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Endoscopic Dacrocystorhinostomy
 

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The Surgical Technique of
Endoscopic Dacrocystorhinostomy

Is this surgery going from the hands of ophthalmologists?

Authors:  Sinha V.*, Chhaya V.**, Mehta K.***, Prajapati V.***, Patel P.***, & Patil S.***
* Dean & Professor, ** Professor & Head, ***Resident

From: Department of Otorhinolaryngology and Head and Neck Surgery
M.P. Shah Medical College, Saurashtra university, Jamnagar (Gujarat) India

Address for Correspondence:
Dr. Vikas Sinha
Dean, M.P.Shah Medical College
Jamnagar ( Gujarat)-361008,  India
email:  dr_sinhavikas@yahoo.co.in

Abstract:  The endoscopic DCR has distinct advantage over external DCR. There is no ugly scar on the face, there is less intraoperative bleeding, it is day care procedure and patient is discharge on the same evening. The satisfaction rate and success rate is as good as external DCR. The endoscopic DCR surgery is being performed more by the ENT surgeons rather then ophthalmologists. The aim of this paper is to make ophthalmic surgeon to understand step by step the simple procedure of endoscopic DCR just by looking to real photographs taken by 30 degree nasal endoscope.

Keywords: endoscopic DCR, lacrimal bone, lacrimal sac

Introduction: Endoscopic DCR has increasing been shown to be as successful as traditional method of external DCR for the management of patient with obstruction of nasolacrimal duct system. DCR was always the surgery of ophthalmic surgeon but with the advancement of nasal endoscope and more and more familiarity of ENT surgeons with endoscopic anatomy of nose, most of the ENT surgeons started doing endoscopic DCR.

The endoscopic DCR has distinct advantage over the external DCR as there is no facial scar and because of this reason many ophthalmic surgeons who do not perform endonasal DCR refer the cases to the ENT surgeon where patient does not give consent for the external scar.  Beside this the endoscopic DCR also maintain the pump action.  It can be done in acute cases and both the sides can be operated in the same sitting.

The success rate of endonasal DCR is as good as external DCR.1-3  Some studies have shown that endoscopic DCR has higher success rate than external DCR.4  The endoscopic DCR is safe and successful as a day-case procedure under local anesthesia with excellent results and great satisfaction to the patiCacent.5,6  The endoscopic DCR has fewer cutaneous complications and less risk of significant bleeding.7  A survey was made in Jamnagar city of India and Seoul city of Korea about number of endoscopic DCRs being performed by the ophthalmic surgeons.

On questioning the ophthalmic surgeons of ophthalmic institute of M.P.Shah Medical College Jamnagar, India it was found that the ophthalmic surgeons of this institute were doing only external DCR and no endoscopic DCR. On surveying the records of department of Otorhinolaryngology at M.P.Shah Medical College Jamnagar, India, it was observed that more than 50% operated cases of endoscopic DCR were referred from the ophthalmologists. The search area was increased to eight ophthalmic institutes within the state and twelve ophthalmic institutes outside the state in India and it was found that no ophthalmic surgeon was doing endonasal, endoscopic DCR.

On questioning from ophthalmologists for not doing endoscopic DCR, the various reasons given were: Lack of knowledge of internal nose, no idea of handling endoscope, absolute no knowledge of endoscopic view of internal nose, fear of bleeding from nasal mucosa while handling the endoscope and interestingly DCR surgery was not on the priority list as compared to surgery of cornea, retina and cataract.  It was only the junior staffs who were performing external DCR.

The main indications for ophthalmic surgeons for referring the case to ENT surgeons were- lacrimal sac abscess, acute dacryocystitis not responding to conservative treatment, patient refusal to give consent for scar at the face. While searching the references of endoscopic DCR in pub med, it was a matter of surprise to know that first 20 references of endoscopic DCR, only 50% references were from the ophthalmic surgeons and rest were from otorhinolaryngologists.

The search area was increased to Seoul, South Korea.  It was found that DCR surgery is being done only by oculoplastic surgeon. The majority of oculoplastic surgeons are doing external DCR. Only 20-30% of oculoplastic surgeons of South Korea are doing non external DCR i.e. either endonasal or transcanalicular laser DCR.  On questioning why external DCR is still popular in South Korea, the reason given that endonasal DCR has less success rate as compared to external DCR, which is contrary to all the reports of endonasal DCR.3  A proper training is required to ophthalmic surgeons about simple and systematic method of doing endoscopic DCR before this surgery goes totally out of hands of ophthalmologists.

The first author has conducted several workshops for residents of ENT department to train them for endonasal endoscopic DCR and has standardized the procedure which can be useful to any surgeon.

Operative procedure:  Click on Pictures to Enlarge, Mouse-Over to Display Caption

1. The nose is packed with 4% xylocaine one hour before the surgery.


2. Premedication of Fortwin and Atropine 30 minutes before the surgery.


3. Nasal endoscopy is performed with a by 30 degree endoscope.

 
Identification of the middle turbinate, trace its anterior arch laterally as maxillary line (Fig. I-A). Area in front of maxillary line is lacrimal sac area covered by lacrimal bone which is to be removed to approach lacrimal sac area for the surgery.
4. Identification of the middle turbinate, trace its anterior arch laterally as the maxillary line (picture to the right).


5. The area in front of maxillary line is the lacrimal sac area.  The sac is covered by the lacrimal bone which is removed during the surgical approach to lacrimal sac.

 
Inject 2% xylocaine with adrenaline (1:100,000) (if no contraindication of adrenaline) to middle turbinate.Inject 2% xylocaine with adrenaline (1:100,000) (if no contraindication of adrenaline) to lacrimal sac area.6. Inject 2% xylocaine with adrenaline (1:100,000) (if no contraindication of adrenaline) to the lacrimal sac area (picture to the right) and also at the middle turbinate (picture to the far right) as middle turbinate is very sensitive to touch.


Cauterize the mucosa of lacrimal sac area.7. Cauterize the mucosa of the lacrimal sac area (picture to the right).

 
Remove the mucosa with sickle knife and expose the lacrimal bone.Remove the mucosa with sickle knife.8. Remove the mucosa with a sickle knife (pictures to the right).

 
Expose the lacrimal bone area completely.
9. Expose the lacrimal bone area completely (picture to the right).

 
Perforate the lacrimal bone with Kerrison DCR punch forceps, the starting point of perforation at the maxillary line.10. Perforate the lacrimal bone with a Kerrison DCR punch forceps, the starting point of the perforation is at the maxillary line (picture to the right).


11. Once small opening is made, press the lacrimal sac from the outside.  The bony dehiscence will be felt at lacrimal sac area. The movement of medial wall of sac in endoscopic view will confirm the lacrimal sac.

 
Enlarge the newly created stoma with DCR forceps as big as possible.
12. Enlarge the newly created stoma with DCR forceps as big as possible (picture to the right).


The lacrimal sac is filled with saline.13. The lacrimal punctum is cannulated and the lacrimal sac is filled with saline. (picture to right).


Create a vertical incision in the lacrimal sac with tonsillar blade.Create a vertical incision in the lacrimal sac with tonsillar blade.14. Create a vertical incision in the lacrimal sac with a #12 BP Parker tonsillar blade (pictures to right).


15. Enlarge this newly created stoma with true cutting forceps (see pictures below).

Enlarge this newly created stoma with true cutting forceps.  Picture 1     Enlarge this newly created stoma with true cutting forceps.  Picture 2    Enlarge this newly created stoma with true cutting forceps.   Picture 3


Pass the lacrimal probe from lower puncta of eye, negotiate it to come out from newly created stoma inside the nose to break any adhesion at opening of nasolacrimal duct near the sac.16. Pass the lacrimal probe from lower punctum of the eye, negotiate it to come out from newly created stoma inside the nose to break any adhesion at opening of nasolacrimal duct near the sac (picture to right).


Irrigate the lacrimal sac. The free flow of saline indicates successful surgery.  Picture 2Irrigate the lacrimal sac. The free flow of saline indicates successful surgery.  Picture 117. Carry out the sac syringing (pictures on right).  The free flow of saline indicates successful surgery.


18. Light anterior nasal pack.


19. Patient is discharged in the evening after the pack removal.


20. One week course of oral antibiotic and antibiotic eye drop.

 
21. Sac syringing at regular intervals for first two months. 

Discussion: Many surgeries have changed hands from one specialty to another. Cleft lip and cleft palate has gone from general surgeon to plastic surgeon.8  Rhinoplasty surgery being shared by ENT surgeons and plastic surgeons.9   Bronchoscopy is done by ENT surgeons,10 cardiothoracic surgeons, head and neck surgeon and pulmonologists.  Thyroid surgery is being done by ENT surgeons, head and neck surgeons,11 oncology surgeon and general surgeon.  The change of surgery or sharing of surgery from one specialty to another specialty always brings a healthy competition among subspecialty and it is very good sign for the development of specialty.   The ophthalmic surgeons have to adapt endoscopic surgery considering all its advantages.  The DCR which is now has become a routine surgery for the ENT surgeons, its time for ophthalmic surgeons to keep pace with ENT surgeons.

References:

1. Kupper DS, Demarco RC, Resende R, Anselmo-Lima WT, Valera FC, & Moribe I.  Endoscopic nasal dacryocystorhinostomy: results and advantages over the external approach. Rev Bras Otorrinolaringol (Engl Ed) 2005;71:356-360.   View Abstract

2. Tsirbas A, Davis G, Wormald PJ.  Mechanical endonasal dacryocystorhinostomy versus external dacryocystorhinostomy. Ophthal Plast Reconstr Surg 2004;20:50-56.     View Abstract

3. Gupta AK, & Bansal S.  Primary endoscopic dacryocystorhinostomy in children-Analysis of 18 patients. Int J Pediatr otorhinolaryngol 2006;70:1213-1217.   View Abstract

4. Ben Simon GJ, Joseph J, Lee S, Schwarcz RM, McCann JD, & Goldberg RA.  External versus endoscopic dacryocystorhinostomy for acquired nasolacrimal duct obstruction in a tertiary referral center. Ophthalmology 2005;112:1463-1468.   View Abstract

5. Durvasula VS, & Gatland DJ.  Endoscopic dacryocystorhinostomy: long- term results and evolution of surgical technique. J Laryngol Otol 2004;118:628-632.   View Abstract

6. Mathew MR, McGuiness R, Webb LA, Murray SB, & Esakowitz L.  Patient satisfaction in our initial experience with endonasal endoscopic non laser dacryocystorhinostomy. Orbit 2004;23:77-85.   View Abstract

7. Fayet B, Racy E, & Assouline M.  Complications of standardized endonasal dacryocystorhinostomy with unciferomectomy. Ophthalmology 2004;111:837-845.   View Abstract

8. Yin N. Bone regeneration in hard palate and cleft palate surgery: reply.  Plast Reconstr Surg 2006;117:2505-2506.  View Abstract

9. Hwang PH, & Maas CS. Correction of the twisted nose deformity: a surgical algorithm using the external rhinoplasty approach. Am J Rhinol 1998;12:213-220.  View Abstract

10. Umapathy N, Panesar J, Whitehead BF, & Taylor JF. Removal of foreign body from the bronchial tree- a new method. J laryngol Otol 1999;113:851-853.   View Abstract

11. Betkowski A, Pogorzelski A, Gotkowska K, Cyran-Rymarz A, Szuber K, & Wewiorska T. The point of view of otolaryngologist and head and neck surgeon on thyroid disease. Otolaryngol Pol 1995;49:574-582.   View Abstract 

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World Articles in Ear, Nose and Throat  www.waent.org   Vol 2-1  Feb. 22, 2009

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