Human papilloma virus (HPV) presence in primary tumors of the lacrimal sac: a case series and review of the literature.

Primary tumors of the lacrimal sac (PTLS) are a rare subtype of ocular adnexa tumors, with potentially life-threatening clinical course. There has been growing evidence of human papilloma virus (HPV) as an etiological agent in these tumors.In this retrospective observational case series, we report three cases of PTLS. All three underwent an initial dacryocystorhinostomy revealing a tissular mass in the lacrimal sac. Histological findings were respectively epithelial papilloma, epithelial Malpighian papilloma, and undifferentiated epidermoid carcinoma. PCR evaluation identified HPV serotype 6 in the first case and 16 in the third, and high p16 expression was found in the second case.These three cases of PTLS with HPV detection complement 36 other cases identified in the literature, further incriminating HPV in the pathogenesis of these neoplasms. Ophthalmologists must remain wary of chronic lacrimal occlusion symptoms, and resort to CT scan and orbital Doppler sonography whenever first-line treatment fails.

Use of the Novel Hourglass Shaping Sutures to Create a Natural Middle Vault Shape as Illustrated by Three-Dimensional Modeling.

SUMMARY: The middle vault plays a major aesthetic and functional role. Excessive narrowing of the middle vault can occur in the absence of appropriate middle vault reconstruction. This can result in both aesthetic flaws and functional issues. Spreader flaps combined with our hourglass shaping sutures technique yield a natural middle vault appearance and prevent unwanted functional and aesthetic complications.

Double pedicled nasoseptal flap for skull base repair after endoscopic expanded endonasal approach.

BACKGROUND: Expanded endonasal approach offers a spectacular corridor for skull base tumour resection but requires reliable multilayer reconstruction techniques with a vascularized nasoseptal flap. METHOD: On the basis on our substantial experience of 136 patients operated on between January 2008 and January 2020, the double pedicled nasoseptal flap technique was developed for skull base repair. The technique is finely detailed. The nasal floor mucosa was preserved. CSF leakage occurred in 4% of patients. CONCLUSION: Double pedicled nasoseptal flap is a reproducible and efficient technique for skull base reconstruction after expanded endonasal approach and is associated with limited rhinological complications.

Powered Rhinoplasty: A Simple Step-by-Step Approach.

SUMMARY: Reduction of a nasal hump and nasal base narrowing are very common steps during a primary rhinoplasty procedure. The greatest difficulty is to obtain stable fracture lines, a natural appearance, beautiful dorsal aesthetic lines, and the absence of palpable or visible irregularities, especially in the long term. The surgeon strives for a reproducible technique, which seems to be more feasible with mechanical osteotomies (powered or piezoelectric) than with traditional manual osteotomies. The aim of this article is to describe powered osteotomy in a step-by-step fashion to provide a clear guideline for rhinoplasty surgeons.

Clinical follow-up of corticotomy-accelerated Invisalign orthodontic treatment with Dental Monitoring.

The demand for fast and invisible treatment options for adults has grown. Treatment protocols involving clear aligners in association with alveolar corticotomy have been developed in response to this demand. Alveolar corticotomy surgery can accelerate orthodontic tooth movement, but good clinical follow-up is crucial and can become cumbersome as the frequency of aligner changes accelerates. Clinical monitoring with patient-managed software can be of assistance in such cases. We present the ortho-surgical treatment of a healthy 21-year-old woman with Class III malocclusion who was treated with corticotomy-accelerated presurgical decompensation and clear aligners, followed by mandibular sagittal split osteotomy. Alveolar corticotomy surgery was performed and the aligners were changed every 4 days. Clinical follow-up of aligner-mediated tooth movement was managed with a patient-managed smartphone application, allowing early interception and correction of minute orthodontic movement errors. Such errors would have been difficult to detect considering the rapidity of aligner change when accelerated by alveolar corticotomy. Clinical follow-up with a patient-managed smartphone application could thus allow for better and easier management of corticotomy-accelerated clear aligner orthodontic treatment.

The Modified Sliding Alar Cartilage Flap: A Novel Way to Preserve the Internal Nasal Valve as Illustrated by Three-Dimensional Modeling.

BACKGROUND: Preservation of the scroll area is essential when performing rhinoplasty to achieve a good functional outcome. This is of particular concern with tip-plasty procedures. The objectives of this study were (1) to describe a novel tip-plasty procedure consisting of sliding the cephalic portion of the alar cartilage beneath its caudal portion to preserve the scroll area and (2) to present the authors' prospective case series, which includes Nasal Obstruction Symptom Evaluation and peak nasal inspiratory flow scores to objectively evaluate functional outcomes. METHODS: The modified sliding alar cartilage surgical technique is described and illustrated by intraoperative photographs and videos and by three-dimensional modeling software. A prospective study of all patients undergoing tip-plasty with alar reduction by the sliding alar cartilage technique was performed from September of 2016 to December of 2017. Peak nasal inspiratory flow and Nasal Obstruction Symptom Evaluation scores were collected preoperatively and at 1 week and 6 months postoperatively. RESULTS: Twenty-five patients were included in the study. Aesthetic outcomes were good, with no major complications. The average preoperative peak nasal inspiratory flow score was 114 liters/minute (95 percent CI, 108.1321 to 119.8679 liters/minute), whereas the average score at 6 months postoperatively was 115.82 liters/minute (95 percent CI, 106.6241 to 125.0159 liters/minute; p = 0.513). The average preoperative Nasal Obstruction Symptom Evaluation score was 17.2 (95 percent CI, 15.99655 to 18.40345), whereas the average score at 6 months postoperatively was 15.2 (95 percent CI, 13.18131 to 17.21869; p = 0.08353), indicating no significant change. CONCLUSION: The sliding alar cartilage is a simple technique allowing tip definition while maintaining nasal airway function by preserving the crucial anatomical scroll area. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Complex Stenoses and CT Features of the Nasolacrimal Canal in Congenital Nasolacrimal Duct Obstruction.

PURPOSE: To study the CT appearance of the nasolacrimal canal (NLC) in cases of congenital nasolacrimal duct obstruction (CNLDO) where there is a tactile sensation of a hard contact (HC) stop in the duct preventing stent intubation. METHODS: The authors retrospectively reviewed all consecutive cases of chronic CNLDO observed between 2003 and 2018 in which an apparent HC obstruction prevented nasolacrimal intubation. CT scans were reviewed to determine the cause of probing failure: distal stenosis, loss of parallelism of the NLC walls, abnormal angulations or an adjacent obstacle blocking tear outflow. RESULTS: Nine patients (12 sides) met the following criteria: CNLDO + HC + probing failure. The mean age at the time of the first HC was 3.9 years (range: 0.8-8.1 years) and at the time of a second confirmation of HC with subsequent dacryocystorhinostomy was 7.8 years (range: 4.1-9.2 years). Nasolacrimal duct opacification was noted in 33% of cases (4/12). Abnormalities of the NLC occurred in 8 of the 12 cases of CNLDO (8/12 = 66.6%) and on the asymptomatic side in 1 case (1/6 = 16.6%). A canine tooth bud situated in the same plane as the NLC was observed in 9 cases of CNLDO (9/12 = 75%) and on the asymptomatic side in 2 cases (2/6 = 33.3%). CONCLUSIONS: HC noted during probing is a sensitive but relatively nonspecific sign which, nevertheless, does indicate either a complex obstruction or at least potential intubation difficulties. As confirmed by CT imaging, a significant anatomical variant is not necessarily predictive of epiphora, but nevertheless may complicate the intubation procedure.The authors describe hard contact palpation during probing for CLNDO and its relationship to anatomic location and etiologies of obstruction in the nasolacrimal canal by CT imaging.

Complex Bony Congenital Nasolacrimal Duct Obstruction Caused by an Adjacent Canine Tooth Bud.

The authors report the case of a 7-year old child with failed probing with stent intubation, who was found to have an unusual curvature of the nasolacrimal duct on the symptomatic side. CT imaging revealed a permanent maxillary canine tooth adjacent to the duct. It appeared that the relationship of the tooth bud to the curved nasolacrimal duct was most likely responsible for the symptoms of epiphora on this anomalous side.

[Orthodontic and orthognathic protocoles: systematization of the consultation of announcement and contribution of integrative medicine]. / Protocole orthodontique et chirurgical : systématisation de la consultation d'annonce et apport de la médecine intégrative.

INTRODUCTION: The consultation of announcement is one of the key periods in an orthodontic and surgical process. The aim of this consultation is not only to make an aesthetic and orthodontic diagnosis but also a fine psychological analysis of the patient and his family before proposing a treatment plan. Integrative medical therapies, a recent evolution of medicine within the framework of the doctor-patient relation, have shown the positive impact on the treatment success of a good relationship. MATERIALS AND METHODS: The preliminary collection of information on the patient's psyches is now part of the treatment guidelines and has a positive impact on treatment observance, management of pre- and post-operative care or more simply surgery acceptance. Therefore, a systematized patient record process including global medical assessment of the patient and not only orthodontic and cephalometric diagnosis is a key factor for the treatment outcome.

[Dysmorphic disorder]. / Dysmorphophobie∗.

The term "dysmorphic disorder" is used in psychiatry to define an obsessive fear of being ugly or deformed. Orthognathic surgery can entail varying degrees of facial change in patients. However, it is widely acknowledged that some patients find it difficult to adjust to the changes, either as a result of what they see in the mirror or of comments from those around them. Occasionally, the psychological impact of the transformation exceeds the extent of the modification itself. The term "dysmorphic disorder" is applied to this type of psychological suffering due to an inability to adapt. It is the duty of practitioners (orthodontists and surgeons) to screen patients who show signs during their first appointments of psychological fragility in order either to dissuade them from choosing a surgical route involving a high potential for transformation or to assist them, with professional support from a psychologist or psychotherapist, towards accepting the change.

[How to choose and deliver orthodontic mini-screws: important notions]. / Choisir et mettre en place les mini-vis d'ancrages orthodontiques : notions importantes.

Orthodontic mini-screws are developing more and more because they make orthodontics easier and broaden its applications. This exponential development has arrived at a well defined mini-screw and a codified installation procedure. The aim of this article is to provide the conceptual elements of mini-screws in order to allow their safe use in orthodontic offices.

Endoscopic dacryocystorhinostomy: the keys to surgical success.

PURPOSE: To describe a surgical technique for endoscopic endonasal dacryocystorhinostomy. METHODS: A consecutive case series of adult endoscopic dacryocystorhinostomy surgery was reviewed. The specific surgical approach of uncinectomy with or without septoplasty and anterior middle turbinectomy was noted. Postoperative follow up including endoscopic examination and results were documented. RESULTS: A total of 300 cases were included (271 patients) with average age of 66 (range 24-94). An uncinectomy was performed in 285 of 300 (95%) cases, a septoplasty in 82 of 300 (27%) cases and an anterior middle turbinectomy performed in 225 of 300 (75%) cases. Postoperative bleeding that required nasal packing occurred in 2 of 300 (0.6%) cases. Persistent nasolacrimal symptoms after surgery occurred in 18 of 300 (6.0%) cases with an average follow up of 28 months (range 1-70). Postoperative nasolacrimal symptoms were attributed to a persistent lacrimal sac (sump syndrome) in 1 of 300 (0.3%) cases, a mucocele recurrence in 2 of 300 (0.6%) cases, and scarring at the rhinostomy in 15 of 300 (5.0%) cases. CONCLUSIONS: Endoscopic endonasal dacryocystorhinostomy is an effective treatment for nasolacrimal duct obstruction. An uncinectomy, septoplasty, and anterior middle turbinectomy contribute to the optimal clearance of the common canaliculus and ultimate surgical success.

Endoscopic removal of large orbito-ethmoidal osteoma in pediatric patient: Case report.

INTRODUCTION: Osteoma is a benign slow growing bone tumor with a prevalence of 3% of all benign paranasal sinuses tumors, with a peak incidence between the fourth and sixth decades, mostly involving frontal sinuses.(1) PRESENTATION OF CASE: We present a case of a large right ethmoidal sinus osteoma in a 12-year-old boy, complaining of frontal headaches and excessive lacrimation of the right eye. CT scan showed a very large tumor in the right anterior ethmoidal sinus (30mm×25mm×15mm). DISCUSSION: Large osteomas of the paranasal sinuses are usually resected by external approaches. However, the minimally invasive endonasal approach, which minimizes external facial scarring, is challenging for such large lesions in pediatrics. In the presented case, the osteoma was successfully resected exclusively by endoscopy-guided endonasal approach assisted by neuronavigation, with no peri or postoperative complications. CONCLUSION: An endoscopic approach assisted with neuronavigation may be a minimally invasive and safe procedure for managing large osteoma of the ethmoidal sinus in pediatrics patients.

Pushed monocanalicular intubation: an alternative stenting system for the management of congenital nasolacrimal duct obstructions.

PURPOSE: To present our experience with a "pushed" monocanalicular nasolacrimal intubation device in the management of nasolacrimal duct obstruction in children. METHODS: The cases of consecutive patients with nasolacrimal duct obstruction who were treated with primary probing and intubation with the Masterka were reviewed retrospectively. The Masterka includes a metal guide placed inside a silicone tube for "pushed" intubation as opposed to material attached at the distal end of the silicone for intranasal retrieval ("pulled" intubations). All procedures were accomplished with the patients receiving masked airway anesthesia; neither laryngeal mask airway nor endotracheal intubation was necessary. Only patients noted to have a membranous (mucosal) obstruction were considered for treatment with the Masterka. The duration of operation, duration of stent intubation, and severity of symptoms on follow-up were noted. Success was defined as absence of symptoms after stent removal or loss. RESULTS: A total of 110 eyes of 88 patients were included (average age, 2.4 years; range, 1-8 years). The average operating time was 3 minutes (range, 2-9 minutes). Persistent tearing on follow-up with the stent in place was noted in 26 eyes (24%); tearing resolved after stent removal in 19 eyes (73%). Success was achieved in 94 eyes (85%). with an average follow-up of 33.7 weeks (range, 4-139). Keratitis was noted in 2 eyes (2%). Early stent loss occurred in 17 ducts (15%). CONCLUSIONS: The Masterka was an effective primary treatment for nasolacrimal duct obstruction associated with mucosal obstructions in this small series of patients.

[Studies of labyrinthine cholesteatoma-related fistulas: report of 22 cases]. / Prise en charge des fistules labyrinthiques cholestéatomateuses: a propos de 22 cas.

OBJECTIVE: To study the incidence, location, pre- and postoperative symptoms (hearing loss, tinnitus, vertigo, facial palsy), preoperative diagnostic imaging, and surgical treatment of labyrinthine fistulae (LF). DESIGN: Retrospective case review. PATIENTS: Twenty-two cases of LF over 382 mastoid operations performed in a 168-month period. MAIN OUTCOME MEASURES: Clinical, imaging, and surgical correlation of extensive fistulae and bone fistulae. RESULTS: LF prevalence was 5.8%. The main primary symptoms were otorrhea and hypoacusis. Only four patients presented vertigo as their main complaint. All patients underwent preoperative computed tomographic (CT) scans and preoperative audiometry. LF diagnosis was made before surgery for 100% of patients on the basis of CT scan. A second fistula was, however, misdiagnosed by imaging in two patients. With respect to surgical technique, a canal wall down procedure was performed in 77% and a conservative procedure was performed in 23%. Fistula was located in the horizontal semicircular canal in 100% of cases, and in 9%, a second fistula was operatively diagnosed. In 91% of cases, the matrix was removed, whereas it was left in the course of a canal down procedure in 9%. With a follow-up of 5.7 years, hearing remained unchanged in 80% of patients. CONCLUSIONS: Surgery with removal of the cholesteatoma matrix and sealing of the fistula with temporalis fascia is a safe procedure that can help preserve cochlear function. The choice of a canal down procedure would be influenced by cholesteatoma characteristics rather than by the finding of an LF.

Surgical anatomy of the lacrimal fossa a prospective computed tomodensitometry scan analysis.

PURPOSE: To establish the accurate surgical anatomy of endonasal dacryocystorhinostomy (DCR) based on the radiological analysis of underlying bony structures. DESIGN: Prospective noncomparative observational case series study. PARTICIPANTS: Fifty-nine patients with complete nasolacrimal stenosis underwent a computed tomodensitometry (CT) scan before endonasal DCR. METHODS: High-resolution CT scanning with contrast injection of the lacrimal sac was performed. Image reconstruction was performed to obtain continuous 1.0-mm axial and coronal sections for review. MAIN OUTCOME MEASURES: Relationship of the lacrimal fossa (LF) to the operculum of the middle turbinate (OMT), the uncinate process (UP), and the frontal recess (FR); symmetry of the right and left anatomies; location of the OMT; position of the most anterior insertion of the UP with respect to 2 main references (the posterior lacrimal crest and the junction between the maxillary and lacrimal bones) on axial sections at 3 different levels (upper, intermediate, and lower of the LF); height of the LF; and distance of the OMT from the lower limit of the LF. RESULTS: The OMT, the UP, and the FR were adjacent to the LF in 41 (53.2%), 73 (94.8%), and 23 cases (29.9%), respectively. There was a right-left symmetry in 10 of 18 patients (55%). The OMT was always anterior to the junction between the maxillary bone and the lacrimal bone. The UP was more frequently posterior (32.5%) or adjacent (45.5%) to the LF at the lower level, adjacent to the maxillary bone (55.8%) at the intermediate level, and adjacent to the middle turbinate (61%) at the upper level. The height of the LF was 12.06+/-1.93 mm. The OMT was located 5.96+/-2.05 mm upward from the lower limit of the LF. CONCLUSION: The almost constant overlapping of the UP onto the LF at the level of the common canaliculus indicates that the most effective approach for successful DCR osteotomy is via a submucosal cleavage and resection of the anterior part of the UP. The management of these landmark structures should be an integral part of the endonasal DCR method.

Complications of standardized endonasal dacryocystorhinostomy with unciformectomy.

PURPOSE: To report the nature and frequency of complications occurring with endonasal dacryocystorhinostomy (DCR) based on routine unciformectomy. DESIGN: Prospective, noncomparative interventional consecutive case series study. PARTICIPANTS: Endonasal DCR was performed on 300 patients with complete nasolacrimal stenosis. METHODS: The uncinate process was resected (unciformian endonasal DCR), except when the lacrimal fossa was anterior to its insertion (23 cases [7.7%]). Preoperative clinical assessment and computed tomography scans, intraoperative endoscopic video recording, and postoperative clinical and endoscopic follow-ups were analyzed for reported endonasal DCR failure and complications. The mean follow-up was 13+/-12.6 months (range, 1-57). MAIN OUTCOME MEASURES: Failure rate, nature, frequency, and time of intraoperative and postoperative complications. RESULTS: Of the 300 patients treated, 39 (13%) suffered from residual epiphora and no passage upon irrigation; there was secondary canalicular stenosis in 2 cases (0.6%), sump syndrome in 4 cases (1.2%), a distal stenosis from progressive healing closure of the ostium in 21 cases (7.0%), a recurrence of lacrimal mucocele in 5 cases (1.7%), and adhesions between the ostium and septum in 2 cases (0.6%). Access to the surgical site required an anterior middle turbinectomy in 103 cases (34.3%) and a septoplasty in 1 case (0.3%). Intraoperative bleeding was minor in 183 (60.6%), moderate in 82 (27.3%), and severe in 35 cases (11.6%). Postoperative bleeding occurred in 4 cases, and was controlled by packing. Transient frontal sinusitis (n = 1), nasal mucosa burn (n = 1), cacosmia (n = 8), phlebitis (n = 1), and maxillary pain (n = 8) also occurred. Orbital fat prolapse, cerebrospinal fluid leaking, cutaneous scarring, diplopia, and loss of vision did not occur. CONCLUSION: Complications from unciformian endonasal DCR may be less frequent or severe than with maxillary endonasal DCR, and comparable to or less frequent than those for external DCR.

Spontaneous intracranial hypotension: a rare cause of labyrinthine hydrops.

Spontaneous intracranial hypotension should be considered as a possible cause of cochlear hydrops. We report a case of unilateral hearing loss attributed to spontaneous intracranial hypotension on the basis of characteristic abnormalities seen on magnetic resonance imaging. The diagnostic gold standards for intracranial hypotension are lumbar measurement of cerebrospinal fluid pressure and magnetic resonance imaging. The usual treatment is an autologous blood injection into the peridural spaces. The mechanism of hearing loss is thought to involve secondary perilymph depression due to a patent cochlear aqueduct. This perilymph depression would induce a compensatory expansion of the endolymphatic compartment, with a subsequent decrease in basilar or Reissner's membrane compliance. Endolymphatic hydrops can occur in the course of intracranial hypotension, and not only because of abnormal endolymph production or resorption. Hydrops can thus be classified into 1) syndromes of endolymphatic origin and 2) syndromes of perilymphatic origin, in which loss of perilymph induces compensatory expansion of the endolymphatic space.