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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4473_Библиотеки_им_академика_М_И_Перельмана

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170. Valdés CJ, Tewk MA. Rhinosinusitis and aller­gies in elderly patients. Clin Geriatr Med. 2018;34(2):217–31.
171. Leszczyńska J, Stryjewska-Makuch G, Ścierski W, Lisowska G.Bacterial Flora of the nose and para­nasal sinuses among patients over 65 years old with chronic rhinosinusitis who underwent endoscopic sinus surgery. Clin Interv Aging. 2020;15:207–15.
172. Morse JC, Li P, Ely KA, Shilts MH, Wannemuehler TJ, Huang LC, Sheng Q, Chowdhury NI, Chandra RK, Das SR, Turner JH.Chronic rhinosinusitis in elderly patients is associated with an exaggerated neutrophilic proinammatory response to pathogenic bacteria. J Allergy Clin Immunol. 2019;143(3):990–
1002. e6
173. Yancey KL, Lowery AS, Chandra RK, Chowdhury NI, Turner JH. Advanced age adversely affects chronic rhinosinusitis surgical outcomes. Int Forum Allergy Rhinol. 2019;9(10):1125–34.
174. Slavin RG. Treating rhinitis in the older popula­tion: special considerations. Allergy Asthma Clin Immunol. 2009;5(1):9.
175. Hofer-Dückelmann C. Gender and polypharmaco­therapy in the elderly: a clinical challenge. Handb Exp Pharmacol. 2012;214:169–82.
176. Ajmani GS, Wroblewski KE, Baroody FM, Naclerio RM, Pinto JM. Allergy and asthma medication use in home-dwelling U.S. older adults. Allergy Asthma Immunol Res. 2017;7(2):192–8. https://doi.
org/10.1002/alr.21856. Epub 2016 Oct 3
177. Tran NP, Vickery J, Blaiss MS. Management of rhinitis: allergic and non-allergic. Allergy Asthma Immunol Res. 2011;3(3):148–56.
178. Chong LY, Head K, Hopkins C, Philpott C, Glew S, Scadding G, Burton MJ, Schilder AG.Saline irriga­tion for chronic rhinosinusitis. Cochrane Database Syst Rev. 2016;4:CD011995.
179. Head K, Snidvongs K, Glew S, Scadding G, Schilder AG, Philpott C, Hopkins C. Saline irrigation for allergic rhinitis. Cochrane Database Syst Rev. 2018;6(6):CD012597.
180. Thorton K, Alston M, Dye H, Williamson S.Are saline irrigations effective in relieving chronic rhi­nosinusitis symptoms? A review of the evidence. J Nurse Pract. 2011;7(8):680–6.
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190. Assanasen P, Baroody FM, Rouadi P, Naureckas E, Solway J, Naclerio RM. Ipratropium bromide increases the ability of the nose to warm and humid­ify air. Am J Respir Crit Care Med. 2000;162(3 Pt
1):1031–7.
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Nutrition andtheUpper
https://t.me/medicina_free
Respiratory Tract
JimBartley
15
Key Points
• Type II diabetes increases susceptibility to viral and bacterial infections.
• Zinc supplementation reduces the duration and severity of common cold symptoms.
• In some situations, a cow’s milk exclusion diet appears to reduce mucus production.
• Probiotic supplementation is benecial in upper respiratory infections and may have a role in allergic rhinitis management.
• Vitamin D supplementation has a role in the prevention of upper respiratory infections.
15.1 Introduction
Nutritional deciencies may lead to cellular dys­function, illness and disease. Type II diabetic subjects are more susceptible to bacterial and viral infections, including pathogenic agents such as COVID-19 [1]. Increasing evidence indi­cates that probiotics and vitamin D supplementa­tion have a role in the management of upper respiratory infections [2, 3].
J. Bartley (*) Department of Otolaryngology—Head and Neck Surgery, Counties Manukau District Health Board, Auckland, New Zealand
15.2 Probiotics
In children, probiotic consumption may decrease the incidence and illness duration of respiratory tract infections and the number of days absent from school or day care in children [4]. Similar conclusions have also been made when adult patients are included in the meta-analysis [2]. Bidobacteria and Lactobacilli are found more commonly in the intestinal ora of healthy chil­dren when compared to allergic children [5]. Probiotic bacteria in the intestinal microbiota may protect against atopy. The current evidence does not support the routine use of probiotics in allergic disease prevention [6]; however, probi­otics may have a role in allergic rhinitis manage­ment [7–9]. Increasing evidence indicates that diet inuences lung health [10] and allergic rhi­nitis [11].
The potential underlying mechanisms of pro­biotics on respiratory tract infections and allergic rhinitis are not well dened. In vitro, certain nor­mal human upper respiratory ora strains, mainly streptococcal species, prevent pathogenic coloni­zation and infection [12]. The possibility exists that the local application of ‘healthy bacteria’, through the use of nasal sprays, could prevent upper respiratory infections and aid in allergy management [13, 14]. Probiotics inuence both innate and adaptive immune responses. They increase interleukin (IL)-10 expression and decrease inammatory cytokine expression, such
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 Ö. Ö. Celebi, T. M. Önerci (eds.), Nasal Physiology and Pathophysiology of Nasal Disorders,
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J. Bartley
as tumour necrosis factor-α, IL-1β and IL-8 [15]. Lactic acid bacteria and Bidobacteria are the most common types of probiotics [2]. The inu­ence of probiotics on respiratory tract health is an area of ongoing research. Debate continues about the most appropriate probiotic strains and dosage regimens to use in a clinical situation.
15.3 Iron
Bacteria need iron for the purposes of respira­tion, DNA synthesis and free radical-scaveng­ing mechanisms. The iron-binding proteins, transferrin and lactoferrin help maintain low iron levels in nasal mucus, which helps protect against microbial infection. In the host, iron deciency signicantly impairs cell prolifera­tion and immune function [16]. Iron deciency is not associated with an increased risk of acute lower respiratory tract infection [17], indicating that it is probably an upper respiratory infection risk factor. The results of iron supplementation in respiratory tract infection management are mixed [16].
15.4 Vitamin A
Vitamin A is required for cellular growth, epithe­lial integrity, the production of red blood cells and immunity. Vitamin A deciency increases the susceptibility to a number of illnesses including diarrhoea, measles and lower respiratory infec­tions but not upper respiratory infections. While vitamin A supplementation reduces morbidity and mortality in children, no signicant inuence on the incidence of respiratory disease or hospi­talisations due to diarrhoea or pneumonia has been noted [18, 19].
Cod liver oil, as well as a children’s multivita­min/mineral supplement with selenium and other trace metals, reduced paediatric visits for upper respiratory illness during the winter and early spring by 36–58%. Cod liver oil not only con­tains vitamin A but also contains vitamin D and omega-3 fatty acids, which makes it difcult to totally attribute these results to vitamin A [20].
15.5 Omega-3
Omega-3 and omega-6 oils are essential fatty acids oils, which play a role in the inammatory response. The results of epidemiological studies investigating maternal sh intake during preg­nancy and allergic outcomes in infants/children of those pregnancies are inconsistent. Interventional studies studying oily sh con­sumption or sh oil supplementation in preg­nancy to prevent infant and childhood allergic diseases are also inconsistent [21, 22]. Omega-3 fatty acid supplementation alone does not improve allergic rhinitis symptoms [23]. In Samter’s triad (salicylate intolerance, asthma and nasal polyps) patients, high-dose omega-3 sup­plementation may be useful [24].
15.6 Zinc
Zinc has numerous roles in the immune response. Zinc is crucial for the normal develop­ment and function of cells such as neutrophils and natural killer cells that mediate innate immunity. Zinc is also involved in T and B lym­phocyte functions as well as Th1 cytokine pro­duction. The macrophage, in particular, is adversely affected by zinc deciency [16]. Zinc taken daily reduces the incidence of the com­mon cold in young children and both the dura­tion and severity of symptoms once one has developed a cold [25]. There has been some dis­cussion of this meta-analysis [26]. In adults, zinc supplementation reduces the duration and severity of common cold symptoms [27]. The role of zinc supplementation in the prevention of lower respiratory infection has not been translated into the possible prevention of upper respiratory bacterial infection [28, 29].
15.7 Milk
Excessive milk consumption has a long associ­ation with increased respiratory tract mucus production and asthma [30]. In the human colon, ß-casomorphin-7 (ß-CM-7), an exorphin
15 Nutrition andtheUpper Respiratory Tract
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derived from the breakdown of A1 milk, stimu­lates mucus production from gut MUC5AC glands [31]. In the presence of inammation, similar mucus overproduction from respiratory tract MUC5AC glands characterizes many respiratory tract diseases [32, 33]. ß-CM-7 from the bloodstream could stimulate the pro­duction and secretion of mucus production from these respiratory glands. A number of studies document that asthma symptoms often improve where milk is excluded from the diet [34–39]. Recent studies indicate that patients with perceived cow’s milk hypersensitivity have increased non-type 2 inammation and airway hyper-responsiveness [40] and that a dairy-free diet reduces the sensation of postna­sal mucus [41]. These studies support the clini­cal observation that in some situations a cow’s milk exclusion diet may aid nasal symptom management.
15.8 Vitamin D
Vitamin D (25(OH)D) deciency is common around the world. Vitamin D is made largely by sun exposure [42]. Vitamin D has important roles in both innate and adaptive immunity [43]. Vitamin D has direct antiviral effects pri- marily against enveloped viruses; coronavirus is an enveloped virus. Blood vitamin D status can inuence the risk of being infected with COVID- 19, the seriousness of COVID-19 and mortality from COVID-19 [44]. Vitamin D may have an important role in oral health [45]. Historically, supplementation with cod liver oil (containing vitamin D) reduced upper respira­tory tract infection frequency [46, 47]. Vitamin D is a hormone, which may be given in supra­physiological bolus doses. High circulating concentrations after bolus dosing may chroni­cally dysregulate the activity of enzymes responsible for the synthesis and degradation of the active vitamin D metabolite 1,25-dihy­droxyvitamin D, resulting in decreased concen­trations and limited effectiveness of this metabolite in extra-renal tissues [48]. Vitamin D supplementation is safe and protects against
acute respiratory infections. Very decient indi­viduals and those not receiving bolus doses experience the most benet [3].
15.9 Type 2 Diabetes
Type II diabetes increases viral and bacterial infection susceptibility [49]. Most Type II diabe­tes respiratory research has focused on the lower respiratory tract. Obesity can lead to obstructive sleep apnoea and obesity-hypoventilation syn­drome. Poor quality sleep is associated with reduced immune function [50]. The adaptive immune response is altered in patients with obe­sity and type 2 diabetes [51]. Obesity is associ­ated with insulin resistance and chronic low-grade inammation. Both obesity and Type 2 diabetes are associated with an increased risk of recurrent and secondary infections. Obese individuals have a higher risk of community-acquired pneumonia, cutaneous infections and aspiration pneumonia during hospitalizations [52]. Poor diabetic con­trol is associated with increased infection risk [53]. Obesity is independently associated with high rates of Staphylococcus aureus nasal car­riage—a proven risk factor for surgical-site infec­tions [49] and for chronic rhinosinusitis [54]. Type 2 diabetic patients are more likely to have nasal polyps, positive Pseudomonas aeruginosa and other gram-negative rods isolated from sinus cultures and signicantly less clinical improve­ment 6months after sinus surgery [55]. Improving Type II diabetic control may be important in managing patients with difculty sinusitis [53].
15.10 Conclusions
Nutritional deciencies may lead to cellular dys­function and disease. Poor diabetic control is asso­ciated with increased infection risk. A milk exclusion diet may reduce respiratory tract mucus production. Increasing evidence indicates that pro­biotic supplementation is benecial in upper respi­ratory infections and allergic rhinitis management. Regular vitamin D supplementation has a role in the prevention of upper respiratory infections.
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11. Cingi C, Conk-Dalay M, Cakli H, Bal C. The effects of spirulina on allergic rhinitis. Eur Arch Otorhinolaryngol. 2008;265:1219–23.
12. Glück U, Gebbers J-O. Ingested probiotics reduce nasal colonization with pathogenic bacteria (Staphylococcus aureus, Streptococcus pneumoniae, and β-hemolytic streptococci). Am J Clin Nutr. 2003;77:517–20.
13. Miraglia Del Giudice M, Indol C, Capasso M, Maiello N, Decimo F, Ciprandi G. Bidobacterium mixture (B longum BB536, B infantis M-63, B breve M-16V) treatment in children with seasonal aller­gic rhinitis and intermittent asthma. Ital J Pediatr. 2017;43:25.
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15. Maldonado Galdeano C, Cazorla SI, Lemme Dumit JM, Velez E, Perdigon G. Benecial effects of pro­biotic consumption on the immune system. Ann Nutr Metab. 2019;74:115–24.
16. Gombart AF, Pierre A, Maggini S.A review of micro­nutrients and the immune system-working in harmony to reduce the risk of infection. Nutrients. 2020;12:236.
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18. Imdad A, Mayo-Wilson E, Herzer K, Bhutta ZA.Vitamin a supplementation for preventing mor­bidity and mortality in children from six months to ve years of age. Cochrane Database Syst Rev. 2017;3:CD008524.
19. Chen H, Zhuo Q, Yuan W, Wang J, Wu T. Vitamin A for preventing acute lower respiratory tract infec­tions in children up to seven years of age. Cochrane Database Syst Rev. 2008;1:CD006090.
20. Linday L. Cod liver oil, young children, and upper respiratory tract infections. J Am Coll Nutr. 2010;29:559–62.
21. Miles EA, Calder PC.Can early omega-3 fatty acid exposure reduce risk of childhood allergic disease? Nutrients. 2017;9:784.
22. Schindler T, Sinn JK, Osborn DA. Polyunsaturated fatty acid supplementation in infancy for the pre­vention of allergy. Cochrane Database Syst Rev. 2016;10:CD010112.
23. Thien F, Menciahuerta J, Lee T.Dietary sh-oil effects on seasonal hay-fever and asthma in pollen-sensitive subjects. Am Rev Respir Dis. 1993;147:1138–43.
24. Healy E, Newell L, Howarth P, Friedmann PS.Control of salicylate intolerance with sh oils. Br J Dermatol. 2008;159:1368–9.
25. Singh M, Das RR. Zinc for the common cold. Cochrane Database Syst Rev. 2013;2:CD001364.
26. Science M, Johnstone J, Roth DE, Guyatt G, Loeb M.Zinc for the treatment of the common cold: a sys­tematic review and meta-analysis of randomized con­trolled trials. CMAJ. 2012;184:E551–E61.
27. Wang MX, Win SS, Pang J. Zinc supplementation reduces common cold duration among healthy adults: a systematic review of randomized controlled trials with micronutrients supplementation. Am J Trop Med Hyg. 2020;103:86–99.
28. Rerksuppaphol S, Rerksuppaphol L. A randomized controlled trial of zinc supplementation in the treat­ment of acute respiratory tract infection in Thai chil­dren. Pediatr Rep. 2019;11:7954.
29. Aggarwal R, Sentz J, Miller MA.Role of zinc admin­istration in prevention of childhood diarrhea and respiratory illnesses: a meta-analysis. Pediatrics. 2007;119:1120–30.
30. Bartley J, McGlashan SR.Does milk increase mucus production? Med Hypotheses. 2010;74:732–4.
31. Zoghbi S, Trompette A, Claustre J, El Homsi M, Garzon J, Jourdan G, etal. Beta-Casomorphin-7 regu­lates the secretion and expression of gastrointestinal mucins through a mu-opioid pathway. Am J Physiol Gastrointest Liver Physiol. 2006;290:G1105–13.
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32. Kirkham S, Sheehan J, Knight D, Richardson P, Thornton D. Heterogeneity of airway mucus varia­tions in the amounts and glycoforms of the major oligomeric mucins MUC5AC and MUC5B.Biochem J. 2002;361:537–46.
33. Ding G, Zheng C. The expression of MUC5AC and MUC5B mucin genes in the mucosa of chronic rhinosinusitis and nasal polyposis. Am J Rhinol. 2007;21:359–66.
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Physiology ofLacrimal Drainage
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AliRizaCenkÇelebi andÖzlemÖnerciCelebi
16
Core Messages
• There are many factors contributing to lacri­mal elimination, but the most important mech­anism is the canalicular and sac pump mechanism.
• Canalicular pump is probably more important than the sac pump because, following DCR, tears are still drained through the canaliculi to the nose.
• The pressure gradient between the canaliculi and the sac cannot be produced if the canalic­ulus is slit open. Therefore, the lacrimal cana­liculi should be preserved and should not be damaged.
• Tear elimination is equivalent through the upper and lower canalicular systems. Therefore, attention should be given not to damage both the upper and lower canaliculus.
The lacrimal drainage system works to remove those tears secreted into the palpebral aperture to cover the cornea at a rate of 1.2μl/min with a total 24-h secretory volume of approximately 10ml [1]. The tear lm travels across the surface of the globe and eyelids, enters the puncta/
ampulla, passes through the canaliculi, and enters the lacrimal sac/nasolacrimal duct/nasal pas­sages. With blinking (orbicularis muscle contrac­tion), the closure of palpebral aperture starts from the lateral and proceeds to the medial. This action propels the tears medially toward the lacrimal lake [1].
Factors contributing to lacrimal elimination
may include:
• Evaporation of tears from the ocular surface.
• Capillary attraction of the tears.
• Reservoir drainage into the lacrimal sac (so­called Krehbiel ow).
• Siphon effect.
• Microciliation and absorption of tears by the lacrimal sac mucosa.
• Bernoulli’s principle and Venturi tube effect.
• Physical forces such as gravity.
• Canalicular and sac pump mechanism.
16.1 Factors inTear Flow
16.1.1 Evaporation
A. R. C. Celebi (*) Department of Ophthalmology, School of Medicine, Acibadem University, Istanbul, Turkey
Ö. Ö. Çelebi Department of Otorhinolaryngology, Faculty of Medicine, University of Health Sciences, Istanbul, Turkey
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 Ö. Ö. Celebi, T. M. Önerci (eds.), Nasal Physiology and Pathophysiology of Nasal Disorders,
https://doi.org/10.1007/978-3-031-12386-3_16
Much of the tears is lost by direct evaporation from the ocular surface. Low humidity and wind increase this loss. According to Schirmer, almost half of the secreted tears were lost by evapora­tion [1].
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16.1.2 Capillarity
Capillarity or capillary action is the ability of a liquid to ow in a narrow tube without the assis­tance of gravity. This effect can be seen in the drawing of liquids in a thin tube or in porous materials such as paper. Capillary action can be noticed in the drainage of tears from the eye. The small canaliculi may act like a capillary tube. The canaliculi may draw tears through the punctum and transfer tears through the canaliculi. The fact that trauma to the canaliculi and loss of capillar­ity does not cause loss of function indicates that capillarity is not the only factor in drawing tears through the punctum [1].
16.1.3 Krehbiel Flow
Krehbiel ow is the ow of the tears from the punctum through the canaliculus due to changes of pressure within the lacrimal sac owing to the effect of the orbicularis tonus on both canaliculi and tear sac when the lids are open [1, 2].
16.1.4 Siphon Eect
The word siphon refers specically to a tube in an inverted U shape which causes a liquid to ow uphill, above the surface of the reservoir, without pumps, powered by the fall of the liquid as it ows down the tube under the pull of gravity, and is discharged at a level lower than the surface of the reservoir. It is important that while the siphon must touch the liquid in the (upper) reservoir (the surface of the liquid must be above the intake opening), it need not touch the liquid in the lower reservoir and indeed there need not be a lower reservoir—liquid can discharge into midair.
lacrimal uid inside the lacrimal ducts [3]. Due to this reabsorption in the nasolacrimal sac and duct, the amount of tears leaving the nasolacri­mal duct orice in the nose is less than the amount of tears entering the puncta.
16.1.6 Bernoulli’s Principle
andVenturi Tube Eect
The relationship between the velocity and pressure exerted by a moving liquid is described by the Bernoulli’s principle: as the velocity of a uid increases, the pressure exerted by that uid decreases. The Venturi effect is similar to Bernoulli’s principle. The velocity of the uid increases as the cross-sectional area decreases, with the static pres­sure correspondingly decreasing. According to the laws governing uid dynamics, a uid’s velocity must increase as it passes through a constriction to satisfy the principle of continuity, while its pressure must decrease to satisfy the principle of conserva­tion of mechanical energy. An equation for the drop in pressure due to the Venturi effect may be derived from a combination of Bernoulli’s principle and the continuity equation.
The canaliculi narrow close to the common
canaliculus, and the common canaliculus is a larger structure. Bernoulli principle and Venturi tube effect may play a role in the ow through the canaliculi. According to the Venturi tube effect, narrowing of the canaliculi from lateral to medial increases the speed of ow from lateral to medial and according to Bernoulli’s principle movement over a low-pressure area creates a suctional effect. Bernoulli’s principle may also play a role in the lacrimal system at the nasal cavity sucking tears from the valve of Hasner area into the nose in addition to the ampulla and just distal to the common internal punctum [4].
16.1.5 Microciliation andReabsorption
The internal wall of the lacrimal canaliculi is lined by a stratied epithelium. Epithelial cells are faced by microvilli. The facing of epithelial cells by microvilli gives hints of reabsorption of
16.2 Tear Flow andElimination
16.2.1 Flow fromtheLacrimal Lake Through thePuncta
The tears enter the puncta with three mecha­nisms [1]:
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1. A negative pressure would develop inside the punctum to suck the tears.
2. The small canaliculi may act as capillary tubes and would suction the tears through the small capillary tubes. However, capillarity is not the only factor in drainage because a slit canalicu­lus where capillarity has been destroyed usually functions well for other reasons.
3. Krehbiel’s effect (Reservoir drainage into the lacrimal sac): Krehbiel suggested that even in the resting phase of the blink cycle, tears pass from the punctum through into the canalicu­lus. This may be due to changes in pressure within the lacrimal sac owing to the effect of the orbicularis tonus on both canaliculi and tear sac when the lids are open. However, if a DCR is performed, this effect may not be seen and therefore it is probably not the intracana­licular suction that is causing this effect, but sac suction [1, 2].
16.2.2 What Canalicular System Is
more Important forTear Elimination: Upper or Lower?
Although it is believed that the upper canalicular system is unimportant, experimental and clinical studies show that tear elimination is equivalent through the upper and lower canalicular systems [5–8]. Surgeons should thus give equal consider­ation to a patient with lacerations of either the upper or lower canaliculus. Studies by White etal. [8] and Daubert etal. [5] have demonstrated equal tear ow between the upper and lower can­alicular systems using radioactive dacryoscintig­raphy ow studies. Meyer et al. [7] studied uorescein dye disappearance in 20 subjects and found that 90% of patients showed minimal or no impairment with monocanalicular (either upper or lower) obstruction.
16.2.3 Flow Through theCanaliculi
into theSac
Although multiple mechanisms may contribute to lacrimal outow, present evidence suggests that the most important factor is the active
palpebral- canalicular pump. It has long been noted that the blinking mechanism readily drains tears even with the head held in an inverted posi­tion. When the palpebral blink mechanism is impaired, however, epiphora is common, such as in patients with facial paralysis.
16.2.4 Lacrimal Pump
There are two most popular lacrimal pump theo­ries: one suggested by Jones [9] and the other by Doane [10]. More recently, Becker [11] proposed a tricompartmental model of the lacrimal pump, which in many ways is similar to the Doane model. The lacrimal pump models agree that eye­lid closure results in a squeezing of the canaliculi with the nasal movement of tears into the lacri­mal sac. The models diverge, however, in the analysis of the changes in the lacrimal sac pres­sure with eyelid closure and opening.
The rst “lacrimal pump” theory is based on classic anatomic studies by Jones [9], describing tendinous and muscular insertions exerting their action on and around the lacrimal sac. The Jones theory for this lacrimal pump involves three components:
1. The deep heads of the pretarsal orbicularis
muscle (Horner’s muscle).
2. The deep head of the preseptal muscle (Jones’
muscle).
3. The lacrimal diaphragm (fascia around the
sac).
The tensor tarsi (Horner’s) muscle originates on the posterior lacrimal crest and divides to sur­round the canaliculi. It then becomes continuous with the pretarsal portions of the orbicularis mus­cle. Since some bers of this muscle run in a par­allel and sometimes spiral manner, the contraction of the muscle can draw the papillae of the puncta in a medial direction. This narrows the ampullae and shortens the canaliculi [12]. The Horner’s muscle around the canaliculi pumps tears from the punctum through to the sac [2].
An additional strand of orbicularis muscle from the preseptal area inserting into the lacrimal fascia and posterior lacrimal crest (the deep head
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of the preseptal orbicularis muscle) was described by Jones and this muscle is named as Jones’ mus­cle. According to Jones, the muscular pull of this preseptal orbicularis muscle (Jones’ muscle) on the lacrimal sac draws the lateral wall of the nasolacrimal sac laterally and creates a negative pressure within the sac [13].
With blinking, contraction of the deep presep­tal orbicularis bers (Jones’ muscle) draws the lateral wall of the nasolacrimal sac laterally, cre­ating a negative pressure within the sac and allowing the inspiration of tears into the sac. The tears are forced along the canalicular system by contraction of the deep head of the pretarsal mus­cle (Horner’s muscle). When the orbicularis relaxes and the eyelid opens, the sac collapses, forcing tears down the nasolacrimal duct. At the same time, the canaliculi open, siphoning tears into their lumen. Closing the eyelids again pushes and propels the accumulated tears into the lacri­mal sac [14].
Doane suggested a different mechanism of tear propulsion through the system. He noted that the puncta came together during the early phases of eyelid closure and occlusion of the puncta occurred as a rst step in the tear pump. He pos­tulated that contraction of the pretarsal orbicu­laris oculi muscle exerts lateral traction on the lacrimal sac wall, compresses the ampulla, and shortens the canaliculi, causing a pressure increase in the canaliculi propelling tear uid within the canaliculi toward the lacrimal sac (i.e., positive pressure is created during a blink in both the canaliculi and the nasolacrimal sac as a result of muscle contraction occurring in the pretarsal and preseptal orbicularis bers) [10, 14]. Doane further theorized that as the tension increases on the lacrimal fascia to open the fundus of the sac, the inferior portion closes more tightly, prevent­ing aspiration of air from the nose. As the eyelids open, the puncta initially remain closed by the opposing lid until the end of the opening move­ment, and partial vacuum forms within the mem­branous lacrimal conduit. As the eyelid-opening phase of the blink continues, the two lacrimal puncta open and expose the adjacent lacrimal lake to this partial vacuum. Tears rapidly ow into the canaliculi during the 1–3-s interval
immediately after the blink. Once again, the can­aliculi ll with uid so that the pumping action of the next blink can continue the lacrimal elimina­tion cycle. With the relaxation of the deep head of the preseptal orbicularis muscle, elastic recoil of the lacrimal fascia collapses the lacrimal sac, expelling any uid within the sac down into the now patent nasolacrimal duct. Thus, the collaps­ing lacrimal drainage conduit was believed to push the tears through the system into the nose without the suction phase postulated by Jones [10]. To date, most evidence supports the Doane model [15].
Becker observed that the superolateral wall of the lacrimal sac, which is attached to the deep head of the preseptal orbicularis, moved laterally with lid closure and medially with lid opening. The inferior half of the lateral wall of the lacrimal sac moved medially with lid closure and laterally with lid opening. Becker suggested a tricompartment model of the lacrimal pump that incorporates these ndings. With lid closure, the orbicularis muscle contracts, compressing the canaliculi and pulling the superior half of the lateral wall of the lacrimal sac laterally. This creates a lower pressure in the superior sac, allowing tears to be propelled from the canaliculi into the sac. At the same time, the inferior half of the lateral sac wall moves medially, creating a positive pressure in the inferior sac and nasolacrimal duct, thus forcing tears down the duct into the nose. With lid opening, the orbicu­laris muscle relaxes, allowing the canaliculi to open and the superior half of the lateral sac wall to move medially. The resulting negative intracana­licular pressure allows tears to ow from the lacri­mal lake into the canaliculi, and the higher pressure in the superior sac closes the valve of Rosenmüller and forces tears from the superior to inferior sac and proximal nasolacrimal duct. At the same time, the inferior half of the lateral sac wall moves later­ally, resulting in negative pressure in the inferior sac and nasolacrimal duct [11]. These observa­tions are in agreement with Doane’s model, with the overall lacrimal sac pressure increasing with eyelid closure and reducing with eyelid opening.
These proposed lacrimal sac pumping mecha­nisms are based on anatomic studies and likely do not have a large role in normal lacrimal elimi-
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