Die Heermann-Modifikation der intranasalen Mikrochirurgie bei Tränenwegstenosen*, **

Abstract

The authors demonstrated Heermann's modification of intranasal microsurgery on the tearways. Since 1912 all intranasal lacrimal sac operations at the Krupp Hospital (up to 98 cases yearly) have been performed according to Randolph and West (1909). During the last 36 years our patients have been operated on in a semisitting-(Fowlers)-position with the help of the binocular microscope and with hypotensive anaesthesia. This technique of lacrimal sac surgery is demonstrated "step-by-step" with the removal of the medial wall of the lacrimal sac in abscesses or dacryoliths. In rare cases of a presaccal stenosis, a circular resection of the stenosis after J. Heermann (1989/1991) was done to leave the common duct open by the retraction of the scar. That is the reason why the insertion of plastic prostheses is rarely necessary (only in patients with congenital aplasia or extensive stenosis of the horizontal lacrimal duct). Funnel-shaped prostheses of glass were developed in 1925 by J. Heermann sen., of steel 1930 by H. Heermann and made by plastic material 1966 by J. Heermann. During a ten-year period (1976-1986) we evaluated 659 cases of intranasal microsurgery on the tearways. The use of plastic prosthesis was necessary in 17 cases. Including reoperations (first operation after Toti) satisfactory results were obtained in 94% of all cases.

Endoillumination-Guided Intranasal Microscopic Dacryocystorhinostomy for Difficult Cases

“…Anatomical variations such as septal deviations, turbinate hyperplasia, or infection of paranasal sinuses may also predispose to failure by persistent inflammation or unwanted scarring. Simultaneous adjunctive corrections like septoplasties, turbinoplasties and ethmoidectomies were necessary in up to 36% of the patients, an experience shared by other authors [2,3].…”

“…This operation technique can be performed with a high degree of precision [1][2][3]7]. Endonasal operation techniques are preferred by otolaryngologists to relieve nasolacrimal duct obstruction, thus avoiding a scar and trauma of the tear passage caused by cutting the medial ligament.…”

“…Comparing the successful outcome in saccal and postsaccal stenosis including secondary cases, the results range from as low as 29% [9] to -with microsurgery or endoscopy -up to 91% symptom-free patients [2,3]. We attribute the good longterm results, with 95% patent tear passages over 1 year after surgery, to the combined approach and teamwork with an ophthalmologist.…”

“…Otolaryngologists choose internal dacryocystorhinostomy for treatment of lacrimal obstruction as well as for the revision of external dacryocystorhinostomy [1][2][3]. External operations according to Toti are standard for ophthalmologists [4] but leave an external scar.…”

Aktuelle Empfehlungen zur Dakryozystorhinostomie

“…Eine Behinderung des Lidschlages tritt praktisch nie auf und ist nur bei deutlicher Dislokation der Ringintubariums im medialen Augenwinkel denkbar. Einige Autoren f ü hren keine Intubation der Tr ä nenwege durch [10,12,17,18] , wohl auch aufgrund der Tatsache, dass Daten f ü r eine h ö here Erfolgsquote durch den Einsatz der Silikonr ö hrchen bislang fehlen und folgende Komplikationen m ö glich sind: ▶ Einschneiden des Punctum lacrimale oder der Canaliculae, ▶ Granulombildung im Bereich der Puncta, Tr ä nensack oder Nasenwand, ▶ Dislokation mit Corneairritationen und ▶ endonasale Krustenbildung, Schwierigkeiten der Entfernung. Ob eine Verbesserung der endonasalen Erfolgsquote mit einem auf den Silkonschlauch gezogenen H ü tchen erreicht werden kann, ist ebenfalls noch nicht belegt.…”