Abstract
Purpose
Conjunctivodacryocystorhinostomy (CDCR) with the insertion of a Jones tube is a surgical procedure used to relieve epiphora caused by upper lacrimal system dysfunction from extensive proximal canalicular obstruction, canalicular stenosis, or canalicular flaccidity. Jones tube obstruction, which is the second most frequent complication of CDCR with tube placement, can result from tube placement against the anterior end of the middle turbinate. In this study, we describe our results in 5 patients who underwent anterosuperior partial middle turbinectomy to prevent obstruction.
Methods
A retrospective analysis was performed on 5 patients who underwent selective anterosuperior partial middle turbinectomy to prevent Jones tube obstruction. Three of these patients developed Jones tube obstruction due to contact between a previously placed Jones tube and the anterosuperior aspect of the adjacent middle turbinate. Two other patients had observed contact between the Jones tube and middle turbinate at initial Jones tube placement and underwent anterosuperior partial middle turbinectomy to prevent development of obstruction. Patency of the Jones tube was assessed symptomatically and by nasal endoscopy at the latest follow-up.
Results
All 5 patients displayed a patent Jones tube after a mean follow-up of 29.6 months without complications. Longer-term complications associated with CDCR with Jones tube placement, including continuous epiphora, dacrocystitis, and poor patient satisfaction, were not observed.
Conclusions
Selective anterosuperior partial middle turbinectomy may prevent or relieve Jones tube obstruction, provide increased room along the lateral nasal wall along which to place the Jones tube, and decrease the need for further surgeries arising from tube blockage.
1
Introduction
Conjunctivodacryocystorhinostomy (CDCR) with the insertion of a Lester Jones glass bypass tube is a surgical procedure used to relieve epiphora caused by extensive proximal canalicular obstruction , canalicular stenosis, or canalicular flaccidity . The lacrimal canaliculi can be obstructed by a variety of causes, including congenital agenesis, herpetic infection, trauma, tumors, inflammation, Stevens–Johnson syndrome, systemic chemotherapy or radiation therapy, or facial nerve palsy . CDCRs with Jones tube are also performed after failed previous dacryocystorhinostomies (DCRs) or in cases of lacrimal pump failure, as may result from orbicularis oculi muscle laceration or dysfunction . CDCR with Jones tube placement is accomplished by creating an osteotomy through either a medial canthal incision (external approach) or an intranasal endoscopic approach (internal approach) in order to bypass the upper lacrimal system .
The Pyrex glass Jones tube is currently the most popular tube used in CDCRs to form a direct pathway for tears to flow from the conjunctival lake at the caruncle to the lateral nasal cavity at the middle meatus just anterior to the middle turbinate . The frosted Jones tube is made of a relatively inert glass material that minimizes tube migration or extrusion. Postoperative complications associated with CDCR with Jones tube placement include tube obstruction that may cause continuing epiphora, secondary inflammation, dacrocystitis, and poor patient satisfaction . Tube obstruction can result from their placement against the anterior or superior end of the middle turbinate. This series describes 5 cases in which the anterosuperior middle turbinate was resected to minimize postoperative Jones tube obstruction. To our knowledge, this technique has not been previously described in the literature.
2
Material and methods
2.1
Subjects
Between March 2008 and June 2014, all CDCRs with Jones tube insertion performed at University Hospital, Newark, NJ by the senior authors (J.A.E. and P.D.L.) were retrospectively reviewed. Patients who underwent anterosuperior partial middle turbinectomy to prevent or relieve an obstructed Jones tube were identified. Five cases that met these criteria are discussed in this report ( Table 1 ). Demographic data, history, presenting symptoms, and perioperative data were reviewed. The protocol for this study was reviewed and approved by the Institutional Review Board of Rutgers New Jersey Medical School, Newark, NJ.
| Patient No ⁎ | Age (yrs) | Co-morbidities | Presenting symptoms | Prior procedures | Side Operated | F/u ⁎⁎ (mos) |
|---|---|---|---|---|---|---|
| 1 | 51 | Significant allergies, history of sinus disease | Chronic epiphora, nasal obstruction, facial pain/pressure/congestion, periorbital headache, nasal purulence/discolored postnasal discharge, ear pain/pressure/fullness | Punctoplasty and DCR 9 mos prior | Left | 52 |
| 2 | 58 | Continued epiphora, continued scarring of canalicular system | Punctoplasty and DCR 6 mos and 2 yrs prior, CDCR with JT | Left | 50 | |
| 3 | 28 | Epiphora | Conjunctivoplasty w/extensive rearrangement; CDCR with JT 6 yrs prior | Right | 10 | |
| 4 | 14 | Choanal atresia, bilateral lacrimal outflow abnormalities | Chronic epiphora, near-complete obstruction of bilateral inferior canaliculi | Choanal atresia reconstruction surgery | Right | 11 |
| 5 | 66 | Epiphora, nasal purulence | CDCR with JT 2 yrs prior | Left | 25 |
2.2
Surgical technique
After induction of general anesthesia, the patients were prepared according to the standard for endoscopic sinus surgery and lacrimal system surgery. Pledgets were soaked in oxymetazoline 0.05% and placed into the relevant nasal cavity for approximately 10 min. The pledgets were then removed and the nasal cavity was examined using a 30° rigid endoscope.
The Jones tubes were evaluated after placement of the endoscope into the middle meatus. In cases of contact between the Jones tube and the middle turbinate, attempts at placement of a shorter Jones tube were made. If the tube was still seen to be abutting the middle turbinate, the anterosuperior aspect of the turbinate was subsequently infiltrated with 1% lidocaine with 1:100,000 of epinephrine solution. The middle turbinate was then medialized and the most anterosuperior aspect was selectively resected using a Thru-Cut forceps in order to provide ample space for the distal end of the Jones tube. The lumen of the Jones tube was subsequently irrigated and tested for adequate flow. The edges of the anterosuperior partial middle turbinectomy site were lightly cauterized to prevent bleeding.
2.3
Postoperative care
Postoperatively, patients were treated with nasal saline sprays and analgesics as needed for pain. Patients were subsequently seen between 7 and 14 days for the first postoperative visit for examination and judicious debridement of the surgical bed, and monthly thereafter until adequate healing had occurred.
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