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The use of polythene tubing in canthorhinostomy
T H E USE OF P O L Y T H E N E T U B I N G IN C A N T H O R H I N O S T O M Y By DERRICK DENCER,F.R.C.S.(Ed.) Birmingham Regional Plastic Unit THE treatment of lachrymal obstruction lies within the province of the plastic surgeon, the rhinologist, and the ophthalmic surgeon, and the surgical remedies feature in the literature of all three specialties. The indications for each operation and the technical details involved have been expertly portrayed by Rycroft (I95I), who described nine procedures according to the site of stricture. The surgery of the tear ducts is, however, not without its difficulties and disappointments, and the diverse operations and modifications that are described bear ample witness to this. The purpose of this article is to describe the treatment of one case of obstructive epiphora in which all the standardised procedures had been carried out to no avail, and in which, as a last resort, a permanent indwelling polythene tube was used to establish an artificial canthorhinostomy. The tube of outside diameter 3 ram. lay superiorly over the caruncle, having several fenestrations to drain the lower fornix, and ran downwards through soft tissue and through an artificial ostium created in the right nasal bone and presented inferiorly in the nasal cavity below the middle turbinate (Figs. I to 3). Many instances of the use of acrylic tubes have been described in the past, and the functions for which the tube has been used can be divided into three main categories :-I. As a temporary dilator of the canaliculi, generally in conjunction with a dacryocystorhinostomy. 2. As an aid to the operation of dacryocystorhinostomy when the technical difficulties of completely suturing the two mucosal layers prove insuperable, and the tube is left in position while epithelial proliferation completes the anastomosis (Wilde, i95i ). It is also used as a temporary indwelling dilator in an attempt to eliminate the scarring and stenosis at the suture line. 3. Rycroft (I95I) uses an acrylic tube as a scaffold for carrying a graft of buccal mucosa in the construction of an epithelial-lined tube from the inner canthus to the nasal cavity. In all these procedures, however, the tube is used in a temporary capacity, and its use as a permanent implant has not hitherto been described. The acrylic resins are in the main completely inert in the human body and can be left in the tissues indefinitely without hurt, depending, of course, on suitable choice of site and on design of implant (Scales, I953; Dencer, I955). One of the criteria for success with these implants is that the cavity must be sterile and closed off from the exterior because they react as any other foreign body in the presence of infection, and it was feared that an implant remaining in constant contact with a persistently infected space such as the nasal cavity might spontaneously extrude itself. Fortunately this did not occur, and the tube and its host remain in a happy symbiotic existence. The other hazard was that of connecting an infected space to a comparatively 53
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Fig. I.--Showing the upper end of the polythene tube overlying the caruncle. Fig. 2 . - - X - r a y of skull to show position of tube with metal probe inserted to outline it. Fig. 3.--Occipito-mental view of tube with probe inserted to show the outline.
FIG. I
Fro. 2
F:G. 3
POLYTHENE TUBING IN CANTHORHINOSTOMY
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clean one with a m a n - m a d e rigid t u b e which possessed n o n e o f the natural defences against ascending infection, b u t there has been no conjunctival reaction or discharge. CASE REPORT The patient, a young woman of 3 o, was involved in a road accident and suffered a complicated injury to the right cheek. This consisted of a completely severed levator, a detached inner canthus, a fractured and displaced malar bone, and severe injury to the lachrymal apparatus. The three former injuries were dealt with satisfactorily at the first operation and left no disability, b u t the injury to the lachrymal apparatus was found to be severe. Both canaliculi had been divided by the extensive laceration which curved from the outer canthus over the upper lid, downwards over the inner canthus and across the malar. In the depths of the wound no sign of the lachrymal sac could be found and the bony walls of the canal that housed the nasolachrymal duct were fractured and its contents destroyed. No further surgery at this stage was contemplated and it was decided to leave reFarative surgery to a time of election. Even before the patient left the ward it became evident that her epiphora was going to be of such dimensions as would call for every effort to reduce it. When she was seen a month later she complained that her job of handling plates of food was causing increasing embarrassment to herself and her customers. At succeeding operations attempts were made to dilate the canaliculi and to reconstruct some sort of natural passage out of scar tissue which was anastomosed to nasal mucosa. Later on a canthorhinostomy was performed and a funnel of conjunctiva was brought down and sewn to nasal mucosa. For a while this functioned admirably but after a month it began to stenose. T h e stricture was dilated regularly by the surgeon and by the patient but failed to allow the ostium to remain patent. For six months the patient wore an acrylic tube dilator but on its removal the scarring again began to contract. The area was opened up once more and the anastomosis refashioned ; this time a piece of right nasal bone the size of a finger nail was removed permitting large flaps of nasal mucosa to be raised. At the time of operation fluid in the lower fornix could easily be expressed into the nose but again the sequence of events was repeated and the obstructive epiphora became complete fairly soon after operation. Rycroft's skin-fined tube was decided against because the area was by this time becoming so scarred that it would have been difficult to find a suitable bed for the graft and the existing fibrous tissue would without doubt have strangulated it. It was decided to create a false passage from the lower fornix to the nose and to implant an acrylic tube therein. T o this there were many objections but it was considered a worth=while chance as there appeared to be little else one could do to relieve the epiphora. With a general anesthetic a tenotome was pushed down into the lower fornix and made to present in the nose beneath the middle turbinate. There was no bony obstruction owing to the previous surgery and it was easy to fashion a small tunnel with as little damage to the surrounding tissue as possible. Through this a polythene tube was inserted and was anchored with two braided nylon sutures in the lower fornix. The upper end lay over the caruncle and two small holes were cut in the tube in the region of the lower fornix to ensure dependent drainage. There was no reaction to this implant and it has remained quiet since its insertion fifteen months ago. The lachrymal secretion irrigates the tube and ensures its cleanliness. The epiphora has completely disappeared and the patient is able to carry on her occupation with comfort.
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BRITISH
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SUMMARY A case of obstructive epiphora due to avulsion of the lachrymal apparatus is described. The various attempts at relief are enumerated, all of which were of no avail. An operation consisting of the insertion of an acrylic tube from the lower fornix to the nasal cavity is described. It has been in situ for fifteen months at the time of writing and has remained completely quiet and provided a totally efficient mechanism of tear drainage. REFERENCES DENCER, D. (1955). Blast. reconstr. Surg., x5, 328. RYCROFT, B. W. (1951). Brit. J. OphthaL, 35, 328. SCALES, J. T. (1953). Pvoc. R. Soc. Med., 46, 647. WILDE, J. (1951). Plast. reconstr. Surg., 8, 234.
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Fig. I.--Showing the upper end of the polythene tube overlying the caruncle. Fig. 2 . - - X - r a y of skull to show position of tube with metal probe inserted to outline it. Fig. 3.--Occipito-mental view of tube with probe inserted to show the outline.
FIG. I
Fro. 2
F:G. 3
POLYTHENE TUBING IN CANTHORHINOSTOMY
55
clean one with a m a n - m a d e rigid t u b e which possessed n o n e o f the natural defences against ascending infection, b u t there has been no conjunctival reaction or discharge. CASE REPORT The patient, a young woman of 3 o, was involved in a road accident and suffered a complicated injury to the right cheek. This consisted of a completely severed levator, a detached inner canthus, a fractured and displaced malar bone, and severe injury to the lachrymal apparatus. The three former injuries were dealt with satisfactorily at the first operation and left no disability, b u t the injury to the lachrymal apparatus was found to be severe. Both canaliculi had been divided by the extensive laceration which curved from the outer canthus over the upper lid, downwards over the inner canthus and across the malar. In the depths of the wound no sign of the lachrymal sac could be found and the bony walls of the canal that housed the nasolachrymal duct were fractured and its contents destroyed. No further surgery at this stage was contemplated and it was decided to leave reFarative surgery to a time of election. Even before the patient left the ward it became evident that her epiphora was going to be of such dimensions as would call for every effort to reduce it. When she was seen a month later she complained that her job of handling plates of food was causing increasing embarrassment to herself and her customers. At succeeding operations attempts were made to dilate the canaliculi and to reconstruct some sort of natural passage out of scar tissue which was anastomosed to nasal mucosa. Later on a canthorhinostomy was performed and a funnel of conjunctiva was brought down and sewn to nasal mucosa. For a while this functioned admirably but after a month it began to stenose. T h e stricture was dilated regularly by the surgeon and by the patient but failed to allow the ostium to remain patent. For six months the patient wore an acrylic tube dilator but on its removal the scarring again began to contract. The area was opened up once more and the anastomosis refashioned ; this time a piece of right nasal bone the size of a finger nail was removed permitting large flaps of nasal mucosa to be raised. At the time of operation fluid in the lower fornix could easily be expressed into the nose but again the sequence of events was repeated and the obstructive epiphora became complete fairly soon after operation. Rycroft's skin-fined tube was decided against because the area was by this time becoming so scarred that it would have been difficult to find a suitable bed for the graft and the existing fibrous tissue would without doubt have strangulated it. It was decided to create a false passage from the lower fornix to the nose and to implant an acrylic tube therein. T o this there were many objections but it was considered a worth=while chance as there appeared to be little else one could do to relieve the epiphora. With a general anesthetic a tenotome was pushed down into the lower fornix and made to present in the nose beneath the middle turbinate. There was no bony obstruction owing to the previous surgery and it was easy to fashion a small tunnel with as little damage to the surrounding tissue as possible. Through this a polythene tube was inserted and was anchored with two braided nylon sutures in the lower fornix. The upper end lay over the caruncle and two small holes were cut in the tube in the region of the lower fornix to ensure dependent drainage. There was no reaction to this implant and it has remained quiet since its insertion fifteen months ago. The lachrymal secretion irrigates the tube and ensures its cleanliness. The epiphora has completely disappeared and the patient is able to carry on her occupation with comfort.
56
BRITISH
JOURNAL
OF PLASTIC
SURGERY
SUMMARY A case of obstructive epiphora due to avulsion of the lachrymal apparatus is described. The various attempts at relief are enumerated, all of which were of no avail. An operation consisting of the insertion of an acrylic tube from the lower fornix to the nasal cavity is described. It has been in situ for fifteen months at the time of writing and has remained completely quiet and provided a totally efficient mechanism of tear drainage. REFERENCES DENCER, D. (1955). Blast. reconstr. Surg., x5, 328. RYCROFT, B. W. (1951). Brit. J. OphthaL, 35, 328. SCALES, J. T. (1953). Pvoc. R. Soc. Med., 46, 647. WILDE, J. (1951). Plast. reconstr. Surg., 8, 234.