Endonasal approaches to the correction of nasolacrimal duct (NLD) ob- struction were described by several investigators, including Caldwell, West, and Mosher in the late 1800s and early 1900s. Because of tech- nical limitations in terms of visualization of the surgical site and e\ufb00ective soft tissue and bone removal, the popularity of intranasal dacryocystorhi- nostomy (DCR) was limited throughout most of the twentieth century; lacrimal bypass surgery was performed more commonly by way of external routes, as reported by Toti and Dupuy-Dutemps and Bouquet. With the advent of the rigid \ufb01beroptic endoscope and its use in paranasal sinus surgery, there has been renewed interest over the past decade in endoscopic surgery for the correction of primary[6\u20138] and recurrent[9\u201311] lacrimal obstruction.
Primary endoscopic DCR (EDCR) may be indicated in the management of tearing or infection that is associated with primary acquired NLD ob- struction or NLD obstruction that is secondary to speci\ufb01c in\ufb02ammatory or in\ufb01ltrative disorders. Generally, this procedure is indicated when the level of obstruction is determined to be at or distal to the junction of the lacrimal sac and duct, although more proximal pathology also may be managed
Portions of this article are reprinted from: Woog JJ. Endoscopic Dacryocystorhinostomy and Conjunctivodacryostorhinostomy. In: John J. Woog, Ed. Manual of Endoscopic Lacrimal and Orbital Surgery. Philadelphia: Butterworth/Heineman, 2004; with permission.
endoscopically. EDCR also is useful in the management of lacrimal duct injuries that are associated with sinus surgery, as well as in selected patients with a history of facial trauma. In addition, it may be appropriate in certain patients who have atypical forms of congenital dacryostenosis.
EDCR has been considered contraindicated in several settings. Most importantly, EDCR is contraindicated for patients who have a suspected neoplasm that involves the lacrimal out\ufb02ow system or for those in whom such a lesion cannot be excluded. Clinical criteria that raise the possibility of a neoplasm may include (1) the presence of an indurated, noncompress- ible mass, possibly with \ufb01xation to the underlying bone or extension above the level of the medial canthal tendon; (2) bloody epiphora; (3) atypical age of onset of obstruction (eg, young adulthood); and (4) the presence of bony destruction or a \ufb01lling defect on radiologic studies, although the latter also may occur in the setting of nonneoplastic causes of obstruction (eg, dacryo- lithiasis). Relative contraindications to EDCR include the presence of a large diverticulum lateral to the lacrimal sac, common canalicular stenosis, or re- trieval of large lacrimal system stones.
For patients who require endoscopic sinus surgery in addition to EDCR, this procedure may be performed conveniently and e\ufb03ciently using the same instrumentation, during the same setting. The endoscopic skills and instru- ments that are used for EDCR are the same as those used routinely for endoscopic sinus surgery by otolaryngologists. The endoscopic approach provides excellent visualization and management of intranasal structures, and may be associated with an improved outcome, because intranasal syn- echiae and improper placement of the rhinostomy site (eg, into an agger nasi cell or the superolateral aspect of the middle turbinate) are common causes of failure of external DCR (EXTDCR). There are no facial incisions. As a re- sult, the risk for cutaneous \ufb01stulas, of concern in patients who had previous radiation therapy or certain granulomatous disorders, also may be reduced.
EDCR may be performed using general or local anesthesia. If general an- esthesia is used, decongestion of the nasal mucosa is achieved by placement of nasal pledgets that contain oxymetazoline 0.05% in the middle meatus, followed by endoscopic injection of 1% xylocaine containing 1:200,000 epi- nephrine into the lateral nasal wall and middle turbinate.
Surgery using local anesthesia begins with instillation of topical propar- acaine or tetracaine in the conjunctival cul-de-sac of the operated eye. Intra- venous administration of short-acting sedative-hypnotics may enhance patient comfort during subsequent anesthetic injection. A 1:1 mixture of 2% xylocaine with 1:200,000 epinephrine and 0.75% bupivacaine is admin- istered to provide an infraorbital nerve block. Additional local anesthetic is
in\ufb01ltrated subcutaneously and subconjunctivally in the medial eyelids and medial canthal region. Pledgets that contain oxymetazoline and viscous xy- locaine solution are placed in the middle meatus, and the local anesthetic is injected submucosally.
The point of insertion of the root of the middle turbinate on the lateral nasal wall and the maxillary line are key intranasal landmarks for identify- ing the location of the lacrimal sac. For surgeons who are becoming familiar with intranasal anatomy and surgery in patients who have atypical anatomy or a history of sinonasal procedures, it may be helpful to introduce a 20- gauge \ufb01beroptic endoilluminator (Fig. 1), as used in vitreoretinal surgery, through the superior or inferior canaliculus after punctal dilation. The en- doilluminator is advanced gently until a hard stop that signi\ufb01es the lacrimal bone medial to the lacrimal sac is identi\ufb01ed. The location of the lacrimal sac then may be visualized endoscopically by transillumination (Fig. 2). Alter- natively, a surgical navigation system may be used to localize the region of the lacrimal fossa and sac.
After lacrimal sac localization, the mucosa on the lateral wall is incised us- ing a sickle knife, blade, or electrocautery and is elevated using a Freer eleva- tor (Fig. 3). It is helpful to place this incision well anterior to the location of the lacrimal sac to allow full exposure of the overlying bone. The incision is oriented vertically, extending from inferior to superior to minimize interfer- ence from bleeding. After the mucosa is elevated widely from the underlying bone, it is removed with Blakesley forceps. Alternatively, mucosal ablation
Fig. 1. The endoscopic approach to the lacrimal sac is demonstrated in this coronal section of the right lacrimal system and nasal cavity. A \ufb01beroptic endoilluminator is introduced through the superior or inferior canaliculus into the lacrimal sac.
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