safe, quick and does not involve sophisticated instruments. Result of 81 consecutive endoscopic inferior DCRs reveals a success rate of over 90% which is maintained with time. Most patients had a wide lacrimal window with preserved lacrimal pump movement at the superior sac remnant.

BACKGROUND Primary non-Hodgkin's lymphoma of the lacrimal sac is extremely rare, with most reported cases representing secondary involvement of a systemic malignancy. METHODS The clinical record of a 70-year-old female who presented with epiphora and swelling of the lacrimal sac area is described. A review of the literature of patients with primary lacrimal sac lymphoma also is presented. RESULTS Computed tomography demonstrated a lacrimal sac mass involving the nasolacrimal canal. Histopathologic examination of a biopsy specimen revealed a diffuse large cell lymphoma. Using immunohistologic staining, the tumor was a B-cell type, similar to those described in the literature. The patient was treated with 50 gray of irradiation and chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisone. The patient remained free of lymphoma 26 months after initial treatment. An ocular examination was unremarkable except for epiphora. CONCLUSIONS Radiotherapy and/or chemotherapy can treat localized lymphoma of the lacrimal sac successfully. Cancer 1997; 80:2151-5. © 1997 American Cancer Society.

Background Fibrous histiocytoma is a slow-growing tumor that most commonly occurs in the superficial and deep soft tissue, with an occasional occurrence in the orbit. However, fibrous histiocytoma of the lacrimal sac is very rare. Methods A case report of a 33-year-old man with a palpable mass in the right lacrimal sac and epiphora is presented, with a review of the literature pertaining to this unusual case. Results The patient was found to have a 3 × 2-cm-sized mass in the right lacrimal sac. Under the impression of benign tumor, the tumor was excised. Histopathologic diagnosis of fibrous histiocytoma was made on the surgical specimen. Following surgical treatment, the patient has remained free of symptoms. Conclusions Fibrous histiocytoma of the lacrimal sac is a rare disease. This case report and a review of the literature demonstrated that surgical excision appears to control the tumor. © 1997 John Wiley & Sons, Inc. Head Neck 19: 72–75, 1997.

Objectives:Dacryocystorhinostomy (DCR) is a surgical procedure whereby a connection is established between the lacrimal sac and the nasal cavity in an effort to bypass an obstruction of the distal lacrimal apparatus. Endoscopic endonasal DCR (EEDCR) is a minimally invasive technique used to achieve this goal. In patients with altered anatomy, EEDCR can be challenging. Here, we describe the use of canalicular transillumination with EEDCR in two complicated cases and discuss the benefits of this technique compared to external DCR and standard EEDCR.Methods:Case series.Results:A 33-year-old woman suffered an iatrogenic skull base injury while undergoing right-sided EEDCR. An intraoperative rhinologic consultation was requested from our service, and the patient underwent emergent endoscopic repair of a right skull base defect. Grossly abnormal endoscopic and radiographic anatomy was noted, and a diagnosis of ozena was ultimately established. Two years later, the patient underwent successful right-sided transi...

Objectives:1) Report our experience and surgical treatment of the unilateral giant dacryocele using the endoscopic technique. 2) Improve the lacrimal sac treatment with endonasal surgery, thus avoi...

Objective: High success rates for endoscopic dacryocystorhinostomy (END-DCR) in partial nasolacrimal duct obstruction (NLDO) have been reported, but comparisons with complete NLDO are lacking. This study compares the success of primary END-DCR with respect to the preoperative nasolacrimal duct patency and reviews factors associated with failure.Method: Retrospective review of END-DCRs performed at a tertiary referral center. Partial and complete NLDO were defined by the presence or absence of flow into the nose with lacrimal sac washout (SWO), respectively. Intraoperative findings including thickness of bone, level and state of the common canaliculus, state of inflammation, and contents of the lacrimal sac during END-DCR were recorded. For patients with at least 3 months follow-up, the outcome of resolution of epiphora (none/partial/complete), postop Jones 1 (J1; positive/ negative) and endoscopy of the neo-ostium (closed/partially or fully-open) were defined.Results: A total of 245 primary END-DCRs were ...

A case is reported of combined coliform and anaerobic bacterial infection of the lacrimal sac, a condition of which there is only one other published case report. In addition, a literature review is presented of the bacteriology of acute dacryocystitis as it applies to this case. Recommendations for the microbiological investigation and management of acute dacryocystitis are made.