Nasal preparation for endoscopic DCR surgery
다운로드This narrated video demonstrates nasal preparation for endoscopic dacryocystorhinostomy (DCR) surgery. It explores the use of different decongesting and vasoconstricting preparations and the technique of placing them in the nasal cavity 다운로드. We also discusses the safe doses of the different preparations.
This video was produced and narrated by Mr Huw Oliphant, oculoplastic surgeon
영화 원더 다운로드O’Donoghue stents for internal ostium fibrosis DCR failure
This narrated video demonstrates the endoscopic insertion of O’Donoghue nasolacrimal stents into a patient whose DCR has failed because of internal ostium fibrosis php.
Voiceover Text: O’Donoghue stents for internal ostium fibrosis DCR failure
DCR failure is typically from fibrosis over the external ostium 말하는 고양이 무료. However, sometimes and in some series in as many of 50% of DCR failures(1), fibrosis only occurs over the internal ostium, or common canalicular opening as in this case 다운로드.
Secondary O’Donoghue tubes are being placed to overcome and stent the obstruction.
Endoscopic visualisation enables close observation of the internal ostium to ensure that a false passage is not made 스택독 다운로드. Multiple gentle attempts are made to pass the stents before they are successfully passed through the ostium. It is very tempting to try and force the stents through, which invariably creates a false passage, but delicate angulation, allows the ostium to be found 바탕화면 메모.
The stents are secured with a small segment of size 8 feeding tube and a couple of liger clips. Whilst the tube is being secured, the position of the loop of the stent at the medial canthus is carefully checked or gently lifted with an instrument such as a ball probe to ensure that it is not pulled tight risking cheese wiring of the puncta macos 모하비.
There is no evidence to guide how long the stents should be left in situ. However, it is probably prudent to leave them at least for a couple of months, and if the epiphora resolves and there are no adverse effects from the stents being in situ, they can probably be left indefinitely 다운로드.
References
- Lin GC, Brook CD, Hatton MP, Metson R. Causes of dacryocystorhinostomy failure: External versus endoscopic approach 아이언맨2 자막 다운로드. Am J Rhinol Allergy. 2017;31(3):181-5.
- Ali MJ, Psaltis AJ, Wormald PJ. Dacryocystorhinostomy ostium: parameters to evaluate and DCR ostium scoring 인크레더블 더빙 다운로드. Clin Ophthalmol. 2014;8:2491-9.
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Flap Formation in Endoscopic DCR
This narrated video demonstrates the formation of lacrimal sac and nasal mucosal flaps in endo DCR and reviews the different instruments that can be used for these steps of endo DCR and the way that the flaps should sit after they have been formed and opened out 다운로드.
Voiceover Text
Forming anterior and posterior lacrimal sac flaps can be one of the more challenging stages of endoscopic DCR 다운로드.
The lacrimal sac is tented up with a Bowman probe. The exquisitely sharp disposable cataract keratome is being used to make a longitudinal, vertical incision in the lacrimal sac 의천도룡기 2019 한글자막 다운로드.
The full vertical height of the sac is incised; this can be continued with the keratome taking great care not to damage the canalicular opening, also known as the internal ostium and the lateral mucosal surface of the lacrimal sac 다운로드. Alternatively an angled spear knife can be used to continue the incision; it is less sharp so may reduce the risk of damage to the sac and ostium but sometimes tears the sac a little
A hooked micro sickle knife is being used to make the horizontal transverse cuts at the top and bottom of the anterior lacrimal sac flap 코코 더빙판 다운로드. This can be an unsatisfactory step because they are frequently blunt and the lack of counter traction, can tear rather than cut the lacrimal sac.
Straight Belucci microscissors are being used to make the transverse cuts at the top and bottom of the posterior lacrimal sac flap 다운로드.
Sometimes the lacrimal sac mucosa is thickened, perhaps from chronic inflammation or even occasional lymphoproliferative disease 다운로드. In this case the microbite lusk forcep can be used to make the transverse incisions at the top and bottom of the posterior lacrimal sac flap. This throughbiting instrument is generally sharp and cuts well but does excise a bit of tissue, which may reduce the mucosal apposition at the top and bottom slightly my summer car.
Depending on one’s endo DCR technique the raised and reflected nasal mucosal flap can be too large to neatly abut the end of the posterior lacrimal sac flap 다운로드. It is being trimmed here with a microbite Lusk forcep. This nice instrument cuts well when the jaws are being closed whilst simultaneously pulling the flap towards you to create couter-traction office 365 학생.
The flaps should open freely, without a tension pulling them forward or closed again, rather like opening an old book with a very worn spine. The anterior lacrimal sac is reflected anteriorly to rest against the lateral nasal wall but does not adjoin a nasal mucosa flap end to end like in external DCR. The posterior flap is reflected backwards and can be positioned to abut the end of the raised and later trimmed nasal mucosa so as to create a continuous mucosal lining. This may reduce the risk of subsequent fibrosis and osteal closure. Most endoscopic DCR surgeons do not suture the flaps and while this can be done studies that have found similar recurrence rates for endo and external DCR report endo DCR without flap suturing.
Paediatric Endoscopic DCR
This narrated video focuses on the challenges of and surgical technique for paediatric endoscopic DCR surgery.
DCR is sometimes required for paediatric congenital or acquired nasolacrimal duct obstruction. Paediatric Endoscopic and external DCR have similar success rates of around 83-96%.
The anatomy and technique of endo DCR in general is explored in more detail in other videos on this website 다운로드.
Voiceover
Endoscopic DCR has the significant advantage in children of avoiding a skin incision with risk of scarring and does not disrupt the medial canthal tendon. It also enables visualisation of the nasal anatomy and ostium, providing the opportunity to address turbinate abnormalities, membranes, polyps and other abnormal findings 다운로드.
The nasal mucosa has already been decongested either with co-phenilcaine or cocaine soaked neuropatties. It is infiltrated with lignospan. The weight adjusted doses must be calculated pre-operatively and carefully adhered to. The safe doses are extremely low in young children.
Similarly, the maximum allowable blood loss should be calculated prior to commencing the procedure and in small children is a surprisingly small volume of blood 톰캣 7 다운로드. The use of the monopolar needle to create the nasal mucosa is of benefit in paediatric DCR as there is less bleeding than when the blade is use.
The nasal space is narrower in children than in adults. Therefore paediatric endoscopic DCR is technically more challenging than in adults. In adults narrow spaces can be improved with septoplasty, but this is contraindicated in children as it may impact on nasal growth and cosmesis 카티아 학생용 다운로드. However, although the space starts of seeming very narrow, it generally accommodates a 4mm scope comfortably after the nasal mucosa is raised and the bony ostium formation commenced. If the 4mm scope is not easily passed, or risks repeated trauma to the nasal septum, then a 2.7mm rigid 30 degree scope should be available for use.
The nasal flap is raised on a posterior base and then reflected over the middle turbinate to keep it out of the way Winxp download. Some surgeons prefer to make a much smaller nasal flap which has the advantage of needing less or no trimming to abut the posterior lacrimal sac flap, but may get in the way during surgery.
The bony ostium is formed initially mechanically with the Hajak koffler. The superior aspect is enlarged with the Malhotra nibbler. It is completed with the DCR burr 실시간티비 다운로드. As with adults the ostium in enlarged until it exposes the entire lacrimal sac, but the created ostium is smaller in children than in adults; typically around 10 x 10mm in younger children and 10mm wide by 15mm high in older children. The vertical height of the nasal cavity is smaller in children. This may increase the risk of a CSF leak if the proximity of the skull base to the surgical site is not considered 다운로드.
The thin lacrimal bone is flaked away from the lacrimal sac.
The inferior canaliculus is probed. The probe is used firstly to assess if there is any canalicular pathology, by feeling if there are any obstructions or a sensation of tightness around it. The lid must be on lateral tension whilst this is assessed, otherwise folds are easily mistaken for membranes and canalicular obstructions, which are in fact extremely rare in children 스카이림 엘더스크롤 다운로드. Secondly the probe is used to tent up the lacrimal sac to minimise the risk of trauma to the internal ostium and internal mucosal lining of the sac when it is incised with the exquisitely sharp cataract keratome.
The keratome and then hooked sickle are used to form anterior and posterior lacrimal sac flaps which are reflected anteriorly and posteriorly respectively 천재교육 교사용 cd 다운로드.
The nasal flap is trimmed to abut the posterior lacrimal sac flap. It is still too large and The is reduced further
The flaps are manipulated into a good position well clear of the internal ostium. Generally, they seem to remain where they are placed intraoperatively, so it is worth spending a bit of time ensuring they are well located and without any tension on them that might pull them out of position 왕좌의 게임 시즌 1 다운로드.
The internal ostium is checked for canalicular restriction or tightness. The role of nasolacrimal stents remains uncertain, but there does not seem to be any benefit to using them if the cause of obstruction is exclusively distal to the internal ostium, that’s to say the pathology is in the nasolacrimal duct, or lacrimal sac, which will of course be bypassed.. Omission of stents is of particular benefit in children in whom the removal of the stents may require another general anaesthetic.
Supporting literature1 2
1. Al-Nuaimi D, Inkster C, Lobo C. Paediatric powered endonasal dacryocystorhinostomy. Eur Arch Otorhinolaryngol 2011;268(12):1823-8. doi: 10.1007/s00405-011-1605-z
2. Leibovitch I, Selva D, Tsirbas A, et al. Paediatric endoscopic endonasal dacryocystorhinostomy in congenital nasolacrimal duct obstruction. Graefes Arch Clin Exp Ophthalmol 2006;244(10):1250-4. doi: 10.1007/s00417-006-0273-y
