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DACRYOCYSTORHINOSTOMY UTILIZING AN ANTERIOR LACRIMAL SAC FLAP TO PERIOSTEUM TECHNIQUE G. RICHARD HOlT, MD JEAN EDWARDS HOlT,MD and
EDWIN A. CORTEZ, MD BY INVITATION
SAN ANTONIO, TEXAS Dacryocystorhinostomy Is used in the effective treatment of epiphora secondary to obstruction of the lacrimal drainage system. Common causes of obstruction include canalicular disruption, lacrimal sac fibrosis, and external and Internal nasal trauma. Most techniques of dacryocystorhinostomy attempt to suture the lacrimal sac mucosa to the nasal mucosa. At best this is technically difficult, and the mucosa frequently tears. A technique Is presented using an anteriorly based lacrimal sac pedicle flap sutured to the periosteum of the anterior lacrimal crest. The sutured flap is quite strong, and the procedure is technkally simpler than others. A brief description of the causes of lacrimal obstruction Is given. The Jones primary and secondary dye tests for lacrimalsystem patency are reviewed.
who performed hot cauterization on the lacrimal fossa to treat chronic dacryocystitis.' The early 19th century proponents of dacryocystorhinostomy (DCR) were rhinologists (Killian, Caldwell, and West) who performed the operation intranasally.! Another rhinologist, Toti, developed the initial approach to DCR via an external incision. It was not until 1921, when ophthalmologists Dupuy-Dutemps and Bourguet! reported the classic DCR using an external incision and mobilizing both anterior and posterior flaps of nasal and lacrimal sac mucosa, that the modern operation was born.
Presented as a Scientific Poster Presentation at the Annual Meeting of the American Academy of Otolaryngology, Las Vegas, Sept 10-13.
In the past 50 years, many variations of the procedure have been used including anterior flaps of nasal and lacrimal sac mucosa, 4-6 an anterior nasal flap swinging back on the nasal periosteum,7 an anterior nasal flap to lacrimal sac,8 one large posterior flap,9 a three-flap technique.w and the classic four-flap technique.! Taiara? and co-workers also sew the anterior lacrimal sac remnant to nasal periosteum in addition to the posterior flap. These have a range of success rates from 85% to 98%." Many authors suggest the implanting of foreign materials into the DCR, including silk or nylon sutures, glass and plastic tubes,12 and Geltoam.?
Reprint requests to the University of Texas Health Science Center, 7703 Floyd Curl Dr, San Antonio, TX 78284 CDr G. Holt).
Most techniques currently use either deep suturing of posterior flaps or the
INTRODUCTION SURGERY on the lacrimal sac may have originated as early as 1 AD with Celsus,
Submitted for publication Sept 11, 1978. From the divisions of otorhinolaryngology (Drs G. Holt andCortez) andopthalmology (Dr J. Holt) ofthe University of Texas Health Science Center, San Antonio. 1978
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suturing of anterior nasal flaps, both of which are technically difficult and frustrating to the surgeon. The nasal mucosal flaps are usually friable, thin, and easily torn. Posterior flaps that are merely laid into the nasal cavity probably undergo the same fate as mucosal flaps into nasalantral windows, namely shrinkage and regression. The technique presented here uses a strong anteriorly based pedicle flap of lacrimal sac sewn to nasal bone periosteum-a formidable combination for success requiring only simple and efficient steps.
PHYSIOLOGY AND ANATOMY Knowledge of the anatomy and physiology of the lacrimal drainage system is essential for surgeons operating on its structures. The lacrimal sac and canaliculi develop from ectodermal cell rests, buried by the closure of the lateral nasal groove. They are met by a column of cells evaginated from the nasal cavity. Failure of fusion of the two systems gives a congenital blockage. Externally the globe is moistened by a continuous film of tears. The normal removal of tears is by evaporation and drainage into the lacrimal system," lpp 13·22) The canaliculi originate as puncta in the medial margin of each eyelid, continue as upper or lower canaliculi for 2 to 2.5 mm, then turn horizontally and join to form the common canaliculus (Fig 1). This structure is approximately 8 mm long and enters the lacrimal sac on its lateral and posterior surface just behind the medial canthal ligament. The lacrimal sac lies within the fossa of the lacrimal bone and is surrounded by an investment of fascia. This fascia (anatomically part of the periorbital is attached tightly to both anterior and posterior lacrimal crests. It is absent in the lower 3 to 4 mm of the lacrimal sac and
Fig1.-Surgical anatomy of lacrimal drainage system. A, Canaliculus; 8, Medial canthal tendon; C, Horner's muscle; 0, Lacrimal sac; E, Lacrimal fascia; F, Nasolacrimal duet; G, Nasal bone periosteum.
forms a constriction just above the nasolacrimal duct. The sac is approximately 14 to 15 mm long with the nasolacrimal duct extending through the maxillary bone for 12 mm and ending as 2 to 3 mm of soft tissue in the inferior meatus, found anteriorly and just below the attachment of the inferior turbinate. 6 (pp l .121 The tendon of the orbicularis oculi muscle splits at the level of the lacrimal sac, with the bulk of it forming the medial cantha I tendon that attaches anterior to the sac and the posterior portion, known as Horner's muscle, attaching behind the sac to the region of the posterior lacrimal crest. The septum orbitale lies lateral to the lacrimal fascia, serving as a barrier to fat extrusion during surgical exposure of the lacrimal fossa. Current theories propose that the c10sure of the eyelids during blinking produces a positive pressure in the canaliculi by shortening them, propelling their con-
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tents into the lacrimal sac. Contraction of the muscles on the fascia surrounding the lacrimal sac opens the sac and produces a negative pressure effect, drawing the tears into the cavity. Opening of the eyelids and the gravity effect are believed to be responsible for the flow of tears into the nasolacrimal duct and nasal cavity.6 (pp 13-22) DIAGNOSIS
Epiphora caused by obstruction or malposition in the lacrimal drainage system must be distinguished from chronic lacrimation or overproduction of tears owing to hypersecretion by the lacrimal gland, probably secondary to reflex irritation.! A Schirmer's tear test, as performed on all patients with facial paralysis, will indicate this hypersecretion. Most patients with epiphora are referred to ophthalmologists. While many ophthalmologists do not perform DCRs, they are able to accurately diagnose the site of the pathologic condition and refer the patient to a surgical colleague. For the most part, otolaryngologists are not part of the management because of a lack of understanding of the specific anatomy and physiology and, more specifically, an inability to correctly diagnose the cause of the epiphora. However, the diagnostic steps are well defined and amenable to use by the otolaryngologist. The main causes of obstruction leading to epiphora include congenital defect, repeated infections, trauma, neoplasms, and nasal and sinus pathology." If the obstruction is congenital, it ls found bilaterally in 550ft of patients and is most commonly caused by an impatency of the meatus (valve of Hasnerl leading to the nasal cavity. Nasolacrimal duct probing in children under 3 years of age will result in nearly 100% patency, and OCR is not necessary. The average age of onset of the acquired obstruction is the 20- to 40year age group, with the younger patients
more likely to have trauma or dacryoliths as the cause. The history with acute dacryocystitis will indicate periodic painful swelling lateral to the nose or chronic sac enlargement with epiphora in chronic infections. Pressure on the sac may produce purulent material at the puncta. A complete head and neck examination is required to rule out nasal, sinus, or bony pathology. The most common ENT diseases affecting the lacrimal drainage system include nasal allergies, mucosal polyps, deviated nasal septum, enlarged turbinates, and posttraumatic facial bone changes. Facial radiographs are helpful in discovering contributing pathologic conditions. The eyelids should be examined carefully to rule out mild punctal or lid ectropion and senile atonicity as causes for poor tear film movement. One should not routinely probe the nasolacrimal duct until obstruction has been diagnosed by other means, as this trauma might convert a partial obstruction into a permanent one. Tumor and dacryoliths may be palpated as firm masses in the lacrimal sac region. Disturbances of the surrounding bone such as midline lethal granuloma, fibrous dysplasia, and other bony tumors should be kept in mind. Recent advances in the radiography of the lacrimal drainage system have contributed valuable information in certain cases of obstruction. Intubation macrodacryocystography involves radiography during catheter injection, filling of the lacrimal drainage system, and enlarging of the image with a subsequent subtraction print. It gives excellent visualization of the excretory apparatus. In addition, quantitative lacrimal scintillography has been employed to assess lacrimal excretory function." Both of these techniques are complementary and, although expensive and technical, give valuable information regarding patency of the canalicular system or identifying the blockage point in a postoperative failure.
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DACRYOCYSTORHINOSTOMY The basic ophthalmologic diagnostic tests used by the surgeon to determine candidacy for a OCR are the primary and secondary Jones dye tests. In the primary Jones dye test, one drop of 1% fluorescein is instilled into the lower conjunctival cul-de-sac. A cotton swab or pledget is placed beneath the inferior meatus and is checked at 1-, 3-, and 5-minute intervals to ascertain if dye has entered the nose. If fluorescence has occurred, a positive primary Jones dye test exists. However, failure to identify the dye occurs in approximately 20% of normal patients. Thus a positive test indicates normal function, but a negative test does not exclude it. The secondary Jones dye test is used if the primary test is negative. Residual fluorescein is flushed from the cul-de-sac, and clear saline is flushed through the lacrimal system. If the irrigant enters the nose heavily stained with fluorescein, the secondary Jones dye test is positive. This indicates that the upper segment of the system is normal, ie, the orbicularis, puncta, and canaliculi are functioning sufficiently to transport the fluorescein into the lacrimal sac." The case of a negative primary dye test and a positive secondary dye test implicates the lacrimal sac and duct as the site of obstruction.
If during the injection of saline the liquid comes out the opposite punctum, one may be dealing with a stenosis of the common canaliculus, and probing or radiography are indicated for confirmation. It is important to have the common canaliculus patent, or a OCR failure will result. A patient with epiphora, a normal Schirmer's test, and negative primary and positive secondary Jones dye tests is a candidate for a OCR if no other extrinsic causes for lacrimal duct obstruction are found. TECHNIQUE In a prospective study using the diagnostic studies mentioned previously, 11
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patients were diagnosed as having obstruction of the nasolacrimal duct. Of these, 7 were caused by chronic dacryocystitis, 3 were secondary to nasal or maxillary fractures, and 1 followed a previous external ethmoidectomy. All patients had unilateral epiphora and obstruction. Ages ranged from 18 to 52 years. Monthly postoperative evaluations were performed to ascertain OCR patency using nasolacrimal irrigation. Followup periods ranged from 4 to 12 months. The operation is normally performed under local anesthesia in adults, but general anesthesia may be required for anxious patients and for children. The incision site is injected with 1% or 2% lidocaine (Xylocaine) with 1:100,000 epinephrine. Infratrochlear, ethmoidal, and infraorbital nerve blocks may be performed. For the expert in its use, nasociliary nerve blockage is helpful. Intranasal packing in the manner used for a septorhinoplasty is performed. A gently curved incision is made 4 to 5 mm nasal to the medial canthus. The incision begins at the level of the medial canthus and gently arches inferiorly for 15 to 20 mm (Fig 2). The soft tissues are dissected free, and the angular vessels are retracted medially. The inferior border of the medial canthal tendon is identified and left intact. The periosteum over the nasal bone just anterior to the anterior lacrimal crest is incised vertically and elevated nasally. The lacrimal sac may then be identified by gently freeing it from its position in the lacrimal fossa; the dissection should not extend beyond the posterior crest as the periorbital fascia and septum orbitale may be violated, causing possible fat extrusion or retrobulbar hemorrhage. One must not dissect the superior 3 mm of the lacrimal sac, as the common canaliculus enters high and posteriorly and should not be violated. Inferior dissection to the limits of the fascia surrounding the lacrimal sac will afford adequate exposure and mobilization.
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7t fI
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-
./-1- ,I· 1---
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f ig 2.- To p, Ga ining exposure via c urved incisio n 4 10 5 mm nasal to med ial canthus, incisio n is made in nasal per iosteum along anter ior lacrimal cres t. Lacrimal sac is dissected free . Bottom , Diagram of photograph .
fig 3.-Top, As sac is retracted laterally, window is formed in lacrimal fossa. This is enlarged with rongeurs to 2.5 cm in d iameter. Nasal mucosa is removed sharply . Bottom , Diagram of photograph.
As the sac is retracted laterally, a window is formed in the lacrimal fossa with either a hand chisel or the Stryker drill with Iliff bone core attachment (Fig 3). The bony w indow is enlarged w ith rongeurs to 2 to 2.5 cm in d iameter, and the edges are smoothed with a small file or rasp. The correspond ing area of nasal mucosa is removed .
defect to determ ine the continuity and size of the open ing (Fig 4). An intranasal examinat ion may also be performed at th is po int to ascerta in the posit ion of the defect in relat ion to the intranasal structures. Rout ine resection of the middle turbinate is not advocated.
A Kelly clamp may be inserted into the nose and visualized through the bony
A No . 00 Bowman lacrimal probe is inserted into the lower punctum and
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Fig 4.-Top, Kelly clamp is insert ed into nasal cavity and visualized through defect to determine continuity and size of bony open ing . Bottom, Diagram of photograph.
passed into the lacrimal sac (Fig 5). By direct visualization of the tenting of the medial wall of the sac by the probe, a large pedicle flap based anteriorly on the lacrimal sac may be outlined and incised with a knife or sharp scissors. Upon completion the flap is lined with mucosa, covered with lacrimal fascia, and extends from the inferior portion of the sac to the level of the medial canthal tendon.
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\ Fig 5.-Top, A No. 00 Bowman lacrimal probe is inserted into lower punctum and passed into lacrimal sac, tenting medial wall. Large pedicle flap based anteriorly is fabr icated from sac. This flap is lined with mucosa and covered by lacrimal fascia. Bottom, Diagram of photograph.
This anteriorly based lacrimal sac flap is then sutured to the previously elevated nasal periosteum at the region of the anterior lacrimal crest (now removed) using fine 5-0 interrupted synthetic absorbable suture (Fig 6). A final suture is placed in the superior portion of the
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is closed with silk or nylon sutures that are removed in five days (Fig 7). The nose is packed lightly for 24 hours with Telfa strips coated with antibiotic ointment. Postoperatively, the wound is routinely cleaned, and an ophthalmic antibiotic ointment is applied. The patient is instructed not to blow his nose for approximately ten days . Antibiotics are used only if a recent acute dacryocystitis has occurred. The patient is discharged on the day following surgery. Saline irrigations
-I Fig 6.-Top, Anteriorly based lacrimal sac flap is then sutured to previously elevated nasal periosteum at region of anterior lacrimal crest. Suture from superior marg in of flap to medial canthal tendon supports newly created OCR space. Bottom , Diagram of photograph.
anastomosis and attached to the inferior border of the medial canthal tendon; this prevents collapse of the OCR space by tenting the flap anteriorly. The subcutaneous tissues are closed in two layers over the anastomosis to create a water-tight compartment, and the skin
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.
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Fig 7.-Top, Subcutaneous tissues are closed in two layers over flap-ta-periosteum anastomos is to create water-tight compartment. Skin is closed with silk or nylon sutures. Bottom , Diagram of photograph.
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DACRYOCYSTORHINOSTOMY may be performed at seven to ten days and continued weekly if blood clots are flushed free.
DISCUSSION With the previously described technique, ten of 11 patients demonstrated patency of the DCR using nasolacrimal irrigation and had no complaints of epiphora. One unsuccessful result occurred in the patient with a previous ethmoidectomy and was believed to be due to the effects of continued paranasal sinus disease and subsequent fibrosis. Only intermittent patency in the patient's DCR could be exhibited. Success rate was therefore 91% in this small, selected series. No complications occurred. Several authors have addressed the possible causes of failure in any form of DCR.ll,12 The most frequent cause is probably inadequate size of the bony window leading to closure of the defect. This can be minimized by making the defect as wide as safely possible, analogous to the nasal-antral window challenge. If the opening into the sac is made too small and too high, the drainage may be ineffective, leading to the "sump syndrome" and stasis.'! It is important to use all of the sac for the flap except for the portion behind the medial canthal tendon. Flap closure in methods used by other authors is probably related to the difficulty of suturing inside a deep hole, to the fact that nasal mucosal sutures frequently pull loose with contraction, and that flaps merely laid into a bony defect rarely remain where they are placed. The use of the strong pedicle flap with fascia sutured to periosteum as well as the tenting support of the medial canthal tendon suture will diminish this problem. If one attempts to drain the sac into the ethmoid sinus rather than the nasal cavity, fallure is the rule.12 The patient with a
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prior ethmoidectomy continued to have disease around the middle meatal and turbinate region with intermittent obstruction. In these cases, continued medical therapy of the sinus disease is imperative. In a patient with recurrent infections, it is believed that the surgery should be performed only after the acute dacryocystitis has been satisfactorily resolved medically and the local tissue reaction has subsided. Surgery in the acute phase has not been satisfactory. Postoperative hemorrhage, development of a hematoma in the DCR space, and inflammation may contribute to the formation of obstructive granulation tissue. Adequate hemostasis with injected Xylocaine-epinephrine solution plus intranasal mucosal shrinkage by cocaine application is mandatory. Postoperative packing of the nose with Telfa strips and the use of oral decongestants and saline nasal irrigations' will decrease the intranasal clotting and crusting. Irrigation of the inferior canaliculus should clear the clots from the lacrimal portion of the DCR. If failure cannot be attributed to these causes, macrodacryocystography may be used to identify a narrowing of the common canaliculus that was not recognized preoperatively or that may be secondary to surgical trauma. The surgical procedure must then be modified to a conjunctival DCR. For other causes of failure, repeat external DCR is often successful if combined with intranasal removal of granulation ttssues.ts Silicone intubation as a stent may be required. The technique of anterior lacrimal sac flap to periosteum OCR may also be carried out at the time of repair of nasal complex fractures, either immediately if the nasolacrimal duct is damaged, or as a later repair of complications of these fractures, including hypertelorism.t"
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This operation has unfortunately not been a part of the armamentarium of the otolaryngologic surgeon in recent times. This is probably due in part to frequent patient referral to the ophthalmologist. However, with the proper knowledge of the anatomy and physiology of the eyelids and lacrimal drainage system, and the use of adequate preoperative evaluation, one can use this technique of anterior lacrimal sac flap to nasal periosteum DCR in a safe, simple, and effective manner with greater than 90% success rate. With the established proficiency in soft tissue reconstructive surgery around the nose and orbit, the otolaryngologic surgeon is uniquely equipped to perform this procedure. The combined approach with both ophthalmologist and otolaryngologist will be professionally and technically rewarding.
SUMMARY A technique using an anterior lacrimal sac pedicle flap to nasal bone periosteum dacryocystorhinostomy has been presented. Proper selection of patients through use of a thorough head, neck and eyelid examination, primary and secondary Jones dye testing, macrodacryocystography, and the accurate knowledge of lacrimal anatomy and function is of utmost importance. The surgical technique is simple and well within the scope of the otolaryngologist. Common complications and causes of failure are presented, and their prevention or correction discussed. REFERENCES 1. Pico G: A modified technique of external dacryocystorhinostomy. Am J aphtha/mol n:679-690, 1971.
2. Shapiro SL: Is dacryocystorhinostomy an ophthalmologic or a rhinologic procedure? Eye Ear Nose Throat Mon 51:155-159, 1972.
3. Dupuy-Dutemps, Bourguet: Bull Acad Nat Med (Paris) 86:293,1921.
4. Strong JDE: Dacryocystorhinostomy: An outpatient procedure. Br J Ophtha/mo/45:724728,1961. 5. Fox S: Ophthalmic Plastic Surgery, ed 5. New York, Grune & Stratton, Inc, 1976, pp 1820, 567-608. 6. Veirs ER: Lacrimal Disorders: Diagnosis and Treatment. St Louis, CV Mosby Co, 1976, pp 1-12, 13-22, 111-139. 7. Snyder J, Rosell LA: Dacryocystorhinostomy (swinging door operation). Laryngoscope 78:411-417, 1968. 8. Hosni FA, Zohairy AFM: Dacryocystorhinostomy-Our experience with 100 cases. Eye Ear Nose Throat Mon 52:251-255, 1973. 9. Taiara C, Sargent RA, Smith B: Dacryocystorhinostomy: The Kasper operation. Ann Ophthalmo/6:1333-1341, 1974.
10. Mostafa HM, Abdel-Latif SM: The three flaps dacryocystorhinostomy. J Laryngo/ Otol 86:829-837, 1972. 11. Charamis J, Koliopoulos J, Palimeris G, et al: Management of the obstruction of the lacrimal passages. Eye Ear Nose Throat Mon 51:116-121, 1972. 12. Thornton SP, Batchelor ED: Dacryocystorhinostomy with nasolacrimal duct prosthesis. Ophthalmic Surg 6:50-52, 1975.
13. Hurwitz H, Welham RAN, Maisey MN: Intubation macrodacyocystography and quantitative scintillography: The "complete" lacrimal assessment. Trans Am Acad Ophthalmol Orolaryngol 81:OP-575-0P-582, 1976. 14. Zappia RJ, Milder B: Lacrimal drainage function. 1. The Jones fluorescein test. Am J aphtha/mol 74:154-159, 1972. 15. Welham RAN, Henderson P: 'Failed dacryocystorhinostomy. Trans Am Acad Oph. thalmol Otolaryngol 78:0P-824-0P-828, 1974. 16. Wobig J: Complicated lacrimal problems and intranasal approaches. Trans Pac Coast Otoophthalmol Soc 56:81-84, 1975. 17. Smith B: Reduction of nasal orbital fractures and simultaneous dacryocystorhinostomy. Trans Am Acad Ophthalmol Otolaryo. gol 82:0RL-527-0RL-530, 1976.
Oto/aryngol Head Neck Surg 87:174-182 (Mar-Apr) 1979 Downloaded from oto.sagepub.com at Purdue University on June 5, 2016
DACRYOCYSTORHINOSTOMY UTILIZING AN ANTERIOR LACRIMAL SAC FLAP TO PERIOSTEUM TECHNIQUE G. RICHARD HOlT, MD JEAN EDWARDS HOlT,MD and
EDWIN A. CORTEZ, MD BY INVITATION
SAN ANTONIO, TEXAS Dacryocystorhinostomy Is used in the effective treatment of epiphora secondary to obstruction of the lacrimal drainage system. Common causes of obstruction include canalicular disruption, lacrimal sac fibrosis, and external and Internal nasal trauma. Most techniques of dacryocystorhinostomy attempt to suture the lacrimal sac mucosa to the nasal mucosa. At best this is technically difficult, and the mucosa frequently tears. A technique Is presented using an anteriorly based lacrimal sac pedicle flap sutured to the periosteum of the anterior lacrimal crest. The sutured flap is quite strong, and the procedure is technkally simpler than others. A brief description of the causes of lacrimal obstruction Is given. The Jones primary and secondary dye tests for lacrimalsystem patency are reviewed.
who performed hot cauterization on the lacrimal fossa to treat chronic dacryocystitis.' The early 19th century proponents of dacryocystorhinostomy (DCR) were rhinologists (Killian, Caldwell, and West) who performed the operation intranasally.! Another rhinologist, Toti, developed the initial approach to DCR via an external incision. It was not until 1921, when ophthalmologists Dupuy-Dutemps and Bourguet! reported the classic DCR using an external incision and mobilizing both anterior and posterior flaps of nasal and lacrimal sac mucosa, that the modern operation was born.
Presented as a Scientific Poster Presentation at the Annual Meeting of the American Academy of Otolaryngology, Las Vegas, Sept 10-13.
In the past 50 years, many variations of the procedure have been used including anterior flaps of nasal and lacrimal sac mucosa, 4-6 an anterior nasal flap swinging back on the nasal periosteum,7 an anterior nasal flap to lacrimal sac,8 one large posterior flap,9 a three-flap technique.w and the classic four-flap technique.! Taiara? and co-workers also sew the anterior lacrimal sac remnant to nasal periosteum in addition to the posterior flap. These have a range of success rates from 85% to 98%." Many authors suggest the implanting of foreign materials into the DCR, including silk or nylon sutures, glass and plastic tubes,12 and Geltoam.?
Reprint requests to the University of Texas Health Science Center, 7703 Floyd Curl Dr, San Antonio, TX 78284 CDr G. Holt).
Most techniques currently use either deep suturing of posterior flaps or the
INTRODUCTION SURGERY on the lacrimal sac may have originated as early as 1 AD with Celsus,
Submitted for publication Sept 11, 1978. From the divisions of otorhinolaryngology (Drs G. Holt andCortez) andopthalmology (Dr J. Holt) ofthe University of Texas Health Science Center, San Antonio. 1978
Otolaryngol Head Neck Surg 87:174-182 (Mar-Apr) 1979 Downloaded from oto.sagepub.com at Purdue University on June 5, 2016
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suturing of anterior nasal flaps, both of which are technically difficult and frustrating to the surgeon. The nasal mucosal flaps are usually friable, thin, and easily torn. Posterior flaps that are merely laid into the nasal cavity probably undergo the same fate as mucosal flaps into nasalantral windows, namely shrinkage and regression. The technique presented here uses a strong anteriorly based pedicle flap of lacrimal sac sewn to nasal bone periosteum-a formidable combination for success requiring only simple and efficient steps.
PHYSIOLOGY AND ANATOMY Knowledge of the anatomy and physiology of the lacrimal drainage system is essential for surgeons operating on its structures. The lacrimal sac and canaliculi develop from ectodermal cell rests, buried by the closure of the lateral nasal groove. They are met by a column of cells evaginated from the nasal cavity. Failure of fusion of the two systems gives a congenital blockage. Externally the globe is moistened by a continuous film of tears. The normal removal of tears is by evaporation and drainage into the lacrimal system," lpp 13·22) The canaliculi originate as puncta in the medial margin of each eyelid, continue as upper or lower canaliculi for 2 to 2.5 mm, then turn horizontally and join to form the common canaliculus (Fig 1). This structure is approximately 8 mm long and enters the lacrimal sac on its lateral and posterior surface just behind the medial canthal ligament. The lacrimal sac lies within the fossa of the lacrimal bone and is surrounded by an investment of fascia. This fascia (anatomically part of the periorbital is attached tightly to both anterior and posterior lacrimal crests. It is absent in the lower 3 to 4 mm of the lacrimal sac and
Fig1.-Surgical anatomy of lacrimal drainage system. A, Canaliculus; 8, Medial canthal tendon; C, Horner's muscle; 0, Lacrimal sac; E, Lacrimal fascia; F, Nasolacrimal duet; G, Nasal bone periosteum.
forms a constriction just above the nasolacrimal duct. The sac is approximately 14 to 15 mm long with the nasolacrimal duct extending through the maxillary bone for 12 mm and ending as 2 to 3 mm of soft tissue in the inferior meatus, found anteriorly and just below the attachment of the inferior turbinate. 6 (pp l .121 The tendon of the orbicularis oculi muscle splits at the level of the lacrimal sac, with the bulk of it forming the medial cantha I tendon that attaches anterior to the sac and the posterior portion, known as Horner's muscle, attaching behind the sac to the region of the posterior lacrimal crest. The septum orbitale lies lateral to the lacrimal fascia, serving as a barrier to fat extrusion during surgical exposure of the lacrimal fossa. Current theories propose that the c10sure of the eyelids during blinking produces a positive pressure in the canaliculi by shortening them, propelling their con-
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tents into the lacrimal sac. Contraction of the muscles on the fascia surrounding the lacrimal sac opens the sac and produces a negative pressure effect, drawing the tears into the cavity. Opening of the eyelids and the gravity effect are believed to be responsible for the flow of tears into the nasolacrimal duct and nasal cavity.6 (pp 13-22) DIAGNOSIS
Epiphora caused by obstruction or malposition in the lacrimal drainage system must be distinguished from chronic lacrimation or overproduction of tears owing to hypersecretion by the lacrimal gland, probably secondary to reflex irritation.! A Schirmer's tear test, as performed on all patients with facial paralysis, will indicate this hypersecretion. Most patients with epiphora are referred to ophthalmologists. While many ophthalmologists do not perform DCRs, they are able to accurately diagnose the site of the pathologic condition and refer the patient to a surgical colleague. For the most part, otolaryngologists are not part of the management because of a lack of understanding of the specific anatomy and physiology and, more specifically, an inability to correctly diagnose the cause of the epiphora. However, the diagnostic steps are well defined and amenable to use by the otolaryngologist. The main causes of obstruction leading to epiphora include congenital defect, repeated infections, trauma, neoplasms, and nasal and sinus pathology." If the obstruction is congenital, it ls found bilaterally in 550ft of patients and is most commonly caused by an impatency of the meatus (valve of Hasnerl leading to the nasal cavity. Nasolacrimal duct probing in children under 3 years of age will result in nearly 100% patency, and OCR is not necessary. The average age of onset of the acquired obstruction is the 20- to 40year age group, with the younger patients
more likely to have trauma or dacryoliths as the cause. The history with acute dacryocystitis will indicate periodic painful swelling lateral to the nose or chronic sac enlargement with epiphora in chronic infections. Pressure on the sac may produce purulent material at the puncta. A complete head and neck examination is required to rule out nasal, sinus, or bony pathology. The most common ENT diseases affecting the lacrimal drainage system include nasal allergies, mucosal polyps, deviated nasal septum, enlarged turbinates, and posttraumatic facial bone changes. Facial radiographs are helpful in discovering contributing pathologic conditions. The eyelids should be examined carefully to rule out mild punctal or lid ectropion and senile atonicity as causes for poor tear film movement. One should not routinely probe the nasolacrimal duct until obstruction has been diagnosed by other means, as this trauma might convert a partial obstruction into a permanent one. Tumor and dacryoliths may be palpated as firm masses in the lacrimal sac region. Disturbances of the surrounding bone such as midline lethal granuloma, fibrous dysplasia, and other bony tumors should be kept in mind. Recent advances in the radiography of the lacrimal drainage system have contributed valuable information in certain cases of obstruction. Intubation macrodacryocystography involves radiography during catheter injection, filling of the lacrimal drainage system, and enlarging of the image with a subsequent subtraction print. It gives excellent visualization of the excretory apparatus. In addition, quantitative lacrimal scintillography has been employed to assess lacrimal excretory function." Both of these techniques are complementary and, although expensive and technical, give valuable information regarding patency of the canalicular system or identifying the blockage point in a postoperative failure.
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DACRYOCYSTORHINOSTOMY The basic ophthalmologic diagnostic tests used by the surgeon to determine candidacy for a OCR are the primary and secondary Jones dye tests. In the primary Jones dye test, one drop of 1% fluorescein is instilled into the lower conjunctival cul-de-sac. A cotton swab or pledget is placed beneath the inferior meatus and is checked at 1-, 3-, and 5-minute intervals to ascertain if dye has entered the nose. If fluorescence has occurred, a positive primary Jones dye test exists. However, failure to identify the dye occurs in approximately 20% of normal patients. Thus a positive test indicates normal function, but a negative test does not exclude it. The secondary Jones dye test is used if the primary test is negative. Residual fluorescein is flushed from the cul-de-sac, and clear saline is flushed through the lacrimal system. If the irrigant enters the nose heavily stained with fluorescein, the secondary Jones dye test is positive. This indicates that the upper segment of the system is normal, ie, the orbicularis, puncta, and canaliculi are functioning sufficiently to transport the fluorescein into the lacrimal sac." The case of a negative primary dye test and a positive secondary dye test implicates the lacrimal sac and duct as the site of obstruction.
If during the injection of saline the liquid comes out the opposite punctum, one may be dealing with a stenosis of the common canaliculus, and probing or radiography are indicated for confirmation. It is important to have the common canaliculus patent, or a OCR failure will result. A patient with epiphora, a normal Schirmer's test, and negative primary and positive secondary Jones dye tests is a candidate for a OCR if no other extrinsic causes for lacrimal duct obstruction are found. TECHNIQUE In a prospective study using the diagnostic studies mentioned previously, 11
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patients were diagnosed as having obstruction of the nasolacrimal duct. Of these, 7 were caused by chronic dacryocystitis, 3 were secondary to nasal or maxillary fractures, and 1 followed a previous external ethmoidectomy. All patients had unilateral epiphora and obstruction. Ages ranged from 18 to 52 years. Monthly postoperative evaluations were performed to ascertain OCR patency using nasolacrimal irrigation. Followup periods ranged from 4 to 12 months. The operation is normally performed under local anesthesia in adults, but general anesthesia may be required for anxious patients and for children. The incision site is injected with 1% or 2% lidocaine (Xylocaine) with 1:100,000 epinephrine. Infratrochlear, ethmoidal, and infraorbital nerve blocks may be performed. For the expert in its use, nasociliary nerve blockage is helpful. Intranasal packing in the manner used for a septorhinoplasty is performed. A gently curved incision is made 4 to 5 mm nasal to the medial canthus. The incision begins at the level of the medial canthus and gently arches inferiorly for 15 to 20 mm (Fig 2). The soft tissues are dissected free, and the angular vessels are retracted medially. The inferior border of the medial canthal tendon is identified and left intact. The periosteum over the nasal bone just anterior to the anterior lacrimal crest is incised vertically and elevated nasally. The lacrimal sac may then be identified by gently freeing it from its position in the lacrimal fossa; the dissection should not extend beyond the posterior crest as the periorbital fascia and septum orbitale may be violated, causing possible fat extrusion or retrobulbar hemorrhage. One must not dissect the superior 3 mm of the lacrimal sac, as the common canaliculus enters high and posteriorly and should not be violated. Inferior dissection to the limits of the fascia surrounding the lacrimal sac will afford adequate exposure and mobilization.
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f ig 2.- To p, Ga ining exposure via c urved incisio n 4 10 5 mm nasal to med ial canthus, incisio n is made in nasal per iosteum along anter ior lacrimal cres t. Lacrimal sac is dissected free . Bottom , Diagram of photograph .
fig 3.-Top, As sac is retracted laterally, window is formed in lacrimal fossa. This is enlarged with rongeurs to 2.5 cm in d iameter. Nasal mucosa is removed sharply . Bottom , Diagram of photograph.
As the sac is retracted laterally, a window is formed in the lacrimal fossa with either a hand chisel or the Stryker drill with Iliff bone core attachment (Fig 3). The bony w indow is enlarged w ith rongeurs to 2 to 2.5 cm in d iameter, and the edges are smoothed with a small file or rasp. The correspond ing area of nasal mucosa is removed .
defect to determ ine the continuity and size of the open ing (Fig 4). An intranasal examinat ion may also be performed at th is po int to ascerta in the posit ion of the defect in relat ion to the intranasal structures. Rout ine resection of the middle turbinate is not advocated.
A Kelly clamp may be inserted into the nose and visualized through the bony
A No . 00 Bowman lacrimal probe is inserted into the lower punctum and
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DACRYOCYSTORHINOSTOMY
Fig 4.-Top, Kelly clamp is insert ed into nasal cavity and visualized through defect to determine continuity and size of bony open ing . Bottom, Diagram of photograph.
passed into the lacrimal sac (Fig 5). By direct visualization of the tenting of the medial wall of the sac by the probe, a large pedicle flap based anteriorly on the lacrimal sac may be outlined and incised with a knife or sharp scissors. Upon completion the flap is lined with mucosa, covered with lacrimal fascia, and extends from the inferior portion of the sac to the level of the medial canthal tendon.
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\ Fig 5.-Top, A No. 00 Bowman lacrimal probe is inserted into lower punctum and passed into lacrimal sac, tenting medial wall. Large pedicle flap based anteriorly is fabr icated from sac. This flap is lined with mucosa and covered by lacrimal fascia. Bottom, Diagram of photograph.
This anteriorly based lacrimal sac flap is then sutured to the previously elevated nasal periosteum at the region of the anterior lacrimal crest (now removed) using fine 5-0 interrupted synthetic absorbable suture (Fig 6). A final suture is placed in the superior portion of the
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is closed with silk or nylon sutures that are removed in five days (Fig 7). The nose is packed lightly for 24 hours with Telfa strips coated with antibiotic ointment. Postoperatively, the wound is routinely cleaned, and an ophthalmic antibiotic ointment is applied. The patient is instructed not to blow his nose for approximately ten days . Antibiotics are used only if a recent acute dacryocystitis has occurred. The patient is discharged on the day following surgery. Saline irrigations
-I Fig 6.-Top, Anteriorly based lacrimal sac flap is then sutured to previously elevated nasal periosteum at region of anterior lacrimal crest. Suture from superior marg in of flap to medial canthal tendon supports newly created OCR space. Bottom , Diagram of photograph.
anastomosis and attached to the inferior border of the medial canthal tendon; this prevents collapse of the OCR space by tenting the flap anteriorly. The subcutaneous tissues are closed in two layers over the anastomosis to create a water-tight compartment, and the skin
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Fig 7.-Top, Subcutaneous tissues are closed in two layers over flap-ta-periosteum anastomos is to create water-tight compartment. Skin is closed with silk or nylon sutures. Bottom , Diagram of photograph.
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DACRYOCYSTORHINOSTOMY may be performed at seven to ten days and continued weekly if blood clots are flushed free.
DISCUSSION With the previously described technique, ten of 11 patients demonstrated patency of the DCR using nasolacrimal irrigation and had no complaints of epiphora. One unsuccessful result occurred in the patient with a previous ethmoidectomy and was believed to be due to the effects of continued paranasal sinus disease and subsequent fibrosis. Only intermittent patency in the patient's DCR could be exhibited. Success rate was therefore 91% in this small, selected series. No complications occurred. Several authors have addressed the possible causes of failure in any form of DCR.ll,12 The most frequent cause is probably inadequate size of the bony window leading to closure of the defect. This can be minimized by making the defect as wide as safely possible, analogous to the nasal-antral window challenge. If the opening into the sac is made too small and too high, the drainage may be ineffective, leading to the "sump syndrome" and stasis.'! It is important to use all of the sac for the flap except for the portion behind the medial canthal tendon. Flap closure in methods used by other authors is probably related to the difficulty of suturing inside a deep hole, to the fact that nasal mucosal sutures frequently pull loose with contraction, and that flaps merely laid into a bony defect rarely remain where they are placed. The use of the strong pedicle flap with fascia sutured to periosteum as well as the tenting support of the medial canthal tendon suture will diminish this problem. If one attempts to drain the sac into the ethmoid sinus rather than the nasal cavity, fallure is the rule.12 The patient with a
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prior ethmoidectomy continued to have disease around the middle meatal and turbinate region with intermittent obstruction. In these cases, continued medical therapy of the sinus disease is imperative. In a patient with recurrent infections, it is believed that the surgery should be performed only after the acute dacryocystitis has been satisfactorily resolved medically and the local tissue reaction has subsided. Surgery in the acute phase has not been satisfactory. Postoperative hemorrhage, development of a hematoma in the DCR space, and inflammation may contribute to the formation of obstructive granulation tissue. Adequate hemostasis with injected Xylocaine-epinephrine solution plus intranasal mucosal shrinkage by cocaine application is mandatory. Postoperative packing of the nose with Telfa strips and the use of oral decongestants and saline nasal irrigations' will decrease the intranasal clotting and crusting. Irrigation of the inferior canaliculus should clear the clots from the lacrimal portion of the DCR. If failure cannot be attributed to these causes, macrodacryocystography may be used to identify a narrowing of the common canaliculus that was not recognized preoperatively or that may be secondary to surgical trauma. The surgical procedure must then be modified to a conjunctival DCR. For other causes of failure, repeat external DCR is often successful if combined with intranasal removal of granulation ttssues.ts Silicone intubation as a stent may be required. The technique of anterior lacrimal sac flap to periosteum OCR may also be carried out at the time of repair of nasal complex fractures, either immediately if the nasolacrimal duct is damaged, or as a later repair of complications of these fractures, including hypertelorism.t"
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This operation has unfortunately not been a part of the armamentarium of the otolaryngologic surgeon in recent times. This is probably due in part to frequent patient referral to the ophthalmologist. However, with the proper knowledge of the anatomy and physiology of the eyelids and lacrimal drainage system, and the use of adequate preoperative evaluation, one can use this technique of anterior lacrimal sac flap to nasal periosteum DCR in a safe, simple, and effective manner with greater than 90% success rate. With the established proficiency in soft tissue reconstructive surgery around the nose and orbit, the otolaryngologic surgeon is uniquely equipped to perform this procedure. The combined approach with both ophthalmologist and otolaryngologist will be professionally and technically rewarding.
SUMMARY A technique using an anterior lacrimal sac pedicle flap to nasal bone periosteum dacryocystorhinostomy has been presented. Proper selection of patients through use of a thorough head, neck and eyelid examination, primary and secondary Jones dye testing, macrodacryocystography, and the accurate knowledge of lacrimal anatomy and function is of utmost importance. The surgical technique is simple and well within the scope of the otolaryngologist. Common complications and causes of failure are presented, and their prevention or correction discussed. REFERENCES 1. Pico G: A modified technique of external dacryocystorhinostomy. Am J aphtha/mol n:679-690, 1971.
2. Shapiro SL: Is dacryocystorhinostomy an ophthalmologic or a rhinologic procedure? Eye Ear Nose Throat Mon 51:155-159, 1972.
3. Dupuy-Dutemps, Bourguet: Bull Acad Nat Med (Paris) 86:293,1921.
4. Strong JDE: Dacryocystorhinostomy: An outpatient procedure. Br J Ophtha/mo/45:724728,1961. 5. Fox S: Ophthalmic Plastic Surgery, ed 5. New York, Grune & Stratton, Inc, 1976, pp 1820, 567-608. 6. Veirs ER: Lacrimal Disorders: Diagnosis and Treatment. St Louis, CV Mosby Co, 1976, pp 1-12, 13-22, 111-139. 7. Snyder J, Rosell LA: Dacryocystorhinostomy (swinging door operation). Laryngoscope 78:411-417, 1968. 8. Hosni FA, Zohairy AFM: Dacryocystorhinostomy-Our experience with 100 cases. Eye Ear Nose Throat Mon 52:251-255, 1973. 9. Taiara C, Sargent RA, Smith B: Dacryocystorhinostomy: The Kasper operation. Ann Ophthalmo/6:1333-1341, 1974.
10. Mostafa HM, Abdel-Latif SM: The three flaps dacryocystorhinostomy. J Laryngo/ Otol 86:829-837, 1972. 11. Charamis J, Koliopoulos J, Palimeris G, et al: Management of the obstruction of the lacrimal passages. Eye Ear Nose Throat Mon 51:116-121, 1972. 12. Thornton SP, Batchelor ED: Dacryocystorhinostomy with nasolacrimal duct prosthesis. Ophthalmic Surg 6:50-52, 1975.
13. Hurwitz H, Welham RAN, Maisey MN: Intubation macrodacyocystography and quantitative scintillography: The "complete" lacrimal assessment. Trans Am Acad Ophthalmol Orolaryngol 81:OP-575-0P-582, 1976. 14. Zappia RJ, Milder B: Lacrimal drainage function. 1. The Jones fluorescein test. Am J aphtha/mol 74:154-159, 1972. 15. Welham RAN, Henderson P: 'Failed dacryocystorhinostomy. Trans Am Acad Oph. thalmol Otolaryngol 78:0P-824-0P-828, 1974. 16. Wobig J: Complicated lacrimal problems and intranasal approaches. Trans Pac Coast Otoophthalmol Soc 56:81-84, 1975. 17. Smith B: Reduction of nasal orbital fractures and simultaneous dacryocystorhinostomy. Trans Am Acad Ophthalmol Otolaryo. gol 82:0RL-527-0RL-530, 1976.
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