The Use of Hand-Held Digital Otoscope as a Basic Nasal Endoscopy Tool for Lacrimal Evaluation and Pedagogy Instrument.

PURPOSE: To investigate the utility of a hand-held digital otoscope for nasal endoscopy and as a pedagogy tool for residents and fellows in patients undergoing external dacryocystorhinostomy (DCR) surgery. METHODS: A digital otoscope (MS450-NTE, Teslong Inc., USA) comprising a digital screen device and a connectible camera probe was used for performing nasal endoscopy. Inspection of nasal cavities was performed pre-, intra-, and post-operatively in sequential patients with nasolacrimal duct obstruction, who underwent DCR or lacrimal probing. Images (1920 × 1080 pixels) and videos (1280 × 720 pixels) were captured. The device was also used for training residents and fellows in performing nasal endoscopy, and to teach basic concepts. RESULTS: The digital otoscope could be used for routine outpatient nasal examination and for performing minor procedures. 53.8% (n = 13) of ophthalmology trainees had never observed nasal endoscopy and 84.6% could not identify more than one major structure correctly prior to the current training. Post-training, all trainees could independently perform nasal endoscopy with the device and 76.9% identified all structures correctly. CONCLUSION: A digital otoscope with a camera probe is a handy tool for nasal endoscopy and pedagogy. Low-cost gadgets such as this device can effectively be used for performing outpatient nasal endoscopy when expensive endoscopes are unavailable and in peripheral healthcare centers.

Endoscopic and Radiologic Findings in Failed Dacryocystorhinostomy: Teaching Pearls for Success.

BACKGROUND: Although several studies have commented on causes of dacryocystorhinostomy (DCR) failure, detailed description of anatomical findings in such cases remains insufficient. OBJECTIVE: Our objective was primarily to analyze radiologic, endoscopic, and intraoperative findings in patients presenting with failed DCR and secondarily to assess the outcome of revision endoscopic DCR (endo-DCR) carried out at our institution. METHODS: Twenty-four failed DCRs presenting to our tertiary care center were retrospectively analyzed. Data collection included patients' history, diagnostic, and management data, as well as thorough analysis of sinonasal CT scans, along with endoscopic and intraoperative findings. Outcome was also assessed in 21 cases with revision endo-DCR performed. RESULTS: The anterior part of uncinate process was not previously removed in 15 sides (62.5%), with unopened agger nasi in 13 sides (54.2%). The lacrimal bone was detected covering the posterior sac despite removal of the anterior ascending process of maxilla in 9 sides (37.5%). Rhinostoma was anterior to lacrimal sac in 2 sides (8.3%) and was below the sac in 7 sides (29.2%). Fibrous membrane covered the rhinostoma despite removal of all sac-overlying bones in 6 sides (25%). Other findings included intranasal adhesions, septal deviation, lateralized middle turbinate, granulation tissue, foreign body reaction, and chronic sinusitis. Nineteen of the 21 revision endo-DCRs were successful (90.5%). CONCLUSION: This study provides a precise anatomical description of findings in cases of failed DCR. Such information is paramount in helping surgeons enhance their learning curve, refine the surgical technique, and improve patients' outcome.

Learning Curve for Endoscopic Endonasal Dacryocystorhinostomy.

PURPOSE: To elucidate the learning curve for endoscopic endonasal dacryocystorhinostomy (EE-DCR) based on the results of EE-DCR performed by three surgeons at three different tertiary hospitals. METHODS: A retrospective review of the medical records of 386 eyes of 337 patients who had undergone EE-DCR by three surgeons at three tertiary hospitals and who were available for a >6-month postoperative observation period was conducted. The success of a given surgery was determined based on the results of a test performed during the patient's last outpatient visit to the hospital. The learning curve was identified by dividing the patients into four groups (20, 30, 40, and 50 eyes in each respective group) and comparing their success rates. RESULTS: The overall success rate of the entire study population was 86.3%. The success rates for each of three surgeons was 83.3%, 85.6%, and 88.1%, respectively. After dividing the patients into groups of 30 eyes each, all three surgeons showed a significant increase in surgery success rates after their first group of 30 eyes (p < 0.05). The overall success rate excluding the first 30 eyes was 92.9%, and all three surgeons exhibited a significantly improved success rate of >90% (A, 94.4%; B, 90.8%; C, 95.4%). CONCLUSIONS: A surgeon should be required to perform at least 30 EE-DCR procedures to obtain stable surgical skill for this procedure.

Learning Curve in External DCR - A Trainee's Perspective.

PURPOSE: The aim of this study is to determine the success rate over time in patients undergoing External Dacryocystorhinostomy (DCR) with acquired naso-lacrimal duct obstruction (NLDO), when done by a trainee ophthalmologist. METHODS: The study was Prospective Observational study and was conducted in Tertiary Eye Hospital, Uttar Pradesh, India. One hundred and fourteen consecutive adult patients underwent external DCR for acquired complete NLDO by a trainee with less than 3 years of experience in ophthalmology between November 2011 and March 2013. Postoperative anatomic success rate was determined at 6 months on the basis of the patency of lacrimal sac syringing and patients were asked to subjectively evaluate improvement of their epiphora using a questionnaire. RESULTS: Anatomical success rate across the entire study period was 93.7% and this improved from 87% in the first tertile of 38 patients to 94% in the second tertile and 100% in the final tertile of cases (p<0.05). Overall complication rate was 16.67% and reduced from 29% in the first tertile to 8% in the final tertile (p<0.05). Loss of anterior nasal flap was the commonest complication (10 cases) during the training period. CONCLUSION: External DCR, as a primary procedure for acquired NLDO, even when operated by trainee ophthalmologists, has a relatively high success rate that improves over time. As the learning curve improves, complication rates reduce significantly. FINANCIAL DISCLOSURE: No author has any financial or proprietary interest in the material or method mentioned.

Learning curve for use of the sonopet ultrasonic aspirator in endoscopic dacryocystorhinostomy.

PURPOSE: The Sonopet Ultrasonic Aspirator is a surgical tool that uses low-frequency ultrasonic vibrations to fragment tissue while simultaneously irrigating and aspirating the surgical field. This technology is becoming more widely used in orbital, lacrimal, neurological, and skull base surgery, but few studies have examined the learning curve associated with adoption of this technology. We present our surgical learning curve, pearls, and pitfalls using the newest generation Sonopet Ultrasonic Aspirator Universal handpiece in endoscopic dacryocystorhinostomy (eDCR) surgery. METHODS: Retrospective chart review of consecutive eDCR surgeries performed by a single surgeon adopting the Sonopet Universal handpiece. Data collected include demographic information, indications for surgery, surgical time, intraoperative findings, anatomic and functional results, and complications. RESULTS: Twenty-six eDCR surgeries in 20 patients were performed from October 2011 - May 2013. Most patients were female (85.7%) with mean age 53.6 years (range 4-84) and mean follow up of 378 days (range 7-761). For routine unilateral and bilateral surgeries, surgery time decreased by 36.4% and 33.9% before reaching a plateau of 67.2 and 80.7 minutes per case, respectively. Mean surgery time for non-sequential unilateral complex cases was 85.1 minutes, which did not vary significantly over the learning curve. We achieved 100% anatomic success and 84.6% functional success. CONCLUSIONS: The Sonopet Ultrasonic Aspirator Universal handpiece can be used safely and effectively for eDCR surgery. A significant learning curve exists for adoption of this technology. Appropriate handpiece tip selection and machine setting adjustments are crucial for successful adoption of this technology and avoidance of complications.

An animal model for endoscopic endonasal surgery and dacryocystorhinostomy training: uses and limitations of the lamb's head.

OBJECTIVES: Structured training in endoscopic sinus surgery is essential, considering the serious potential complications. We have developed a detailed endoscopic endonasal surgery training programme, using a lamb's head model. This study aimed to assess the possibilities of using such a model for endoscopic dacryocystorhinostomy training. MATERIALS AND METHODS: Dacryocystography was performed on lamb's head models, which were then meticulously dissected, both macroscopically and endoscopically, to assess the nasolacrimal system. RESULTS: Dacryocystography showed the absence of a lacrimal sac in all the lamb's heads dissected. This result was confirmed by dissection. CONCLUSION: Lamb's heads are excellent models with which to teach endoscopic sinus surgery techniques. However, this study clearly demonstrated the absence of a lacrimal sac in all such models dissected. Thus, this animal model is inappropriate for endoscopic dacryocystorhinostomy training.