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.

Incision of Hasner's valve under endoscopic intranasal surgery for the treatment of nasolacrimal duct obstruction in children.

OBJECTIVE: To evaluate the effectiveness and safety of a Hasner's valve incision performed under endoscopic intranasal surgery for the management of congenital nasolacrimal duct obstruction. METHODS: This retrospective study comprised 484 patients with congenital nasolacrimal duct obstruction who underwent incision of Hasner's valve under endoscopic intranasal surgery between April 2000 and October 2016. The primary endpoint was the procedure's functional success rate. The secondary endpoints were Hasner's valve and inferior turbinate anatomical findings, demographic data, complication rate and surgical duration. RESULTS: In patients with no medical history of nasolacrimal duct probing, 91 per cent had a successful result, 5 per cent had a partially successful result, 3.9 per cent showed no change and 0.1 per cent had a worse result following the procedure. Concerning the secondary endpoints, outcomes were more frequently successful in children younger than three years. Only one patient had a post-operative infection. All patients underwent general anaesthesia; no complications related to general anaesthesia were observed. Mean surgical duration was 13.1 ± 5.7 minutes. CONCLUSION: Incising Hasner's valve after medially displacing the inferior turbinate under nasal endoscopy seems to be an adequate primary surgical treatment for congenital nasolacrimal duct obstruction.

Botulinum neurotoxin A injection for the treatment of epiphora with patent lacrymal ducts.

HEADINGS: Retrospective longitudinal study to evaluate the efficacy of botulinum neurotoxin A (BoNT/A) therapy for epiphora with patent lacrimal ducts. BACKGROUND/PURPOSE: BoNT/A has been used since 2000 in axillary hyperhidrosis to reduce sweat secretion. Some isolated cases of hyperlacrimation or crocodile tear syndrome have been treated with BoNT/A on this basis. We report our experience in the treatment of tearing despite patent lacrimal ducts by BoNT/A injection into the lacrimal gland. METHODS: We reviewed qualitative and quantitative criteria to evaluate the degree of improvement of epiphora after BoNT/A injections in the palpebral lobe of the lacrimal gland in patients referred for epiphora despite patent lacrimal ducts between 2009 and 2016. Epiphora was graded using a functional questionnaire, Munk score and Schirmer test performed before and after the injections. Side effects were recorded. RESULTS: Sixty-five palpebral lacrimal glands of forty-two patients with epiphora despite patent lacrimal ducts, of mean age 65 years, sex ratio 0.8, were treated with BoNT/A (IncobotulinumtoxinA, XEOMIN®, MERZ Pharma France) from April 2009 to April 2016. The etiology of the epiphora was represented by 56 paroxysmal lacrimal hypersecretion, 2 crocodile tear syndrome and 7 facial palsies. No conventional medical or surgical treatment had been effective in these cases. The technique of injection, dilution and dosage of BoNT/A were specific. We re-injected 33/65 cases a second time upon patient request due to recurrence of epiphora, 16/65 cases three times, 8/65 cases four times, 6/65 cases five times and 3/65 six times. The Schirmer's test measured a decrease of lacrimal secretion in 51/65 glands (78%) after the first botulinum neurotoxin injection. Side effects were limited to ptosis in 2 cases (3%) and six patients (9%) with rapidly regressing diplopia. Two patients experienced immediate lacrimal gland hematoma (3%) with no sequelae. The authors describe the injection techniques, the dosage, the volume and concentration of BoNT/A. CONCLUSION: Patients with intractable epiphora despite patent lacrimal ducts can be effectively treated with BoNT/A (IncobotulinumtoxinA) injection into the palpebral lobe of the lacrimal gland. Most of the patients (80%) were very satisfied with few side effects (hematoma, ptosis or mild diplopia lasting from 3 days to 3 weeks). More studies are needed to delineate which types of epiphora can be treated with BoNT A.

Botulinum neurotoxin injection for the treatment of epiphora in nasolacrimal duct obstruction.

PURPOSE: Retrospective long-term study to evaluate the efficacy of botulinum neurotoxin A (BoNT/A) therapy for epiphora due to non-surgical nasolacrimal duct obstruction. INTRODUCTION: BoNT/A has been used successfully since 2000 in axillary hyperhidrosis to reduce secretory disorders. Some isolated cases of hyperlacrimation or crocodile tear syndrome have been treated on this basis. We used BoNT/A to decrease lacrimal secretion in cases of epiphora. METHODS: We reviewed the qualitative and quantitative degree of improvement of epiphora after botulinum neurotoxin injections in the palpebral lobe of the lacrimal gland, carried out in an ophthalmic centre between 2009 and 2016. Epiphora was graded using a questionnaire, Munk scores and Schirmer tests before and after injections. Severity of side effects was recorded. RESULTS: Twenty-seven palpebral lacrimal glands of twenty patients with epiphora, mean age 65±13, were treated with BoNT/A (Botox® or Xeomin®) from April 2009 to April 2016. The epiphora was induced by persistent nasolacrimal duct stenosis after surgical treatment. No conventional medical nor surgical treatment was effective at this time. The technique of injection, dilution and dosage were specific. We re-injected 14/27 cases on an as-needed basis, 7/27 cases three times, 3/27 cases four times, and 2/27 cases (same patient both glands) five times. The Schirmer test measured a decrease of lacrimal secretion in 24/27 (89%) lacrimal glands after neurotoxin injection. Side effects were ptosis in 4 cases and transient esotropia in 2 cases. The authors describe the injection techniques, the dosage, the volume and concentration of BoNT/A. CONCLUSION: Patients with epiphora can be treated effectively with BoNT/A to reduce lacrimal secretion of the principal lacrimal gland in its palpebral portion. Ninety percent of the patients were very satisfied, with few side effects (ptosis or mild diplopia lasting from 3 days to 3 weeks). More studies are needed to delineate which types of epiphora can be treated with BoNT/A.

[Lacrimal duct tumors: diagnostic and therapeutic dilemmas]. / Tumeurs primitives des voies lacrymales: pièges diagnostiques et thérapeutiques.

INTRODUCTION: Fewer than 250 primary tumors of the lacrimal duct have been reported in the international literature. Because their signs and symptoms are nonspecific and usually subclinical, delayed diagnosis is common. Treatment for malignant epithelial tumors is surgical, with or without radiation. PATIENTS AND METHODS: The present study is a retrospective analysis of five patients with malignant lacrimal duct tumors. RESULTS: Three patients were diagnosed with carcinoma requiring wide en bloc surgical resection with surgical reconstruction. One underwent adjuvant radiation therapy. Another experienced simultaneous local and lymph node recurrence after 3 years and underwent curative surgery. Two additional patients were diagnosed with diffuse malignant large B-cell non-Hodgkins lymphoma. DISCUSSION: Early symptoms of lacrimal duct tumors are nonspecific and mimic acute dacryocystitis. Lacrimal system CT, MRI and rhinoscopy may allow for earlier diagnosis. Surgical treatment requires resection with wide margins and reconstruction of the medial canthal region. CONCLUSION: Only an early diagnosis can reduce the impairment related to surgery and the extent of the required reconstruction, as well as improve survival.

[Dacryolithiasis: diagnosis using nasal endoscopy]. / Lithiase lacrymale: diagnostic par l'endoscopie nasale.

PURPOSE: The purpose of this study was to assess the value of two new clinical findings for the diagnosis of dacryolithiasis discovered with nasal endoscopy: anatomical abnormalities of the Hasner valve (HV) and mucopurulent discharge visible at this valve. The value of these findings is compared with other clinical and radiological signs of dacryolithiasis. A hypothesis is developed as to the responsibility of the HV in the formation of dacryolithiasis. METHOD: This study was prospective and based on 797 operations performed for epiphora: 647 endonasal dacryocystorhinostomies and 150 meatotomies of the HV, with systematic preoperative nasal videoendoscopy. Ninety dacryocystographies (DCGs) and 129 lacrimal computed tomographies (LCT) were preoperatively performed. RESULTS: Dacryoliths were found in 55 of 797 patients (6.9%). The HV could be examined in 48 patients in the lithiasis group and in 687 patients in the control group. Mucopurulent discharge was observed in 22 patients with lithiasis (45.8%) and in 40 patients (5.8%) (p<10(-6)) of the control group. Anatomical abnormalities of the HV were found in 40 patients with dacryolithiasis (83.3%) as compared to 82 patients ing the control group (11.4%) (p<10(-6)). In 13 patients, the VH was very small (<2 mm), in 12 patients it was very long (>15 mm), and in 15 patients both abnormalities were observed. Other clinical signs were young age (mean, 48.2 years vs 59.1% in the control group) (p<0.05), a history of acute noninfectious dacryocystic retention (38.2% vs 9.5%) (p<10(-5)), partial obstruction of the lacrimal pathway (LP) (61.8% vs 30.5%) (p<10(-5)). The 28 LCTs that were performed in subjects who had lithiasis made it possible to diagnose 19 cases of dacryolithiasis and confirmed abnormalities of the HV causing narrowing of the LP in 20. CONCLUSION: Dacryolithiasis is frequent and often misdiagnosed. When dacryolithiasis is suspected, a nasal videoendoscopic exam must be done to seek HV abnormalities and mucopurulent discharge at this valve. This latter finding, i.e., the association of mucopurulent discharge with a patent lacrimal system, has high specificity. The finding of numerous anatomical abnormalities of the HV may be an indication that congenital malformation of the HV is the cause of many cases of lithiasis.

[First line endonasal dacryocystorhinostomy Technique and results. Comparison between diode laser and electrocautery instrument. Study based on 422 procedures]. / Dacryocystorhinostomie endonasale de première intention. Technique et résultats. Comparaison entre le laster diode et le bistouri électrique. Etude sur 422 interventions.

PURPOSE OF THE STUDY: To assess the results of the first procedures of endoscopic endonasal dacryocystorhinostomy (ENL DCR). To study the efficiency of diode laser in this operation versus electrocautery instruments (ECI). DESIGN: Prospective study; comparative study. METHODS: Intraoperative comparison between ECI and diode laser is based on 422 ENL DCR achieved between June 1997 until June 2000. Three hundreds and sixty three procedures were diode laser assisted and 59 procedures were done with the use of an ECI. The diode laser was only used to vaporize nasal mucosa laying on the osteotomy site, to realize partial turbinectomy and to vaporize polyps and synechiae. Intraoperative comparison was based on the followings: frequency and extent of bleeding, quality of visibility, perception of pain during the use of the instrument and duration of the operation. Postoperative comparison is based on 318 procedures. Comparison was based on: frequency of granuloma formation in the nasal mucosa at the site of the osteotomy, frequency of acquired nasal synechiae, frequency of important crusting reaction of the nasal mucosa; success rates after a minimum follow up of 6 months. RESULTS: Intraoperative haemorrhages were fewer and smaller in the diode laser assisted procedures than in ECI assisted procedures; visibility was better with the diode laser; the use of the diode laser was painless versus 24% of patients complaining of pain during the use of electro-cautery. The duration of the procedure was shorter with the diode laser (29'30 vs 37'). In the postoperative follow-up frequency of granuloma formation was equal with the two instruments, synechiae were fewer with the diode laser (11% vs 22%) just like crusting reaction of the nasal mucosa (7% vs 36%). Success rates were similar (diode laser: 91.94% vs EC: 86.66%). CONCLUSION: Because of the effeciency of the vaporization and coagulation, the diode laser, in comparison with the ECI, allows to shorten mean operative time, to improve the visibility and to decrase bleeding. Contrary to EC it's use is painless. Fewer important crusting reactions and fewer synechiae after diode laser assisted procedures tend to prove than postoperative inflammation and surgical trauma are smaller than with ECI. There is no statiscally signifant difference between the success rates of ENL laser diode assisted procedures and ENL ECI assisted procedures.

[Holmium: YAG and neodymium: YAG laser assisted trans-canalicular dacryocystorhinostomy. Results of 317 first procedures]. / Dacryocystorhinostomie trans-canaliculaire de première intention au laser néodymium: YAG et holmium: YAG.

PURPOSE: To assess the results of the first procedures of trans-canalicular dacryocystorhinostomy according to two different lasers: Neodymium: YAG (Nd: YAG) laser or Holmium: YAG (Ho: YAG) laser. To study the efficiency of two anti-metabolite drugs: mitomycin-C (MMC) and 5 fluoro-uracile (5 FU). To analyse the rate of efficiency of the Ho: YAG laser in the canalicular obstructions. METHODS: Three hundred and seventeen patients were operated: 226 with the Nd: YAG laser, 77 with the Ho: YAG laser and 14 with both lasers; 68 were treated with an application of MMC and 40 patients with an application of 5-FU. Sixty-three patients suffered from a canalicular obstruction. RESULTS: The results are based on 289 procedures 6 months after the operation. The global rate of success was 63.32% after one intervention and 70.24% after one or two revisions. There is no statistically significant difference between Nd: YAG or Ho: YAG lasers. The use of antimetabolites did not improve the success rate. In 65% of the cases the canalicular patency is reached. CONCLUSION: Laser-assisted transcanalicular dacryocystorhinostomy is a very useful method because it does not cause cutaneous scarring and for it has a low rate of morbidity given that it causes very little surgical traumatism. Consequently, it can be used under topical anaesthesia and for patients at risk or suffering from coagulation problems. It can be undertaken in the cases of extremely narrow nasal fossae when an endonasal dacryocystorhinostomy is impossible. This procedure is less successful than external or endonasal dacryocystorhinostomy. The success rate is not modified by the use of antimetabolites or by the type of laser.

[Revision of failed dacryocystorhinostomies using the transcanalicular approach. Results of 118 procedures]. / Reprises des échecs des dacryocystorhinostomies par la technique trans-canaliculaire.

PURPOSE: To assess the efficacy of transcanalicular dacryocystorhinostomy for the revision of other procedures. The results are analyzed following the use of two different types of laser: the Neodymium: YAG (Nd: YAG) laser and the Holmium: YAG (Ho: YAG) laser. To study the efficacy of using two antimetabolite drugs in this context: mytomycin-C (MMC) and 5-fluoro-uracile (5-FU). METHODS: One hundred and fourteen patients were operated on. Of these, 88 had already undergone one procedure, 25 two procedures, and 5 three procedures. The Nd: YAG laser was used in 78 procedures, the Ho: YAG in 30 procedures, and both lasers in 10 procedures. Twenty patients were treated with an application of MMC and 25 patients with an application of 5-FU. RESULTS: The results are based on 106 procedures. The total success rate was 49.06% after one revision and 58.49% after two or three revisions. There is no statistically significant difference between the Nd: YAG and Ho: YAG lasers. The use of antimetabolites did not improve the success rate. CONCLUSION: Transcanalicular dacryocystorhinostomy is a very useful method because it does not cause cutaneous scarring and it has a low rate of morbidity given that it causes very little surgical traumatism. The revision of other dacryocystorhinostomy methods using the transcanalicular approach is theoretically a positive indication because it does not dissect scarring tissues and because the osteotomy has already been performed. However, the success rate is lower than for the external and endonasal approaches. The success rate is not modified by the use of antimetabolites or by the type of laser.

[Transcanalicular endodacryocystorhinostomy using Neodymium:YAG laser]. / Endodacryocystorhinostomie transcanaliculaire au laser Neodymium: YAG.

UNLABELLED: We describe a new technique of dacryocystorhinostomy (DCR) and we present our first clinical cases. The principle of this technique is to create a fistula between the lacrimal sac and the nose with a quartz fibre advanced through a canaliculus and connected to a Neodymium:YAG. TECHNIQUE: An 800 microns outer diameter metallic pipe was inserted through a lacrimal canaliculus up to bone contact. An optical fibre light probe was inserted through the pipe in order to locate the lacrimal sac in the nasal fossa by translumination using a nasal video-endoscope. The optical fibre light probe was then replaced with a laser fibre and a lacrimo-nasal fistula (approximately 5 mm diameter) was created in a few minutes by juxtaposition of twenty or more 10 watt energy pulses. Finally, a silicone stent was positioned for 6 months. MATERIAL AND METHOD: We have operated 41 DCR using this transcanalicular method with the Nd:YAG laser. Our mean follow-up was 6 months (max 16 months). Indications were stenosis of the naso-lacrimal duct, failed classical DCR, abscesses of the lacrimal sac uncurable by antibiotherapy and canaliculary stenosis. RESULTS: Success rate was 75%, both for primary procedures and for operations after failed classical DCR. CONCLUSION: The advantages of this method are its simplicity, its atraumatic feature, minimal bleeding, the absence of scar and its ability to treat obstructions located at all levels of the excretory lacrimal system. Minimal operating traumatism makes it a very convenient method for out patient clinic.

Study of a new series of large relaxing retinotomies.

Silicone oil injection followed by retinotomy was performed in a second series of 37 patients with retinal detachment and advanced proliferative vitreoretinopathy. The retina posteriorly to the retinotomy was attached in 16 eyes with at least 18 months of follow-up. Ambulatory vision or better vision was restored in 12 eyes. The size and the site of the retinotomy depend on the size and the site of the retraction.