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Head and Neck
Published in Rui Diogo, Drew M. Noden, Christopher M. Smith, Julia Molnar, Julia C. Boughner, Claudia Barrocas, Joana Bruno, Understanding Human Anatomy and Pathology, 2018
Rui Diogo, Drew M. Noden, Christopher M. Smith, Julia Molnar, Julia C. Boughner, Claudia Barrocas, Joana Bruno
The tarsal glands are embedded in the posterior surface of each tarsal plate, the fibrous “skeleton” of the upper eyelid. The orbital septum is a sheet of connective tissue separating the superficial facial fascia and the contents of the orbit. The tarsal glands drain by orifices lying posteriorly to the eyelashes and secrete an oily substance onto the margin of the eyelids that prevents the overflow of tears (lacrimal fluid). The lacrimal gland lies in the lacrimal fossa of the frontal bone. The lacrimal sac lies posterior to the medial palpebral ligament, which is attached to the anterior lacrimal crest that forms the anterior border of the lacrimal groove (Plate 3.32). The lacrimal sac receives lacrimal fluid from the medial angle of the eye through the lacrimal canaliculi. When lacrimal fluid accumulates in excess and cannot be removed from the medial corner of the eye via the lacrimal canaliculi, it overflows the eyelids (visible crying or shedding of tears). Tears also drain into the nasal cavity via the lacrimal sac, resulting in a runny nose.
Disorders of the Orbit
Published in John C Watkinson, Raymond W Clarke, Louise Jayne Clark, Adam J Donne, R James A England, Hisham M Mehanna, Gerald William McGarry, Sean Carrie, Basic Sciences Endocrine Surgery Rhinology, 2018
Nithin D. Adappa, James N. Palmer
The medial wall is most relevant to otorhinolaryngologists due to the proximity of the paranasal sinuses. From an anterior to posterior direction, the boney contribution of anterior lacrimal crest originates at the frontal process of the maxilla. The lacrimal bone makes up the second one half of the lacrimal sac fossa and the posterior lacrimal crest. The lamina papyracea (arising from ethmoid bone) makes up the majority of the medial orbital wall. The paper-thin bone overlies the ethmoid sinuses.2 The anterior and posterior ethmoid foramina are found in the superior aspect of the orbit along the fronto-ethmoidal suture line. The anterior ethmoid foramen is a useful landmark and is identified 20–25 mm posterior to the anterior lacrimal crest and the posterior ethmoid foramen is 30–35 mm posterior to the anterior lacrimal crest.3 The thick bone of the sphenoid body forms the most posterior portion of the medial orbital wall adjoining the optic canal.
Orbital Fractures
Published in Jeffrey R. Marcus, Detlev Erdmann, Eduardo D. Rodriguez, Essentials of CRANIOMAXILLOFACIAL TRAUMA, 2014
Regina M. Fearmonti, Jeffrey R. Marcus
Composed of the lacrimal bone and lamina papyracea of the ethmoid, the medial orbital wall occupies a vertical position with a slightly lateral slant. Anteriorly, it houses the lacrimal sac between the frontal process of the maxilla (anterior lacrimal crest) and the lacrimal bone (posterior lacrimal crest). A fracture in this anterior third (the medial rim) is typically classified as a nasoorbital ethmoid fracture, whereas a fracture of the weak lamina papyracea connotes a pure medial wall injury. Because the medial wall separates the orbit from the ethmoid sinus, epistaxis and orbital emphysema are commonly seen with floor fractures that involve the medial wall.
Surgical success of ‘W’ shaped incision versus Tear Trough incision in External Dacryocystorhinostomy
Published in Orbit, 2022
Isha Acharya, Jolly Rohatgi, Pramod Kumar Sahu
Blunt dissection of subcutaneous tissues and orbicularis muscle in layers was carried out. The medial palpebral ligament (MPL) and periosteum overlying the anterior lacrimal crest were exposed. MPL was excised in all cases of Group W only. An adequate-sized osteotomy was made extending vertically from MPL to the proximal end of the nasolacrimal duct and anteriorly including the anterior lacrimal crest. The nasal cavity was then packed with ribbon gauze soaked with a local anaesthetic to elevate the nasal mucosa and also tamponade the bleeding mucosa. H-shaped flap of the lacrimal sac and nasal mucosa were formed. Both anterior and posterior flaps were sutured wherever possible with 6/0 Vicryl. 6/0 Vicryl was also used to suture the two cut ends of MPL. The skin incision was closed using interrupted 6/0 vicryl sutures. Intraoperative complications were recorded and managed simultaneously.
Variation of the minimally invasive CDCR technique
Published in Orbit, 2020
Austin Pharo, James Chelnis, Tara Goecks, Kendra C. DeAngelis, Brian Fowler, J. Chris Fleming, Thomas C. Naugle
Surgical technique: The anterior lacrimal crest is identified. The sharp tip of the NKD is placed at the junction of the caruncle and conjunctiva within the lacrimal groove and pushed infero-medially at a 45-degree angle (Figure 2a) to penetrate through conjunctiva to the nasal mucosa, creating an osteotomy from the external conjunctiva into the middle meatus. Using nasal endoscopy or illuminated speculum, the tip of the NKD can be observed entering the nasal cavity, confirming optimal tract placement. If the middle turbinate obstructs the tract, a middle partial turbinectomy can be performed.13,14 Takahashi forceps can be used to remove any bone fragments created by the NKD that obstruct the osteotomy or impede placement of the Jones tube.
The Cry of the Third Eye: Exceptionally Rare Location of a Post-Traumatic Acquired Lacrimal Fistula
Published in Ocular Immunology and Inflammation, 2023
Richa Dharap, Nandini Bothra, Mohammad Javed Ali
A probe was placed through the glabellar fistulous opening, and the necrotic edges were freshened, and the retained discharge was evacuated. An incision was taken below the medial canthus, over the lacrimal sac area. Several layers of thick scarred and fibrous tissue were encountered while dissecting to reach the anterior lacrimal crest and the lacrimal sac. The regional anatomy was distorted with loss of sharp edge of the anterior lacrimal crest due to callus formation and a distorted and superiorly migrated lacrimal sac. Simultaneously, two probes were placed to identify the communication point (Figure 1f), one from the external fistulous opening and the second from the punctum into the lacrimal sac. Endoscopic guidance was used at every step further for better visualization and assessment. A part of the fundus of the lacrimal sac was found to be like a narrow diverticulum traversing (Figure 1f) through a bony canal in the frontal bone right up to the glabellar region and opening on the contralateral side just outside the midline. The sac communication was severed at a superior point near the internal entrance of the bony canal (Figure 1g). The lacrimal sac flaps were fashioned to accurately allow the two probes to identify the internal fistulous opening and the common canalicular opening (Figure 1h). The overhanging edges of the internal bony fistula were punched out to expose the internal fistulous tract (Figure 2a,b) and excise it entirely. The external aspect of the fistulous tract was approached and excised through the freshened external opening (Figure 2c). The excised portions were sent for histopathological examination. The whole length of the bony canal harboring the fistulous tract was assessed with endoscopy, and remnant tissues were curetted (Figure 2d). Endocautery was performed from within the bony canal to ensure complete clearance (Figure 2e). Powered drills were used to perform the DCR osteotomy. Nasal mucosal flaps were created (Figure 2f). Circumostial injection of mitomycin C in a dose of 0.04% and Crawford bicanalicular stent were performed as per standard protocols.6 Skin over fistulous tract was closed by a local advancement flap from the glabellar region to cover the defect.