Serial blood serotonin levels in a randomized controlled trial comparing the efficacy of low-dose amitriptyline, amitriptyline with pindolol and surrogate placebo in patients with chronic tension-type facial pain.

BACKGROUND: Patients often present with chronic facial pain despite normal nasal endoscopy and sinus computerized tomography. Such pain has increasingly been recognized as being of neurological origin with one of the commonest underlying causes being mid-facial segmental tension-type pain (MFP) which is a version of tension headache in the face. Descending serotonergic neuronal projections are known to modulate pain and intra-platelet serotonin levels are an accepted model reflecting central intra-neuronal serotonin. OBJECTIVES: 1.To determine whether low-dose amitriptyline significantly changes whole blood serotonin compared to a surrogate placebo in patients with chronic MFP 2. To determine whether the addition of pindolol, a beta blocker with serotonin receptor blocking properties further alters blood serotonin. METHODOLOGY: Sixty-two patients were randomized to three treatment groups a) amitriptyline , b) amitriptyline with pindolol, and c) loratadine as surrogate placebo. Whole blood serotonin was taken before and after 8 weeks of treatment. Serotonin was also measured in 40 age-matched healthy controls. RESULTS: There was a significant reduction in blood serotonin levels in the amitriptyline with pindolol group. A non-significant reduction was seen in the amitriptyline group, with no change in serotonin levels in the surrogate placebo group. A comparison of change in serotonin with change in pain frequency and intensity scores is presented. Women in the control group had significantly higher serotonin levels than men. Women with tension-type facial pain who failed to respond to treatment had significantly lower blood serotonin than women in the control group. CONCLUSION: When linked to the clinical response this study provides evidence that the serotonergic system is involved in the modulation of chronic MFP. Serotonin levels are sex-dependent and related to treatment response.

A Randomized Controlled Trial comparing the efficacy of low-dose amitriptyline, amitriptyline with pindolol and surrogate placebo in the treatment of chronic tension-type facial pain.

BACKGROUND: Patients often present to otolaryngologists with chronic facial pain, presumed to be of sinus origin despite normal nasal endoscopy and sinus CT. This pain has increasingly been recognized as being of neurological origin with one of the commonest underlying causes being mid-facial segmental tension-type pain (MFP) which is a version of tension-type headache affecting the midface. PRIMARY OUTCOME MEASURES: 1. To determine whether low-dose amitriptyline reduces pain scores compared to surrogate placebo in patients with chronic MFP. 2. To determine whether the addition of pindolol, a beta blocker with serotonin receptor blocking properties hastens onset of action or improves efficacy of amitriptyline. SECONDARY OUTCOME MEASURE: to determine whether amitriptyline or amitriptyline with pindolol significantly reduces analgesic consumption. METHODOLOGY: Sixty two patients were randomized to three treatment groups (a) amitriptyline 10mg daily (b) amitriptyline 10mg daily with pindolol 5mg twice daily and (c) loratadine 10mg daily. Daily pain scores using a facial pain diary were recorded over eight weeks. RESULTS: At 8 weeks, pain frequency and intensity were significantly reduced in patients treated with amitriptyline and in those receiving amitriptyline with pindolol compared to surrogate placebo. Patients on the combination therapy showed significantly improved clinical outcome and significantly reduced analgesic intake compared to those on amitriptyline alone. CONCLUSION: Low dose amitriptyline is effective in the management of MFP and is enhanced by the addition of pindolol.

Intranasal contact points as a cause of facial pain or headache: a systematic review.

BACKGROUND: There is a body of opinion in the clinical literature advocating the removal of intranasal contact points to treat facial pain. OBJECTIVES: To review the evidence that intranasal mucosal contact points cause facial pain or headache and their removal is therapeutic. TYPE OF REVIEW: Systematic review. SEARCH STRATEGY: A systematic search of the available literature was performed using MEDLINE, EMBASE, Cochrane library and NHS Evidence from inception to September 2011. Terms used include facial pain and contact point (3628), rhinologic headache (6) contact point and surgery/endoscopy (38). EVALUATION METHOD: Inclusion criteria applied. Assessment of papers were undertaken by one reviewer and checked by the second. A narrative review of each study was performed and results recorded in tables. RESULTS: In one study, 973 consecutive patients with a provisional diagnosis of rhinosinusitis were divided into groups with (42%) and without facial pain. There was a 4% prevalence of nasal contact in both groups, which was unrelated to the presence of facial pain. In another study of 100 patient's coronal paranasal sinus CT scans, 29% had headache and 55% had a contact point but their presence was inversely related to the presence of pain.(1) In a further study, ten healthy volunteers had palpation, adrenaline, substance P and placebo applied to different areas throughout the nasal cavity and none of these stimuli caused facial pain. Nineteen studies were identified where nasal mucosal contact points had been removed surgically for the treatment of facial pain. They were small case series, not randomised and subject to selection bias, had no control group, a limited follow-up and were open to observer bias with level IV evidence. Seven studies had a statistically significant improvement in pain postoperatively compared with preoperative questionnaire results but the majority had residual facial pain. CONCLUSION: The majority of people with contact points experience no facial pain. The presence of a contact point is not a good predictor of facial pain. The removal of a contact point rarely results in the total elimination of facial pain making the theory that a contact point is responsible unlikely. The improvement in postoperative symptoms following the removal of contact points in some patients may be explained by cognitive dissonance or neuroplasticity. A randomised, controlled and blinded trial with a followed up period of over 12 months is needed to assess the place of surgery in the removal of a contact point for the treatment of facial pain.

12 minute consultation: evidence based management of a patient with facial pain.

BACKGROUND: There is a common misconception that facial pain and headache are mainly caused by sinusitis. The findings of nasal endoscopy, computer tomography (CT) and the results of observational studies reveal that this is not the case. Moreover, when sinus surgery is performed in patients where headache/facial pain has been a feature, it has been found that these symptoms persist after sinus surgery, particularly where there had been no nasal symptoms or endoscopic signs of paranasal sinusitis. METHODS: This review was based on a literature search performed on 30 November 2011. The MEDLINE, EMBASE and Cochrane databases were searched using the subject heading of facial pain, that is, rhinosinusitis, migraine, cluster headaches, midsegment facial pain, trigeminal neuralgia, paroxysmal hemicrania, hemicrania continua and drug-dependent headache. The search was limited to English language articles. Relevant references from selected articles were reviewed after reading the abstract. RESULTS: A review of the literature shows that headaches are rarely caused by sinusitis. Similarly, only a small proportion of patients with facial pain have sinusitis, and these patients have either acute sinusitis or an acute exacerbation of chronic purulent sinusitis. Importantly, most patients with chronic rhinosinusitis rarely have facial pain unless they develop an acute infection or suffer barotrauma. CT scans should not routinely be performed for facial pain because of the prevalence of incidental changes in asymptomatic patients. Surgery is very rarely indicated in the treatment for chronic facial pain. CONCLUSION: A structured history of the pain and its associated symptoms, nasendoscopy and relevant targeted investigations should lead to a correct diagnosis and the appropriate treatment.

'Entopy': local allergy paradigm.

Allergy is defined as an immediate hypersensitivity type I immunological disease, which can be IgE or non-IgE driven, and in the latter case may be antibody or cell mediated. Atopy is a term used to describe individuals with a genetic predisposition for developing IgE-mediated allergic disease. But more recently, it has become evident that IgE-mediated disease can occur in non-atopic subjects. While it is now generally accepted that mucosal local IgE has a role in the expression of atopic allergic disease, the concept of 'local allergy' in non-atopic subjects has been proposed, with the term 'entopy' given to this condition. Although there is increasing evidence supporting this paradigm, entopy is only applicable to a proportion of non-atopic patients, suggesting that other disease mechanisms exist to explain non-atopic disease. This review considers the evidence for local mucosal allergy in atopic and non-atopic individuals with an emphasis on diseases affecting the upper airways and eye. Furthermore, the diagnosis, treatment and relationship between local allergy and conventional (systemic) allergy are discussed, and alternative disease mechanisms predominantly involving antibodies or their sub-components (free light chain Igs) are postulated to explain the 'entopy' paradigm. This review is intended to provide an improved understanding of the mechanisms and causes of local mucosal hypersensitivity.

Lessons learnt from an audit of 95 cases of major nasal reconstruction.

BACKGROUND: Several texts detail the possible complications of nasal reconstruction but few critically describe a series. We present an audit of the complications of 95 major nasal reconstructions. METHODS: This is a retrospective analysis of 95 consecutive major nasal reconstructions (49 male, 46 female, aged between 4 and 92 years) over a 16-year period treated in a tertiary refer-ral centre. RESULTS: Fifty-eight patients in our series required nasal reconstruction after Moh's Micrographic surgery for a morpheiform basal cell or a squamous cell carcinoma. Eight patients had further removal using frozen section to determine the margins, as the disease was very extensive. Minor procedures with local random flaps or full thickness skin grafts were excluded. Ninety-five patients underwent major reconstructive procedures and had an average of 2.8 operations. SUMMARY: The main problem was the suboptimal contouring of the alar margin in 6 of 54 patients who had a full thickness defect repaired. Other complications included telangectasia or hair growth requiring laser ablation (13), stenosis of the nasal valve area (2), ectropion after a cheek advancement flap, donor site haematoma of the pinna, and neuropathic pain.

Differential protein expression by dendritic cells from atopic and non-atopic individuals after stimulation by the major house dust mite allergen Der p 1.

BACKGROUND: Dendritic cells (DCs) are sentinels of the immune system and are known to play a key role in allergic responses. However, it is not clear how DCs that have been exposed to an allergen support Th2 type immune responses. It is possible that DCs from atopic individuals are inherently programmed to support allergic disease, or it is the exposure of dendritic cells to allergens that is key to the development of allergic sensitisation. METHODS: We used 2D gel electrophoresis and MALDI mass spectrometry to compare the proteome of DCs from atopic and non-atopic individuals in both the resting state and after stimulation with the major house dust mite allergen Der p 1. RESULTS: Our data show that unstimulated DCs from atopic and non-atopic individuals are very similar at the whole cell proteome level, showing few differentially expressed proteins. However, upon stimulation with Der p 1, a number of additional proteins are differentially expressed, and of these several were of potential relevance to Th2 cell differentiation and the allergic response, including GTP-binding regulatory protein Gi alpha-2, frabin and cathepsin D. CONCLUSION: Whilst there are inherent differences between DCs from atopic and non-atopic individuals, it seems that exposure to allergen plays a key role in differential expression of proteins by these key immune cells. Further studies should now focus on establishing the biological relevance of these proteins as biomarkers in house dust mite allergy and their role in allergen induced Th2 cell differentiation.

Prescribing antibiotics for sore throat: adherence to guidelines in patients admitted to hospital.

AIM: We prospectively studied patients referred to secondary care with acute tonsillitis, peritonsillar cellulitis and quinsy (peritonsillar abscess) to see if recommended treatment guidelines were being followed and whether antibiotic resistance was contributing to admission. STUDY DESIGN: Prospective observational study in a university teaching hospital of 90 consecutive patients admitted to secondary care over an 18 month period with acute tonsillitis, peritonsillar cellulitis or quinsy were studied. The geographical distribution by postcode, pre-admission history and treatment of each patient was recorded. The patients' general practitioners (GPs) were questioned about the patients' history, their use of antibiotics and prescribing guidelines and a patient questionnaire was completed. The result of hospital admission including throat swabs and blood cultures were recorded together with their treatment and outcome. RESULTS: 58% (n = 28) of patients who were prescribed antibiotics before admission received an inadequate dose or inappropriate antibiotic. Only 56% (n = 45) of GPs said they used guidelines for the treatment of acute sore throat. In 34 cases an organism was isolated, with 33 (97%) being sensitive to penicillin. No resistant organisms were isolated. Hospital doctors prescribed antibiotics contrary to guidelines in 39% (n = 35) of cases. CONCLUSIONS: Antibiotic resistance was not demonstrated in this study. Adherence to guidelines for prescribing antibiotics in patients with features of group A beta-haemolytic streptococcal sore throat is poor. Information support may help to improve prescribing.

Management of composite defects of the nose, cheek, eyelids and upper lip.

AIM: To assess the results of reconstruction of composite defects involving the nose which extend to involve the cheeks, eyelids or upper lip. STUDY DESIGN: Retrospective observational study. MATERIAL: Sixteen patients with defects of the nose extending to the adjoining cheek, upper lip or eyelid. METHOD: A combination of flaps and grafts were needed to reconstruct these defects so that the aesthetic subunits were replaced and joined at their junctions wherever possible. RESULTS: Where the defect required three or four flaps, there was some unpredictable cicatrisation at their junction that resulted in some asymmetry. This problem primarily occurred at the alar base, and was compounded if there was tissue loss of the premaxilla or maxilla. CONCLUSION: If a defect that involves the nose, cheek and upper lip is repaired with a combination of cheek advancement, nasolabial, paramedian forehead and/or septal flaps, there can be unpredictable cicatrisation at their junction, particularly at the alar base. In these circumstances, we recommend replacing the nasal and other defects with a slightly more generous amount of tissue than would be taken to repair a similar, but solitary, defect. It is important to replace any loss of the facial skeleton, in order to provide support for overlying flaps.

BSACI guidelines for the management of rhinosinusitis and nasal polyposis.

This guidance for the management of patients with rhinosinusitis and nasal polyposis has been prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI). The recommendations are based on evidence and expert opinion and are evidence graded. These guidelines are for the benefit of both adult physicians and paediatricians treating allergic conditions. Rhinosinusitis implies inflammation of the nose and sinuses which may or may not have an infective component and includes nasal polyposis. Acute rhinosinusitis lasts up to 12 weeks and resolves completely. Chronic rhinosinusitis persists over 12 weeks and may involve acute exacerbations. Rhinosinusitis is common, affecting around 15% of the population and causes significant reduction in quality of life. The diagnosis is based largely on symptoms with confirmation by nasendoscopy. Computerized tomography scans and magnetic resonance imaging are abnormal in approximately one third of the population so are not recommended for routine diagnosis but should be reserved for those with acute complications, diagnostic uncertainty or failed medical therapy. Underlying conditions such as immune deficiency, Wegener's granulomatosis, Churg-Strauss syndrome, aspirin hypersensitivity and allergic fungal sinusitis may present as rhinosinusitis. There are few good quality trials in this area but the available evidence suggests that treatment is primarily medical, involving douching, corticosteroids, antibiotics, anti-leukotrienes, and anti-histamines. Endoscopic sinus surgery should be considered for complications, anatomical variations causing local obstruction, allergic fungal disease or patients who remain very symptomatic despite medical treatment. Further well conducted trials in clearly defined patient groups are needed to improve management.

BSACI guidelines for the management of allergic and non-allergic rhinitis.

This guidance for the management of patients with allergic and non-allergic rhinitis has been prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI). The guideline is based on evidence as well as on expert opinion and is for use by both adult physicians and paediatricians practicing in allergy. The recommendations are evidence graded. During the development of these guidelines, all BSACI members were included in the consultation process using a web-based system. Their comments and suggestions were carefully considered by the SOCC. Where evidence was lacking, consensus was reached by the experts on the committee. Included in this guideline are clinical classification of rhinitis, aetiology, diagnosis, investigations and management including subcutaneous and sublingual immunotherapy. There are also special sections for children, co-morbid associations and pregnancy. Finally, we have made recommendations for potential areas of future research.

Distribution and clearance of bioadhesive formulations from the olfactory region in man: effect of polymer type and nasal delivery device.

There is an increasing need to identify novel approaches by which to improve the efficiency of drug transport from the nasal cavity (olfactory region) to the CNS, especially for treatment of central nervous system disorders. It is suggested, that one approach is the combination of active targeting of a bioadhesive formulation, that will retain the drug at the absorption site, potentially in combination with, an absorption enhancer. Two low methylated pectins, LM-5 and LM-12 were selected for evaluation as drug delivery systems, due to their ability to gel in the nasal cavity and their bioadhesive characteristics, together with chitosan G210, which acts both as a bioadhesive material and as an efficient absorption enhancer. It was found that all of the bioadhesive formulations were able to reach the olfactory region in the nasal cavity of human volunteers when delivered using a simple nasal drop device. Furthermore, the formulations displayed a significantly increased residence time on the epithelial surface. This was in contrast to a non-bioadhesive control delivered with the same device. In contrast, a pectin formulation administered with a nasal spray system did not show an increase in residence time in the olfactory region. It was further shown that the reproducibility of olfactory delivery of a polymer formulation was significantly better intra-subject than inter-subject.

Lessons learnt in the management of Wegener's Granulomatosis: long-term follow-up of 60 patients.

OBJECTIVE: To assess all patients with Wegener's Granulomatosis treated in Nottingham, with particular focus on relapse rate and the useful predictors of relapse. We evaluated how well the findings of nasal examination correlated with disease relapse compared to other parameters such as c-ANCA, ESR and CRP. Presenting features, diagnosis, adverse effects of treatment and mortality rate, were also studied. DESIGN: Retrospective examination of 60 patient notes, diagnosed and treated for Wegener's granulomatosis at Queen's Medical Centre, Nottingham. The mean follow up period was 8.7 years. Relapse was defined as per the European Vasculitis Study criteria. RESULTS: cANCA is a useful test at presentation for diagnosis but a negative result does not rule out the disease. Those presenting with ENT symptoms alone may have less raised inflammatory markers but similar cANCA titres as patients with multi-system disease. However, at relapse, patients with ENT disease alone have similar levels of inflammatory markers as those with multi-system relapse. Nasal examination was useful at monitoring the presence of disease activity where the nasal lining is affected. CONCLUSIONS: Signs of intranasal disease in the form of granular tissue, erythema and bleeding to light touch and crusting over granulation tissue are good predictors of disease activity. A raised cANCA, ESR or CRP provide supporting information about disease activity but if they are negative this does not exclude active disease. cANCA levels were as elevated at relapse in patients who had isolated nasal symptoms and signs as in those with evidence of systemic disease. Low relapse rates were found possibly due to prompt and rigorous initial immunosuppression even in limited disease. This seemed to lead to less progression of patients to multi-system disease and hence a low mortality rate of 5%.

Paediatric fibro-osseous lesions of the nose and paranasal sinuses.

OBJECTIVE: The term "fibro-osseous lesion" is a generic description for a group of lesions involving the paranasal sinuses and anterior skull base. We aim to improve understanding of the clinical and pathological presentation of fibro-osseous lesions in children. METHODS AND RESULTS: We report two cases of aggressive "fibro-osseous" lesions arising from paranasal sinuses and anterior skull base in childhood that were successfully managed surgically. We compare our case reports with a review of the available literature and evaluate the management of these lesions. CONCLUSIONS: The clinical behaviour and radiological features of fibro-osseous lesions is variable. Aggressive lesions require a radical surgical approach to ensure complete excision, in spite of an increase in associated morbidity. Incomplete excision of aggressive lesions may result in disease recurrence with severe morbidity or mortality. In contrast a slowly progressive lesion often does not warrant extensive surgical excision. Understanding the nature of fibro-osseous lesions facilitates appropriate clinical management.

"Post-nasal drip syndrome": most patients with purulent nasal secretions do not complain of chronic cough.

INTRODUCTION: Post-nasal drip syndrome (PNDS) is quoted as a common cause of chronic cough. However, there is little evidence to explain the mechanism by which PNDS may stimulate the cough reflex. This cohort study looks at patients with purulent nasal secretions, who may best represent any potential candidate for PNDS, and observes the frequency of symptomatic coughing. METHODS: One-hundred and eight consecutive patients referred to a rhinology clinic with symptoms of chronic infective rhinosinusitis, all with purulent nasal secretions identified on nasendoscopy, were observed through investigation and treatment. Patients were initially treated with broad-spectrum antibiotics and nasal douching. The frequency of coughing was recorded pre- and post- treatment. RESULTS: Eighty-nine percent of patients complained of post-nasal secretions. Twenty-three (21%) patients complained of cough. Eight had co-existing asthma, 3 had bronchiectasis, 1 had sarcoid and 2 had had a recent respiratory tract infection. Therefore 9 patients (8%) had purulent nasal secretions and a cough with no other discernable pathology. Cough improved in 8 of the 9 patients following treatment. Cough improved in 9 of the 14 patients with other possible co-existing causes for cough. CONCLUSIONS: Only a small proportion of patients with purulent rhinosinusitis without coexisting chest disease complain of cough. Although nasal disease may be a genuine cause for chronic cough it is unlikely to be as common a cause as has been reported. Postnasal secretions do not appear to be an adequate cause for cough and the term 'PNDS' should be replaced by rhinosinusitis when nasal disease is the cause of chronic cough.

Sinonasal cerebrospinal fluid leaks: management of 97 patients over 10 years.

INTRODUCTION: Although endoscopic closure is now the treatment of choice in the majority of patients with sinonasal cerebrospinal fluid (CSF) leaks, there is a recurrence rate of up to 10% in most series. OBJECTIVES: Our aim was to review our experience in the management of CSF leaks and in particular the cause of recurrent leaks. METHODS: We prospectively collected data on all cases referred as a suspected CSF leak to us, a tertiary referral center, over a 10 year period between 1994 and 2004. RESULTS: The 121 patients referred with an apparent CSF leak had a mean age of 51 (range 2-87) years. Fifty-three percent were male, and 47% were female. In 24 cases, investigations revealed that there was in fact no CSF leak, and in 17 posttraumatic cases, the leak ceased spontaneously. Twenty-nine patients had a spontaneous CSF leak. Of the 80 cases surgically repaired, 72 had an endoscopic approach, with a success rate of 90%, increasing to 97% after a second procedure and 99% by a third procedure. Eight patients with a posterior wall frontal sinus leak underwent an external frontal sinus procedure. There were 8 failures, and 6 occurred in the 13 patients with a spontaneous leak and evidence of raised intracranial pressure (ICP). CONCLUSIONS: In conclusion, our endoscopic repair rate for sinonasal CSF leaks are good and compare well with the standards in the literature. Raised ICP is the most common reason for recurrent CSF leak after repair. Patients with a spontaneous CSF leak and evidence of raised ICP had a 46% failure rate. When consenting such patients for surgery, they must be informed of the lower success rate and that they may need additional procedures, including shunting.

The aetiology of chronic cough: a review of current theories for the otorhinolaryngologist.

Most studies agree that post-nasal drip syndrome (PNDS), asthma, gastroesophageal reflux disease (GORD), and laryngopharyngeal reflux (LPR) are the commonest causes of chronic cough in the immunocompetent, non-smoking patient who is not taking an angiotensin-converting enzyme inhibitor. No diagnostic test has been found to define those who are said to have PNDS other than a response to a first-generation antihistamine. Examining the available evidence suggests that mechanical stimulation of the pharynx by mucus is not an adequate theory for the production of cough. Inflammatory mediators in the lower airways are raised in PNDS, cough variant asthma and GORD, and the theory that an inflammatory process is affecting 'one airway' is a plausible one. Nasal disease is more likely to result in cough from the co-existing involvement of the lower airways through an as yet undefined pathway, and eosinophil and mast cell mediation appear a likely mechanism.

Tonsillectomy: haemorrhaging ideas.

Tonsil surgery has been described for over 3000 years. Haemorrhage following tonsillectomy remains the most serious complication of surgery. Over recent years several audits have been gathering data on current trends in tonsil surgery and clinical outcomes throughout England, Scotland and Northern Ireland. The results support a return to traditional dissection with ties to reduce the risk of post-operative haemorrhage. We describe the changes that have occurred to improve efficacy and safety during the evolution of the modern tonsillectomy.

Medicare competitive pricing: lessons learned in Phoenix and Kansas City.

Many lawmakers have embraced the idea of bringing more competition to the Medicare program as a way to achieve greater cost efficiency and provide more choice for beneficiaries. Advocates of this strategy believe Medicare should move away from its historical administrative pricing approach toward a competitive bidding process similar to those used by many private purchasers. Yet, despite support for the concept, every effort to test it in the marketplace has been met with strong opposition. Most recently, competitive bidding demonstration projects set to take place in Phoenix and Kansas City have been delayed by congressional action. Nevertheless, it is clear that those participating in the demonstration projects-notably private purchasers, consumers, health plans, and the Health Care Financing Administration-have already learned a great deal about the types of issues that must be considered if Medicare is truly to pay health plans in a competitive manner. This article explores the lessons learned so far in Phoenix and Kansas City, including design considerations such as plan participation, the standard benefit package, the bidding process, and the government contribution to premiums. It also examines the reasons for opposition to the project and their implications for broader Medicare reform efforts.

Endonasal laser dacryocystorhinostomy--medium term results.

BACKGROUND/AIMS: Endonasal laser dacryocystorhinostomy (ELDCR) has many potential advantages over conventional external DCR. Although the short term results of this technique have been reported, little is yet known of the long term results, and the occurrence of late rhinostomy failure. The aim of this study was to examine the results at 3 and 12 months following ELDCR. METHOD: The notes of all consecutive ELDCRs performed between November 1993 and May 1995 were retrieved. Demographic information, details of surgery, and the postoperative results were noted. RESULTS: ELDCR procedures which did not undergo lacrimal stenting showed a short term success rate of 67% at 3 months, and a further failure rate of 9% at 12 months. ELDCRs which did undergo lacrimal stenting showed a short term success rate of 82% at 3 months, and a further failure rate of 21% at 12 months. Lacrimal intubation increased the long term success rate by 8%. The success rate was lower in the presence of local risk factors for nasal mucosal scarring. CONCLUSIONS: ELDCR requires some adjunctive treatment to improve maintenance of the nasal mucosal ostia if it is to complete successfully with external DCR on grounds other than cosmesis and patient convenience.