Dynamic radiologic changes in repeated barotraumatic frontal sinusitis: A CARE case report.

INTRODUCTION: Flight staff are at particular risk of iterative sinus barotrauma. We here report a case of barotraumatic atelectasic frontal sinusitis with dynamic radiologic change in frontal sinus volume. CASE REPORT: A 46-year-old air pilot was referred for right frontal pain occurring at each landing. Two sinus CT scans were taken: one after a period of intense flying and the other after a month without flying. In the right frontal sinus, a type-3 Kuhn cell changed in volume from 6×11×12mm to 13×18×19mm. The alteration involved a modification in the medial wall, which was demineralized and changed position within the frontal sinus. Removal during endoscopic frontal sinusotomy allowed complete resolution of pain. DISCUSSION: This article reports radiologic change in a frontal sinus wall in a setting of repeated barotraumatic frontal sinusitis with a dynamic atelectasic component. In iterative barotrauma, we advocate imaging at different time points. When the ostial obstruction is identified, functional aeration surgery can be applied.

Primary Lacrimal Canaliculitis with clinically detected concretions: One-snip punctoplasty with lateral canaliculotomy vs. punctum sparing canalicular curettage.

PURPOSE: To compare two distinct surgical techniques in the management of chronic Primary Lacrimal Canaliculitis (PLC) with clinically detectable concretions. MATERIALS AND METHODS: Inclusion criteria: Patients presenting with symptoms consistent with the diagnosis of primary lacrimal canaliculitis (PLC) with ocular involvement were gathered. Gomori-Grocott Methenamine Silver test was used for concretion staining. Two groups were identified based on the surgical technique. Group A consisted of patients who underwent a punctum sparing canalicular curettage using a chalazion curette, while the patients in Group B underwent one-snip punctoplasty with lateral canaliculotomy. Failure was defined as recurrence of the initial symptoms at any time (ocular and canalicular inflammation with purulent discharge and pouting punctum). The results were analyzed by comparisons using a Fisher's exact test. RESULTS: Ninety-six consecutive patients (96) with a confirmed diagnosis of PLC underwent surgical treatment between 1987 and 2017. Data were collected and divided based on the surgical technique discussed above (Group A and B). Group A: 51 cases with a mean follow-up time of 22 months [1-224] presented with a mean age of 51.5 [25-83] and a surgical failure rate of 19.6%. Group B: 45 patients with a mean follow-up time of 27 months [1-176], a mean age of 68 [17-87] years and a surgical failure rate of 4.4%. Statistical significance was demonstrated, with a p-value of 0.033, odds ratio (OR) of 0.1936 and Standard Deviation (SD) at a 95% confidence interval of [0.0195-0.9885]. CONCLUSIONS: One-snip punctoplasty with lateral canaliculotomy is a simple, fast and effective procedure that allows better anatomical visualization intraoperatively and is thus shown to be statistically superior to punctum sparing canalicular curettage using a chalazion curette.

Preloaded Monoka (Lacrijet) and congenital nasolacrimal duct obstruction: Initial results.

STUDY OBJECTIVE: To study the performance of a pre-loaded Monoka stent in the management of congenital nasolacrimal duct obstruction (CNLDO). STUDY DESIGN: Non-randomized study of consecutive cases. MATERIALS AND METHODS: A preloaded classic Monoka silicone stent contained entirely inside its introducer (Lacrijet) was used to treat a consecutive series of subjects with CNLDO over an 11-month period (May 2019-March 2020). Only subjects with chronic symptomatic CNLDO were included. Subjects with intermittent tearing, canalicular pathology, trisomy 21, facial cleft, or history of lacrimal surgery were excluded. Intraoperative findings were recorded, including the degree and location of the nasolacrimal obstruction, successful metal to metal contact with the probe, any difficulties encountered by the Lacrijet device itself, procedure duration, tolerability of the fixation punctal plug, and finally, inspection of the stent after withdrawal of the inserter. Functional success was defined as disappearance of all symptoms of epiphora. RESULTS: A total of 45 preloaded Monoka Lacrijet stents (Lcj) were placed consecutively in 38 children. The mean age was 27.9 months (12-78 months). The mean procedural duration was 2.8minutes (range: 1-10min). The overall success with disappearance of all symptoms of epiphora was 88.8% (40/45). Surgery in cases of simple mucosal stenosis was successful in 92.2% (35/38) of cases, with a mean follow-up time of 7.9 months (range: 1 to 12 months). The duration of stent intubation was for this group was 32 days (range: 1-103). The surgical outcomes for the other 7 cases with more complex intraoperative findings are summarized in the publication. All withdrawn probes were intact. CONCLUSIONS: The Lacrijet stent system is a simple and reliable pushed intubation device for CNLDO in appropriately selected cases where bony stenosis of the canal is minimal.

Insertion of a preloaded Monoka™ stent for congenital nasolacrimal obstruction: Intraoperative observations. A preliminary study.

STUDY OBJECTIVE: To study the intraoperative deployment of a pre-loaded probe for a "pushed" monocanalicular nasolacrimal intubation. STUDY DESIGN: Non-randomized study of consecutive cases. MATERIALS AND METHODS: Description: A classical Monoka™ silicone stent with the silicone tube attached at right angles to the punctal plug is contained entirely inside an introducer connected to a piston. Insertion: The procedure begins with intubation of the nasolacrimal duct with the metallic introducer. Traction on the piston retracts the metallic introducer inside the handpiece. This relative shortening progressively ejects the stent, starting with its free end at the bottom of the introducer. The operation was observed endoscopically under single-blind conditions. RESULTS: Twenty-eight preloaded Monoka™ stents were placed consecutively, in 28 congenital nasolacrimal duct intubations in 22 patients (28 sides). Endoscopic examination showed that the free part of the stent was progressively ejected from the introducer during retraction of the piston. Insertion of this pushed stent into the nasal cavity was effective in 23/28 cases (82.1%). A total of 28 preloaded stent insertions were attempted and 23 were correctly deployed. DIFFICULTIES ENCOUNTERED: At the end of nasolacrimal duct intubation, contact between the punctal plug and the lacrimal punctum was problematic in four cases (4/28=14.2%). At the beginning of stent placement, premature ejection of the punctal plug within the end of the introducer occurred in five cases (5/28=17.8%). These five stents failed to insert properly into the nasal cavity. At the end of insertion, retention of the punctal plug in the introducer occurred in two cases (2/28=7.1%). COMPLICATIONS: No cases of intraoperative or postoperative epistaxis were observed. CONCLUSIONS: Intraoperative nasal endoscopy validated the concept of the preloaded Monoka stent and its deployment. Reproducibility and improved reliability may require a change in stenting technique and a design modification.

Pediatric endonasal dacryocystorhinostomy and operative standardization.

OBJECTIVE: The objective of this study was to confirm that the standardized endonasal dacryocystorhinostomy (DCR) technique routinely performed in adults can be used in children. MATERIALS AND METHODS: A consecutive series of children undergoing endonasal DCR between 2003 and 2017 was analysed. The surgical procedure consisted of: preoperative CT scan, anatomical localization of the ideal surgical zone, access to the nasal cavity via an optional planned enlargement, creation of a mucoperiosteal flap, osteotomy with rongeurs and equatorial resection of the medial wall of the lacrimal sac. This pediatric series was compared to a series of adult patients operated according to the same standardized technique. RESULTS: A total of 20 DCRs (17 patients, with a mean age of 8 years (range: 4-16)) were included. Anatomical localization was effective in 100% of cases without the need for transillumination. With a mean follow-up of 4 years, the success rate was 95%, and no major complications were observed. Comparison with the same surgical technique in adults revealed similar results. DISCUSSION: Our experience suggests that standardized endonasal DCR can be adapted to the nasal cavities of children. Anatomical localization is effective. The physiologically narrow nasal cavity does not constitute a major obstacle with the use of slightly smaller instruments. The results and complications are similar to those observed in adults. CONCLUSION: The same standardized endoscopic endonasal DCR surgical technique can be used in adults and children with a similar good success rate.

Intralacrimal migration of Masterka® stents.

BACKGROUND: Tearing and conjunctivitis in children are commonly due to lacrimal drainage system obstruction. Congenital nasolacrimal obstruction is a common pathology treated by probing with or without silicone stent insertion, depending upon the age of the child. The silicone stent is self-retaining and placed for at least one month. Masterka® is a recent version of Monoka®, which may lead to the same surgical complications, such as intralacrimal migration. SUBJECTS AND METHODS: The medical records of two patients surgically treated with the Masterka® probe for nasolacrimal duct obstruction, who developed intralacrimal migration of the stent, were retrospectively reviewed and analyzed. A 41-month-old child and an 18-month-old child presented with disappearance of the silicone tube after 7 days and 2 years respectively. In the first case, the tube migrated completely within the lacrimal system and became externalized through the nose at 2 years, while in the second case, the Masterka® was retrieved through a canalicular approach. In both cases, infants had no further tearing. DISCUSSION: The frequency self-retaining stent disappearance is estimated at 15%. Among these cases, intralacrimal migration is only reported in 0.5% of cases. To prevent intralacrimal migration, the surgical technique must follow a certain number of rules. Management, based on residual epiphora, is discussed. CONCLUSION: Prevention of intralacrimal migration of self-retaining stents involves a rigorous analysis of the relationship between the meatus and the fixation head at the time of placement. After lacrimal intubation, scheduled monitoring is necessary to screen for stent disappearance. Management is based on clinical findings, anterior rhinoscopy and even exploratory canaliculotomy.

Acquired fistula of the lacrimal sac and laisser-faire approach. Description of the natural history of acquired fistulas between the lacrimal sac and the skin occurring before planned endonasal dacryocystorhinostomy (DCR) and without any treatment of the fistula.

INTRODUCTION: The formation of a fistula between the lacrimal sac and the skin is a classic outcome of resistant lacrimal sac abscesses. There is currently no consensus about treatment in such cases. The goal of this study was to describe the natural history of acquired fistulas between the lacrimal sac and the skin, occurring before planned endonasal dacryocystorhinostomy (DCR) and without any treatment of the fistula. MATERIALS AND METHODS: This prospective study was only descriptive and included patients between 1999 and 2012. The patients included were adults with a nasolacrimal duct (NLD) obstruction that was planned to be treated with endonasal DCR. A resistant lacrimal sac abscess appeared a few days before the planned surgery, and fistulized spontaneously despite medical treatment. The surgery was not delayed. The DCR was endoscopic. Nothing was done for the fistula. Its healing was spontaneous. The exclusion criteria were the following: congenital fistulas, post-traumatic and/or iatrogenic fistulas, fistulas which had regressed by the day of the surgery, postoperative follow-up less than 5 months, post-traumatic and/or iatrogenic fistulas, any history of previous DCR or any other lacrimal surgery, children. RESULTS: Twenty adults (25 cases) were included in the analysis. Mean age was 79 years old (from 41 to 90). The mean follow-up was 41 months (from 5 to 108 months). The fistula spontaneously disappeared in all cases, less than one month after it had appeared and in a permanent fashion. No unsightly scar developed. DISCUSSION: Spontaneously acquired fistulas between the lacrimal sac and the skin may occur in the natural course of abscessed acute dacryocystitis. Our study showed spontaneous healing of the fistula post-endoscopic DCR. CONCLUSION: Fistula excision in fistulous acute dacryocystitis does not seem essential to its healing. The laisser-faire approach appears adequate for aesthetic outcomes as well as for functional outcomes of DCR.

Pushed monocanalicular intubation. Pitfalls, deleterious side effects, and complications.

PURPOSE: To present our experience with pushed monocanalicular nasolacrimal intubation in the management of 90 consecutive cases of nasolacrimal outflow obstruction. MATERIALS AND METHOD: This paper reports a non-randomized study of 90 consecutive cases treated with a pushed Monoka intubation system (Masterka™). A metal guide is placed inside a silicone tube rather than being attached at the distal end of the tube, as done with traditional pulled intubations. Three probe lengths are available: 30, 35, and 40 mm. SURGICAL PROCEDURE: The silicone stent was pushed into a punctum, canaliculus, and nasolacrimal duct by means of the guide. After passing through the valve of Hasner and reaching the nasal floor, the guide was then delicately withdrawn while remaining oriented along the axis of the lacrimal sac and duct. Throughout this phase, the anchoring plug was held in contact with the punctum. Three study groups were set up chronologically: group 1: endo-DCR procedures done with Masterka insertions under endoscopic observation. Group 2: Masterka insertions done with endoscopic guidance. Group 3: blind Masterka insertions without endoscopic guidance. The patients in groups 2 and 3 were selected on the information obtained by lacrimal probing. Only cases with mucosal nasolacrimal stenoses were included. All patients had surgery under general anesthesia with mechanically assisted ventilation (groups 1 and 2) or spontaneous ventilation (group 3). The anchoring plug was inserted into the punctum and vertical canaliculus, either by pulling on the probe (group 1) or using an inserting instrument. RESULTS: A total of 90 pushed Monoka intubations were done. Endoscopic examination (groups 1 and 2) demonstrated visually that the pushed intubation method was effective. In none of the 28 cases did the silicone bunch up when the guide was withdrawn. DEGREE OF DIFFICULTY: This was dependent upon proper selection for pushed Monoka intubation; the length of the probe and confirmation that there no false passage was created. The pushed intubation technique was only slightly more difficult than a simple lacrimal probing. The average operating time, excluding the anesthetic procedures, was respectively 5 min (group 2) and 4 min (group 3). COMPLICATIONS DURING SURGERY: There were no anesthetic or general problems observed in the three groups. Epistaxis was also not noted. POSTOPERATIVE COMPLICATIONS: Fifteen percent (13/90). The 13 complications noted were: two cases of canaliculitis, one intracanalicular migration, eight probes that disappeared, one keratitis, and one case of involuntary removal by the patient. DELETERIOUS SIDE EFFECTS: Tearing with the probe was in place was noted in 21.1% of the cases (19/90). This tearing disappeared as soon as the probe was removed in 50% of these cases (10/19). FUNCTIONAL RESULTS: Overall, the success rate (absence of epiphora, absence of mucous discharge) was 90% (81/90) with an average follow-up period of 19 weeks (Range, 1 day to 60 weeks). Two cases were lost to follow-up at day 1 and day 7. Group 1: 90.9% (20/22 cases; average age: 65 years, with an average follow-up period of 24 weeks). Group 2: 100% (6/6 cases; average age: 3.1 years, with an average follow-up period of 14 weeks). Group 3: 88.3% (53/60 cases excluding the two cases that were lost to follow-up; mean age: 2.3 years, with an average follow-up period of 16 weeks). CONCLUSIONS: From a technical perspective, pushed nasolacrimal intubation is much simpler than the traditional pulled types of nasolacrimal intubation. The anesthetic procedure required is the same as that for a late probing procedure, but the functional results are better. The Masterka is an alternative to simple late probing in the treatment of mucosal nasolacrimal stenoses in patients of over 12 months of age.

"Pushed" monocanalicular intubation in children under general anesthesia with spontaneous ventilation. A preliminary report.

PURPOSE: We studied the possibility of placing a new type of monocanalicular nasal intubation under general anesthesia with spontaneous mask ventilation in congenital nasolacrimal duct obstruction. PATIENTS AND METHOD: This was a non-randomized study of consecutive cases using a monocanalicular stent called the "pushed Monoka". The benefits of anchoring with meatus fixation are similar to the original Monoka device, but the probe guide or introducer is inside the silicone tube. The external diameter of the "pushed Monoka" is 0.96 mm (versus 0.64 mm in the traditional Monoka). There are three lengths: 30, 35, and 40 mm. General anesthesia was administered by inhalation of a halogen gas using a facial mask. The technique was selected by lacrimal exploration to evaluate the extent of the stenosis (simple or complex). The location and freedom of movement of the stent into the inferior nasal meatus was tested using a second lacrimal probe. Only simple stenosis cases with positive metal-to-metal contact were included in the study. INSERTION TECHNIQUE: The introducer pushes the stent into the lacrimal duct. The introducer should be removed from the silicone sleeve very carefully by gently pulling it out, millimeter by millimeter. This action is carried out while paying careful attention to keeping the stent aligned with the major axis of the lacrimal sac. Throughout this phase, the anchoring plug should remain in contact with the lacrimal punctum. Once the introducer is completely removed, the anchoring plug is secured into the vertical canaliculus. A single-use plug inserter was used. RESULTS: Fourteen children (18 sides) with congenital nasolacrimal duct obstruction were consecutively included in the study. The pushed intubations were all performed under general anesthesia with spontaneous ventilation. The average age of the children was 26.2 months (range: 14 to 46 months). The average duration of the procedure, measured between the moment that the facial mask was put into place and the child's awakening (crying, restlessness) was 14 minutes (range: 9 to 27 minutes). The most variable parameter was the use of the venous portal. The introduction of the pushed probe itself required an average 7 minutes (range: 3 to 11 minutes). None of the children showed epistaxis. In general terms, no intraoperative or postoperative complications were noted. The "pushed Monoka" tubes were withdrawn during postoperative appointments with a mean intubation duration of 34 days (range: 1 to 59 days). Postoperative success (absence of epiphora, absence of mucous discharge) was achieved in 88% of cases (16/18 sides). The average follow-up was 8.7 weeks (range: 3 to 26 weeks). Complications and side effects were minimal. One stent was withdrawn on day 1 due to a keratitis with respect to the anchoring plug. Three stents were spontaneously lost (16%) between day 2 and day 30. Anterior rhinoscopy found none of the stents in the inferior nasal meatus. These four cases were all considered successful as there was no postoperative epiphora noted. CONCLUSIONS: Pushed nasolacrimal intubation can be safely utilized under general anesthesia with spontaneous mask ventilation. This technique appears to be a simple and safe alternative to late and very late probing in the treatment of membranous congenital nasolacrimal duct obstruction in children older than 12 months.

Pushed monocanalicular intubation: a preliminary report.

OBJECTIVE: To study the behavior of a "pushed" monocanalicular stent by means of nasal endoscopy. PATIENTS AND METHODS: Four children (six affected sides) with congenital nasolacrimal duct obstruction were treated with monocanalicular intubation with an anchoring plug. The children's mean age at the time of the operation was 33 months (range, 30-37 months). The procedure began with probing in order to verify (a) dacryostenosis (simple or extensive nasolacrimal duct impatency) and (b) the metal-to-metal contact in the lower nasal meatus. The stent was similar to a Monoka(TM), but the guide (a malleable stainless steel probe) is located inside the silicone stent rather than projecting from it. The silicone's total length is 40 mm and the external diameter 0.96 mm. Simultaneously, the guide acts to catheterize the nasolacrimal duct by pushing the silicone through the upper and lower parts of the outflow system. The guide is removed via a punctal approach. This mode of intubation dispenses with the nasal recovery step. Nasal endoscopy was used to monitor (a) the position of the stent in the lower nasal meatus (free or submucosal), (b) mucosal damage and bleeding, and (c) the behavior of the silicone tube during removal of the guide. RESULTS: Because of the complexity of nasolacrimal ducts, two of the six sides were treated with the classical Monoka intubation method of pulling the silicone tubing out from the nasal exit of the duct (the pull technique). The pushed intubation method was used for the four simple nasolacrimal stenoses, with no problems whatsoever. In all four cases, endoscopic examination showed (a) no submucosal tunneling (false passage), (b) no noteworthy mucosal damage, and (c) no retraction (bunch-up) of the silicone tube during the metal guide removal. No particular complications were reported during the procedure or the intubation period, which lasted an average of 3 weeks. The stents were removed in the consulting room. Tearing ceased during the 1(st) week in two cases, during the intubation period. Tearing persisted throughout the intubation period in the other two cases, but ceased during the week following stent removal. The follow-up lasted 2 months. CONCLUSIONS: The pushed procedure simplifies monocanalicular nasal intubation. Its indications remain to be determined.

[Neonatal pathologies of the lacrimal system]. / Pathologie néonatale du sac lacrymal.

Neonatal obstruction of the distal part of the lachrymal system can lead to dilatation of the lachrymal sac if associated with a canaliculus problem. Clinical presentation is a blue tumor of the internal canthus. This external expansion of the lachrymal sac communicates with a nasal expansion under the inferior nasal turbinate. Even if this typical presentation is spectacular, spontaneous resolution occurs in 80% of cases. There are two main types of progression: an abscess of the lachrymal sac can occur (20%) or bilateral nasal respiratory obstruction in cases of bilateral obstacle because newborns are obligatory nose breathers (<0.1%).

[Foreign body granuloma resulting from a lacorhinostomy tube's migration associated with actinomycosis of the lacrimal sac]. / Granulome à corps étranger suite à une migration d'un tube de lacorhinostomie, associé à une actinomycose du sac lacrymal.

INTRODUCTION: Lacorhinostomy is a surgical procedure that establishes a permanent communication between the caruncular region and the nasal fossa using a fixed tube. The main complications involve the biotolerance of this tube. OBSERVATION: Fifteen years after lacrimal surgery, a patient presented with repeated canthal inflammation associated with epistaxis on the same side. The anterior rhinoscopy showed an occlusion of the inferior meatus by a mucous tumor, bleeding to the contact. A lacrimal sac scan disclosed a local tumor without bone erosion. With an endonasal dacryocystorhinostomy, a lacorhinostomy tube was found hidden in the canthal region associated with actinomycosis of the lacrimal sac. DISCUSSION: Lacrimal actinomycosis is mostly primitive, although actinomycosis in other locations may be associated with the presence of a foreign body. In that case, the association is probably a coincidence. CONCLUSION: When a tumor develops after lacrimal surgery, a foreign body reaction must be suspected.

Cerebrospinal fluid leakage after endonasal dacryocystorhinostomy.

An endonasal dacryocystorhinostomy (DCR) was followed by cerebrospinal fluid leakage and pneumoencephalocele in an 80-year-old female patient presenting four independent risk factors for an ethmoidal breach: severe septal deviation requiring forced reclining, a cranial insertion of the perpendicular plate of the ethmoid directly onto the cribriform plate, meningeal prolapse, and extensive osteoporosis of the skull base. The use of a Killian valve speculum to recline the nasal septum was probably the main cause of the anterior skull base fracture. The defect was repaired by a composite patch of septal cartilage, abdominal fat grafts, Surgicel, and inferior turbinate mucosa. Thirty-four months after surgery, there was no residual symptom. A narrow nasal fossa makes endoscopic DCR more difficult to perform. The use of a Killian valve speculum to enlarge the nasal fossa may carry a risk for structural damage to the skull base. A narrow nasal fossa may require an external DCR or a prior endoscopic septoplasty to facilitate an endonasal approach. Closing an ethmoidal defect causing cerebrospinal fluid leakage can be successfully achieved by an endonasal approach rather than by a more conventional neurosurgical method.

[Mastering endonasal dacryocystorhinostomy]. / Comprendre la dacryocystorhinostomie par voie endonasale.

A persistent, symptomatic lacrimal duct stenosis is treated by dacryocystorhinostomy (DCR), with external (EX) or endonasal (EN) access. The basic indication is the same in all cases and either route can be used. The EX route seems better in terms of speed of surgery, learning curve and cost. It is logical to use the external route to treat the disorder when it is associated with a lacrimal sac diverticulum, an irreducible stenosis of the union canal, or a canthopexy. The EN route has been shown to be worth consideration whenever there is a nasal sinus disorder that can be repaired at the same time. Moreover, it is indicated in a rare case of lacrimal abscess that cannot be treated medically, where the risk of scarring would contraindicate standard surgery, or when DCR is recurrent. A series of prospective randomized studies is needed to determine whether the route materially influences the outcome. Until then, it is best to have both methods available for an unbiased case-by-case decision.