Figure 3 (A) Endoscopic visualization ensures proper positioning of the Jones tube without contact with the nasal septum or middle turbinate. (B) Illustration depicting proper Jones tube placement. (Color version of figure is available online.)

Complications

The most common complication associated with Jones tube placement is tube migration.2,9 Commonly, patients require tube repositioning or adjustment of tube size, and this adjustment can often be performed as an office procedure under local anesthesia.1,2 It should be noted, however, that postoperative tube adjustment is also frequently required after the external approach.2 Spontaneous tube extrusion can also occur, which necessitates prompt replacement.5-8 Because frequent tube maintenance or intervention may be necessary after CDCR, this can lead to patient dissatisfaction in some cases.7

Obstruction of the tube may result from medial migration, allowing the conjunctiva to cover the tube orifice.2,6 This internal migration of the tube also can be associated with nasoseptal irritation, epistaxis, and poor tube functioning as the result of an obstruction of the inner opening.2 Obstruction of the tube may also result from excessive

mucus accumulation as the result of a conjunctival or nasal allergy.6,8 External tube migration also can result in undesired complications, including conjunctival and corneal inflammation.2 Pyogenic granuloma formation may cause tube obstruction even though the tube is properly positioned.2,5 Complications specific to the endoscopic approach may include an increased incidence of intranasal adhesions. This has been reported to be only of mild concern as the incidence has been noted to be low.1

Discussion

The endoscopic approach to Jones tube placement is a reasonable approach and may offer advantages over the external route, including potentially shorter operative times, less blood loss, and avoidance of a cutaneous scar.1 Some surgeons have also noted a greater primary success rate with endoscopically assisted CDCR procedures over procedures not assisted endoscopically.2 Greater equipment costs and the “learning curve” required in the endoscopic approach are potential drawbacks.1,7 Once the skills of using the endoscope are mastered, excellent intranasal visualization may be granted.1,3 Not all patients are anatomically amenable to this approach, however, and patients with a deviated nasal septum or tight middle meatus may be more appropriately managed with an external approach. With proper patient selection in addition to consideration of intraoperative needs and potential obstacles, the lacrimal surgeon can appropriately utilize both the endoscopic and external routes effectively.1

References

1.Trotter WL, Meyer DR: Endoscopic conjunctivodacryocystorhinostomy with Jones tube placement. Ophthalmology 107:1206-1209, 2000

2.Woog JJ, Sindwani R: Endoscopic dacryocystorhinostomy and conjunctivodacryocystorhinostomy. Otolaryngol Clin North Am 39:10011017, 2006

3.Watkins LM, Janfaza P, Rubin PA: The evolution of endonasal dacryocystorhinostomy. Surv Ophthalmol 48:73-84, 2003

4.Mandeville JT, Woog JJ: Obstruction of the lacrimal drainage system. Curr Opin Ophthalmol 13:303-309, 2002

5.Steinsapir KD, Glatt HJ, Putterman AM: A 16-year study of conjunctival dacryocystorhinostomy. Am J Ophthalmol 109:387-393, 1990

6.Jones LT: Conjunctivodacryocystorhinostomy Am J Ophthalmol 59: 773-783, 1965

7.Duffy MT: Advances in lacrimal surgery. Curr Opin Ophthalmol 11:352-356, 2000

8.Hurwitz JJ, Howcroft MJ: Use of Lester Jones tubes: A review of 40 cases. Can J Ophthalmol 16:176-7, 1981

9.Devoto MH, Bernardini FP, de Conciliis C: Minimally invasive conjunctivodacryocystorhinostomy with Jones tube. Ophthal Plast Reconstr Surg 22:253-255, 2006

10.Meyer DR: Comparison of oxymetazoline and lidocaine versus cocaine for outpatient dacryocystorhinostomy. Ophthalmic Plast Reconstr Surg 16:201-205, 2000

Orbital complications of rhinosinusitis (RS) have decreased in the postantibiotic era. Nonetheless, RS continues to be the most common cause of orbital inflammation and infection, especially in the pediatric population. By far, the most common form of orbital complications of RS is preseptal cellulitis. The spread of infection into the postseptal space of the orbit may occur and represents a serious condition that requires prompt diagnosis and management. This typically manifests as a subperiosteal orbital abscess (SPOA) adjacent to the infected sinuses. Most SPOAs are located medially, but some may occur in the superior part of the orbit and are usually associated with frontal rhinosinusitis (Figure 1). Less commonly, an abscess may organize in the extraconal or intraconal compartments of the orbit. Extension of orbital infections to the cavernous sinus and intracranial compartment, although infrequent, may occur and is associated with morbidity and mortality rate of 10% to 20% despite aggressive management.1,2 Diagnosis of a SPOA is based on clinical evaluation and radiographic imaging. Computed tomography (CT) remains the diagnostic imaging modality of choice for orbital abscesses.

Management of orbital complications of RS is best achieved through a multidisciplinary approach with close cooperation among an otorhinolaryngologist, ophthalmologist, and infectious disease specialist who is familiar with local microbial resistance patterns. Surgical management of SPOAs may be achieved through an external approach, a

Address reprint requests and correspondence: Samer Fakhri, MD, FACS, FRCS(C), Department of Otorhinolaryngology–Head and Neck Surgery; University of Texas Medical School at Houston, 6431 Fannin MSB 5.036, Houston, TX 77030.

E-mail address: samer.fakhri@uth.tmc.edu.

transnasal endoscopic approach, or combined approaches. The endoscopic route offers several advantages. It provides superb visualization of the surgical field, therefore allowing comprehensive and precise treatment of the SPOA and the offending sinuses. Also, angled telescopes can be used to visualize laterally and around corners into the orbit especially in the case of an intraorbital abscess. Finally, the transnasal endoscopic route obviates the need for facial incisions. The main limitation of the endoscopic approach is related to the bleeding potential of acutely inflamed sinonasal mucosa. The preoperative and intraoperative use of surgical navigation technology may be a useful adjunct in the endoscopic drainage of some SPOAs. A detailed discussion of the merit of this technology in the drainage of orbital abscesses has been previously reviewed and is beyond the scope of this article.3 This article describes the transnasal endoscopic drainage of SPOAs, which is the approach of choice in many institutions including ours.

Indications

Controversy exists regarding the optimal initial management of SPOAs. Some authors favor prompt drainage of the abscess, whereas others recommend a trial of medical man- agement.2,4-6 Regardless of treatment philosophy, however, changes in visual acuity and absence of rapid clinical improvement on medical therapy are robust indications to proceed with definitive surgical drainage. The objectives of surgery include drainage of the SPOA, drainage of offending sinuses, obtaining intraoperative cultures and, if necessary, decompression of one or more orbital walls.

Surgical technique

The operation is performed with the patient under general anesthesia and with orotracheal intubation. The patient is placed on the operating table supine or in a slight reverse Trendelenburg position. We typically ask the anesthesia team to maintain the lowest mean arterial pressure and pulse that is safe for the patient. The eye should be left uncovered, but corneal exposure should be avoided. A vibrissectomy is performed. The nose is decongested with 1% oxymetazoline hydrochloride on cotton pledgets placed in the nasal cavity. This step should be done in the least traumatic way, to avoid mucosal lacerations and unnecessary bleeding. A greater palatine foramen block is performed with 1% lidocaine with 1:100,000 units of epinephrine. The mucosa of the lateral nasal wall is also injected with the same solution. Multiple mucosal stabs should be avoided considering the bleeding potential of an acutely inflamed mucosa.

Frequent and sequential decongestion is often required to achieve optimal visualization as the surgeon proceeds deeper into the sinonasal cavity. Sometimes the mucosa in the anterior nasal cavity is severely edematous, friable, and responds poorly to decongestion. If this is the case and visualization of the middle turbinate and middle meatus cannot be achieved, the surgeon should consider converting to an external approach. In our experience, this has never been necessary. Additional measures to improve hemostasis and/or enhance visualization should be considered. Lens

cleaning devices such as Endo-Scrub (Medtronic Xomed, Jacksonville, FL) are often very helpful, but they add to the diameter of the telescope and their use may therefore become problematic in pediatric noses. Microdebriders with their concurrent suction and fast tissue removal are terrific tools to enhance visualization and expedite the surgical procedure. They should be used cautiously to avoid complications and unnecessary mucosal injury.

We use the 4-mm telescopes in all adult and the majority of pediatric cases. Newer 3-mm scopes are now available and should be given consideration in pediatric patients and adults with relatively small nasal passages. The 0-degree telescope is used to perform the uncinectomy, ethmoidectomy, and sphenoidotomy if the latter is indicated. The 30-deg telescope is used to perform the maxillary antrostomy and to drain the orbital abscess. Sometimes, a frontal recess dissection and frontal sinusotomy are necessary and require visualization with the 30-degree and 70-degree telescopes. Angled telescopes afford significant surgical advantages but they also add to visual distortion and their use should be reserved to experienced surgeons.

At the beginning of the procedure, any purulence in the middle meatus should be collected in a sterile fashion and the specimen sent for cultures. The results are used to guide postoperative antimicrobial therapy. The initial maneuver is to remove the uncinate process and identify the natural ostium of the maxillary sinus. If there is no disease or there

is minimal mucosal thickening in the maxillary sinus, a formal maxillary antrostomy may not be necessary and the maxillary sinus outflow tract is best left undisturbed. The bulla ethmoidalis is then penetrated and removed with through-cutting instruments or with a microdebrider. Care should be taken to avoid injury to the middle turbinate and medial orbital wall especially when using powered instrumentation. The blade of the microdebrider should be pointing perpendicular to the medial orbital wall. If there is significant posterior ethmoid disease and posterior extension of the abscess, a complete anterior and posterior ethmoidectomy should be performed.

The lamina papyracea is then skeletonized from the orbital apex to the nasolacrimal system with through-cutting instruments in preparation for the drainage of the orbital abscess. Sometimes pus can be seen streaming from the orbit at the completion of the ethmoidectomy. This leakage usually occurs through a natural dehiscence or a crack in the lamina papyracea, especially when orbital pressures are elevated. Purulence should be collected and sent for cultures. Drainage of the orbital collection is initiated by cracking the lamina papyracea with a Cottle or freer elevator. The 30degree telescope may be used to perform this maneuver (Figure 2). Bone from the lamina papyracea is gently elevated with a freer elevator or spoon curette and removed until adequate drainage of a subperiosteal abscess into the middle meatus is achieved. Complete drainage of the abscess is ensured by taking down adhesions in the abscess cavity and developing a plane of dissection between the bony orbital wall and the periorbita (Figure 3). Care should be taken to avoid unintended violation of the periorbita. Prolapsing fat may impair safety and completeness of the surgical plan. Complete drainage of the abscess is confirmed by gently retracting the periorbita laterally with a freer elevator and placing gentle pressure on the eye as the surgeon observes the abscess cavity for any residual pus. The nasal

Figure 2 A 30-degree endoscopic view of the left medial orbit. A spoon curette is used to elevate bone off the lamina papyracea (LP), allowing drainage of a SPOA. The asterisk indicates periorbita.

Figure 3 Intraoperative 30-degree endoscopic view of the left medial orbit after decompression of the LP. A spoon curette is used to develop a plane of dissection between the LP (white arrow) and the periorbita (asterisk), ensuring complete drainage of the SPOA. (Color version of figure is available online.)

cavity is then irrigated with normal saline. If the middle turbinate is sitting in a lateral position and there is a risk of scarring to the decompressed orbit, a middle turbinate medialization technique may be performed. Alternatively, a piece of Gelfilm or Gelfoam may be placed. Nasal packing is avoided.

Additional steps

1.The Presence of isolated sphenoid or frontal sinus disease in patients with orbital abscesses is rare, especially in the pediatric population. Therefore, sphenoidotomy or frontal sinusotomy are only undertaken on rare occasions. SPOAs located superiorly in the orbit may also be accessed endoscopically after performing a wide frontal sinusotomy. An effort must be

made to identify and stay anterior to the anterior ethmoidal artery (Figure 4).7

2.In cases of persistently elevated orbital pressures, it may be necessary to widely decompress the medial orbital wall. This situation may be encountered when dealing with intraorbital abscesses but is rarely needed in SPOAs.

3.Incision of the periorbita is usually necessary to drain an intraorbital abscess. We use a sickle knife under the guidance of the 30-degree telescope. The tip of the knife should remain superficial and the incision is made from posterior to anterior. This maneuver usually affords good drainage of most extraconal abscesses. Drainage of intraconal abscesses is best achieved through a combined approach and should never be attempted without the active participation of ophthalmology colleagues. The intraoperative measurement of orbital pressures is extremely helpful and often dictates the extent of orbital decompression.