- Email: [email protected]
Dacryocystorhinostomy: Indications and surgical technique
Accepted Manuscript
Dacryocystorhinostomy: Indications and Surgical Technique Christopher Weller MD , Ilya Leyngold MD PII: DOI: Reference:
S1043-1810(18)30082-4 https://doi.org/10.1016/j.otot.2018.10.004 YOTOT 831
To appear in:
Operative Techniques in Otolaryngology - Head and Neck Surgery
Please cite this article as: Christopher Weller MD , Ilya Leyngold MD , Dacryocystorhinostomy: Indications and Surgical Technique, Operative Techniques in Otolaryngology - Head and Neck Surgery (2018), doi: https://doi.org/10.1016/j.otot.2018.10.004
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Dacryocystorhinostomy: Indications and Surgical Technique
Affiliations: 1
Penn State Health Milton S. Hershey Medical Center, Department of Ophthalmology, Division
AN US
of Oculofacial Plastic and Reconstructive Surgery 2
CR IP T
Authors: Christopher Weller, MD1*, Ilya Leyngold, MD2
Duke University Hospital, Department of Ophthalmology, Division of Oculofacial Plastic and
*Corresponding author
ED
M
Reconstructive Surgery
PT
The Penn State Eye Center. 200 Campus Drive, Suite 800, Hershey, PA 17033. Tel: 717-
AC
CE
5315690, email: [email protected]
ACCEPTED MANUSCRIPT
Abstract: The following article reviews the clinical presentation, evaluation, and surgical treatment of patients with nasolacrimal duct obstruction, with an emphasis placed on the surgical techniques of external and internal/endoscopic dacryocystorhinostomy.
CR IP T
Introduction: Dacryocystorhinostomy refers to the creation of an alternate tear drainage pathway via the union of the lacrimal sac and the nasal cavity achieved through the removal of bone within the nasolacrimal fossa. This technique bypasses the nasolacrimal duct and is the surgical treatment for clinically significant nasolacrimal duct obstruction not responsive to medical therapy.
M
AN US
Dacryocystorhinostomy (DCR) can be achieved through an external or internal/endoscopic endonasal approach. Although within the early literature the reported success rate of external DCR was slightly higher than internal/endoscopic, later studies have shown comparable rates of success.1-3 This discrepancy is thought to be representative of individual surgeon experience and technique. Advantages of external DCR include direct visualization of the nasolacrimal fossa prior to rhinostomy creation and poses less of a technical instrumentation burden. Internal DCR avoids a visible incision, requires less operative time in experienced hands, and allows the surgeon to assess and address any associated intranasal pathology under direct visualization. It also avoids disruption of the facial nerve branches that may result in temporary lagophthalmos seen after external DCR.4
CE
PT
ED
Intubation of the canalicular system and rhinostomy using a silicone stent may be performed in conjunction with DCR. This is thought to decrease the theoretical risk of post-operative scarring within the canalicular system and at the junction of the common canaliculus with the lacrimal sac. It is controversial as to whether intubation in uncomplicated primary DCR increases success rate.5-7 Intubation may be performed at the surgeon’s discretion in routine cases and should be considered in patients with high risk of canalicular stenosis or scarring and those requiring revision surgery. If employed, either bicanalicular or monocanalicular stents may be utilized.8
Clinical Evaluation:
AC
Clinically acquired nasolacrimal duct obstruction presents with epiphora and/or dacryocystitis. This is more common in women over the age of 40, but it is not unusual to see in younger individuals and men as well. The etiologies are vast, with most common being primary nasolacrimal obstruction (PNLDO) due to involutional stenosis. Other causes include trauma, inflammatory disorders, neoplasia, sinus surgery, radioactive iodine therapy or dacryolithiasis (more common in younger females). Without adequate treatment, patients with nasolacrimal duct obstruction are at risk for the development of, or worsening, epiphora and infection. Medical therapy is considered supportive, with antibiotic eye drops to decrease bacterial load and symptomatic mucous discharge in conjunction with systemic antibiotic therapy for acute infection if present, until surgical correction can be achieved.
ACCEPTED MANUSCRIPT
CR IP T
Epiphora, defined as tearing that results in spillage of tears over the lower eyelid margin, results from an imbalance between tear production and outflow. The clinical evaluation of a patient with epiphora should begin with assessment of the ocular surface, eyelid position, orbicularis strength and subsequent lacrimal pump function, punctal positioning, and examination for any physical barrier to outflow, including lesions or conjunctivochalasis (redundant fold of conjunctiva at the lower eyelid margin). Patients with nasolacrimal duct obstruction will often have an increased tear lake and mucocellular debris evident within the tear film. Attention can then be paid to the evaluation of the puncta, canalicular system, and nasolacrimal duct utilizing dye disappearance testing, Jones I and II tests, and/or nasolacrimal probing with irrigation. These tests are used in various combinations based on physician preference to identify and localize obstruction within the canalicular system or nasolacrimal duct.
ED
M
AN US
Dacryocystitis refers to inflammation or infection within the lacrimal sac. The presence of nasolacrimal duct obstruction can be inferred in patients presenting with dacryocystitis, negating the need for additional clinical evaluation of the nasolacrimal system to establish the diagnosis. Infection within the lacrimal sac is thought to develop from chronic tear stasis secondary to outflow obstruction and subsequent bacterial overgrowth. Clinically, patients present with distention of the lacrimal sac and edema or erythema of the surrounding tissue accompanied by increased mucous discharge and tearing. The swelling is typically noted below the medial canthal tendon; if it extends above the tendon evaluation for a mass lesion should be undertaken. Infection may assume a chronic smoldering form or present more acutely with associated cellulitis of the adjacent tissues.
PT
The definitive treatment for acquired nasolacrimal duct obstruction is dacryocystorhinostomy.
CE
Surgical Technique:
External Dacryocystorhinostomy: The procedure is initiated by placing neurosurgical cottonoids soaked in oxymetazoline, 4% cocaine, or 1:10,000 adrenaline within the nasal cavity at the site of future rhinostomy, located just anterior to the junction of the middle turbinate with the lateral nasal wall.
AC
Local Anesthetic is injected at the external surgical site.
An incision is made within the nasofacial sulcus using a #15 blade, starting superiorly at the level of the medial commissure and extending inferiorly for approximately 1 cm. (Fig. 1)
ACCEPTED MANUSCRIPT
Blunt dissection using tenotomy scissors is performed through the orbicularis muscle, exposing the underlying periosteum. Blunt technique is utilized during this dissection to minimize risk of injury to the nearby angular vessels and facial nerve branches.4
After exposing the periosteum for the entire length of the skin incision, the periosteum is scored using a Freer elevator or monopolar microdissection needle. (Fig. 2)
While retracting the superficial tissues with blunt rakes, the subperiosteal plane is developed anteriorly and posteriorly toward the anterior lacrimal crest with a Freer periosteal or a Cottle elevator. Once the innominate suture is encountered the surgeon is approximately 2 mm from the anterior lacrimal crest. When crossing the innominate suture, the surgeon should take care to attain hemostasis using cautery or bone wax, as this is a common location for small perforating vessels.
After identifying the anterior lacrimal crest, dissection in continued posteriorly exposing the nasolacrimal fossa in its entirety while carefully elevating the overlying lacrimal sac.
A large curved hemostat is used to initiate the rhinostomy by infracturing the thin lacrimal bone comprising the posterior aspect of the nasolacrimal fossa. The hemostat is then spread to enlarge the rhinostomy prior to removal. (Fig. 3)
The rhinostomy is enlarged using a Kerrison rongeur or high speed burr to approximately 1.5x1.5 cm, taking care to preserve the underlying nasal mucosa.
A 0 Bowman probe is passed through the canalicular system into the lacrimal sac.
While tenting the lacrimal sac medially with the Bowman probe, the medial aspect of the lacrimal sac is opened using a # 66 curved Beaver blade or #11 blade. The opening is extended superiorly to the lacrimal sac fundus and inferiorly to the lacrimal duct with a pair of Stevens tenotomy scissors. During the marsupialization of the lacrimal sac, care is taken to avoid injury to the common canaliculus, as this can lead to scarring and dacryocystorhinostomy failure.
The newly created anterior flap of the lacrimal sac is preserved for future coaptation with the nasal mucosa. The posterior flap is removed.
The nasal mucosa within the rhinostomy is then injected with local anesthesia containing 1:100,000 parts epinephrine to aid in additional hemostasis. A #11 blade and tenotomy scissors are used to incise the nasal mucosa along the superior, posterior, and inferior margins of the rhinostomy creating an anteriorly based flap. The nasal mucosal flap is then reflected anteriorly.
AC
CE
PT
ED
M
AN US
CR IP T
ACCEPTED MANUSCRIPT
If desired a monocanalicular or bicanalicular silicone nasolacrimal stent is then placed through the upper nasolacrimal complex and retrieved within the naris. If a bicanalicular stent is used the two ends are united using 6-0 silk suture or with knots distal to the common canaliculus within the nasal cavity, creating a circuit between the upper and lower canalicular system to prevent stent prolapse. The stent is then cut at the naris. (Fig. 4)
The nasal mucosal flap is united with the anterior nasolacrimal sac flap using 4-0 vicryl suture. (Fig. 5)
Closure of the skin edges is performed using 6-0 plain gut suture placed in interrupted fashion.
AN US
Internal/Endoscopic Dacryocystorhinostomy:
CR IP T
The procedure is initiated by decongesting the nasal mucosa using neurosurgical cottonoids soaked in oxymetazoline or 1:10,000 adrenaline.
A 0 or 30 degree 4mm nasal endoscope is then used to visualize the junction of the middle turbinate with the lateral nasal wall and the nasolacrimal convexity as it extends inferiorly. (Fig. 6) The nasolacrimal sac and duct correspond to these anatomical landmarks respectively. If there is difficulty visualizing the area of interest due to significant septal deviation, a septoplasty is performed prior to initiation of DCR.
A retinal light pipe can be passed through the canalicular system to aid in localizing the common punctum within the nasolacrimal sac in relation to the nasal sidewall by advancing the light pipe until the hard stop of the bone within nasolacrimal fossa is encountered and then briefly turning on the light while the endoscope is in place.
Creation of the rhinostomy is initiated by incising, elevating, and removing the nasal mucosa overlying the desired area of bone removal.
The bone of the nasolacrimal fossa is then removed using a combination of rongeurs, high speed burr, or ultrasonic burr. Visualization of the lacrimal sac can be aided during bone removal by gently applying external digital pressure within the nasolacrimal fossa.
AC
CE
PT
ED
M
Bone removal is extended superior to the fundus of the lacrimal sac to ensure clear exposure of the common canaliculus. Adequate superior bone removal can be confirmed after marsupialization of the lacrimal sac by passing a Bowman probe through the canalicular system ensuring there is clear passage into the nasal cavity while the probe is oriented horizontally. (Figs. 7 &8)
ACCEPTED MANUSCRIPT
Bone removal is extended inferiorly along the nasolacrimal convexity exposing the superior portion of the nasolacrimal duct.
A 0 Bowman lacrimal probe is passed through the canalicular system and used to tent the lacrimal sac medially into the nasal cavity. The lacrimal sac is then marsupialized from the fundus to the nasolacrimal duct using a #66 Beaver blade and sinus seeker. The anterior and posterior flaps of the lacrimal sac are then reflected or removed at the surgeon’s discretion.
If desired a monocanalicular or bicanalicular nasolacrimal stent is then placed, retrieved within the naris, and secured as previously described. (Fig. 9)
Removal of the anterior portion of the middle turbinate can be performed as needed if it is deemed to pose potential outflow obstruction from the rhinostomy to the nasal cavity.
AN US
CR IP T
Post-Operative care:
AC
CE
PT
ED
M
Patients are instructed to use a combination antibiotic-steroid ophthalmic suspension, one drop to the operative eye four times a day for two weeks, as well as daily saline nasal rinses and fluticasone nasal spray once daily for three weeks. Post-operative examinations are performed at two weeks and three months. If placed, stents are typically removed at three months. Nasal endoscopy may be performed in clinic at 2 weeks postoperatively with gentle debridement and 3 months postoperatively to confirm rhinostomy patency and lacrimal pump function. Patients are counseled that it may take up to four weeks after surgery until a noticeable improvement in tearing is appreciated.
ACCEPTED MANUSCRIPT
References: 1. Ben Simon GJ, Joseph J, Lee S, Schwarcz RM, McCann JD, Goldberg RA. External versus endoscopic dacryocystorhinostomy for acquired nasolacrimal duct obstruction in a tertiary referral center. Ophthalmology. 2005 Aug;112(8):1463-8.
CR IP T
2. Tsirbas A, Davis G, Wormald PJ. Mechanical endonasal dacryocystorhinostomy versus external dacryocystorhinostomy. Ophthal Plast Reconstr Surg. 2004 Jan;20(1):50-6.
3. Dolman PJ. Comparison of external dacryocystorhinostomy with nonlaser endonasal dacryocystorhinostomy. Ophthalmology. 2003 Jan;110(1):78-84.
AN US
4. Vagefi MR, Winn BJ, Lin CC, Sires BS, LauKaitis SJ, Anderson RL, McCann JD. Facial nerve injury during external dacryocystorhinostomy. Ophthalmology. 2009 Mar;116(3):585-90. 5. Buttanri IB, Serin D. Silicone intubation indications in external dacryocystorhinostomy. Med Hypothesis Discov Innov Ophthalmol. 2014 Winter; 3(4): 101–102.
M
6. Bartley GB. Lacrimal intubation during dacryocystorhinostomy. Am J Ophthalmol. 1988;106(5):635
ED
7. Anderson RL, Edwards JJ. Indications, complications, and results with silicone stents. Ophthalmology. 1979 Aug;86(8):1474–87.
AC
CE
PT
8. Detorakis ET, Mavrikakis I, Ioannakis K, Pallikaris IG. Monocanalicular intubation in external dacryocystorhinostomy. Ophthal Plast Reconstr Surg. 2011 Nov-Dec;27(6):43941.
CR IP T
ACCEPTED MANUSCRIPT
AC
CE
PT
ED
M
AN US
Figure 1: Marking of incision for external dacryocystorhinostomy.
Figure 2: Exposure and scoring of periosteum.
ED
M
AN US
CR IP T
ACCEPTED MANUSCRIPT
AC
CE
PT
Figure 3: Initiation of rhinostomy using a large curved hemostat.
ED
M
AN US
CR IP T
ACCEPTED MANUSCRIPT
AC
CE
PT
Figure 4: Bicanalicular silicone lacrimal stent in place, traveling from common canaliculus through rhinostomy.
ED
M
AN US
CR IP T
ACCEPTED MANUSCRIPT
AC
CE
PT
Figure 5: Nasal mucosal flap sutured into position.
AN US
CR IP T
ACCEPTED MANUSCRIPT
AC
CE
PT
ED
M
Figure 6: Initiation of rhinostomy using ultrasonic burr for endoscopic dacryocystorhinostomy.
AN US
CR IP T
ACCEPTED MANUSCRIPT
AC
CE
PT
ED
M
Figure 7: Obstruction of rhinostomy outflow tract by middle turbinate.
Figure 8: Lacrimal probe demonstrating rhinostomy outflow tract clear of obstruction.
AN US
CR IP T
ACCEPTED MANUSCRIPT
AC
CE
PT
ED
M
Figure 9: Endoscopic view of silicone lacrimal stent emerging from common canaliculus.
Dacryocystorhinostomy: Indications and Surgical Technique Christopher Weller MD , Ilya Leyngold MD PII: DOI: Reference:
S1043-1810(18)30082-4 https://doi.org/10.1016/j.otot.2018.10.004 YOTOT 831
To appear in:
Operative Techniques in Otolaryngology - Head and Neck Surgery
Please cite this article as: Christopher Weller MD , Ilya Leyngold MD , Dacryocystorhinostomy: Indications and Surgical Technique, Operative Techniques in Otolaryngology - Head and Neck Surgery (2018), doi: https://doi.org/10.1016/j.otot.2018.10.004
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Dacryocystorhinostomy: Indications and Surgical Technique
Affiliations: 1
Penn State Health Milton S. Hershey Medical Center, Department of Ophthalmology, Division
AN US
of Oculofacial Plastic and Reconstructive Surgery 2
CR IP T
Authors: Christopher Weller, MD1*, Ilya Leyngold, MD2
Duke University Hospital, Department of Ophthalmology, Division of Oculofacial Plastic and
*Corresponding author
ED
M
Reconstructive Surgery
PT
The Penn State Eye Center. 200 Campus Drive, Suite 800, Hershey, PA 17033. Tel: 717-
AC
CE
5315690, email: [email protected]
ACCEPTED MANUSCRIPT
Abstract: The following article reviews the clinical presentation, evaluation, and surgical treatment of patients with nasolacrimal duct obstruction, with an emphasis placed on the surgical techniques of external and internal/endoscopic dacryocystorhinostomy.
CR IP T
Introduction: Dacryocystorhinostomy refers to the creation of an alternate tear drainage pathway via the union of the lacrimal sac and the nasal cavity achieved through the removal of bone within the nasolacrimal fossa. This technique bypasses the nasolacrimal duct and is the surgical treatment for clinically significant nasolacrimal duct obstruction not responsive to medical therapy.
M
AN US
Dacryocystorhinostomy (DCR) can be achieved through an external or internal/endoscopic endonasal approach. Although within the early literature the reported success rate of external DCR was slightly higher than internal/endoscopic, later studies have shown comparable rates of success.1-3 This discrepancy is thought to be representative of individual surgeon experience and technique. Advantages of external DCR include direct visualization of the nasolacrimal fossa prior to rhinostomy creation and poses less of a technical instrumentation burden. Internal DCR avoids a visible incision, requires less operative time in experienced hands, and allows the surgeon to assess and address any associated intranasal pathology under direct visualization. It also avoids disruption of the facial nerve branches that may result in temporary lagophthalmos seen after external DCR.4
CE
PT
ED
Intubation of the canalicular system and rhinostomy using a silicone stent may be performed in conjunction with DCR. This is thought to decrease the theoretical risk of post-operative scarring within the canalicular system and at the junction of the common canaliculus with the lacrimal sac. It is controversial as to whether intubation in uncomplicated primary DCR increases success rate.5-7 Intubation may be performed at the surgeon’s discretion in routine cases and should be considered in patients with high risk of canalicular stenosis or scarring and those requiring revision surgery. If employed, either bicanalicular or monocanalicular stents may be utilized.8
Clinical Evaluation:
AC
Clinically acquired nasolacrimal duct obstruction presents with epiphora and/or dacryocystitis. This is more common in women over the age of 40, but it is not unusual to see in younger individuals and men as well. The etiologies are vast, with most common being primary nasolacrimal obstruction (PNLDO) due to involutional stenosis. Other causes include trauma, inflammatory disorders, neoplasia, sinus surgery, radioactive iodine therapy or dacryolithiasis (more common in younger females). Without adequate treatment, patients with nasolacrimal duct obstruction are at risk for the development of, or worsening, epiphora and infection. Medical therapy is considered supportive, with antibiotic eye drops to decrease bacterial load and symptomatic mucous discharge in conjunction with systemic antibiotic therapy for acute infection if present, until surgical correction can be achieved.
ACCEPTED MANUSCRIPT
CR IP T
Epiphora, defined as tearing that results in spillage of tears over the lower eyelid margin, results from an imbalance between tear production and outflow. The clinical evaluation of a patient with epiphora should begin with assessment of the ocular surface, eyelid position, orbicularis strength and subsequent lacrimal pump function, punctal positioning, and examination for any physical barrier to outflow, including lesions or conjunctivochalasis (redundant fold of conjunctiva at the lower eyelid margin). Patients with nasolacrimal duct obstruction will often have an increased tear lake and mucocellular debris evident within the tear film. Attention can then be paid to the evaluation of the puncta, canalicular system, and nasolacrimal duct utilizing dye disappearance testing, Jones I and II tests, and/or nasolacrimal probing with irrigation. These tests are used in various combinations based on physician preference to identify and localize obstruction within the canalicular system or nasolacrimal duct.
ED
M
AN US
Dacryocystitis refers to inflammation or infection within the lacrimal sac. The presence of nasolacrimal duct obstruction can be inferred in patients presenting with dacryocystitis, negating the need for additional clinical evaluation of the nasolacrimal system to establish the diagnosis. Infection within the lacrimal sac is thought to develop from chronic tear stasis secondary to outflow obstruction and subsequent bacterial overgrowth. Clinically, patients present with distention of the lacrimal sac and edema or erythema of the surrounding tissue accompanied by increased mucous discharge and tearing. The swelling is typically noted below the medial canthal tendon; if it extends above the tendon evaluation for a mass lesion should be undertaken. Infection may assume a chronic smoldering form or present more acutely with associated cellulitis of the adjacent tissues.
PT
The definitive treatment for acquired nasolacrimal duct obstruction is dacryocystorhinostomy.
CE
Surgical Technique:
External Dacryocystorhinostomy: The procedure is initiated by placing neurosurgical cottonoids soaked in oxymetazoline, 4% cocaine, or 1:10,000 adrenaline within the nasal cavity at the site of future rhinostomy, located just anterior to the junction of the middle turbinate with the lateral nasal wall.
AC
Local Anesthetic is injected at the external surgical site.
An incision is made within the nasofacial sulcus using a #15 blade, starting superiorly at the level of the medial commissure and extending inferiorly for approximately 1 cm. (Fig. 1)
ACCEPTED MANUSCRIPT
Blunt dissection using tenotomy scissors is performed through the orbicularis muscle, exposing the underlying periosteum. Blunt technique is utilized during this dissection to minimize risk of injury to the nearby angular vessels and facial nerve branches.4
After exposing the periosteum for the entire length of the skin incision, the periosteum is scored using a Freer elevator or monopolar microdissection needle. (Fig. 2)
While retracting the superficial tissues with blunt rakes, the subperiosteal plane is developed anteriorly and posteriorly toward the anterior lacrimal crest with a Freer periosteal or a Cottle elevator. Once the innominate suture is encountered the surgeon is approximately 2 mm from the anterior lacrimal crest. When crossing the innominate suture, the surgeon should take care to attain hemostasis using cautery or bone wax, as this is a common location for small perforating vessels.
After identifying the anterior lacrimal crest, dissection in continued posteriorly exposing the nasolacrimal fossa in its entirety while carefully elevating the overlying lacrimal sac.
A large curved hemostat is used to initiate the rhinostomy by infracturing the thin lacrimal bone comprising the posterior aspect of the nasolacrimal fossa. The hemostat is then spread to enlarge the rhinostomy prior to removal. (Fig. 3)
The rhinostomy is enlarged using a Kerrison rongeur or high speed burr to approximately 1.5x1.5 cm, taking care to preserve the underlying nasal mucosa.
A 0 Bowman probe is passed through the canalicular system into the lacrimal sac.
While tenting the lacrimal sac medially with the Bowman probe, the medial aspect of the lacrimal sac is opened using a # 66 curved Beaver blade or #11 blade. The opening is extended superiorly to the lacrimal sac fundus and inferiorly to the lacrimal duct with a pair of Stevens tenotomy scissors. During the marsupialization of the lacrimal sac, care is taken to avoid injury to the common canaliculus, as this can lead to scarring and dacryocystorhinostomy failure.
The newly created anterior flap of the lacrimal sac is preserved for future coaptation with the nasal mucosa. The posterior flap is removed.
The nasal mucosa within the rhinostomy is then injected with local anesthesia containing 1:100,000 parts epinephrine to aid in additional hemostasis. A #11 blade and tenotomy scissors are used to incise the nasal mucosa along the superior, posterior, and inferior margins of the rhinostomy creating an anteriorly based flap. The nasal mucosal flap is then reflected anteriorly.
AC
CE
PT
ED
M
AN US
CR IP T
ACCEPTED MANUSCRIPT
If desired a monocanalicular or bicanalicular silicone nasolacrimal stent is then placed through the upper nasolacrimal complex and retrieved within the naris. If a bicanalicular stent is used the two ends are united using 6-0 silk suture or with knots distal to the common canaliculus within the nasal cavity, creating a circuit between the upper and lower canalicular system to prevent stent prolapse. The stent is then cut at the naris. (Fig. 4)
The nasal mucosal flap is united with the anterior nasolacrimal sac flap using 4-0 vicryl suture. (Fig. 5)
Closure of the skin edges is performed using 6-0 plain gut suture placed in interrupted fashion.
AN US
Internal/Endoscopic Dacryocystorhinostomy:
CR IP T
The procedure is initiated by decongesting the nasal mucosa using neurosurgical cottonoids soaked in oxymetazoline or 1:10,000 adrenaline.
A 0 or 30 degree 4mm nasal endoscope is then used to visualize the junction of the middle turbinate with the lateral nasal wall and the nasolacrimal convexity as it extends inferiorly. (Fig. 6) The nasolacrimal sac and duct correspond to these anatomical landmarks respectively. If there is difficulty visualizing the area of interest due to significant septal deviation, a septoplasty is performed prior to initiation of DCR.
A retinal light pipe can be passed through the canalicular system to aid in localizing the common punctum within the nasolacrimal sac in relation to the nasal sidewall by advancing the light pipe until the hard stop of the bone within nasolacrimal fossa is encountered and then briefly turning on the light while the endoscope is in place.
Creation of the rhinostomy is initiated by incising, elevating, and removing the nasal mucosa overlying the desired area of bone removal.
The bone of the nasolacrimal fossa is then removed using a combination of rongeurs, high speed burr, or ultrasonic burr. Visualization of the lacrimal sac can be aided during bone removal by gently applying external digital pressure within the nasolacrimal fossa.
AC
CE
PT
ED
M
Bone removal is extended superior to the fundus of the lacrimal sac to ensure clear exposure of the common canaliculus. Adequate superior bone removal can be confirmed after marsupialization of the lacrimal sac by passing a Bowman probe through the canalicular system ensuring there is clear passage into the nasal cavity while the probe is oriented horizontally. (Figs. 7 &8)
ACCEPTED MANUSCRIPT
Bone removal is extended inferiorly along the nasolacrimal convexity exposing the superior portion of the nasolacrimal duct.
A 0 Bowman lacrimal probe is passed through the canalicular system and used to tent the lacrimal sac medially into the nasal cavity. The lacrimal sac is then marsupialized from the fundus to the nasolacrimal duct using a #66 Beaver blade and sinus seeker. The anterior and posterior flaps of the lacrimal sac are then reflected or removed at the surgeon’s discretion.
If desired a monocanalicular or bicanalicular nasolacrimal stent is then placed, retrieved within the naris, and secured as previously described. (Fig. 9)
Removal of the anterior portion of the middle turbinate can be performed as needed if it is deemed to pose potential outflow obstruction from the rhinostomy to the nasal cavity.
AN US
CR IP T
Post-Operative care:
AC
CE
PT
ED
M
Patients are instructed to use a combination antibiotic-steroid ophthalmic suspension, one drop to the operative eye four times a day for two weeks, as well as daily saline nasal rinses and fluticasone nasal spray once daily for three weeks. Post-operative examinations are performed at two weeks and three months. If placed, stents are typically removed at three months. Nasal endoscopy may be performed in clinic at 2 weeks postoperatively with gentle debridement and 3 months postoperatively to confirm rhinostomy patency and lacrimal pump function. Patients are counseled that it may take up to four weeks after surgery until a noticeable improvement in tearing is appreciated.
ACCEPTED MANUSCRIPT
References: 1. Ben Simon GJ, Joseph J, Lee S, Schwarcz RM, McCann JD, Goldberg RA. External versus endoscopic dacryocystorhinostomy for acquired nasolacrimal duct obstruction in a tertiary referral center. Ophthalmology. 2005 Aug;112(8):1463-8.
CR IP T
2. Tsirbas A, Davis G, Wormald PJ. Mechanical endonasal dacryocystorhinostomy versus external dacryocystorhinostomy. Ophthal Plast Reconstr Surg. 2004 Jan;20(1):50-6.
3. Dolman PJ. Comparison of external dacryocystorhinostomy with nonlaser endonasal dacryocystorhinostomy. Ophthalmology. 2003 Jan;110(1):78-84.
AN US
4. Vagefi MR, Winn BJ, Lin CC, Sires BS, LauKaitis SJ, Anderson RL, McCann JD. Facial nerve injury during external dacryocystorhinostomy. Ophthalmology. 2009 Mar;116(3):585-90. 5. Buttanri IB, Serin D. Silicone intubation indications in external dacryocystorhinostomy. Med Hypothesis Discov Innov Ophthalmol. 2014 Winter; 3(4): 101–102.
M
6. Bartley GB. Lacrimal intubation during dacryocystorhinostomy. Am J Ophthalmol. 1988;106(5):635
ED
7. Anderson RL, Edwards JJ. Indications, complications, and results with silicone stents. Ophthalmology. 1979 Aug;86(8):1474–87.
AC
CE
PT
8. Detorakis ET, Mavrikakis I, Ioannakis K, Pallikaris IG. Monocanalicular intubation in external dacryocystorhinostomy. Ophthal Plast Reconstr Surg. 2011 Nov-Dec;27(6):43941.
CR IP T
ACCEPTED MANUSCRIPT
AC
CE
PT
ED
M
AN US
Figure 1: Marking of incision for external dacryocystorhinostomy.
Figure 2: Exposure and scoring of periosteum.
ED
M
AN US
CR IP T
ACCEPTED MANUSCRIPT
AC
CE
PT
Figure 3: Initiation of rhinostomy using a large curved hemostat.
ED
M
AN US
CR IP T
ACCEPTED MANUSCRIPT
AC
CE
PT
Figure 4: Bicanalicular silicone lacrimal stent in place, traveling from common canaliculus through rhinostomy.
ED
M
AN US
CR IP T
ACCEPTED MANUSCRIPT
AC
CE
PT
Figure 5: Nasal mucosal flap sutured into position.
AN US
CR IP T
ACCEPTED MANUSCRIPT
AC
CE
PT
ED
M
Figure 6: Initiation of rhinostomy using ultrasonic burr for endoscopic dacryocystorhinostomy.
AN US
CR IP T
ACCEPTED MANUSCRIPT
AC
CE
PT
ED
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Figure 7: Obstruction of rhinostomy outflow tract by middle turbinate.
Figure 8: Lacrimal probe demonstrating rhinostomy outflow tract clear of obstruction.
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Figure 9: Endoscopic view of silicone lacrimal stent emerging from common canaliculus.