2008-87 endoscopic dacryocystorhinostomy

(2008)79,772-776
in 0totaryngotogy
0perativeTechniques
OperativeTechniquesin
Otolaryngology
E LS E V I E R
Endoscopic
nostomy
dacryocystorhi
RajSindwani,
MD,"RalphB. Metson,MDb''
From the "Department of Otolaryngology-Head and Neck Surgery, Division of Rhinology & Sinus Surgery, St. Loui,s
University, St. Louis, Missouri;
bDepartmentof Otolaryngology, MassachusettsEye and Eai lryfirmary, Boston, Massachusetts;and the
'Department of Otology and l-a.ryngology,
Harvard Medical School, Boston, Massachusetts.
KEYWORDS
Endoscopic
dacryocystorhinostomy ;
EDCR;
Epiphora;
Nasolacrimal duct
obstruction (NLDO)
With the recent proliferation of endoscopic surgical techniques, there has been renewed interest in
performing dacryocystorhinostomy (DCR) via an intranasal endoscopic approach. Advantages of
endoscopic dacryocystorhinostomy (EDCR) include: excellent visualization, the ability to thoroughly
evaluate the location and size of the rhinostomy site, and the avoidance of a facial scar. EDCR is a safe
and effective alternative to raditional external DCR surgery, and offers comparable successrates.
O 2008 Elsevier tnc. All rishts reserved.
Intranasal approachesto correct nasal lacrimal duct obstruction (NLDO) were first described more than a century
ago.l-3 These techniques were limited becausethey provided poor visualization of the lacrimal sac in the superior
nasal cavity and lacked effective instrumentation to adequately open the sac. With the recent proliferation of endoscopic surgical techniques,there has been renewed interest
in performing dacryocystorhinostomy (DCR) via an intranasal endoscopic approach.a-6In addition to avoiding a
facial scar,endoscopicDCR (EDCR) enablesthe surgeonto
identify and correct common intranasal causes of DCR
failure, such as adhesions, an obstructing middle turbinate,
or an infected ethmoid sinus.
Patientselection
Primany EDCR may be indicated in the management of
epiphora or dacryocystitis associated with either primary
acquired NLDO or obstruction secondaryto specific inflammatory, infiltrative, congenital, or traumatic causes,including injuries from sinus surgery.7This procedure is most
effective when the level of obstruction is determined to be
at or distal to the junction of the lacrirnal sac and duct,
although more proximal pathology may also be managed
endoscopically.The use of EDCR is particularly advantaAddress r:eprint requests and correspondence: Raj Sindwani, MD,
Department of Otolaryngology-Head and Neck Surgery, Division of Rhinoiogy & Sinus Surgery, St, Louis University. 3635 Vista Avenue. 6 FDT,
St. Louis. MO 63104.
E-maiL address: [email protected].
1043-t810/$ -scc front matter O 2008 F,lsevier Inc. AII rishts reserved.
doi : | 0. t0l 6/j.otot.2008.09.009
geous in patients with concomitant sinonasaldisease,patients with a previous history of radiation therapy to the
head and neck, pediatric patients, and in revision procedures. For patients who require endoscopic sinus surgery
(ESS) in addition to EDCR, this proceduremay be convenientiy and efficiently performcd with use of the same
instrumentation during the same setting. EDCR is contraindicated in patients with a suspectedneoplasm involving the
lacrimal apparatusor in those in whom such a lesion cannot
be excluded. Relative contraindications to EDCR include
the presenceof a large diverticulum lateral to the lacrimal
sac, common canalicular stenosis,or retrieval of laree lacrimal system stones.
SurgicaItechnique
EDCR may be .performed under either local or general
anesthesia.The nasal cavity is decongestedwith 0.05Vo
oxymetazoline spray, and a 4-mm diameter zero degree
endoscopeis used for the injection of lVo Xylocaine containing 1:100,000 epinephrinejust anterior to the attachment of the middie turbinate along the lateral nasal wall.
Pledgets soaked tn 4Vococaine solution may then be placed
along the lateral nasal wall and middle meatus for further
decongestion, if preferred.
Lacrimalsaclocalization
From an endoscopic,intranasalperspective,the lacrimal
sac can be found beneath the bone of the lateral nasal wall
just anterior to the attachment of the middle turbinate (Fig-
Dacryocystorhinostomy
Sindwaniand Metson Endoscopic
L73
Bone removal
To expose the lacrimal sac, the bony lacrirnal fossa must
be uncovered. Bone removal may be achieved with a variety
of instmments and should commence at the maxillary [ine,
proceeding anteriorly. Although the lacrirnal bone located
posterior to the maxillary line may be taken down with
minimal force, the authors recommend the use of a highspeed drill with a cutting burr or an ultrasonic surgical
aspirator for removal of the dense frontal process of the
maxilla which is situated anteriorly (Figure 5). Adequate
exposure of the sac is confirmed by blotting of the medial
canthus and movement of a lacrirnal probe which has been
passedby the assistantthrough a canaliculusinto the sac. A
well-placed,generousbony rhinostomy (at least8-12 mm in
diameter) will facilitate a successful outcome.
Openingof the lacrima[sacand intubation
Figure 1 The lacrimalsacis locatedbeneaththeboneof the lateral
nasalwall just anteriorto the attachmentof the middle tLrbinate.
ure l). The maxillary line is the key intranasal landmark for
endoscopic DCR (Figure 2).8 It is readily identified as a
curvilinear eminence along the lateral nasal wall that runs
from the anterior attachment of the middle turbinate to the
root of the inferior turbinate, Its location corresponds to the
suture line between the maxillary and lacrimal bones which
runs in a vertical direction through the lacrimal fossa. The
maxillary line bisects the lacrimal sac such that the frontal
processof the maxilla covers the anterior half of the sac, and
the thin lacrimal bone covers the posterior half. The uncinate processlies just medial to the lacrimal sac and must be
removed to accessthe thin lacrimal bone covering the posterior portion of the sac. In contrast, exposure of thc anterior
sac necessitatesremoval of thicker bone locatedjust anterior to the maxillary line. Sac localization in difficult cases
may be facilitated through transillumination using a 20gauge fiberoptic endoilluminator introduced through the superior or inferior canaliculus, or with the aid of a surgical
navigation system (Figure 3).
After removal of the overlying bone, the lacrimal sac is
incised with a sickle knife (Figure 6). It is often helpful for
the assistantto "tent out" the medial wall of the lacrimal sac
with the previously inserted lacrimal probe(s). The medial
wall of the lacrimal sac may then be removed with forceps
and submitted for histopathologic examination. After the
media-l sac wall has been resected, a bicanalicular tube is
placed by intubating both canaliculi, with subsequentretrieval of the probes from the rhinostomy site endoscopically (Figure 7). The tubing is then tied at the nasalvestibule
forming a closed-loop stent (Figure 8). The stents are usually removed at 6 weeks postoperatively, but intervals tbr
stent removal ranging from 4 weeks to 6 months have been
advocatedbv others.e'to
MucosaI incision
Surgical dissection is begun with removal the uncinate
processlocatedposteriorto the maxillary line (Figure 4). An
air space is often entered which corresponds to the infundibulum or an anterior ethmoid air cell overlying the lacrimal sac. Next, an incision is made in the mucosa on the
lateral wall with a sickle-knife and it is elevated with a Freer
elevator. It is helpful to place this incision well anterior to
the location of the lacrimal sac to allow for full exposure of
the overlying bone. After the mucosa is widely elevated
from the underlying bone, thru-cutting forceps are used to
remove it.
Figure 2
The maxillary line bisects the lacrimal sac such that
the lrontal process of the maxilla covers the anterior half of the sac,
and the thin lacrimal bone beneath the uncinate process covers the
posterior half.
774
2008
Vol 19, No3, September
in Qtotaryngology,
Techniques
0perative
Location of the lacrimal fossa (cross-hairs) relative to anterior ethmoidal air celis demonstrated in 3-dimeirsions using an image
Figure 3
guidance system. (Kolibri system, BrainLAB, Munich, Germany). (Color version of figure is available online.)
Mitomycin-C
and adjunctiveprocedures
Some surgeonselect to apply topical mitomycin-C to the
intranasalrhinostomy site. Mitomycin-C is an antimetabolite that inhibits fibroblast function and has been used to
modulate postsurgical fibrosis in a variety of applications.
Figure 4
Surgical dissection begins with the removal of the
uncinate process located posterior to the maxillary line. An incision is next made in the mucosa on the lateral wall over the reeion
of tlre lacrirnal fossa/sac.
Reports on the utility of mitomycin-C in prevention of
postoperative mucosal fibrosis and rhinostomy closure have
demonstratedmixed results.tt-t+ 1g used, mitomycin-C is
applied to the rhinostomy site in a concentration of 0.4
mglmL with the use of a cotton-tip applicator, for a period
of 4 minutes, after which copious saline irrigation is performed.
Figure 5
A high-speed drill with a cutting burr is used to
remove the thick frontal processof rhe maxilla, which overlies the
anterior oortion of the lacrimal sac.
176
Operative
Techniques
in Otolaryngology,
Vo|.].9, No 3, September
2008
Conclusions
Endoscopic surgery for lacrimal outflow obstruction is a
safe and effective alternative to traditional external DCR
surgery. EDCR is particularly advantageousin patients with
concomitant sinonasaldisease,patientsWith a previous history of radiation therapy, pediatric patients, and in revision
procedures. Advantages include excellent visualization, the
ahility to thoroughly evaluate the location and size of the
rhinostomy site, and the avoidanceof a facial scar. Recent
studiessuggestthat the successratesof endoscopicDCR are
comparable to those achieved through external approaches.
References
1. Caldwell GW; Two new operations for obshuction of the nasal duct, with
prcservation of the canaliculi. Am J Ophthalmol l0:189-192, 1893
2. West .IM: A window resection of the nasal duct in cases of stenosis.
Trans Am Ophthalmol Soc 12:654, 1.914
3. Mosher HP: Re-establishing intranasal drainage of the lacrimal sac.
Laryngoscope 3I :492-521, l92l
4. Mctson R: The endoscopic approach for revision dacryocystorhinostorny. Laryngoscope I0O: 1344-1347, 1990
5. Massalo BM, Gonnering RS, Harris GJ: Endonasal laser dacryocystorhinostomy: A new approach to nasolacrima.l duct obstruction. Arch
Ophthalmol 108:I 172-l t76, 1990
6. Woog JJ, Sindwani R: Endoscopic dacryocystorhinostomy and conjuncti vodacryr:cystorhinostomy. Otolaryngol Clin North Am 39: I 00 I 1 0 1 7 .2 0 0 6
7. Bartley GB: Acquired lacrimal drainage obstruction; an etiologic clas_
sification system, case reports, and a review of the literature. part l.
Ophthal Plast Reconstr Surg 8:237-242, 1992
8. Chastain JB, Cooper MH, Sindwani R: The maxillary line: anatomic
characterization and clinical utility of an important surgical landrnark.
Laryngoscope L 15:990-992, 2005
9. Yung MW, Hardman-Lea S: Endoscopic inferior dacryocystorhinostomy. Clin Otolaryngol Allied Sci 23:152- 157, 1998
10. Morl"imore S, Banhegy CY, Lancaster JL, et al: Endoscopic dacryocystorhinostomy without silicone steuting. J R Coll Surg Edinb 44:
37t-373.t999
11. Deka A, BhattacharjeeK, Bhuyan SK, et al: Effect of mitomycin C on
ostium in dacryocystorhinostomy. Clin Exp Ophthalmol 34:557-561,
2006
12. Chan KO. Gervais M, Tsaparas Y, et al: Effectiveness of intraoperative mitomycin C in maintaining thc patency of a frontal sinusotomy:
A preliminary report of a double-blind randomized placebo-controlled
trial. Am J Rhinol 20:295-299,2Q06
i3. Zilelioglu G, Ugurbas SH, Anadotu Y, et al: Adjuncrive use of miromycin C on endoscopic lacrimal surgcry. Br J Ophthalmol 82:63-66.
1998
14. Camara JG, Bengzon AU, Henson RD: The safety and efficacy of
mitomycin C in endonasal endoscopic laser-assisted dacryocystorhinostomy. Ophthal Plast Reconstr Surg l6: I 14-l 18, 2000
15. Tsirbas A, Davis G, Wormald PJ: Mechanical endonasal dacryocystorhinostomy versus external dacryocystorhinostomy. Ophthal Plast
Reconstr Surg 20:50-56, 2004
16. Apaydin KC, Fisenk F, Karayalcin B, et al: Endoscopic transnasal
17.
18.
19.
20.
dacryocystorhinostomy and bicanalicular silicone tube intubation.
Ophthalmologica 2 18:306-3I l, 2004
Metson R, Woog JJ, Puliafito CA: Endoscopic laser dacryocystorhinostomy. Laryngoscope 104:269-274, 1994
Orrerci M, Orhan M, Ogrchnenoglu O, et al: Long-term results and
reason$ for failure of intranasal endoscopic dacryocystorhinostorny.
Acta Otolaryng ol 120:319-372, 2000
Ityet ts, Racy E, Assnuline M: Complications of standardizedendonasal dacryocystorhinostonry with unciformectomy. Ophthalmology
I I l:837-845, 2004
Migliori ME: Endoscopic evaluation and management of the lacrimal
sump syndrome. Ophthal Plast Reconstr Surg l3:28 l-284, lggT