Endoscopic dacryocystorhinostomy (DCR) is a well-established treatment for epiphora caused by anatomic or functional obstruction of the nasolacrimal apparatus.

A thorough understanding of the endonasal anatomy, wide marsupialization of the lacrimal sac, and meticulous care of the mucosa are critical for success.

The lacrimal sac extends approximately 10 mm above the axilla of the middle turbinate.

The common canaliculus opens high up on the lateral wall of the sac. This area must be exposed during a DCR for best results.

The lacrimal bone extends from the frontal process of the maxilla anteriorly to the attachment of the uncinate process posteriorly.

This retrolacrimal region of the lamina papyracea is extremely thin; inadvertent disturbance of the uncinate at this point can lead to orbital penetration.

It is important to recognize that the lacrimal bone and sac lie anterior to the orbit; therefore, the orbit is not at risk unless the surgeon is inadvertently posterior to these landmarks ( Fig. 17.1 ).

Artist’s depiction of an endoscopic view of the left middle turbinate, frontal process of the maxilla, lacrimal bone, and insertion of the uncinate. The lacrimal sac extends above the axilla of the middle turbinate and the opening of the common canaliculus is high up on the lateral wall of the sac.

Surgery is performed under general anesthesia.

The nose is prepared with local injections and vasoconstrictive neurosurgical cottonoids.

With a dental syringe, 2 mL of 1% lidocaine with 1:100,000 epinephrine is infiltrated into the axilla of the middle turbinate and frontal process of the maxilla ( Fig. 17.2 ).

Endoscopic view showing site of infiltration with a local anesthetic and vasoconstrictor. MT, Middle turbinate.

Three neurosurgical cottonoids soaked in 1:3000 epinephrine are then placed in the middle meatus, along the frontal process of the maxilla and adjacent to the septum.

A septoplasty is performed if a septal deflection is preventing access to the middle meatus and lateral nasal wall. The septal incision is ideally placed on the side contralateral to the DCR, because this prevents inadvertent trauma to the septal flap when the endoscope is inserted into the nasal cavity. It also minimizes clouding of the endoscope with blood from the septal incision as well as the potential for the development of postoperative synechiae between the septum and lateral nasal wall.

0-degree and 30-degree endoscopes

Scalpel with a No. 11 blade or Beaver blade

Hajek-Koffler punch or 2-mm upbiting Kerrison rongeur

DCR spear knife

Bellucci micro ear scissors (from micro ear tray)

Round knife (from micro ear tray)

Punctum dilators

Bowman lacrimal probes (sizes 00 and 000)

DCR sickle knife

Lusk pediatric through-biting forceps

DCR bur

Crawford silicone elastomer (Silastic) tubes

Have a low threshold for performing a septoplasty. Limited access restricts the surgeon in making the precise surgical cuts required for the mucosal flaps.

Use a 30-degree endoscope to perform the DCR. This will provide a better view of the lateral nasal wall than a 0-degree endoscope.

The Hajek-Koffler punch and/or Kerrison rongeurs are faster at removing bone than the DCR bur. Perform as much of the removal of the hard bone of the frontal process of the maxilla with the hand instruments and move to the DCR bur only when the punch is unable to grip the bone adequately.

When using the Hajek-Koffler punch, release the jaws after each bite. If a small amount of lacrimal sac has been caught inadvertently between the jaws of the punch, it can be released and only the bone removed. This will prevent inadvertent trauma to the sac.

Use the DCR bur on the bone–sac interface to expose the sac in its entirety but never between the sac and the bone, because this can potentially traumatize the sac.

Remove all of the lacrimal bone up to the insertion of the uncinate, but do not disturb the uncinate itself. This retrolacrimal region where the uncinate inserts into the lamina papyracea is extremely thin, and inadvertent orbital injury might result.

When probing the lacrimal system, do so delicately so that a false passage is not created. The upper and lower canaliculi have an angulated course that must be carefully navigated to avoid creating a false passage. Working on a team with an oculoplastic surgeon will enable the ear, nose, and throat surgeon to obtain the requisite skills in probing and examining the lacrimal system.

Make an incision into the sac only when the lacrimal probe can be clearly seen through the sac wall.