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1/42. Nasolacrimal tuberculosis in a patient with conjunctivodacryocystorhinostomy.

    PURPOSE: To present an unusual case of nasolacrimal tuberculosis that was diagnosed with polymerase chain reaction (PCR) and to discuss the role of PCR as a diagnostic aid. methods: Case presentation with diagnostic modalities including PCR, cytopathologic, and histopathologic examinations with special stains. RESULTS: A 40-year-old woman with bilateral lacrimal drainage system obstruction underwent a right dacryocystorhinostomy with stents and left conjunctivodacryocystorhinostomy with Jones bypass tube. Although the findings of direct and endoscopic examinations of the nasal cavity were within normal limits, the tissue removed during surgery from the middle turbinate revealed caseating granulomatous lesions on histopathologic examination. Acid-fast organisms were demonstrated in postoperative nasal washings, and mycobacterium tuberculosis infection was confirmed with PCR. CONCLUSION: Primary tuberculosis of the nasolacrimal mucosa is rare, and its occurrence without any symptoms, as in this patient, is even less frequent. The most interesting aspect of this case was the identification of the M. tuberculosis dna in the mucosa of anterior turbinate and fibrous tissue within the previous surgical site. Histopathologically, the presence of caseating granulomas was seen only in the nasal mucosa, indicating that PCR may be of use in identifying the causative organism even in the absence of typical histopathologic features.
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2/42. Jones tube insertion in children with canalicular agenesis.

    The purpose of this report is to describe a simplified method of Jones tube insertion in the management of pediatric patients with symptomatic upper and lower punctal and canalicular agenesis. A 5-year-old female with bilateral upper and lower canalicular agenesis, and a 4-year-old male with agenesis of the right upper and lower canaliculi, underwent placement of Jones tubes without performing standard external conjunctivodacryocystorhinostomy. The first child requiring bilateral Jones tube insertion has remained asymptomatic for 24 months. The Jones tube dislodged in the second patient 6 weeks postoperatively. The tube was replaced, and the child has been asymptomatic for 16 months. The technique of Jones tube insertion without a previous or concomitant external dacryocystorhinostomy may be a useful modification in the management of pediatric patients with symptomatic upper and lower canalicular agenesis.
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3/42. Benign pleomorphic adenoma arising from the palpebral lobe of the lacrimal gland associated with elevated intraocular pressure.

    A 46-year-old man complained of a painless mass in the left upper eyelid. At age 51 years, the patient complained of dull pain in the left eye and diplopia. His left intraocular pressure had increased to 33 mm Hg. No proptosis was noted. The nontender mass in the eyelid was palpable. Computed tomography showed a mass anterior to the orbital rim compressing the globe. The lesion was removed en bloc by a transconjunctival approach. Histopathologic examination of the excised mass showed myxomatous stroma and highly cellular epithelial areas. Postoperatively, the left intraocular pressure normalized. To our knowledge, benign pleomorphic adenomas arising from the palpebral lobe of the lacrimal gland associated with elevated intraocular pressure, as demonstrated in our patient, may be rare.
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4/42. Invasion of the lacrimal system by basal cell carcinoma.

    BACKGROUND: The rate of recurrence of basal cell carcinoma (BCC) in the periorbital region is higher than that in other areas because of the spread of the tumor along barrier structures. OBJECTIVE: A better understanding of the biological behavior of BCC in this area, in particular as it relates to the lacrimal system, should improve the outcome of surgery. methods: A study was made of two cases of BCC that developed in the periorbital region and invaded the lacrimal system. RESULTS: The tumors were found to have invaded the lacrimal system along the mucosal epithelium. magnetic resonance imaging (MRI) did not suggest any abnormalities in this area. In one patient, the tumor had infiltrated the nasal cavity without destruction of the periorbital bone and nasal cartilage. A preoperative fiberscopic examination clearly demonstrated the involvement of the nasal cavity in this case. CONCLUSION: The lacrimal system is often invaded by BCC that originates from the periorbital region. physicians and surgeons need to be well aware of the possibility of such aggressive infiltration by BCC.
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5/42. Primary localized bilateral conjunctival amyloidosis and epiphora.

    BACKGROUND: Conjunctival amyloidosis is a rare entity, which can present with epiphora. The management options, including the surgical treatment of this disease, are illustrated with a case study. methods: A combination of retrospective and prospective review of a patient's clinical findings, course and treatment outcome. RESULTS: A middle-aged patient with epiphora due to localized conjunctival amyloidosis is described. The clinical course of the epiphora during a 10-year period revealed a decrease on the initially symptomatic side and involvement of the opposite side despite bilateral progressive lacrimal drainage stenosis. The pathophysiology of this phenomenon is discussed. The progressive conjunctival deposits in this patient eventually required operative debulking through a conjunctival approach. Medial ectropion and punctal stenoses were also simultaneously corrected. The patient became symptom free one week after these operative interventions. CONCLUSIONS: Localized conjunctival amyloidosis is a chronic, slowly progressive disease, which is frequently bilateral. Associated ocular involvement does not seem to be a part of this disease, even with long-term follow-up. The treatment of associated epiphora requires an organized approach to the underlying cause(s). The epiphora may be managed by a staged correction of its pathogenic mechanisms.
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6/42. Eosinophilic fungal rhinosinusitis of the lacrimal sac.

    OBJECTIVES/HYPOTHESIS: Chronic sinusitis is a condition affecting millions of individuals each year. Recent findings indicate that chronic rhinosinusitis is a response to fungi mediated by the eosinophil in some of these individuals. We report a case of eosinophilic fungal rhinosinusitis of the lacrimal sac, an entity not previously reported. STUDY DESIGN: Case report. methods: A 69-year-old man presented with a 1-cm cystic lesion in the right-side medial canthal region. This lesion was fluctuant, and mucoid material was freely expressed from the medial canthal area. Endoscopic examination revealed bilateral nasal polyps anteriorly and superiorly with mucopurulent drainage from both maxillary sinuses. He had undergone three prior sinus surgeries and two prior lacrimal cannulations elsewhere. A computed tomography scan showed opacification of both maxillary sinuses, ethmoid sinuses, and the left sphenoid sinus and moderate thickening in the frontal sinuses. There was significant soft tissue prominence in the area of both lacrimal fossae with erosion into the medial orbit. The patient underwent bilateral endoscopic revision ethmoidectomies, middle meatal antrostomies, sphenoidotomies, frontal sinusotomies, and endoscopic right-side dacryocystorhinostomy at the Department of Otorhinolaryngology, Mayo Clinic (Rochester, MN). RESULTS: At the time of surgery, massive amounts of thick mucoid material were aspirated from both lacrimal regions. The aspiration of the lacrimal duct on the left side was sufficient treatment, whereas the dacryocystorhinostomy was necessary to decompress the cyst of the face on the right side. The material aspirated was allergic mucin, and the patient met the criteria for diagnosing eosinophilic fungal rhinosinusitis. The patient was started on a regimen of antifungal nasal irrigations postoperatively and has done well in follow-up. CONCLUSIONS: Although never previously reported, eosinophilic fungal rhinosinusitis can occur in the lacrimal sac. It is important to recognize this so that the underlying disease process can be treated appropriately.
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7/42. adenocarcinoma ex-pleomorphic adenoma of the lacrimal sac and nasolacrimal duct: a case report.

    OBJECTIVES: To present the clinical presentation, workup, surgical approach, and pathological findings of the first case report of a patient with adenocarcinoma ex-pleomorphic adenoma of the lacrimal sac and nasolacrimal duct. STUDY DESIGN: Retrospective review of the records of a case of adenocarcinoma ex-pleomorphic adenoma of the lacrimal sac and nasolacrimal duct. methods: The clinical presentation, workup, surgical approach, and pathological findings were reviewed. RESULTS: A 51-year-old man presented with a 10-year history of recurrent epiphora of the right eye. At dacryocystorhinostomy a small lesion was visualized within the lumen of the lacrimal sac. A biopsy specimen was consistent with adenocarcinoma. En bloc resection was accomplished using a lateral rhinotomy and medial maxillectomy. The final specimen showed adenocarcinoma ex-pleomorphic adenoma. The patient was given postoperative radiation therapy. He was free of disease 16 months after treatment. CONCLUSIONS: Lacrimal sac tumors should be considered in the differential diagnosis of chronic epiphora. Management of nasolacrimal adenocarcinoma requires complete surgical resection. radiation treatment in and of itself is not curative but may be useful as adjuvant therapy. Carcinoma ex-pleomorphic adenoma can develop in the lacrimal sac and nasolacrimal duct.
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8/42. Lacrimal drainage system injury in functional endoscopic sinus surgery. incidence, analysis, and prevention.

    Injury to the lacrimal drainage system with resultant epiphora is a complication of functional endoscopic sinus surgery. A study of 24 patients was conducted to determine the incidence and significance of lacrimal drainage system injuries during functional endoscopic sinus surgery. Intraoperative testing demonstrated seven occult injuries (15%) in 46 endoscopic procedures. Postoperative testing demonstrated diversion of lacrimal drainage into the middle meatus in two patients and spontaneous healing of the injured lacrimal drainage system with restoration of normal drainage in three of the patients available for follow-up testing. In no patient did epiphora develop. It is concluded that the nasolacrimal drainage system is in close proximity to the dissection cavity during functional endoscopic sinus surgery and, hence, is at risk for inadvertent injury. Occult damage to the nasolacrimal drainage system would appear to be a common event during functional endoscopic sinus surgery; however, the complication of postoperative epiphora is rare.
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ranking = 3
keywords = operative
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9/42. Orbitotemporal neurofibromatosis. Clinical features and surgical management.

    PURPOSE: To classify the periorbital deformities of adult orbitotemporal neurofibromatosis (NF) and describe new clinical findings, and to recommend guidelines for surgical treatment and management of surgical complications. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Thirty-three patients over age 16 with orbitotemporal NF. methods: Retrospective surgical case record and serial photographic review recording the laterality and the severity of periorbital involvement, the presence of complications from previous surgery, the surgical techniques undertaken, and the surgical outcome and complications. MAIN OUTCOME MEASURES: Comparison of preoperative and postoperative level of deformities. RESULTS: New classification of periorbital deformities: (1) brow ptosis, (2) upper lid infiltration with ptosis, (3) lower lid infiltration, (4) lateral canthal disinsertion, and (5) conjunctival and lacrimal gland infiltration. Two patients had bilateral and 31 patients (94%) had unilateral orbitotemporal NF. All patients had upper and 19 patients (58%) had lower lid involvement. Six (18%) patients had significant brow infiltration. Fourteen (42%) patients had a dropped lateral canthus requiring surgical reattachment, 28 (85%) required anterior levator resection for ptosis, and 28 (85%) had lid-debulking surgery. New findings included severe brow infiltration, lacrimal gland involvement, and functional nasolacrimal duct obstruction. Complications from previous surgery included residual ptosis, ptosis overcorrection, poor lid contour, dry eye, corneal exposure, and upper and lower lid entropion/ectropion. CONCLUSIONS: The periorbital appearance and comfort of patients with NF type 1 who have orbitotemporal NF can be significantly improved through oculoplastic surgery.
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10/42. Rosai-Dorfman disease revealed in the upper airway: a case report and review of the literature.

    Rosai-Dorfman disease (RDD) is a systemic disease and its etiology is not well understood. It is a very rare but established disease. We report a case of RDD diagnosed in the upper airway that became a life-threatening condition because of the stricture of the subglottic space. A 49-year-old female complained of nasal obstruction, hoarseness and lacrimation. After evaluation following by fiberscopic examination and CT scanning of the head and neck, sinusitis and laryngeal masses were detected. Endoscopic sinus surgery and endolaryngeal microsurgery were performed simultaneously. The masses in the nasal cavity and larynx showed the same histological findings. Proliferative large histiocytes with voluminous clear cytoplasm and rounded nuclei, and lymphophagocytosis known as emperipolesis are the characteristic features of RDD. In this case, extranodal manifestations in the subglottic space gradually emerged postoperatively. tracheotomy was performed to ensure an airway and prevent suffocation. An extensive treatment is not required in most patients with RDD, however, some patients who have extranodal manifestations involving the airway may detoriorate into a life-threatening condition.
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