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Endoscopic Dacrocystorhinostomy

Endoscopic Dacryocystorhinostomy Nasolacrimal duct dysfunction, whether by lacrimal pump failure or nasolacrimal obstruction, prevents the flow of tears through the lacrimal system, resulting in epiphora. Dacryocystorhinostomy (DCR) is a commonly performed procedure for cases of nasolacrimal duct dysfunction. The endoscopic approach offers a different view from the originally described endonasal approach in 1893 by Caldwell. After the advent of endoscopes, the endoscopic DCR was described, allowing…

Evaluation and Management of Acquired Nasolacrimal Duct Obstruction

In the evaluation of patients with acquired tearing, the first step is to assess whether epiphora (tearing caused by insufficient drainage) or lacrimation (hypersecretion of tears) is the cause of tearing. Systematic examination helps isolate the cause of acquired tearing and distinguish patients with obstruction of the lacrimal drainage system from those with secondary hypersecretion. This chapter discuss the symptoms, clinical characteristics, causes, and management options…

Evaluation and Management of Congenital Nasolacrimal Duct Obstruction

Congenital nasolacrimal duct obstruction (NLDO) is a blockage of the lacrimal drainage system and the most common cause of persistent tearing and ocular discharge in infants and young children. The anatomic site of obstruction is an imperforate membrane at the valve of Hasner located at the distal end of the nasolacrimal duct. The obstruction can be unilateral or bilateral, and signs usually consist of epiphora, discharge,…

Optimizing Visualization and Localization During Endoscopic Orbital Surgery

Surgical Technique The endoscopic transnasal approach to the orbit usually starts with complete sphenoethmoidectomy and wide opening of the maxillary ostium to oversee the orbital floor. Then the papyraceus lamina is identified and resected, and the periobit is opened to gain access to the intraorbital space. To facilitate identification of the lamina, the periorbit, or the tumor at a later stage, a simple trick is to…

Radiologic Evaluation of the Orbit: Computed Tomography and Magnetic Resonance Imaging

Imaging plays an important role in the evaluation of patients with suspected orbital disease. Radiography, ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) are commonly used in clinical practice. Each modality has its advantages and disadvantages in terms of diagnostic value, accessibility, speed of acquisition, and radiation exposure. This chapter focuses on the cross-sectional modalities of CT and MRI, as these methods have evolved to…

Neuro-Ophthalmologic Evaluation and Testing

The impact of intraorbital, intracranial, and sinus lesions on visual function and eye movement can be difficult to quantify. Imaging yields information on lesion location and possible etiology. The role of the neuro-ophthalmologist is to provide quantifiable measurements of the damage caused by disease processes in the orbit, skull base, and sinuses. This quantification allows for more concise decision making regarding lesion progression, surgical timing, and…

Ophthalmologic Evaluation in Orbital and Lacrimal Disease

The orbit and lacrimal system is bounded by the paranasal sinuses, eyelids, temporal region, and intracranial fossa ( Figs. 7.1 and 7.2 ). The orbit contains all of the supporting structures of the eye and produces unique signs and symptoms depending on the location and pathology of the underlying disease. Careful evaluation of these structures and their function allows for localization and identification of many processes,…

Rhinologic Evaluation in Orbital and Lacrimal Disease

Sinonasal Examination Examination and palpation of the external nose shows deformities and crepitation and confirms soft-tissue or firm masses. Transillumination of the frontal and maxillary sinuses is an unreliable maneuver. Anterior rhinoscopy can assess the anterior septum and inferior turbinates but rarely provides the entire picture. Tests of olfaction, nasal airflow, or mucociliary flow are rarely indicated in orbital or lacrimal disease. The most important rhinologic…

Surgical Anatomy of the Nose, Septum, and Sinuses

The nasal cavity and paranasal sinuses are intimately associated with the orbit, and as such frequently serve as an appropriate surgical corridor for endoscopic access to orbital pathology. For instance, the lamina papyracea, or the medial wall of the orbit, serves as the lateral boundary of a complete ethmoid sinus dissection, and inadvertent orbital entry is possible during routine endoscopic sinus surgery. A high nasal septal…

Surgical Anatomy of the Orbit, Including the Intraconal Space

Anatomy of the Orbit Orbital Cavity The orbits are the bony spaces that divide the upper facial skeleton from the middle face. The bony walls of the orbit, a four-sided pyramid, consist of a mosaic of seven bones: the zygomatic bone laterally, the frontal bone superiorly, the sphenoid bone posteriorly, with its lesser and greater wing forming the optic canal and the superior orbital fissure, the…

Endoscopic Orbital Surgery: The Neurosurgeon’s Perspective

Neurosurgical approaches to the orbit are often done with the aid of ophthalmologist or otolaryngologist, to address intraorbital lesions invading intracranial spaces or, more recently, to gain skull base exposure. Dandy first reported use of a frontotemporal craniotomy to resect lesions from the orbit that then grew intracranial. The approach Dandy described has now evolved into the skull base workhorse approaches now commonly used for lesions…

Endoscopic Orbital Surgery: The Rhinologist’s Perspective

The specialties of otolaryngology and ophthalmology are separated by little more than the width of the lamina papyracea. This paper-thin bone that forms the boundary between the orbital and sinonasal cavities serves as a metaphor for the aligned interests of two specialties whose practitioners often find themselves operating in close anatomic proximity. Indeed, cooperative surgical endeavors between otolaryngologists and ophthalmologists have risen rapidly since the introduction…

Older Adults With Dizziness: Rehabilitation Strategies and Novel Interventions

Introduction Dizziness is a common problem in the elderly (65 years and older), with a prevalence between 13% and 38% depending on the population studied. Dizziness affects the lives of older adults and is associated with restrictions in activities of daily living, worsening of cognitive status, fear of falling, and an increased risk of falling. Dizziness and its relationship to falls are of particular concern because…

Medication-Related Dizziness in the Older Adult

Key Points Dizziness is highly prevalent among patients aged 65 years and older and may be associated with several common health conditions and the medications used to treat those conditions. The consequences of dizziness affect patients’ health and quality of life and create an enormous economic burden on the health care system. For physicians to manage dizziness appropriately in older adults, it is crucial to assess…

Dizziness in the Elderly

Introduction Dizziness is a broad term used to describe a variety of sensations such as vertigo, unsteadiness, imbalance, light-headedness, and similar symptoms. The prevalence of dizziness increases steadily with age. Although debate is still ongoing regarding the underlying causes of this increase in prevalence, there is universal agreement on the devastating consequences and high physical, cognitive, emotional, and financial toll of dizziness and imbalance on the…

Vertebrobasilar Infarcts and Ischemia

Clinical Vignette A 68-year-old male with a history of myocardial infarction 5 years ago, hypertension, hypercholesterolemia, and diabetes presents with the acute onset of rotational vertigo with nausea and vomiting and hearing loss in the right ear. Left-beating nystagmus is present in center gaze and increases velocity in left gaze. The head impulse test, originally known as the Halmagyi-Curthoys test, demonstrates catch-up saccades with head impulses…

The Cardiovascular Dizziness Connection: Role of Vestibular Autonomic Interactions in Aging and Dizziness

Introduction Without a doubt, vestibular dysfunction can cause dizziness; however, other systems that interact with the vestibular system can also be involved. The goal of this chapter is to discuss the role of cardiovascular reflexes in contributing to dizziness. A common symptom that often causes a patient to seek medical attention for the evaluation of dizziness is presyncope: the feeling of “lightheadedness” before fainting. Even young…

Uncommon Causes of Disequilibrium in the Adult

Uncommon Causes of Chronic Disequilibrium in the Adult Bilateral Vestibular Loss Epidemiology . Bilateral vestibular loss is uncommon. In some patients the cause is known, whereas in other patients the condition seems to be idiopathic, and these patients tend to be older adults. Pathophysiology . The percentage of patients with ideopathic bilateral vestibular loss varies from 21% to 51%. In the remaining patients the most common…

Meniere’s Disease: A Challenging and Relentless Disorder

Clinical Vignette A.S. was a 34-year-old healthy female, without significant past medical history, who presented to the otology clinic 10 years ago for evaluation of a 3-day complaint of a “blocked” right ear: muffled hearing, aural fullness, and a low-pitched “oceanlike” sound. She denied vertigo or significant disequilibrium. She denied any recent viral illnesses. The otoscopic examination was normal. She had a similar episode 8 months…