Endoscopic Dacryocystorhinostomy

DISEASE DESCRIPTION

Nasolacrimal duct obstruction in adults is generally due to chronic fibrosis of the duct mucosa, likely from inflammation. Other causes include injury, neoplasm, infection, radiation, radioactive iodine, and trauma. Symptoms may be unilateral or bilateral and include epiphora, crusting, and intermittent blurred vision due to optical media fluctuation.

MANAGEMENT OPTIONS

Conservative management
- Observation
- Topical drops (antihistamine, mast cell stabilizer, corticosteroid)
Surgical intervention
- Silicone intubation alone
- External or endoscopic dacryocystorhinostomy (DCR)
  - The efficacy of external and endoscopic DCR are generally considered equal with proper equipment and an experienced surgeon.

SURGICAL DESCRIPTION

Preparation
- During preoperative preparation, administer two to three puffs of intranasal oxymetazoline/tetracaine spray in the operative side.
- Vasoconstriction by local anesthetic injection
  - Inject a small volume, high above middle turbinate axilla.
  - Inject several points anterior to planned vertical portion of mucosal incision.
  - Inject superior surface of inferior turbinate.
  - Injection of septum may help if the septum is laterally deviated.
- Vasoconstriction by topical
  - Soak cottonoid pledgets in oxymetazoline/tetracaine mix.
  - Fold the pledget (or even fold twice) for compressive effect.
  - Advance the pledget into place at the middle turbinate.
Visualization
- Rigid nasal endoscope — 0° or 30°, 4.0 mm diameter, 175 mm length
- Endo-Scrub lens cleaning sheath
  - Sheath fits over scope (shaped specifically for the angle of the scope) and delivers irrigation to surgical field, washes front of scope.
  - Increases diameter of scope, which can be an advantage if scope is used to push septum medially — but better to just do septoplasty.
- Septoplasty indicated if surgical target/middle turbinate axilla not visible with short nasal speculum and anterior visualization
  - If unilateral DCR, septal incision contralateral to DCR
  - Extend septoplasty very anterior on quadrangular cartilage, almost to dorsum
  - Release quadrangular cartilage with high cartilage incision parallel to dorsum

Mucosal incisions (Figure 28.1)

Superior horizontal incision as high as possible above middle turbinate axilla
Vertical incision just anterior to frontal process of maxillary line

Inferior horizontal incision along superior surface of inferior turbinate, back to uncinate

FIGURE 28.1. A, Endoscopic view of the relevant anatomy with markings of the initial mucosal incision sites. B, Illustration of anatomic landmarks visible in the photograph.

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