Nasolacrimal Duct Obstruction Secondary to Eosinophilic Chronic Rhinosinusitis: A Case Report.

A 47-year-old Japanese woman presented with a 1-year history of right-sided epiphora. On initial consultation, the patient had a high right tear meniscus height. CT images revealed bilateral soft tissue opacification in the nasal cavity and maxillary, frontal, and ethmoid sinuses. The lesion in the right nasal cavity and maxillary sinus involved the right lacrimal sac and nasolacrimal duct. Blood test results showed elevated eosinophil count. Endoscopic sinus surgery and excisional biopsy of the nasolacrimal duct were performed. Histopathological examinations of the excised right nasolacrimal duct and nasal polyps from the nasal cavity and maxillary sinus showed high levels of eosinophilic inflammatory infiltrates. The definite diagnosis of eosinophilic chronic rhinosinusitis was made, based on clinical, radiological, and histopathological findings. At 1.5-year follow-up, tear meniscus height was normal, the lacrimal drainage system remained patent, and the rhinosinusitis did not recur.

Primary Lacrimal Sac Tumors with Extension into Vicinity: Outcomes with Endoscopy-Assisted Modified Weber-Ferguson's Approach.

PURPOSE: To evaluate the outcomes of endoscopy-assisted modified Weber-Ferguson's approach in the management of primary lacrimal sac tumors with extension into the neighboring tissues. METHODS: A retrospective interventional study was performed on all patients with lacrimal sac tumors treated with the endoscopy-assisted modified Weber-Ferguson approach between January 2010 and June 2022 at the Shanghai Ninth People's Hospital, China. Data assessed include demographics, clinical presentations, imaging features, surgical techniques, histopathology, adjuvant modalities of management, complications, and outcomes. RESULTS: A total of 13 patients were included in the analysis. Epiphora and palpable mass lesion were the presenting complaint in 84.6% (11/13) of the patients. Nearly half of the patients (46.1%, 6/13) were misdiagnosed as lacrimal duct obstruction. All the lacrimal sac tumors in the present series showed uneven enhancement on T1-weighted MRI imaging. Postoperatively, 84.6% (11/13) patients recovered well with excellent esthetics and were disease-free after a mean follow-up of 58.6 months. Two patients who underwent additional exenteration developed recurrence and succumbed (at 41 and 96 months follow up) while they were on palliative chemoradiation. CONCLUSION: The endoscopic-assisted modified Weber-Fergusson surgical approach is effective in providing better visibility and accessibility to lacrimal sac tumors with extension into neighboring tissue.

Caruncle and plica hypertrophy causing mechanical secondary acquired lacrimal duct obstruction: - SALDO update study (SUP) - paper I.

PURPOSE: To exclusively report the clinical category of mechanical secondary acquired lacrimal duct obstruction (SALDO) secondary to the caruncle and plica hypertrophy. METHODS: Prospective interventional case series involving 10 consecutive eyes with megalocaruncle and plica hypertrophy were enrolled in the study. All patients presented with epiphora secondary to a demonstratable mechanical obstruction of the puncta. All patients underwent high magnification slit-lamp photography and Fourier-domain ocular coherence tomography scans (FD-OCT) of the tear meniscus height (TMH) pre- and post-operatively at 1-month and 3-months. Caruncle and plica size, position, and their relationship to the puncta were noted. All patients underwent partial carunculectomy. Primary outcome measures were demonstrable resolution of the mechanical obstruction of the puncta and the reduction in the tear meniscus height. The secondary outcome measure was the subjective improvement of the epiphora. RESULTS: The mean age of the patients was 67 years (range: 63-72 years). The average TMH was 843.1 (range: 345-2049) microns pre-operatively and 195.1(91-379) microns at 1-month follow-up. All patients reported significant subjective improvement in epiphora at 6-months follow-up. One patient had bilateral granuloma at the surgical site at two weeks and was managed by simple excision and topical tapering steroids. Histopathology revealed hyperplastic epithelium with goblet cells with chronic inflammatory cells in the sub-epithelial region and the stroma. CONCLUSION: The role of the caruncle in the causation of mechanical SALDO needs to be carefully assessed in patients beyond the sixth decade. Excellent objective and subjective outcomes can be achieved by a partial carunculectomy and plica semilunaris excision.

Minimally Anterior Medial Maxillary Approach (MAMMA): a novel technique for a wide access to the maxillary sinus.

PURPOSE: To describe a novel endoscopic technique to approach the maxillary sinus (MS), the Modified Anterior Medial Maxillary Approach (MAMMA), preserving the inferior turbinate (IT) and the nasolacrimal duct (NLD). To perform radiological measurements and describe a case series to study the feasibility and limits of MAMMA. METHODS: Computed tomography (CT) scans (n = 150 nasal cavities) were used to calculate areas of the MAMMA to define surgical limits and extensions. Measurement of distances to critical anatomy landmarks and total area for the MAMMA were calculated. An instructional case illustrating the surgical technique and outcome was also included. RESULTS: Radiological analysis showed a mean distance from the Piriform Aperture (PA) to the anterior limit of the NLD of 1.03 ± 0.18 cm (range 0.59-1.48) and a mean distance from de PA to the posterior limit of the NLD of 1.57 ± 0.22 cm (range 1.02-2.11). The mean distance from the nasal floor to the Hasner's valve was 1.61 ± 0.27 cm (range 1.06-2.52) and the distance from the nasal floor to the insertion of the IT was 2.20 ± 0.36 cm (range 1.70-3.69). Finally, the mean total area for the MAMMA was 4.04 ± 0.52 cm2 (range 3.17-5.53). No complications or recurrence of the pathology were observed in operated patients. CONCLUSION: The MAMMA provides a wide surgical field of the MS walls comparable to more aggressive techniques, with preservation of the sinonasal and lacrimal function. MAMMA is an effective alternative to treat different MS pathologies including benign recurrent maxillary sinus tumors.

Assessment of the prelacrimal recess in different maxillary sinus pneumatizations in relation to endoscopic prelacrimal recess approaches: a computed tomography study.

PURPOSE: To assist in planning before the endoscopic prelacrimal recess (PLR) approach, we aimed to investigate the relationship between morphometry and variations of PLR in maxillary sinus (MS) pneumatizations. METHODS: Retrospective analysis of the paranasal sinus computed tomography images of 150 patients was conducted to determine the pneumatization patterns of the MS, PLR variations, and the applicability of the PLR approach. The results were compared based on lateralization, gender, and age groups. RESULTS: The PLRwidth, the anteroposterior diameter of the nasolacrimal duct (NLD), the vertical and horizontal diameters of the MS were the highest in hyperplasic MS, and decreased significantly with increasing age (p = 0.005, p = 0.017, p = 0.000), respectively. Most of the morphometric measurements were higher in hyperplasic MS, while the medial wall thickness of PLR was higher in hypoplasic MS. The PLRwidth for feasibility of the PLR approach were Type I (48%) in hypoplasic MS and Type III (80%) in hyperplasic MS (p < 0.001), respectively. The PLR medial wall thickness was higher in Type I, while the piriform aperture angle (PAA), MS volume, length, and slope of the NLD were higher in Type III PLRwidth (p = 0.000), respectively. The highest anterior and separation-type variations of the PLR were observed in hyperplasic MS, whereas 31.0% of hypoplasic MS had no PLR (p < 0.001). CONCLUSION: This study revealed that PLRwidth and PAA were the highest in hyperplasic MS, which allows the endoscopic PLR approach to be performed more easily. For safer and uncomplicated surgery, surgeon should be aware of the PLR anatomy in different MS pneumatization patterns.

Meibomian Gland Dysfunction in Primary Acquired Nasolacrimal Duct Obstruction.

This study was designed to investigate the influence of primary nasolacrimal duct obstruction (PANDO) on the structure and function of the Meibomian gland and to examine whether it is related to functional failure after dacryocystorhinostomy surgery. Medical records of patients diagnosed as PANDO from August 2021 to February 2022 were retrospectively studied. Results of slit lamp examination, lacrimal drainage test, tear break-up time, anterior segment optical coherence tomography, and meibography were collected. Tear meniscus height, tear break-up time, meiboscore, and lipid layer thickness of tear membrane were parameters compared between the eyes with complete PANDO and the control group. Medical records of 44 patients, therefore 88 eyes were collected, and there were 28 eyes with complete PANDO (total obstruction group), while normal eyes (control group) were 30. Mean tear meniscus height was significantly higher than that of the control group ( P value<0.001), but tear break-up time ( P value=0.322), lipid layer thickness ( P value=0.755), and meiboscore ( P value=0.268) were not significantly different. However, in the cases with moderate and severe meibomian gland destruction, the lipid layer thickness of the total obstruction group was significantly thinner than the control group. Lipid secretion of meibomian glands was less in eyes with PANDO than in eyes without PANDO, under moderate to severe meibomian gland destruction. It can lead to persistent epiphora after dacryocystorhinostomy due to a compensatory response against evaporative dry eye disease. Patients should be educated before the decision to undergo surgeries about the possibilities of persistent epiphora. Further studies are needed to prove the mechanism of meibomian gland function disturbance in PANDO.

Dependence of radioactive iodine-131 capture by the lacrimal ducts on the tear production level.

Purpose: Secondary acquired lacrimal duct obstruction (SALDO) is one of the complications of radioiodine therapy. SALDO is formed a few months after therapy if there is a sufficient uptake of radioactive iodine by the nasolacrimal duct. To date, risk factors leading to SALDO are unclear. The objective was to determine the correlation between the tear production level and radioactive iodine-131 uptake in the lacrimal ducts. Methods: Basal and reflex tear production was studied in 64 eyes prior to the therapy with radioactive iodine-131 after drug-induced hypothyroidism. The condition of the ocular surface was assessed using the Ocular Surface Disease Index (OSDI) questionnaire. Seventy-two hours after the radioactive iodine therapy, scintigraphy was performed, which determined the presence or absence of iodine-131 in the lacrimal ducts. T-statistics and the Mann-Whitney criterion were used to identify the differences between the groups. The differences were considered significant at P ≤ 0.05. The current tear production level in patients receiving radioiodine therapy was determined using a mathematical model. Results: A statistically significant difference between the basal (p = 0.044) and reflex (p = 0.015) tear production levels was found in cases with and without iodine-131 uptake by the lacrimal ducts. The probable current tear production level corresponds to the sum of basal and 10-20% of reflex tear production. The uptake of iodine-131 was found regardless of the OSDI results. Conclusion: The probability of iodine-131 uptake by the lacrimal ducts rises as the tear production level increases.

[Disorders of lacrimal drainage: the way from theory to practice]. / Narushenie slezootvedeniya: put' ot teorii k praktike.

The article summarizes the results of research conducted over the past decade concerning the current problems of dacryology, analyzes the improvements made to the methods of diagnostics used in disorders of lacrimal passages on the basis of modern imaging and functional studies, describes the techniques aimed at improving the clinical effectiveness of the intervention, as well as drug and non-drug methods of intraoperative prevention of excessive scarring in the area of the artificial ostium. The article also analyzes the experience of using balloon dacryoplasty in relapses of tear duct obstruction after dacryocystorhinostomy, and presents the modern minimally invasive surgical techniques, including nasolacrimal duct intubation, as well as balloon dacryoplasty and endoscopic plastic surgery of the ostium of the nasolacrimal duct. Additionally, the work lists the fundamental and applied tasks of dacryology and outlines promising directions of its development.

Topographic and anatomical features of the nasolacrimal duct obstruction due to radioiodine treatment.

PURPOSE: To investigate the topographic and anatomical features of secondary acquired nasolacrimal duct obstruction (SALDO) due to radioiodine therapy. METHODS: Dacryocystography-computed tomography (DCG-CT) scans of the nasolacrimal ducts in 64 cases with SALDO due to radioiodine therapy and in 69 cases with primary acquired nasolacrimal duct obstruction (PANDO) were studied. The anatomical site of obstruction was located, and morphometric characteristics of the nasolacrimal ducts were calculated: volume, length, and average sectional area. The statistical analysis was performed using the t-criterion, ROC analysis, and the odds ratio (OR). RESULTS: The mean nasolacrimal section area was 10.7 ± 0.8 mm2 in patients with PANDO and 13.2 ± 0.9 mm2 in patients with SALDO due to radioiodine therapy (p = 0.039); the AUC value in ROC analysis for this parameter was 0.607 (p = 0.037). The development of "proximal" obstruction including lacrimal canaliculi obstruction and obstruction at the site of the lacrimal sac was 4.076 times more likely (CI: 1.967-8.443) in patients with PANDO than in patients with SALDO due to radioactive iodine exposure. CONCLUSIONS: By comparing CT scans of the nasolacrimal ducts, we observed that in SALDO obstruction due to radioactive iodine therapy is predominantly "distal," while in PANDO it is more often "proximal." The development of obstruction within SALDO is followed by more pronounced suprastenotic ectasia.

Accumulation of 131Iodine in the nasolacrimal sac/duct after radioiodine therapy for papillary thyroid cancer.

SPECT/CT is a powerful tool for assessing unexpected concentrations of radioiodine resulting from benign uptake in organs with sodium-iodide symporter (NIS) expression. We report a case of accumulation of 131Iodine in the nasolacrimal sac/duct after radioiodine therapy for papillary thyroid cancer. A whole-body scan was taken 3 days after the administration of 5.5 GBq of 131Iodine. SPECT/CT images localized the focal tracer uptake in the nasolacrimal sac/duct likely due to nasolacrimal duct obstruction secondary to prior radioiodine or iodine therapies. Hybrid SPECT/CT allows precise anatomical localization and help differentiate benign mimics of disease, which can alter patient management.

Clinico-radiologic characteristics of lacrimal sac area swellings misdiagnosed as dacryocystocele or mucocele.

PURPOSE: Several non-lacrimal lesions can present with lacrimal sac area swelling mimicking a dacryocystocele or mucocele with a possibility of misdiagnosis. This study investigates the clinic-radiologic characteristics of the mimicking conditions compared to true lacrimal sac distension. DESIGN: Retrospective, comparative, interventional case series. PARTICIPANTS: Patients referred by primary care ophthalmologists between January 2015 and October 2021 with a misdiagnosis of dacryocystocele or lacrimal sac mucocele (n = 39) and an age-matched group of proven true lacrimal sac swelling (TLS group, n = 44). METHODS: Data collected included demographics, presenting features, investigations, management, histopathology, and outcomes. Both groups were statistically compared for several clinical and radiological variables. RESULTS: Final diagnoses in the mimicking group were skin/subcutaneous swellings (14/39, 35.9%), vascular malformations (10/39, 25.6%), inferomedial anterior orbital cysts (7/39, 17.9%), sino-orbital masses (5/39, 12.8%). Female gender (<0.001), epiphora (p = 0.001), and discharge (p < 0.001) were significantly more frequent in the TLS group. The mimicking group was more likely to be associated with a longer swelling duration (p < 0.001), a swelling extending beyond the lacrimal sac area (p <0.001), orbital signs (p <0.001), and periorbital abnormality. Non-patent lacrimal irrigation (p < 0.001) was significantly more frequent in the TLS group. On imaging, all swellings in the mimicking group were separate from the lacrimal pathway and 94.9% (37/39) extended beyond the lacrimal sac fossa. CONCLUSION: Various cutaneous, subcutaneous, vascular, inferomedial orbital cystic, and sinonasal pathologies can present with lacrimal sac area swelling and mimic a TLS. A high index of suspicion, a thorough clinical evaluation and proper imaging are essential to avoid a misdiagnosis.

Non-contrast MR dacryocystography for the evaluation of epiphora and recurrent dacryocystitis: A preliminary study.

INTRODUCTION: Obstruction of the lacrimal drainage represents a common ophthalmologic issue. The blockage may interest any level of the lacrimal drainage pathway, and it is important to find the site of obstruction to plan the most appropriate treatment. In this study, findings from magnetic resonance (MR) dacryocystography were compared with findings from endoscopic and surgical procedures to evaluate the accuracy of MR dacryocystography in localizing the site of nasolacrimal duct obstruction. METHODS: We enrolled twenty-one patients with clinical suspicion of nasolacrimal duct obstruction who underwent dacryoendoscopy and surgery. MR dacryocystography was performed with a heavily T2-weighted fast spin echo sequence in the coronal planes. Before the MRI was performed, a sterile 0.9% NaCl solution was administered into both conjunctival sacs. For each examination, two independent readers (with 8 and 10 years of experience in head and neck imaging) evaluated both heavily 3D space T2-weighted and STIR sequences. RESULTS: Stenosis/obstruction of nasolacrimal duct or lacrimal sac was diagnosed in all 21 patients who underwent MRI dacryocystography. In particular, the site of the obstruction was classified as lacrimal sac in 12 (57%) patients, nasolacrimal duct in 6 (29%) patients, and canaliculi in 3 (14%) patients by both readers. By comparison with the evidence resulting from the endoscopy, there were differences between MRI dacryocystography and dacryoendoscopy in the evaluation of the obstruction's site in three patients, with an overall accuracy of 85.7%. CONCLUSION: MR dacryocystography allows a non-invasive evaluation of the lacrimal drainage pathway, valid for the planning of the most appropriate treatment.

Dacryolithiasis diagnosis and treatment: a 25-year experience using nasal endoscopy.

BACKGROUND: Dacryolith-induced epiphora is caused by a chronic obstruction of the nasolacrimal duct whose aetiology is often specified peroperatively. Dacryocystorhinostomy (DCR) has been often regarded as the gold standard to treat dacryolithiasis. Hasner's valve (HV) incision is a technique to evacuate lithiasis through its physiological track. The purpose of this study was to describe clinical and radiological findings associated with presence of dacryoliths in patients who underwent surgery and to assess the efficacy of these two procedures. METHODS: This study was a comparative interventional multicentric retrospective study including patients referred for an epiphora. The primary endpoint was to determine clinical and endoscopic findings associated with dacryoliths. The secondary endpoints were to evaluate the performance of CT dacryocystography (CT-DG) in the diagnosis of dacryoliths and the success rate of the surgical treatment 6 months postoperatively. RESULTS: 4677 nasolacrimal ducts (NLDs) (78.0% female, mean age 59.2) were included in the study. 3913 underwent DCR, and 764 underwent HV incision. 291 out of 4677 NLDs (6.2%) were found to have dacryoliths. Presence of mucocele associated to a permeable lacrimal system (OR 8.17 (95% 4.62 to 14.44), p<0.01) was associated with presence of lithiasis peroperatively. Success rates at 6 months were 95.6% for endonasal DCR and 94.6% for incision of HV in dacryolithiasis group (p<0.01). CT-DG had a negative predictive value of 96.3% to detect lithiasis (p<0.01). CONCLUSION: Strong clinical and endoscopic findings may improve the imputability of dacryoliths in epiphora. Evacuation of dacryolithiasis through its physiological track was first described in this study in adults with similar results to DCR in patients presenting with dacryolithiasis.

Bilateral acquired canaliculops: Report of two cases.

We report two rare cases of bilateral acquired canaliculops. A 67-year-old woman and an 89-year-old man showed cystic lesions in the medial-upper eyelid on both sides. In both of the cases, re-canalization using dacryoendoscopy was failed because of firm obstruction at the canaliculus and/or junction between the lacrimal sac and nasolacrimal duct. Although 15 cases with canaliculops had been reported previously, only one congenital case showed bilateral canaliculops. The results of our study indicate more complex obstruction in cases with bilateral canaliculops compared to those with unilateral canaliculops.

Reference role of middle turbinate axilla in lacrimal sac localization assisted by computed tomographic dacryocystography-reference value of middle turbinate in locating lacrimal sac.

BACKGROUND: The middle turbinate axilla (MTA) has always been used as a stable anatomic landmark for endoscopic surgeons to locate the lacrimal sac on the lateral nasal wall. Yet, little is known about whether the lacrimal sac size will affect the positioning effect of MTA on lacrimal sac. The aim of this study was to investigate the regularity of lacrimal sac size and lacrimal sac localization through the reference position of the MTA on computed tomographic dacryocystography (CT-DCG) images. METHODS: A series of 192 endoscopic dacryocystorhinostomy (DCR) surgeries were performed. All the patients had been diagnosed as unilateral nasolacrimal duct obstruction and received CT-DCG examinations. According to the maximum transverse diameter of the lacrimal sac on CT-DCG, the patients were classified into three groups. Measurements were taken on CT-DCG parasagittal images. RESULTS: The average distance from the sac superior fundus (SSF) to the MTA was 7.52 mm ± 3.23 mm, and it increased with the increase of the maximum transverse diameter of the sac among groups (p < 0.01). The average distance from the common canaliculus (CC) to the MTA was 3.95 mm ± 2.49 mm. No significant difference was observed among the groups (p = 0.11). The average distance from the CC to the SSF was 3.41 mm ± 1.31 mm, and it increased with the increase of the sac transverse diameter among groups (p < 0.01). CONCLUSIONS: The lacrimal sac can be accurately located on the lateral nasal wall by the reference position of the MTA on CT-DCG images. The distance of the SSF to the MTA and the SSF to the CC is related to the lacrimal sac size. The relative position of the CC to the MTA is relatively stable on CT-DCG images, which make it possible to locate the lacrimal sac of different sizes and the corresponding nasal mucosa incision design in endoscopic DCR.

Unusual presentation of HPV-positive squamous cell carcinoma of the nasolacrimal duct as carcinoma of unknown primary.

Most human papillomavirus (HPV)-positive carcinomas of unknown primary (CUP) in the cervical lymph nodes are ultimately found to arise from the oropharynx, which has by far the highest prevalence of HPV-positivity among head and neck tumors. However, HPV is also detected in a subset of tumors from other sites. In this case report, we describe the first reported instance of a lacrimal sac carcinoma presenting as an HPV-positive CUP. A 64-year-old male presented with isolated right-sided neck swelling, found on core biopsy to be HPV-positive squamous cell carcinoma (SCC). Initial diagnostic workup did not reveal a primary site, and he was treated for T0N1M0 oropharyngeal SCC with chemoradiation. Shortly afterwards he developed epiphora and was found to have an FDG-avid lesion along his inferior right orbit. Biopsy revealed HPV-positive SCC, presumed to be the true primary site of his previously diagnosed CUP. He was treated with surgical resection, proton-beam radiation, and carboplatin-paclitaxel. He had an excellent outcome with no evidence of disease 18 months following treatment completion. This case underscores the importance of continued vigilance and thorough investigation for a primary tumor site even when cervical nodal metastases are HPV-positive. While the vast majority of HPV-positive head and neck tumors arise in the oropharynx, other anatomical sites may also harbor HPV-positive malignancies.

Persistent epiphora after endonasal ENT surgery: CT dacryography findings.

OBJECTIVES: To analyze postoperative CT dacryography features in patients with persistent epiphora after endonasal surgery. METHODS: We conducted a retrospective study of 76 patients with a history of persistent epiphora after endonasal ENT surgery who underwent CT dacryography between January 2014 and February 2020. Volume acquisition of sub-millimeter sections allowed 2D and 3D reconstructions with virtual endoscopy of the nasosinusal cavities and the lacrimal canal. RESULTS: The postsurgical appearance of the nasosinusal cavities revealed a middle meatal antrostomy in 37% of cases, less frequently an ethmoidectomy or an inferior meatal antrostomy, sometimes completed by a middle or inferior turbinectomy. In thirty-five patients (46%), the lacrimal canal was distant from the endonasal ENT procedure. Epiphora was related to mucosal hypertrophy, constricting all or part of the lacrimal canal. Thirty-three patients (43%) showed changes in the lacrimal canal at the surgical site. In the inferior meatus, the nasolacrimal orifice was sometimes involved in the inferior turbinectomy or meatotomy, but most of the time, in the middle meatus, resection of the uncinate process prior to ethmoidectomy or middle meatotomy was associated with a lesion of the contiguous lacrimal canal. CONCLUSION: As a rare cause of persistent tearing, involvement of the nasolacrimal duct at the edge of the endonasal ENT surgery highlights the importance of intraoperative localization of the nasolacrimal duct before resection of the uncinate process or the inferior turbinate, ideally predicted by preoperative CT imaging.

Surgical and Anatomic Consideration in Endoscopic Dacryocystorhinostomy of a Patient with Damaged Sinonasal Anatomy Post-Caldwell-Luc Surgery: A Case Report.

Background: The Caldwell-Luc (CL) procedure, an outdated operative procedure that is used to treat inflammatory sinus diseases, is rarely performed presently. However, physicians may encounter patients with a history of CL surgery who develop considerable postoperative changes that may lead to diagnostic confusion in imaging evaluation; increase the difficulty of future surgery, such as sinonasal surgery; and increase the incidence of future intraoperative complications. Case summary: A 67-year-old man with a surgical history of chronic sinusitis reported epiphora of the left eye for five years. Balloon dacryocystoplasty was attempted but failed. Endo-DCR (Endoscopic dacryocystorhinostomy) was indicated; however, preoperative CT (computed tomography) imaging and nasal endoscopic examination showed sinonasal anomalies and the loss of internal landmarks for localizing the lacrimal sac. Preoperative CT results indicated previous CL surgery. Endo-DCR was performed with the aid of nasal forceps and a 20-gauge vitreoretinal fiberoptic endoilluminator. A six-month follow-up revealed the complete resolution of symptoms and no signs of recurrence. Conclusions: Epiphora might be a delayed complication of the CL procedure. Before performing endo-DCR, ophthalmologists should be familiar with the sinonasal anatomy and carefully assess preoperative imaging to identify anatomical variations. Nasal forceps and transcanalicular illumination can assist in determining the precise location of the lacrimal sac during endo-DCR.

Opening a dacryocystorhinostomy into the opposite nasal cavity in a case of hemiarhinia.

Heminasal agenesis is an exceedingly rare congenital anomaly which is frequently associated with disorders of eye, lacrimal drainage system and face. At times, a proboscis may also be noted with this condition. Herein, we present a case of a 13-year-old boy who presented to us with heminasal agenesis with concomitant microphthalmos, leucomatous corneal opacity, blepharoptosis, dacryocystocoele and maxillary hypoplasia. The child underwent a modified transeptal external dacryocystorhinostomy with placement of a lacrimal stent. There was significant improvement of epiphora and discharged following surgery. Heminasal aplasia with dacryocystocoele is surgical challenge; however, a well thought out surgical approach can yield satisfactory outcomes.

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.