Abstract
Conjunctivodacryocystorhinostomy (CDCR) with Jones tube placement is usually performed as a primary procedure for severe stenosis or obstruction of both upper and lower canaliculi of the lacrimal drainage pathway, or occasionally, after unsuccessful dacryocystorhinostomy (DCR). Jones tube obstruction is quite common, and often requires removal of the obstructed tube and replacement or exchange of the tube in the operating room. This procedure is typically performed under general anesthesia, and is associated with the risks of general anesthesia, a significant investment of time, and the cost of the operating suite. Recently, there has been a movement toward in-office procedures in otolaryngology and ophthalmology due to greater patient satisfaction and savings in time and money for patients and physicians. In this report, we describe a novel in-office method to exchange an obstructed Jones tube that provides the aforementioned benefits while preserving patient comfort. No similar case has been previously reported in the literature.
1
Introduction
Conjunctivodacryocystorhinostomy (CDCR) with Jones tube placement is usually performed as a primary procedure or for severe stenosis or obstruction of both upper and lower canaliculi of the lacrimal drainage pathway, or occasionally, after unsuccessful dacryocystorhinostomy (DCR). The purpose of the procedure is to create a new conduit for tear outflow, bypassing the lacrimal system by careful positioning of a small Pyrex tube between the tear lake at the region of the caruncle and the middle meatus just anterior to the middle turbinate ( Fig. 1 ).
Jones tube obstruction is a very common problem encountered by ophthalmologists and otolaryngologists after CDCR ( Fig. 2 ). Typically, treatment of Jones tube obstruction consists of reoperation and insertion either of a new Jones tube or of the previously used tube after appropriate cleansing. However, this procedure is usually performed in an operating room and subjects patients to the risks associated with general anesthesia. In this report, we describe a novel in-office method of reinserting a Jones tube using the Seldinger technique. This method avoids the need for reoperation under general anesthesia as well as the cost associated with the operating room and anesthesia service while preserving patient comfort. To our knowledge, this technique has not been previously described in the office setting. The protocol for this study was reviewed and approved by the Institutional Review Board of the University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, New Jersey.
2
Illustrative case
A 66-year-old woman with a history of multiple procedures (including Jones tube placement) for treatment of lacrimal duct obstruction presented with left-sided tearing. Physical examination confirmed left epiphora. Rigid 30-degree nasal endoscopic examination revealed a deviated nasal septum superiorly to the right side with an obstructed Jones tube lumen secondary to thick crusting ( Fig. 2 ). An in-office exchange of the Jones tube using the Seldinger technique was performed.
2.1
Surgical technique
The patient was placed in the seated position and vital signs were assessed. The bilateral nasal cavities were decongested and anesthetized with a combination of oxymetazoline hydrochloride 0.05% and topical lidocaine hydrochloride 4%. After 5 min had elapsed, the left nasal cavity was packed with cottonoids soaked in topical lidocaine hydrochloride 4% and oxymetazoline hydrochloride 0.05% solution. Care was taken to lay the cottonoids in the middle meatus, anterosuperiorly in the region of the Jones tube and against the nasal septum and anterolateral nasal wall to anesthetize the path of potential instrument contact. Ten minutes were subsequently allowed to elapse with the cottonoids in place against the nasal mucosa. Using a tuberculin syringe, the areas surrounding the Jones tube were injected with 1% lidocaine hydrochloride with 1:100,000 of epinephrine solution. Proparacaine hydrochloride ophthalmic solution 0.5% drops were placed in the area of the caruncle. This area was subsequently injected with 1% lidocaine hydrochloride with 1:100,000 of epinephrine solution. The area near the intranasal lumen of the tube was carefully debrided using endoscopic technique. A 3-0 Prolene suture was passed through the tube ( Fig. 3 A ) which was subsequently removed while leaving the Prolene suture in place ( Fig. 3 B). The tube was removed, cleaned, and re-introduced into the old tract over the Prolene suture ( Fig. 3 C). Jones tube patency was confirmed by placing balanced salt solution in the caruncle area, and examining for quick egress in the distal end under endoscopic examination. The patient tolerated the procedure well without complications and was treated postoperatively with oral and topical antibiotics. She is currently doing well 2 years after the procedure and only requires periodic Jones tube care.
