Dacrycystorhinostomy

• Idiopathic (80%)


• Trauma/midface fractures


• Iatrogenic


1. Irradiation


2. Radioactive iodine treatment (RAI)


3. Extensive maxillary antrostomy


4. Nasal osteotomy in rhinoplasty


Neoplasm


• Inverting papilloma


• Lacrimal sac tumor


Systemic


• Granulomatosis with polyangiitis (GPA)


• Sarcoidosis


• Sicca/Sjögren’s syndromes


Anatomic


• Eyelid laxity/malposition


• Facial palsy/paralysis


• Scarring/mass obstruction


• Entropion


• Ectropion


Diagnostic Evaluation of Epiphora


Ophthalmologic Testing


• Fluorescein dye test


1. Fluorescein solution of 2% instilled in conjunctival cul-de-sac


2. Persistence/asymmetric clearance at 5 minutes indicates decreased outflow


• Jones Test


1. Jones 1: performed following fluorescein dye test


– Dye placed in inferior conjunctival cul-de-sac


– Duration of 5 to 10 minutes: attempt to recover from inferior meatus


2. Jones 2: performed following Jones 1 testing


– Saline irrigation through lacrimal system


– Irrigant in nose indicates low grade obstruction


– Dye in irrigant indicates low sac or duct obstruction and patent canalicular system


3. Lacrimal Probing


– Performed after negative Jones 2 test


– Measure distance at which obstruction encountered


Imaging


• Computed Tomography (CT)


1. Allows identification of associated sinus disease, septal deviation, anatomic abnormality, or tumor


2. Good for evaluation of bony anatomy


3. Useful for intraoperative image guidance


• Magnetic Resonance Imaging (MRI)


1. Rarely utilized


2. Good for soft tissue anatomy


• Ultrasound


1. Simple, noninvasive evaluation of nasolacrimal system


2. Cannot evaluate canalicular or physiologic obstruction


3. Able to identify dilated sac, neoplasm, or dacryolith


• Dacryoscintigraphy (DS)


1. Radionuclide solution instilled in eye and physiologic flow assessed while images obtained


2. Poor resolution limits usefulness


• Dacryocystography (DCG)


1. Gold standard of nasolacrimal system imaging


2. Radiopaque contrast solution instilled into canaliculus


3. DCG-CT allows for greater bony detail


4. DCG-MRI allows for fine soft tissue detail and can differentiate mucous, blood, and neoplasm


5. Percutaneous-contrasted DCG allows bypass of common canalicular obstruction and evaluation of lacrimal sac

Jul 20, 2019 | Posted by in OTOLARYNGOLOGY | Comments Off on Dacrycystorhinostomy
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