Endoscopic and Radiologic Findings in Failed Dacryocystorhinostomy: Teaching Pearls for Success

Background Although several studies have commented on causes of dacryocystorhinostomy (DCR) failure, detailed description of anatomical findings in such cases remains insufficient. Objective Our objective was primarily to analyze radiologic, endoscopic, and intraoperative findings in patients presenting with failed DCR and secondarily to assess the outcome of revision endoscopic DCR (endo-DCR) carried out at our institution. Methods Twenty-four failed DCRs presenting to our tertiary care center were retrospectively analyzed. Data collection included patients’ history, diagnostic, and management data, as well as thorough analysis of sinonasal CT scans, along with endoscopic and intraoperative findings. Outcome was also assessed in 21 cases with revision endo-DCR performed. Results The anterior part of uncinate process was not previously removed in 15 sides (62.5%), with unopened agger nasi in 13 sides (54.2%). The lacrimal bone was detected covering the posterior sac despite removal of the anterior ascending process of maxilla in 9 sides (37.5%). Rhinostoma was anterior to lacrimal sac in 2 sides (8.3%) and was below the sac in 7 sides (29.2%). Fibrous membrane covered the rhinostoma despite removal of all sac-overlying bones in 6 sides (25%). Other findings included intranasal adhesions, septal deviation, lateralized middle turbinate, granulation tissue, foreign body reaction, and chronic sinusitis. Nineteen of the 21 revision endo-DCRs were successful (90.5%). Conclusion This study provides a precise anatomical description of findings in cases of failed DCR. Such information is paramount in helping surgeons enhance their learning curve, refine the surgical technique, and improve patients’ outcome.

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Virtual Mapping of the Frontal Recess: Guiding Safe and Efficient Frontal Sinus Surgery

Otolaryngology ◽

10.1177/0194599817699562 ◽

2017 ◽

Vol 156 (5) ◽

pp. 946-951 ◽

Cited By ~ 4

Author(s):

Neil S. Patel ◽

Amy C. Dearking ◽

Erin K. O’Brien ◽

John F. Pallanch

Keyword(s):

Frontal Sinus ◽

Tertiary Care ◽

Middle Turbinate ◽

Uncinate Process ◽

Sinus Surgery ◽

Preoperative Imaging ◽

Level Of Evidence ◽

Frontal Recess ◽

Frontal Sinus Surgery ◽

Sinus Opening

Objective To define relationships between the frontal sinus opening, ostia of other frontal recess cells, and endoscopic landmarks and to develop a clinically useful framework to guide frontal sinus surgery. Study Design Retrospective review. Setting Tertiary care academic referral center. Methods Adult patients with computed tomography (CT) without sinonasal pathology were included. Virtual endoscopy (using OsiriX) and corresponding CT reconstructions were used to identify all visible ostia in the frontal recess and characterize their positions in spaces between the uncinate/agger nasi (U), bulla ethmoidalis (EB), and middle turbinate (MT). Results Two hundred sides in 100 patients (median age 51 years, 62% female) were analyzed. The “center” of each map was defined as the intersection of spaces between U, EB, and MT. The frontal sinus opening was in the “center” in 53% of frontal recesses, lateral to this position in 29%, and anterior in 11%. When the frontal sinus opening was at the “center,” anterior ostia drained frontal Kuhn T cells in 51% and intersinus septal cells in 23%. The skull base attachment of the apical strut of the uncinate process demarcated medial and lateral within the space between U and EB, with the opening to the frontal sinus medial in 68% and lateral in 31%. Left-right asymmetry in frontal sinus openings was noted in 46% of patients. Conclusion Combining preoperative imaging and knowledge of these anatomic relationships may facilitate more efficient frontal outflow tract identification and instrumentation. This represents the first and largest description of ostial configurations relative to endoscopic structural landmarks. Level of Evidence: 4

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Role of anatomical variations in chronic rhinosinusitis on diagnostic nasal endoscopy and computed tomography scan of paranasal sinuses

International Journal of Otorhinolaryngology and Head and Neck Surgery ◽

10.18203/issn.2454-5929.ijohns20195697 ◽

2019 ◽

Vol 6 (1) ◽

pp. 101

Author(s):

Falguni J. Parmar ◽

Avani D. Patel

Keyword(s):

Computed Tomography ◽

Chronic Rhinosinusitis ◽

Paranasal Sinuses ◽

Care Center ◽

Tertiary Care ◽

Middle Turbinate ◽

Anatomical Variations ◽

Sinus Surgery ◽

Nasal Endoscopy ◽

Advantages And Disadvantages

Background: Diagnostic nasal endoscopy (DNE) and computed tomography (CT) of para nasal sinuses play an important role in the diagnosis and treatment of chronic rhinosinusitis (CRS). The aim and objective of the study is to see the anatomical variations of the sinonasal region in CRS on DNE and CT paranasal sinuses (PNS).Methods: A descriptive type retrospective study of 30 patients attending the ENT outpatient department of our tertiary care center clinically diagnosed as CRS with symptoms persisting for 12 weeks or more, along with previously failed medical management, including topical nasal steroids, systemic decongestant and extended courses of antibiotics and who were willing to undergo endoscopic sinus surgery are included. Results: Majority of the patients had septal deviation either an anterior or posterior deviation but majority of the cases are asymptomatic for the deviation. Anatomical variations of uncinate process, middle turbinate, inferior turbinate, frontal recess, agger nasi cells, haller cells were studied as well.Conclusions: Prolonged duration of rhinosinusitis symptoms (more than 8-12 weeks) is the primary reason to evaluate a patient for CRS and making the choice between CT PNS or DNE is patient and disease dependent. Understanding the advantages and disadvantages of each helps us realize that they are of synergistic in nature and not competitive.

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Anatomical variations in patients with chronic sinusitis

International Journal of Otorhinolaryngology and Head and Neck Surgery ◽

10.18203/issn.2454-5929.ijohns20180702 ◽

2018 ◽

Vol 4 (2) ◽

pp. 428 ◽

Cited By ~ 1

Author(s):

Pragadeeswaran Kumarasekaran ◽

Rajprakash Dharmapuri Yadhava krishnan ◽

Gurumani Sriraman

Keyword(s):

Nasal Septum ◽

Chronic Sinusitis ◽

Anatomical Variation ◽

Middle Turbinate ◽

Anatomical Variations ◽

Uncinate Process ◽

Sinus Surgery ◽

Concha Bullosa ◽

Deviated Nasal Septum ◽

Anatomical Variant

Background: Chronic sinusitis is repeated bouts of acute infection or persistent inflammation of the sinuses. The range of anatomic variants that can interfere with the mucociliary drainage of osteomeatal complex including concha bullosa, deviated nasal septum, uncinate process variations, ethmoid bulla, paradoxical middle turbinate, agger nasi and Haller cells. This is also important in surgeon point of view to know about detail knowledge of lateral nasal wall, paranasal sinuses, surrounding vital structures and anatomical variation. Methods: Observational case series study in which 90 cases of chronic rhinosinusitis patients attending the ENT outpatient department from November-2015 to November-2016 in Shri Sathya Sai Medical college and Hospital, who had chronic sinusitis for more than three months duration not responding to the medical line treatment and who are willing to undergo functional endoscopic sinus surgery are studied and statistically analysed. Results: In our study we found anatomical variation in 93% of chronic sinusitis patients. In our study it was observed that 52% of patients with two anatomical variation, 41% patients presented with single anatomical variation and 7% patients presented with no anatomical variation. In our study deviated nasal septum was the most common anatomical variant noted followed by unilateral concha bullosa, medialized uncinate process, paradoxical middle turbinate, haller cell and agger nasi. Conclusions: In our study it was concluded that presence of anatomical variations is common in patients with chronic sinusitis. Presence of more than one anatomical variations significantly contributes to disease process. Deviated nasal septum is the most common anatomical variation in our study followed by concha bullosa, medialized uncinate process.

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Influence of Superior Attachment of the Uncinate Process on the Presence of Agger Nasi

Clinical Rhinology An International Journal ◽

10.5005/jp-journals-10013-1257 ◽

2016 ◽

Vol 9 (1) ◽

pp. 21-23

Author(s):

Rahul Shivaraj ◽

Cimona Dsouza ◽

George Pinto

Keyword(s):

Chronic Sinusitis ◽

Statistical Significance ◽

Middle Turbinate ◽

Close Relation ◽

Uncinate Process ◽

Sinus Surgery ◽

Chi Square ◽

Statistical Tool ◽

Chi Square Test ◽

The Relationship

ABSTRACT Objective The superior attachment of the uncinate process and the agger nasi cell are important landmarks in frontal sinus surgery and are in close relation with each other. The aim of this study is to investigate the relationship between the two. Study design A retrospective radiological study. Materials and methods A total of 50 patients with features of chronic sinusitis were evaluated radiographically, i.e., by computed tomography. Hundred sides, i.e., 50 scans, were evaluated for superior attachment of the uncinate process and the presence of agger nasi. Chi-square test was used as a statistical tool for eliciting the relationship between the two. Results The agger nasi cell was found in 68 (68%) of 100 sides. The prevalence of agger nasi cell according to the superior attachment of uncinate process types was 64.1% for lamina papyracea, 79.41% for skull base, and 53.84% for middle turbinate. The presence of agger nasi cell according to the superior attachment types of uncinate process was not statistically significant (X2 = 3.5925, p = 0.16592). Conclusion The agger nasi cell was found in 68 sides (68%), and there was no statistical significance between the superior attachment of the uncinate process and the presence of agger nasi cell. How to cite this article Shivaraj R, Dsouza C, Pinto G. Influence of Superior Attachment of the Uncinate Process on the Presence of Agger Nasi. Clin Rhinol An Int J 2016;9(1):21-23.

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Anatomical Variations of Uncinate Process in a Tertiary Care Hospital of a Coastal city in Karnataka

Asian Journal of Medicine and Health ◽

10.9734/ajmah/2021/v19i1130394 ◽

2021 ◽

pp. 17-21

Author(s):

Carol Jacob ◽

Anita Aramani ◽

Basavaraj N. Biradar ◽

Shaista Naaz

Keyword(s):

Tertiary Care ◽

Middle Turbinate ◽

Anatomical Variations ◽

Uncinate Process ◽

Ciliary Activity ◽

Care Hospital ◽

Lamina Papyracea ◽

Osteomeatal Complex ◽

The Right ◽

Observational Descriptive Study

Introduction: Superior attachment of uncinate process is the most important anatomical landmark in frontal recess surgery. The uncinate process is an integral structure of osteomeatal complex and prevents the direct contact of the inspired air with the maxillary sinus. It acts as a shield and also plays a role in muco-ciliary activity. Anatomic variations of the uncinate process have surgical implications. Aim: This study was done to know the different variations of superior attachment of uncinate process. Materials and Methods: In this retrospective observational descriptive study, Computed Tomography (CT) scans of Para Nasal Sinuses (PNS) of 256 patients from Sept 2018 to May 2020 were studied. The results were expressed in percentages and proportions. Results: Among 256 CT images, 139 belonged to males and 117 females. In the CT films examined, on the right side, the most common attachment of uncinate was to lamina papyracea which was (64.8%) followed by skull base (19.5%) and to the middle turbinate(15.6%). Similar findings were seen on left side. Conclusion: Uncinate process shows different variations in its superior attachment. Superior attachment to lamina papyracea was the most common attachment of uncinate in our study.

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Influence of Superior Attachment of Uncinate Process on Presence of Agger Nasi

Clinical Rhinology An International Journal ◽

10.5005/jp-journals-10013-1244 ◽

2015 ◽

Vol 8 (3) ◽

pp. 104-106

Author(s):

Rahul Shivaraj ◽

Cimona Dsouza ◽

George Pinto

Keyword(s):

Chronic Sinusitis ◽

Statistical Significance ◽

Middle Turbinate ◽

Close Relation ◽

Uncinate Process ◽

Sinus Surgery ◽

Statistical Tool ◽

Important Landmark ◽

Chisquare Test ◽

The Relationship

ABSTRACT Objective The superior attachment of uncinate process and agger nasi (AN) cell are important landmark in frontal sinus surgery, and are in close relation to each other. The aim of the study is to investigate the relationship between the superior attachment of uncinate process (UP) and presence of AN cell. Study design A retrospective radiological study. Materials and methods Fifty patients with features of chronic sinusitis were evaluated radiographically, i.e. computed tomo graphy (CT), 100 sides, i.e. 50 scans were evaluated for superior attachment of UP and presence of AN. Chisquare test was used as statistical tool for eliciting the relationship between the two. Results The AN cell was found in 68 (68%) of 100 sides. The prevalence of AN cell according to superior attachment of UP types were 64.1% for lamina papyracea, 79.41% for skull base, 53,84% for middle turbinate. The presence of AN cell accor ding to superior attachment types of UP was not statistically significant (χ2 = 3.5925, p = 0.16592). Conclusion The AN cell found in 68 sides (68%), and there was no statistical significance between the superior attachment of UP and presence of AN cell. How to cite this article Shivaraj R, Dsouza C, Pinto G. Influence of Superior Attachment of Uncinate Process on Presence of Agger Nasi. Clin Rhinol An Int J 2015;8(3):104106.

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Antimicrobial Resistance in Bacterial Chronic Sinusitis

American Journal of Rhinology ◽

10.2500/105065898781390055 ◽

1998 ◽

Vol 12 (4) ◽

pp. 243-248 ◽

Cited By ~ 59

Author(s):

John Hsu ◽

Donald C. Lanza ◽

David W. Kennedy

Keyword(s):

Antimicrobial Resistance ◽

Chronic Sinusitis ◽

Care Center ◽

Tertiary Care ◽

Cross Sectional Study ◽

Resistant Bacteria ◽

Coagulase Negative Staphylococcus ◽

Tertiary Care Center ◽

Cross Sectional ◽

Gram Negative

Recent reports describe the emergence of antimicrobial resistant bacteria in acute sinusitis and an increased incidence of enteric gram negative bacilli in chronic sinusitis. The objective of this cross sectional study is to identify the emergent resistance patterns in bacterial chronic sinusitis. Specifically, this article seeks to characterize the bacteriology of outpatient chronic sinusitis, then to compare the antimicrobial susceptibilities of the bacterial isolates with standard culture data from a tertiary care center. Between March and August, 1994, 113 new outpatients presented with chronic sinusitis at a major teaching institution. Of these patients 34 underwent endoscopically guided aerobic culture of the paranasal sinuses and nasal cavities. Of the 48 total cultures, there were 43 positive cultures yielding 72 isolates. Thirty-eight cultures had two or fewer isolates; four cultures had three plus isolates, and one culture grew out normal flora. The most frequently isolated organisms were coagulase negative Staphylococcus (SCN), 20 (28%); Pseudomonas aeruginosa, 12 (17%); and Staphylococcus aureus, 9 (13%). Within the limited sample size for each isolate, Staphylococcus coagulase negative, Pseudomonas, and Pneumococcus demonstrated higher antimicrobial resistance compared to the medical center's corresponding nonurinary isolates. Additionally, three of six patients with Pseudomonal aeruginosa (50%) had a quinolone resistant strain. These preliminary data suggest that both an increased incidence of antimicrobial resistance and of enteric gram negative bacilli may exist in these outpatient, tertiary care center patients with chronic bacterial sinusitis.

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Incidence of sinonasal anatomical variations associated with chronic sinusitis by CT scan in Karaikal, South India

International Journal of Otorhinolaryngology and Head and Neck Surgery ◽

10.18203/issn.2454-5929.ijohns20172291 ◽

2017 ◽

Vol 3 (3) ◽

pp. 576 ◽

Cited By ~ 1

Author(s):

Kranti Gouripur ◽

Udaya Kumar M. ◽

Anand B. Janagond ◽

S. Elangovan ◽

V. Srinivasa

Keyword(s):

Ct Scan ◽

Endoscopic Sinus Surgery ◽

Frontal Sinus ◽

Chronic Sinusitis ◽

Middle Turbinate ◽

Anatomical Variations ◽

Uncinate Process ◽

Sinus Surgery ◽

Nasal Endoscopy ◽

Deviated Nasal Septum

Background: Variations in sinonasal anatomy of adults are common and vary among different populations. Their role in development of pathological conditions such as sinusitis, epistaxis, etc is debated. Having clear picture of sinonasal anatomy of a person is essential in avoidance of complications during surgery. This study was done to analyze sinonasal anatomy in adults from Karaikal region having chronic sinusitis by nasal endoscopy and CT scan imaging.Methods: A total of 50 patients undergoing endoscopic sinus surgery were studied by preoperative nasal endoscopy, CT scanning and endoscopy at the time of definitive surgery and variations recorded and analyzed. Results: The incidence of the sinonasal anatomical variations in CT scan study were – discharge in the frontal sinus (100%), agger nasi cells (96%), deviated nasal septum (70%), anterior ethmoidal cells (86%), posterior ethmoidal cells (58%), sinus lateralis (52%), frontal cells (50%), discharge in sphenoid sinus (50%), pneumatised superior turbinate (46%), INSA (34%), prominent bulla ethmoidalis (30%), supra orbital cells (26%), pneumatised septum(16%), medialised uncinate process (16%), paradoxical middle turbinate (16%), Haller cells (14%), supreme turbinate (14%), pneumatised inferior turbinate (12%), frontal recess obliteration (12%), absent pneumatisation of frontal sinus (12%), pneumatised middle turbinate (10%), Onodi cells (6%), pneumatised uncinate process (2%), maxillary sinus septation (2%).Conclusions: The high incidence of variations emphasises the need for proper preoperative assessment for safe and effective endoscopic sinus surgery.

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