Endoscopic versus external dacryocystorhinostomy: temporal and regional trends in the United States Medicare population.

Purpose: Endoscopic surgeries, such as dacryocystorhinostomy (DCR), are increasingly performed for orbital and lacrimal conditions. This study describes and compares recent trends in endoscopic DCR with open, or external, DCR in the United States (US). Methods: Medicare-Part-B National Summary data files were analyzed from 2000 to 2015 for temporal and geographic trends in endoscopic and external DCR. Medicare Physician and Other Supplier public use files detailing provider information were collected and analyzed from 2012 to 2015. Results: Between 2000 and 2015, the number of external DCRs remained relatively unchanged (8008 to 7086, -0.7% average annual growth), while the number of endoscopic DCRs steadily increased (881 to 1674, 4.6% average annual growth). The greatest number of endoscopic DCRs were performed in the South Atlantic region, whereas the Mountain region had the greatest number per capita. From 2000 to 2015, the average payment per procedure for external DCR was $526.63, compared with $512.45 for endoscopic DCR. Of endoscopic DCRs performed from 2012 to 2015, 831 (79%) were performed by Ophthalmology, 184 (18%) were performed by Otolaryngology, and the remainder by other subspecialties. Conclusions: The number of endoscopic DCR surgeries increased over the last 15 years while the number of external DCR surgeries remained stable and continued to surpass endoscopic procedures. While ophthalmologists perform the overwhelming majority of endoscopic DCR, otolaryngologists are performing a growing number.

Localización de la apófisis unciforme respecto a la fosa lagrimal / Location of the uncinate process with respect to the lacrimal fossa

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[Whether external dacryocystorhinostomy will be abandoned].

External dacryocystorhinostomy (DCR) has long been considered as the gold standard treatment for nasolacrimal duct obstruction or chronic dacryocystitis. Recently, however, endoscopic endonasal DCR is becoming increasingly popular with the development of endoscopic surgery technique in naso-orbit related diseases. Endoscopic DCR has the advantages of avoiding an external incision scar and simultaneously handling with nasal conditions. Nevertheless, the new method also has some disadvantages, for example, the lower long-term success rate, the high technical requirement, long learning curves, expensive equipment and the high cost of surgery. The choice of the surgical approaches should be based on the patient's condition, experience of the surgeon and available resources. After nearly a century of proven, external DCR still has incomparable superiority and should receive widespread attention and application.

[Treatment of lacrimal stenosis. Causes, diagnostics, and surgical procedures]. / Behandlung von Tränenwegsstenosen. Ursachen, Diagnostik und operatives Vorgehen.

The nasolacrimal system lies in direct proximity to the nasal cavity and the paranasal sinuses. Consequently, different nasal pathologies may influence the lacrimal drainage system. Hence, a standardized rhinological examination using endoscopy and, when indicated, modern imaging is mandatory to clarify malfunctions of lacrimal drainage. This paper describes the different possible causes and the necessary diagnostic tools from an ENT physician's point of view. Furthermore, the results of a series of 48 patients with endoscopic dacryocystorhinostomy performed between 2005 and 2008 were entered into the study. Follow-up examination of these patients showed satisfactory results in 91% and complete reduction of symptoms in 82%. Accompanying surgical procedures were done in 14 patients (septoplasty, infundibulotomy, or reduction of the middle turbinate).

[Current status of dacryocystorhinostomy]. / Aktueller Stellenwert der Dakryozystorhinostomie.

The history of the treatment of lacrimal duct stenosis dates back to the ancient world. Modern lacrimal duct surgery began with the description of external dacryocystorhinostomy (DCR) by Toti and the endonasal procedure by West. Modifications include construction of a mucous membrane flap and the use of different instruments such as microscopes, endoscopes, and laser. This article reviews the various methods currently in use, although the analysis makes clear how difficult it is to compare studies. Because of the high success rate and the possibility of correcting multiple disturbing factors of the lacrimal drainage system, external DCR remains the gold standard for the ophthalmologist; other methods must be measured by the success rate of external DCR. The future of lacrimal duct surgery lies in a better understanding of wound healing and thus the possibility for precise modulation. Better results may be possible by combining different surgical methods. Prospective studies are urgently necessary.

[Lacrimal system lacerations and their surgical repair]. / Tränenwegsverletzungen und ihre chirurgische Versorgung.

In lacrimal system lacerations the canaliculi are involved in 70% of cases and the lacrimal sac and/or nasolacrimal duct in 30%. Lacrimal system lacerations can be the result of sharp or blunt trauma. Nasolacrimal ducts may become obstructed by indirect trauma as an aftereffect of naso-orbital fractures. The epidemiology, main principles of surgical repair of canaliculi and of lacrimal sacs and/or nasolacrimal ducts, special techniques of surgical reconstruction and approximate success rates are reviewed with respect to the outcome of our patient collective compared to the literature. Canalicular and lacrimal sac lacerations need urgent primary microsurgical repair with silicone intubation and paying special attention to the medial nasal canthus. In cases of traumatic nasolacrimal duct obstruction as an aftereffect of mid-facial fractures, a secondary reconstruction should be planned.

Dacriocistitis por Candida Lusitaniae / Dacryocystitis caused by Candida Lusitaniae

Caso clínico: Se presenta el caso de una mujer de 60 años con episodios recurrentes de dacriocistitis aguda derecha que no cedían con tratamiento médico ni tras una dacriocistorrinostomía con intubación bicanalicular. Presentó también una dacriocistitis izquierda que requirió una dacriocistorrinostomía. Se tomaron muestras intraoperatorias y en el cultivo apareció Candida Lusitaniae como germen responsable. Tras tratamiento tópico con Anfotericina B, asociado a dacriocistorrinostomía, la clínica desapareció. Discusión: La dacriocistitis por Candida Lusitaniae es muy rara. Cabría preguntarse si Candida Lusitaniae es el germen primario o la dacriocistitis podría ser por sobreinfección fúngica debido al tratamiento antibiótico de las distintas dacriocistitis agudas sufridas

Case report: We report the case of a 60-year-old woman with recurrent dacryocystitis of the right lacrimal sac. She did not recover after medical treatment, nor after dacryocystorhinostomy with canalicular intubation. She also had dacryocystitis on the left side. The material that was obtained during surgery was grown in a culture medium and Candida Lusitaniae was identified as the responsible organism. All symptoms disappeared after topical treatment with amphotericin B and dacryocystorhinostomy. Discussion: Dacryocystitis caused by Candida Lusitaniae is very rare. We should always consider whether Candida Lusitaniae is responsible for the primary infection or is the agent resulting from a superadded infection caused by previous antibiotic therapy

Resultados de la aplicación de mitomicina en la dacriocistorrinostomía endonasal y endocanalicular con láser diodo / Results the application of mitomicyn during endonasal and endocanalicular dacryocystorhinostomy by diode laser

Objetivo: Valorar el beneficio, efectos secundarios y seguridad de la aplicación de mitomicina C (MMC) de forma intraoperatoria, durante la realización de una dacriocistorrinostomía endonasal y endocanalicular con láser diodo (TLA-ELA DCR). Métodos: Se realizó un estudio prospectivo randomizado, intervencional y doble ciego. Se estudiaron 200 pacientes a 150 pacientes se les aplicó MMC intraoperatoria (0,4 mg/0,2 ml) durante un tiempo de 5 minutos, mediante un apósito de acetato de polivinilo que se coloca sobre la osteotomía. En el resto de pacientes fueron revisados a las 24 horas, 10 días, 1, 3 y 6 meses postcirugía. Se estudió el aspecto endoscópico y las posibles complicaciones. Los resultados se comparan mediante el test de Chi-cuadrado con la corrección de Yates. Se estudió la presencia o ausencia de efectos secundarios por la aplicación de MMC. Resultados: El seguimiento medio fue 15,25 meses (rango= 6-21 meses). El porcentaje de alteraciones por cicatrización excesiva fue del 21,77% y del 8,03%, en los pacientes sin y con MMC respectivamente. La diferencia fue estadísticamente significativa (p=0,02). No hubo efectos secundarios por la aplicación de MMC. Conclusiones: La aplicación de MMC intraoperatoria tópica durante TLA-ELA DCR disminuye los hallazgos patológicos por cicatrización del área periférica al nuevo drenaje sin producir efectos secundarios

Aim of the study: To study the effects, secondary effects and security of the intrasurgical application of mitomicyn C during endonasal and endocanalicular dacryocystorhinostomy with diode laser (TLA-ELA DCR). Methods: We carried out a randomized, prospective, interventional and double blind study in 200 patients: intrasurgical mitomicyn C was applied in 150 of then (0.4 mgr/0.2 ml) for 5 minutes by means of a polivinil acetate dressing over the osteotomy. In other 50 patients MMC was not used we followed up at 24 hours, 10 days and 1, 3 and 6 months after surgery. Endoscopic aspects and possible complications were valued. The results were compared using the Chi-squared test with the Yates correction. We looked for the presence or abscense of secondary effects in the application of mitomicyn C. Results: The average follow up was 15.25 months (range 6 to 21 months). The percentages of alterations for excesive scarring were 21.77% in patients without and MAC 8.03% in the ones MMC. The difference was statisticaly significant (p= 0.02). We did not find secondary effects due to application of mitomcyn. Conclusions: Intrasurgical application of topical MMC during TLA-ENL DCR reduces the number of pathological findings due to scarring of the surrouding area of the new drainage without secondary effects

[Modern principles of endonasal surgery on the lacrimal duct]. / Sovremennye printsipy éndonazal'noi khirurgii slezootvodiashchikh putei.

Intranasal operations on the lacrimal duct developed in 1910 by G. West are rarely used now. The author analyzes his experience gained in 5000 endonasal dacryocystorhinostomies (96.7% of which were effective) and the advantages of intranasal approach to the lacrimal duct and presents a working classification of dacryocystitis. Indications for endonasal surgery on the lacrimal duct and contraindications precluding it are defined and a table for selecting the appropriate intranasal intervention in cases with abnormal discharge of tears offered. The author emphasizes the efficacy of endonasal operations and advocates wide use of this method in dacryology.

Macrodacriocistografía digital: imágenes digitales de las vías lagrimales / Digital sustraction of dacryocystography of the lachrymal tract

En un estudio prospectivo realizado entre marzo de 1992 y julio de 1994 se estudiaron ochenta pacientes que tuvieron como denominador común epífora. Se evaluó las bondades de un nuevo método para el estudio de las vías lagrimales que incorporó técnicas de computación permitiendo obtener imágenes digitales libres de elementos óseos (sustracción digital)

Macrodacriocistografía digital: imágenes digitales de las vías lagrimales / Digital sustraction of dacryocystography of the lachrymal tract

En un estudio prospectivo realizado entre marzo de 1992 y julio de 1994 se estudiaron ochenta pacientes que tuvieron como denominador común epífora. Se evaluó las bondades de un nuevo método para el estudio de las vías lagrimales que incorporó técnicas de computación permitiendo obtener imágenes digitales libres de elementos óseos (sustracción digital) (AU)