Endoscopic Dacryocystorhinostomy [1st ed.] 9789811581113, 9789811581120

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Endoscopic Dacryocystorhinostomy Nishi Gupta

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Endoscopic Dacryocystorhinostomy

Nishi Gupta

Endoscopic Dacryocystorhinostomy

Nishi Gupta Dr Shroff Charity Eye Hospital New Delhi India

ISBN 978-981-15-8111-3    ISBN 978-981-15-8112-0 (eBook) https://doi.org/10.1007/978-981-15-8112-0 © Springer Nature Singapore Pte Ltd. 2021 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

“I don’t want to end up simply having visited this world.”— Mary Oliver. Dedicated to all those women who struggle to follow their passion while playing multiple roles. Heartfelt thanks to my husband Gyan, for nurturing my dreams with his unwavering support that enabled me to complete this work. All the love and constant encouragement that I received from him and my children Shreya and Vyom acted as a pillar of strength for me.

Foreword

In the past few years, we could watch the great advances in endoscopic surgery. In the same proportion, endoscopic surgery of the lacrimal system, especially on DCR (dacryocystorhinostomy), has grown considerably. This book’s third edition, brilliantly written by Dr Nishi Gupta, will provide to the whole national and international medical community great knowledge and also great visibility. Her outstanding compilation of all her experience in endoscopic DCR and lacrimal surgery is truly a masterpiece. Having the opportunity to dive into this book, may I say the most complete one in this field, one will find a rich and diverse content. From basics to very advanced, these pages offer to its readers the most complete endoscopic techniques and also provide detailed chapters with important topics such as complications, training and education. It is a great honour to preface Dr Gupta’s contribution to medicine and to all of those who will benefit from her work when treating patients with lacrimal system diseases. I wish you all a great and enjoyable reading. Prof Aldo Stamm Director, ENT and Skull Base Center of Sāo Paulo Hospital Professor Edmundo Vasconcelos Sāo Paulo, Brazil

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Preface

Writing the preface for the third edition of my book gives me an opportunity to express my gratitude to all those who have been a part of my journey. Their trust and support gave me the strength to carry on. I am grateful to my institution, Dr Shroff’s Charity Eye Hospital, for giving me an opportunity to explore the endoscopic management of lacrimal drainage system disorders at a time when this field was not much explored in the country. There was not much literature available on this subject close to three decades ago. Thus, after working for a few years our preliminary experience in endoscopic dacryocystorhinostomy was consolidated and published as the first edition of our book on endoscopic dacryocystorhinostomy in 2006, followed by the second edition in 2011, and here is the third edition. I would like to express my gratitude to Mr Arun K. Arora, chief executive officer of the organization, for providing the state-of-the-art infrastructure and equipment to enhance capability. I express my deepest appreciation to Dr Satish Jain, a surgeon with exceptional professional abilities, for his help and support. I very much appreciate the contribution of Dr Vandana Kalra for the hard work and assistance in bringing out a comprehensive chapter on radiology. My sincere thanks to Dr Suma Ganesh for having faith in me and supporting the good work done for the children with epiphora in society. Special thanks to Dr Javed Ali for continuous sharing of ideas, discussions and motivation. I would like to extend my sincere thanks to my team Dr Nidhi Dhawan, Dr Poonam Singla and Dr Sonil Jain. I would like to thank Springer for the opportunity and acknowledge great contribution of Springer team for beautiful compilation of the manuscript. Finally, I would like to thank everyone who provided me with the opportunity, advice and support throughout my journey. New Delhi, India

Nishi Gupta [email protected]

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Contents

1 Embryology of the Lacrimal Drainage System ����������������������������   1 1.1 Congenital Defects in Lacrimal Drainage System��������������������   2 1.1.1 Puncta����������������������������������������������������������������������������   2 1.1.2 Congenital Canalicular Obstructions����������������������������   3 1.1.3 Nasolacrimal Duct (NLD)��������������������������������������������   3 1.1.4 Lacrimal fistula ������������������������������������������������������������   5 References������������������������������������������������������������������������������������������   7 2 Anatomy of Lacrimal Drainage System����������������������������������������   9 2.1 Nasal Cavity������������������������������������������������������������������������������   9 2.1.1 Clinical Relevance��������������������������������������������������������   9 2.2 Turbinates����������������������������������������������������������������������������������   9 2.2.1 Clinical Relevance��������������������������������������������������������  10 2.3 Puncta����������������������������������������������������������������������������������������  11 2.3.1 Clinical Relevance��������������������������������������������������������  13 2.4 Canaliculi����������������������������������������������������������������������������������  13 2.4.1 Clinical Relevance��������������������������������������������������������  14 2.5 Bony Lacrimal Fossa and Lacrimal Sac ����������������������������������  14 2.5.1 Clinical Relevance��������������������������������������������������������  15 2.6 Lacrimal Bone��������������������������������������������������������������������������  15 2.6.1 Clinical Relevance��������������������������������������������������������  15 2.7 Lacrimal Sac ����������������������������������������������������������������������������  17 2.7.1 Clinical Relevance��������������������������������������������������������  17 2.8 Nasolacrimal Duct��������������������������������������������������������������������  17 2.9 Valve and Mucosal Folds in NLD��������������������������������������������  18 References������������������������������������������������������������������������������������������  20 3 Endoscopic Anatomy of the Lacrimal Drainage System��������������  23 3.1 The Lateral Wall of Nose����������������������������������������������������������  23 3.1.1 First Pass ����������������������������������������������������������������������  23 3.1.2 Second Pass������������������������������������������������������������������  25 3.1.3 Third Pass����������������������������������������������������������������������  25 3.2 Agger Nasi��������������������������������������������������������������������������������  26 3.2.1 Clinical Relevance��������������������������������������������������������  27 3.3 Uncinate Process����������������������������������������������������������������������  27 3.3.1 Clinical Relevance��������������������������������������������������������  27

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3.4 Bulla Ethmoidalis���������������������������������������������������������������������  28 3.4.1 Clinical Relevance��������������������������������������������������������  28 3.5 Hiatus Semilunaris��������������������������������������������������������������������  28 3.6 Ethmoid Infundibulum��������������������������������������������������������������  28 3.7 Fontanelle����������������������������������������������������������������������������������  28 3.8 Middle Turbinate����������������������������������������������������������������������  29 3.8.1 Clinical Relevance��������������������������������������������������������  30 3.9 Paranasal Sinuses����������������������������������������������������������������������  30 3.9.1 Clinical Relevance��������������������������������������������������������  32 3.10 Meatuses ����������������������������������������������������������������������������������  32 3.10.1 Clinical Relevance��������������������������������������������������������  32 3.11 Lacrimal Sac and NLD with Their Relation to the Different Structures on the Lateral Wall ����������������������������������  32 3.11.1 Clinical Relevance��������������������������������������������������������  33 References������������������������������������������������������������������������������������������  33 4 Radiological Anatomy of the Lacrimal Drainage System������������  35 4.1 Computed Tomographic Dacryocystography (CT DCG) ��������  35 4.2 Procedure����������������������������������������������������������������������������������  36 4.3 Various Structures of Lacrimal Drainage System on CT DCG������������������������������������������������������������������������������������  36 References������������������������������������������������������������������������������������������  52 5 Imaging in Disorders of the Lacrimal Drainage System��������������  55 5.1 Computed Tomography (CT)/Computed Tomographic Dacryocystography (CT DCG) ������������������������������������������������  55 5.1.1 CT DCG in PANDO ����������������������������������������������������  56 5.1.2 CT DCG in Primary Acquired Nasolacrimal Duct Obstruction (PANDO) with Medial Canthal Mass ������  56 5.1.3 CT/CT DCG in Post-Traumatic Dacryocystitis������������  60 5.1.4 CT DCG in Failed Cases of External or Endoscopic DCR����������������������������������������������������������  62 5.2 Ultrasonography������������������������������������������������������������������������  63 5.3 Magnetic Resonance Imaging (MRI) of Lacrimal Drainage System��������������������������������������������������������������������������������������  64 5.4 Lacrimal Scintigraphy��������������������������������������������������������������  64 5.5 Digital Subtraction Dacryocystography������������������������������������  67 References������������������������������������������������������������������������������������������  68 6 Preoperative Evaluation in Endoscopic Dacryocystorhinostomy ������������������������������������������������������������������  71 6.1 History��������������������������������������������������������������������������������������  72 6.1.1 Epiphora in Children����������������������������������������������������  72 6.1.2 Evaluation of Adults Based on History������������������������  73 6.1.3 Examination������������������������������������������������������������������  74 6.1.4 Fluorescein Dye Test����������������������������������������������������  82 6.1.5 Nasal Endoscopy����������������������������������������������������������  83 6.2 Radiological Investigations������������������������������������������������������  85 6.3 Optical Coherence Tomography (OCT)������������������������������������  85 References������������������������������������������������������������������������������������������  86

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7 Surgical Technique of Endoscopic Dacryocystorhinstomy����������  89 7.1 Indications of Endoscopic DCR������������������������������������������������  90 7.2 Surgical Technique��������������������������������������������������������������������  90 7.2.1 Optimization of Surgical Field��������������������������������������  90 7.2.2 Preparation of Nose������������������������������������������������������  90 7.2.3 Final Inspection������������������������������������������������������������  97 7.3 Postoperative Instructions: Post-Operative Instructions ����������  98 7.4 Additional Points����������������������������������������������������������������������  99 7.4.1 Effective Use of Kerrison Punch����������������������������������  99 7.4.2 Uncinectomy and Endoscopic DCR ���������������������������� 100 7.5 Difficulties During Endoscopic DCR �������������������������������������� 102 7.6 Advantages of Endoscopic DCR���������������������������������������������� 102 7.7 Disadvantages �������������������������������������������������������������������������� 103 7.8 Results�������������������������������������������������������������������������������������� 103 7.9 Causes of Failure in Endoscopic DCR ������������������������������������ 103 References������������������������������������������������������������������������������������������ 104 8 Improving Results in Endoscopic Dacryocystorhinostomy��������� 107 8.1 Bone Removal�������������������������������������������������������������������������� 109 8.1.1 Site of Bone Removal �������������������������������������������������� 109 8.1.2 Importance of Initial Incision in Bone Removal���������� 109 8.1.3 Adequacy of Bone Removal ���������������������������������������� 110 8.2 Advantages of Common Canaliculus Opening (CCO) Visualization ���������������������������������������������������������������������������� 112 8.2.1 Effective Marsupialization of the Portion of the Sac Lying Above the Level of CCO������������������������ 112 8.2.2 Identification of Intrasac Septation and Detection of Hidden Diverticulum�������������������������������� 112 8.2.3 Identification and Management of Canalicular Obstructions���������������������������������������������� 114 8.3 Intrasac Granulomas ���������������������������������������������������������������� 115 8.4 Flap Creation and Role of Mucosal Coverage of the Raw Area���������������������������������������������������������������������������������� 116 8.5 Identification and Correction of Associated Nasal Pathologies���������������������������������������������������������������������� 116 8.6 Mitomycin C ���������������������������������������������������������������������������� 116 8.7 Intubation���������������������������������������������������������������������������������� 117 8.8 The Role of Regular Post-­Operative Nasal Endoscopy������������ 119 References������������������������������������������������������������������������������������������ 124 9 Management of the Associated Nasal Conditions in Endoscopic Dacryocystorhinostomy���������������������������������������������� 127 9.1 Septoplasty�������������������������������������������������������������������������������� 127 9.1.1 Types of Incisions �������������������������������������������������������� 128 9.1.2 Surgical Procedure�������������������������������������������������������� 128 9.1.3 Advantages of Endoscopic Septoplasty������������������������ 130 9.1.4 Limitations of Endoscopic Septoplasty������������������������ 131 9.1.5 Complications of Septoplasty �������������������������������������� 131

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9.2 Endoscopic Conchoplasty�������������������������������������������������������� 131 9.2.1 Surgical Technique�������������������������������������������������������� 132 9.3 Endoscopic Sinus Surgery�������������������������������������������������������� 134 References������������������������������������������������������������������������������������������ 140 10 Upper Lacrimal Pathway Disorders���������������������������������������������� 141 10.1 Punctal Disorders�������������������������������������������������������������������� 141 10.1.1 Examination���������������������������������������������������������������� 142 10.1.2 Management���������������������������������������������������������������� 143 10.2 Canalicular Disorders�������������������������������������������������������������� 145 10.2.1 Assessment of the Level of Canalicular Obstruction���������������������������������������������� 145 10.2.2 Distal or common canalicular obstruction������������������ 147 10.2.3 Proximal Canalicular Obstructions ���������������������������� 149 References������������������������������������������������������������������������������������������ 151 11 Difficult Situations in Endoscopic Dacryocystorhinostomy�������� 155 11.1 Maxillary Bone Dominant Fossa�������������������������������������������� 155 11.1.1 Interpretation�������������������������������������������������������������� 157 11.2 Associated Nasal Conditions�������������������������������������������������� 157 11.2.1 Interpretation�������������������������������������������������������������� 158 11.3 Lacrimal Sac Diverticulum ���������������������������������������������������� 159 11.3.1 Interpretation�������������������������������������������������������������� 161 11.4 Post-Traumatic Cases�������������������������������������������������������������� 162 11.5 Concomitant Presence of Punctal and Canalicular Disorders�������������������������������������������������������������� 164 11.6 Bleeding���������������������������������������������������������������������������������� 164 References������������������������������������������������������������������������������������������ 164 12 Complications of Endoscopic Dacryocystorhinostomy���������������� 167 12.1 Bleeding���������������������������������������������������������������������������������� 167 12.2 Surgical Failures �������������������������������������������������������������������� 168 12.3 Cerbrospinal Fluid (CSF) Leak���������������������������������������������� 169 12.4 Meningitis ������������������������������������������������������������������������������ 170 12.5 Pneumatoencephalocele���������������������������������������������������������� 170 12.6 Synechiae and Granulations���������������������������������������������������� 171 12.7 Injury to Lamina Papyracea���������������������������������������������������� 172 12.8 Subcutaneous Emphysema������������������������������������������������������ 172 12.9 Periorbita Breach, Ecchymosis and Diplopia ������������������������ 172 12.10 Infections�������������������������������������������������������������������������������� 173 12.11 Complications Due To Stent �������������������������������������������������� 173 12.12 False Passage in the Canaliculi ���������������������������������������������� 174 12.13 Air Reflux�������������������������������������������������������������������������������� 174 References������������������������������������������������������������������������������������������ 174 13 Paediatric Endoscopic Dacryocystorhinostomy with Special Emphasis on Congenital Nasolacrimal Duct Obstruction and Approach to a Child with Epiphora������������������ 177 13.1 Congenital Nasolacrimal Duct Obstruction (CNLDO)���������� 177 13.1.1 Symptoms������������������������������������������������������������������ 177

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13.1.2 Examination �������������������������������������������������������������� 178 13.1.3 Conservative Management���������������������������������������� 179 13.1.4 Probing and Irrigation������������������������������������������������ 179 13.1.5 Classification of CNLDO������������������������������������������ 183 13.1.6 Dacryoendoscopy������������������������������������������������������ 186 13.2 Endoscopic DCR�������������������������������������������������������������������� 186 13.3 Surgical Technique������������������������������������������������������������������ 187 13.4 Challenges in Paediatric Endoscopic DCR and Its Success Rate: �������������������������������������������������������������������� 192 13.4.1 Narrow Dimensions of the Nasal Cavity:������������������ 192 13.4.2 Handling the Septal Deviations in Children�������������� 192 13.4.3 Success Rate�������������������������������������������������������������� 192 13.4.4 Complications of Paediatric Endoscopic DCR���������� 192 References������������������������������������������������������������������������������������������ 193 14 Revision Endoscopic Dacryocystorhinostomy������������������������������ 195 14.1 Important Points in History of Failed Cases �������������������������� 195 14.2 Preoperative Assessment in Failed Cases of DCR������������������ 196 14.3 Surgical Steps�������������������������������������������������������������������������� 197 14.3.1 Situation 1������������������������������������������������������������������ 197 14.3.2 Situation 2������������������������������������������������������������������ 201 14.3.3 Situation 3������������������������������������������������������������������ 205 14.3.4 Situation 4������������������������������������������������������������������ 207 14.4 Analysis of the Causes of Failure ������������������������������������������ 209 References������������������������������������������������������������������������������������������ 212 15 An Overview of Nasolacrimal Duct (NLD) Encountered in Different Situations; Identification, Prevention and Management of NLD Injuries������������������������������ 215 15.1 Mode of NLD Injury in Endoscopic Sinus Surgery���������������� 215 15.2 Importance of Preoperative CT DCG in Lacrimal Drainage Disorders ���������������������������������������������������������������� 217 15.3 NLD in Pre-Lacrimal Approaches������������������������������������������ 219 15.4 NLD Damage in Endoscopic Extended Maxillary Mega Antrostomy�������������������������������������������������������������������� 221 References������������������������������������������������������������������������������������������ 222 16 Transcanalicular Laser Assisted Dacryocystorhinostomy ���������� 223 16.1 Indications of Laser DCR ������������������������������������������������������ 223 16.2 Mode of Delivery�������������������������������������������������������������������� 223 16.3 Steps of Laser DCR���������������������������������������������������������������� 224 16.4 Advantages of Laser DCR������������������������������������������������������ 229 16.5 Disadvantages of Laser DCR�������������������������������������������������� 230 16.6 Complications ������������������������������������������������������������������������ 230 16.7 Success Rate���������������������������������������������������������������������������� 230 16.8 Contraindications of Transcanalicular Laser DCR ���������������� 231 16.9 Causes of Failure in Conventional Endoscopic DCR and Its Relation to the Laser DCR������������������������������������������ 231 16.10 Advantage of Vitreoretinal Probe with Diode Laser�������������� 231

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16.11 Key Points ������������������������������������������������������������������������������ 231 References������������������������������������������������������������������������������������������ 231 17 Endoscopic Dacryocystorhinostomy in Post-­Traumatic Nasolacrimal Duct Obstruction������������������������������������������������������ 233 17.1 Mode of NLD Injury in Nasoethmoid Fractures and Time of Evaluation of Lacrimal Drainage System (LDS)������ 233 17.2 Clinical Presentation �������������������������������������������������������������� 234 17.3 Examination���������������������������������������������������������������������������� 234 17.3.1 Local Examination ���������������������������������������������������� 234 17.3.2 Nasal Endoscopy�������������������������������������������������������� 235 17.3.3 Computed Tomographic Dacryocystography (CT DCG)������������������������������������������������������������������ 235 17.4 Surgical Management ������������������������������������������������������������ 237 17.5 External Verses Endoscopic DCR in Post-Traumatic NLD Obstruction�������������������������������������������������������������������� 243 References������������������������������������������������������������������������������������������ 246 18 Navigation Guided Surgery in Complex Lacrimal Drainage Disorders�������������������������������������������������������������������������� 247 18.1 Types of Navigation System �������������������������������������������������� 247 18.2 Situation1�������������������������������������������������������������������������������� 248 18.3 Situation2�������������������������������������������������������������������������������� 251 References������������������������������������������������������������������������������������������ 254 19 Endoscopic Dacryocystorhinostomy in Chronic Granulomatous Lesions of the Lacrimal Drainage System �������� 257 19.1 Tuberculosis (TB) of the LDS������������������������������������������������ 257 19.1.1 Incidence�������������������������������������������������������������������� 257 19.1.2 Clinical Presentation and Examination���������������������� 257 19.1.3 Diagnosis�������������������������������������������������������������������� 257 19.1.4 Histopathology���������������������������������������������������������� 258 19.1.5 Treatment ������������������������������������������������������������������ 258 19.2 Rhinosporidiosis of LDS�������������������������������������������������������� 259 19.2.1 Background���������������������������������������������������������������� 259 19.2.2 Site Predilection and Spread of Rhinosporidiosis������ 259 19.2.3 Clinical Presentation�������������������������������������������������� 259 19.2.4 Radiology in Lacrimal Sac Rhinosporidiosis������������ 260 19.2.5 Choice of Surgical Procedure������������������������������������ 260 19.2.6 Steps of Surgery �������������������������������������������������������� 260 19.2.7 Post-Operative Instructions���������������������������������������� 263 19.3 Wegener’s Granulomatosis of LDS���������������������������������������� 264 19.3.1 Management�������������������������������������������������������������� 264 19.4 Sarcoidosis of LDS ���������������������������������������������������������������� 265 References������������������������������������������������������������������������������������������ 266 20 Dacryoendoscopy in Lacrimal Drainage System�������������������������� 269 20.1 Dacryoendoscopy�������������������������������������������������������������������� 270 20.1.1 Technique������������������������������������������������������������������ 270

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20.1.2 Findings��������������������������������������������������������������������� 272 20.1.3 Puncta������������������������������������������������������������������������ 272 20.1.4 Canaliculi ������������������������������������������������������������������ 272 20.1.5 Lacrimal Sac�������������������������������������������������������������� 272 20.1.6 Sac Duct Junction������������������������������������������������������ 274 20.1.7 NLD �������������������������������������������������������������������������� 274 20.2 Dacryoendoscopy in CNLDO������������������������������������������������ 274 20.2.1 Membranous Obstruction (Fig. 20.9)������������������������ 274 20.2.2 Dacryolith (Fig. 20.10)���������������������������������������������� 274 20.2.3 Agenesis of NLD (Figs. 20.11 and 20.12) ���������������� 275 20.3 Dacryoendoscopy in Canalicular Obstructions���������������������� 279 20.4 Dacryoendoscopy Primary Acquired Nasolacrimal Duct Obstruction�������������������������������������������������������������������� 279 20.5 Challenges of Dacryoendoscopy�������������������������������������������� 280 References������������������������������������������������������������������������������������������ 281 21 Balloon Dacryoplasty in Lacrimal Drainage System Disorders Using Coronary Angioplasty Balloons�������������������������� 283 21.1 Balloon Dacryoplasty in Congenital Nasolacrimal Duct Obstruction (CNLDO) �������������������������������������������������� 283 21.1.1 Coronary Angioplasty Balloons�������������������������������� 284 21.1.2 Procedure ������������������������������������������������������������������ 286 21.1.3 Advantages of Using a Coronary Balloon over the Conventional LacriCATH������������������������������������ 290 21.2 Balloon Dacryoplasty in Adults���������������������������������������������� 290 21.2.1 Complete NLD Obstructions ������������������������������������ 290 21.2.2 Role of Balloon in Ostium Dilatation������������������������ 291 21.2.3 Revision DCR������������������������������������������������������������ 291 21.3 Balloon Catheter Dilatation of Common Canaliculus in Functional Epiphora���������������������������������������������������������������� 291 21.4 Conclusion������������������������������������������������������������������������������ 294 References������������������������������������������������������������������������������������������ 294 22 Endoscopic Conjunctivodacryocystorhinostomy�������������������������� 297 22.1 Key Words������������������������������������������������������������������������������ 298 References������������������������������������������������������������������������������������������ 298 23 Training Aspects in Endoscopic Dacryocystorhinostomy and Role of Cadaver Dissection������������������������������������������������������ 301 23.1 Training Trough Cadaver Dissection�������������������������������������� 302 23.1.1 Steps of Nasal Endoscopy������������������������������������������ 303 23.2 Endoscopic DCR in Cadaveric Specimen������������������������������ 304 23.2.1 Advantages of Cadaver Dissection���������������������������� 306 23.2.2 Comparison of the Cadaveric Dissection with Other Simulating Models������������������������������������������ 307 References������������������������������������������������������������������������������������������ 308 24 Instrumentation in Endoscopic Dacryocystorhinostomy ������������ 311 References������������������������������������������������������������������������������������������ 324

About the Author

Nishi Gupta  obtained her MS degree in otorhinolaryngology from the prestigious Mahatma Gandhi Institute of Medical Sciences, Wardha (Nagpur University), in 1992 and postgraduate diploma in hospital management from NIHFW, Delhi, and completed training at Great Ormond Street Hospital for children in London. She has been associated with this institute for close to three decades where she has done extensive work on endoscopic sinus and lacrimal surgeries. She has been passionate about endoscopic management of lacrimal disorders and has been conducting annual live surgical and cadaveric dissection workshops on endoscopic dacryocystorhinostomy. Thirty two live surgical demonstrations on endoscopic lacrimal procedures have been given in India and abroad. Her work on endoscopic lacrimal surgey received recognition and and was chosen for Ranbaxy award in 1999 and a Wolf Endoscopic Quiz debate award in 2000. It was subsequently presented at Geneva, Hong Kong, Athens, Nepal and Bangladesh. Her stay at Great Ormond Street Hospital for children, London, in 2008 generated special interest in paediatric epiphora. She has published 3 textbooks and 35 research papers in national and international journals and is a reviewer of a national and 3 international journals. She is currently working as Associate Medical Director and Head Department of ENT at Dr Shroff`s Charity Eye Hospital (SCEH), New Delhi, India.

xix

1

Embryology of the Lacrimal Drainage System

Knowledge of the embryological development of the lacrimal drainage system (LDS) is important to understand the congenital malformations [1]. The lacrimal drainage pathway includes lacrimal puncta, lacrimal canaliculi, lacrimal sac and nasolacrimal duct. These structures collect the tears and drain it into the nasal cavity [2]. In an embryo, the development of head and neck is contributed by pharyngeal arches which appear in the fourth and fifth weeks of development [3]. At the end of fourth week, the first pair of pharyngeal arches form facial prominences and the periocular structures begin to develop from the frontonasal and maxillary processes, which consist of neural crest cells [1, 3]. Maxillary prominences are formed lateral to stomodeum and the mandibular prominence is formed caudal to it (Fig.  1.1). During the fifth week, lateral and medial nasal prominences are formed [3] (Fig. 1.2). Initially, the maxillary and the lateral nasal prominences are separated by a deep groove called as the nasolacrimal groove [3] (Fig. 1.3). During days 37–42, a thickening of the epithelial cells starts developing at the bottom of the lacrimal groove. This thickening is known as the lacrimal lamina. The lacrimal lamina separates from the surface ectoderm and forms the lacrimal cord [2]. Following detachment of the cord, the maxillary and nasal prominences merge with each other [3].

The upper and lower eyelids form separately by the proliferation of the surface ectoderm, during the fifth gestational week and fuse at approximately 10 weeks gestation [1]. Embryo is formed first, at 8 weeks post-ovulation which then forms the foetus [4] and the lacrimal sac is roughly completed 10 weeks post-ovulation [5]. At the end of the embryonic period, the lateral portion of the lacrimal cord differentiates into the superior and inferior lacrimal canaliculi and in the lacrimal sac [2]. The medial portion of the lacrimal cord continues caudal to the inferior meatus although the epithelia have not yet joined [2]. From the tenth week, the following occur 1. Canalization in the lacrimal cord occurs forming a true nasolacrimal duct. 2. The epithelium of the lacrimal canaliculi makes contact with the palpebral conjunctival epithelium. 3. The inferior meatal lamina starts cavitating and makes contact with caudal extreme of the lacrimal duct. 4. Fibres of Horner’s muscle surround the lacrimal canaliculi [2]. The nasolacrimal duct then runs from the medial corner of the eye to the interior meatus of the nasal cavity [3].

© Springer Nature Singapore Pte Ltd. 2021 N. Gupta, Endoscopic Dacryocystorhinostomy, https://doi.org/10.1007/978-981-15-8112-0_1

1

1  Embryology of the Lacrimal Drainage System

2 Frontonasal process

Nasal placodes Nasolacrimal groove Nasal pits

Mandibular process

Fig. 1.3  The maxillary and the lateral nasal prominences are separated by a deep groove called as the nasolacrimal groove [3]. (Photo courtesy Dr. Shreya Aggarwal)

Fig. 1.1  Schematic diagram showing the development of lacrimal drainage system. Maxillary prominences are formed lateral to stomodeum and the mandibular prominence is formed caudal to it. (Photo courtesy Dr. Shreya Aggarwal)

Medial nasal process

Lateral nasal process

1.1

Congenital Defects in Lacrimal Drainage System

1.1.1 Puncta The diameter of the puncta is 0.2–0.3  mm [6]. During embryologic development maxilla grows more rapidly than the frontal bone, it thus pulls the inferior canaliculus laterally. The lower punctum is seen to lie approximately 1 mm lateral to the upper one [7]. In some syndromic conditions like BPES (Blepharophimosis ptosis-epicanthus inversus syndrome) there is lateral displacement of the puncta (Fig. 1.4).

1.1.1.1 Punctal Agenesis Congenital punctal agenesis (Fig. 1.5) is usually associated with canalicular agenesis [8] and results from the failure of outpouching of the epithelial bud from the upper end of the lacrimal cord and is found to be associated with a number of syndromes [5, 9–11].

Fig. 1.2  During the fifth week, lateral and medial nasal prominences are formed [3]. (Photo courtesy Dr. Shreya Aggarwal)

1.1.1.2 Supernumerary Punctum Supernumerary punctum is a congenital anomaly, in which there is more than one lacrimal punctum [12] and have also been reported as double puncta

1.1  Congenital Defects in Lacrimal Drainage System

3

Fig. 1.4  Lateral placement of puncta in a child of BPES syndrome Fig. 1.6  Slit lamp photograph showing supernumerary punctum (arrow)

1.1.3 Nasolacrimal Duct (NLD)

Fig. 1.5  Slit lamp photograph demonstrating punctal stenosis

by some authors [13, 14] (Fig.  1.6). They result from multiple epithelial buds developing from the upper end of the lacrimal cord [8, 11, 12]. It is often asymptomatic, but sometimes may be associated with dry eye or epiphora and NLD obstruction.

1.1.2 Congenital Canalicular Obstructions Canalicular agenesis is usually associated with punctal agenesis [8] and results from the failure of outpouching of the epithelial bud from the upper end of the lacrimal cord. Congenital canalicular obstructions are seen in anophthalmus or severe microphthalmos [15].

1.1.3.1 Agenesis of NLD There could be a completely absent NLD and the sac ends blindly in the bone of the frontal process of the maxilla (Fig. 1.7a). On dacryoendoscopy the sac shows a blind bottom with no NLD opening as is often seen in well-formed NLD [16]. During on endoscopic DCR these cases, a small sac can be seen ending into the bone of maxila [16]. 1.1.3.2 An Incomplete Development of NLD An incomplete development of NLD where NLD has begun to form but the growth gets arrested immediately after the NLD formation starts (Fig.  1.7b). The condition can be diagnosed on dacryoendoscopy [16]. 1.1.3.3 Buried Probe NLD may extend down the submucosa for several millimetres or even up to the floor of the nose without opening; hence, the probe goes down to the nasal floor without mucosal perforation into the nasal cavity, a condition commonly referred to as ‘buried probe’ [17–19] (Fig. 1.7c). 1.1.3.4 Distal NLD Obstruction Intact membrane at the valve of Hasner:

1  Embryology of the Lacrimal Drainage System

4

a

b

c

d

Fig. 1.7  Schematic diagram showing congenital nasolacrimal defects. (d) Membranous obstruction over the valve of Hasner in the inferior meatus with a bulging mem-

brane. (c) Inferolateral extension of the NLD along the inferior meatus indicating a buried probe. (b) Partially formed NLD. (a) Complete absence (agenesis) of NLD

The canalization of the entire lacrimal system occurs simultaneously starting from the eighth week until birth [1, 20]. There may be persistent membrane at the distal end on NLD consisted of lacrimal epithelial tissue on the NLD side and nasal mucosa on the other side [21]. Incomplete cavitation occurs at birth at this site leading to a condition known as Congenital nasolacrimal duct obstruction (CNLDO) [22]. CNLDO is the most common cause of epiphora in infants. It is usually the result of the failure of canalization of the distal end of NLD [23]. This is commonly a mucous membrane obstruction at the lower end of NLD that bulges at the NLD opening and is found in up to 20% of newborn infants [24]. The most common site of obstruction however is the distal end where a membranous bulge is present at the NLD opening [22] and can be treated by endoscopic probing and syringing (Fig. 1.7d). However, a fibrous infiltration of the distal NLD openings puts it into the category of complex CNLDO [16]. This condition does not respond to endoscopic probing and syringing and needs endoscopic DCR [16].

1.1.3.5 Congenital Dacryocystocele Congenital dacryocystocele is an uncommon sequelae of the congenital nasolacrimal duct obstruction. It occurs as a result of a simultaneous obstruction at the valve of Rosenmuller and lower obstruction at the valve of Hasner [25]. Lower obstruction occurs due to the presence of a persistent membrane between the NLD and the mucosal epithelium of the inferior meatus in newborns [1]. The upper obstruction occurs at the common canaliculus as it enters the lacrimal sac at an acute angle forming a valve of Rosenmuller at the junction between the common canaliculus and the lateral wall of the lacrimal sac. When tears get collected in the lacrimal sac due to impaired drainage into the nasolacrimal duct, the hydrostatic pressure in the sac increases, leading to the valve fold pressure and closure of the common canaliculus ostium [6]. This membrane fails to rupture leading to the accumulation of the fluid in the lacrimal sac. The pressure inside the sac increases leading to the expansion of the lacrimal sac and formation of a dacryocystocele. The fluid gets accumulated in

1.1  Congenital Defects in Lacrimal Drainage System

the sac leading to its distension that presents as a medial canthal mass. The membrane over the distal NLD opening bulges into the inferior meatus to produce an NLD cyst [6].

1.1.4 Lacrimal fistula 1.1.4.1 Congenital Lacrimal Fistula Congenital lacrimal fistulae are accessory ducts that connect the lacrimal drainage system to the skin. The fistula may be a small blind-ended tract and may remain asymptomatic. They are found in around 1 in 2000 live births [26–28]. They are often asymptomatic and most commonly located inferonasal to the medial canthal angle (Fig.  1.8). In some cases, may occur along the skin of the eyelids, around the medial canthus area and on the conjunctival surface [26, 29–31]. There may be associated redness, swelling and discharge from the opening (Fig. 1.9). They are often unilateral but can also be bilateral [30, 31].

Fig. 1.8  Endoscopic picture demonstrating a typical congenital lacrimal sac fistula

5

1.1.4.2 Etiopathogenesis of the  Lacrimal Fistula There are various theories that explain the etiopathogenesis of the lacrimal fistula. It could be due to the overgrowth of the outer wall of NLD, dysfunctional closure of embryonic fissure [32] or failure of involution of lacrimal anlage [33]. The most accepted hypothesis states that the fistula is an accessory canaliculus as was confirmed with the histopathological finding of the presence of stratified squamous epithelium in the fistulous tract identical to the lacrimal canaliculus [33]. 1.1.4.3 Acquired Lacrimal Sac Fistula Acquired lacrimal sac fistula formation between the lacrimal sac and the skin occurs as a result of resistant lacrimal sac abscesses that may rupture spontaneously (Figs. 1.10 and 1.11). Such fistulas show spontaneous healing following endoscopic dacryocystorhinostomy (DCR) and no fistulectomy is needed [34]. The congenital lacrimal fistula needs to be differentiated from the acquired fistulas and various differentiating features have been described in the following table.

Fig. 1.9  Congenital lacrimal sac fistula with cleft lip in a child

1  Embryology of the Lacrimal Drainage System

6

S.N 1 Location

2

Symptoms

3

Causes

4

Systemic associations

5

Treatment

Congenital lacrimal sac fistula Inferonasally to the medial canthus

Often asymptomatic (except in long-standing NLD obstruction and infections) It is a congenital developmental defect occurring as a result of an accessory canaliculus [33]

It is associated with various systemic conditions like Thalassemia, Down’s syndrome, naso-orbital meningocele [2] Fistulectomy is often needed. It can be with or without probing or DCR depending on the clinical findings as described in the flow chart

Acquired lacrimal sac fistula Variable depending on the site of rupture of the abscess Always symptomatic

Infections, spontaneous rupture of lacrimal abscess, incision and drainage of lacrimal abscess, due to trauma (laceration) or operations. Systemic association is not very common

Fistulectomy is generally not needed as the fistula often heals following DCR and the obstruction is relieved

1.1.4.4 Treatment Asymptomatic congenital fistulas can be observed while in symptomatic fistula the management depends on the status of NLD [26]. Treatment options include fistulectomy alone, fistulectomy with DCR or DCR alone. In congenital fistula, in absence of NLDO, fistulectomy alone may suffice [26]. Fistulectomy

Fig. 1.10  Clinical photograph showing an acquired fistula below the left medial canthal area

Fig. 1.11  Clinical photograph showing an acquired fistula below the right medial canthal area. On irrigation regurgitation of mucopurulent discharge can be seen through the fistula

can be done by a closed approach as well as an open approach. Although in the closed approach a study reported 100% failure but with a more formal closed approach in which two probes are passed, one through the lower canaliculus and other through the fistula and the complete tract was excised and the success rate was almost 99%(9/10) [35]. This method also avoids damage to the canaliculi. The acquired fistula generally heals with DCR as the obstruction that was causing fistula is relieved. The decision is based primarily on the presence or absence of NLDO and the treatment plan has been shown in the flow chart given below.

References

7 Lacrimal Sac Fistula

Acquired

Congenital

Without NLDO

Fistulectomy by Closed and formal approach

Pass a probe through lower Canaliculus pass another probe through fistula till it meets the first probe

Excise the tract & Suture

Confirm NLDO by Syringing on FDDT

With NLDO

Younger Child < 5 Years

Older Child > 5 Years

Fistula with normal skin no redness or discharge

1M Examination

Favorable situation with membranous bulge over VHSimple CNLDO

Epithelized Long standing Fistula/posttraumatic case Fistula with swelling discharge redness

Fistula following rupture of lacrimal sac abscess

Endoscopic DCR alone

Unfavorable situation no membranous bulge over VH No Probe seen in IM Complex CNLDO Endoscopic Probing & Syringing

Endoscopic Probing & Syringing with Fistulectomy

Patent

Blocked

Endoscopic DCR with Fistulectomy

Flow Chart showing management of lacrimal fistulas

NLDO; Nasolacrimal duct obstruction, IM; Inferior meatus, FDDT; Fluorescein dye disappearance test Key Points • Embryological developmental defects are common in the lacrimal system. Some of them do not produce symptoms. Congenital nasolacrimal duct obstruction (CNLDO) is the most common NLD defect and presents in multiple forms. Though membranous CNLDO is amenable to probing and syringing but more complex ones need DCR. Acknowledgement  I acknowledge Dr. Shreya Aggarwal, All India Institute of Medical Sciences (AIIMS) Delhi for assisting me in preparing this manuscript and providing the schematic diagrams.

References 1. Lueder GT.  The association of neonatal dacryocystoceles and infantile dacryocystitis with nasolacrimal duct cysts. Trans Am Ophthalmol Soc. 2012 Dec;110:74–9.

2. de La C-BC, Peces-Peña MD, Jáñez-Escalada L, Mérida-Velasco JR.  Morphogenesis of the human excretory lacrimal system. J Anat. 2006 Aug;209(2):127–35. https://doi. org/10.1111/j.1469-7580.2006.00606.x. 3. Langman’s Medical Embrology, 12th Edition, T.W. Sadler, Wolter Kluwer 2012 Lippincott Williams & Wilkins, p.  260–86, Chapter 17, Head and Neck. ISBN-13;978-81-8473-910-7. 4. O’Rahilly R. Early human development and the chief sources of information on staged human embryos. Eur J Obstet Gynecol Reprod Biol. 1979;9:273–80. 5. Whitnall SE. The lacrimal apparatus. In: Whitnall SE, editor. The anatomy of the human orbit and accessory organs of vision. Oxford: Oxford University Press; 1921. p. 223–52. Google Scholar. 6. Maliborski A, Różycki R. Diagnostic imaging of the nasolacrimal drainage system. Part I.  Radiological anatomy of lacrimal pathways. Physiology of tear secretion and tear outflow. Med Sci Monit. 2014;20:628–38. 7. Gray H. The complete Anatomy of the Human Body, published. 20th U.S. edition; 1918. NB, p.  1028. Warreh H Lewis. Philadelphia. 8. Kirk RC.  Developmental anomalies of the lacrimal passages. A review of the literature and presentation of three unusual cases. Am J Ophthalmol. 1956;42:227–32. CrossRefPubMedGoogle Scholar 9. Ali MJ. Supernumerary Puncta. In: Atlas of lacrimal drainage disorders. Singapore: Springer; 2018. 10. Duke-Elder S.  Development of ocular adnexa. In: Duke-Elder S, editor. System of ophthalmology, volume 1. St. Louis, MO: CV Mosby; 1938. p.  364–5. Google Scholar.

8 11. Wicherkiewicz W. Proceeding of XI international congress of medicine, vol. 6. Rome, 1895. p. 49. Google Scholar. 12. Lacroix Z, Bitton E.  Supernumerary Punctum: an unusual case of seeing double. Clin Exp Optom. 2015;98(4):375–8. https://doi.org/10.1111/ cxo.12231. Epub 2015 May 5 13. Bair PJ, Tsai YY, Lin JM.  Congenital reduplication of the lacrimal punctum and canaliculus in a patient with dry eye. Ophthalmic Surg Lasers Imaging. 2004;35(2):156–8. PMID: 15088828 Review 14. Satchi K, McNab AA.  Double lacrimal puncta: clinical presentation and potential mechanisms of epiphora. Ophthalmology. 2010;117(1):180–183.e2. https://doi.org/10.1016/j.ophtha.2009.06.054. Epub 2009 Oct 28. PMID: 19875171 15. Schittkowski MP, Guthoff RF.  Results of lacrimal assessment in patients with congenital clinical anophthalmos or blind microphthalmos. Br J Ophthalmol. 2007;91:1624–6. 16. Gupta N, Singla P, Kumar S, Ganesh S, Dhawan N, Sobti P, Aggarwal S.  Role of dacryoendoscopy in refractory cases of congenital nasolacrimal duct obstruction. Orbit. 2019; https://doi.org/10.1080/016 76830.2019.1668434. 17. Gupta N, Chawla N, Ganesh S, Das S, Dhawan N, Bansal S, Singla P.  Prevalence of buried probe in complex congenital nasolacrimal duct obstruction and evaluation of its success rate post ‘probing and irrigation’: a single-centre retrospective study. Orbit. 2018; https://doi.org/10.1080/01676830.2018.1435695. 18. Nesi FA, Lishman RD, Levine MR. Ophthalmic plastic and reconstructive surgery. In: Congenital lacrimal disorders, vol. 34. 2nd ed. St. Louis: Mosby-Year Book, Inc.; 1998. p. 649–60. 19. Mirecki R. Cause of failure in probing the nasolacrimal duct in infants and children and ways of avoiding them. J Paediatr Ophthalmol. 1968;5:171–5. 20. Sevel D.  Development and congenital abnormalities of the nasolacrimal apparatus. Pediatr Ophthalmol Strabismus. 1981;18(5):13–9. 21. Mayou MS, et al. R Lond Ophthalmic Hosp Rep. 1908;17:246–53. 22. Gupta N, Neeraj C, Smriti B, Sima D. A comparison of the success rates of endoscopic-assisted probing in the treatment of membranous congenital nasolacrimal duct obstruction between younger and older children

1  Embryology of the Lacrimal Drainage System and its correlation with the thickness of the membrane at the Valve of Hasner. Orbit. 2017; https://doi.org/10 .1080/01676830.2017.1383483. 23. MacEwen CJ, Young JDH, Barras CW, Ram B, White PS. Value of nasal endoscopy and probing in the diagnosis and management of children with congenital epiphora. Br J Ophthalmol. 2001;85:314–8. 24. Wallace EJ, Cox A, White P, MacEwen CJ. Endoscopic-assisted probing for congenital nasolacrimal duct obstruction. Eye. 2006;20:998–1003. https://doi.org/10.1038/sj.eye.6702049. 25. Cavazza S, Laffi GL, Lodi L, Tassinari G, Dall’Olio D.  Congenital dacryocystocele: diagnosis and treatment. Acta Otorhinolaryngol Ital. 2008;28(6):298–301. 26. Chaung JQ, Sundar G, Ali MJ.  Congenital lacrimal fistula: a major review. Orbit. 2016; https://doi.org/10 .1080/01676830.2016.1176052. 27. Francois J, Bacskulin J. External congenital fistulae of the lacrimal sac. Ophthalmologica. 1969;159:249–61. 28. Welham RA, Bergin DJ.  Congenital lacrimal fistulas. Arch Ophthalmol. 1985;103:545–8. Mandal J. A peculiar congenital fistula of the lacrimal sac. Ind J Ophthalmol. 1972; 20:158 29. Toda C, Imai K, Tsujiguchi K, Komune H, Enoki E, Nomachi T. Three different types of congenital lacrimal sac fistulas. Ann Plast Surg. 2000;45:651–3. 30. Zhuang L, Sylvester CL, Simons JP. Bilateral congenital lacrimal fistulae: A cayse report and review of the literature. Laryngoscope. 2010;120(Suppl 4):S230. 31. Duke-Elder S.  Development of ocular adnexa. Syst Ophthalmol. 1:364–5. 32. Jones LT, Wobig JL. Surgery of the eyelids and lacrimal system: Aesculapius Publishing Company; 1976 33. Welham RA, Bates AK, Stasior GO. Congenital lacrimal fistula. Eye. 1992;6(Pt 2):211–4. 34. Pison A, Fau JL, Racy E, Fayet B.  Acquired fis tula of the lacrimal sac and laisser-faire approach. Description of the natural history of acquired fistulas between the lacrimal sac and the skin occurring before planned endonasal dacryocystorhinostomy (DCR) and without any treatment of the fistula. J Fr Ophtalmol. 2016;39(8):687–90. https://doi. org/10.1016/j.jfo.2016.03.009. 35. Caputo AR, Smith NH, Cinotti AA, Angiuoli D. Definitive treatment of congenital lacrimal sac fistula. Arch Ophthalmol. 1978;96:1443–4.

2

Anatomy of Lacrimal Drainage System

The lacrimal drainage system includes upper and lower punctum, canaliculi, lacrimal sac and nasolacrimal duct (Fig. 2.1). It is divided into upper and lower parts. The upper part of the lacrimal drainage system includes lacrimal puncta, upper and lower canaliculi and common canaliculus and is lined with stratified cuboidal epithelium [1]. The lower lacrimal system comprises of the lacrimal sac and nasolacrimal duct (NLD). It is lined by double-layered columnar epithelium [1]. The sac and NLD are located in the nose and therefore, it is important to understand nasal anatomy first.

2.1

Nasal Cavity

The nasal cavity is divided into two parts by the nasal septum (Fig.  2.2). The septum comprises three parts, a membranous part that is formed by the fibrofatty tissue, a cartilaginous part formed by a quadrilateral cartilage and a bony part. The bony part is formed by vomer, the perpendicular plate of ethmoids and palatine bone inferiorly (Fig. 2.3). The perpendicular plate of the ethmoid bone is continuous with the cribriform plate superiorly and sphenoid rostrum posterosuperiorly [2] (Fig. 2.3).

2.1.1 Clinical Relevance Significant septal deviation especially high posterior deviation found during endoscopic

dacryocystorhinostomy (DCR) needs correction (Figs.  2.4 and 2.5). Endoscopic septoplasty should be done by preserving the dorsal and the caudal strut. Severe septal deviations found during should not be forcibly pushed to the contralateral side as it may lead to fracture extending up to the cribriform plate leading to CSF leak as described in the chapter on complications of endoscopic DCR. Good anatomical knowledge helps in preventing complications.

2.2

Turbinates

There are three pairs of nasal turbinates, superior, middle inferior and sometimes a supreme turbinate may also be present (Figs. 2.2, 2.4, and 2.6). Turbinates are important anatomical structures within the nasal cavity [3, 4]. The location and relationship of the turbinates to the surrounding other anatomic landmarks are important in endoscopic nasal and sinus surgeries. The inferior turbinate is a separate bone while the other turbinates are parts of the ethmoid bone. The inferior turbinate is the largest turbinate in the nose and it arises from the medial wall of the maxillary sinus while the middle, superior and supreme turbinates are smaller in dimension (Fig.  2.3). There are certain anatomical variations found in the middle turbinate like a paradoxical middle turbinate or concha. Normally the middle turbinate has a concave surface fac-

© Springer Nature Singapore Pte Ltd. 2021 N. Gupta, Endoscopic Dacryocystorhinostomy, https://doi.org/10.1007/978-981-15-8112-0_2

9

10 Fig. 2.1  A schematic diagram depicting the various parts of the lacrimal drainage system. (Photo courtesy: Dr Shreya Aggarwal)

2  Anatomy of Lacrimal Drainage System Lacrimal Upper sac canaliculus

Upper punctum

Lower punctum Lower canaliculus Common canaliculus NLD

2.2.1 Clinical Relevance

Fig. 2.2  A skull photograph showing nasal septum dividing the nasal cavity into two compartments

ing the lateral wall. If this concave surface of the middle turbinate faces the septum, it is called a paradoxical middle turbinate [5]. A pneumatized middle turbinate is known as concha bullosa and is a common finding [5–11] (Fig.  2.7). Maru et al. have described three types of pneumatization of the middle turbinate lamellar, bulbous and extensive [3] They however could not find its association with the sinus pathology [3].

Concha bullosa or a paradoxical middle turbinate can block the osteomeatal complex leading to impaired drainage [5]. Therefore, if needed conchoplasty should be performed preferably by a mucosal preservation technique as described in the chapter on the management of associated nasal conditions. The middle turbinate is a crucial landmark in relation to endoscopic DCR. Axilla of the middle turbinate is an important landmark during endoscopic DCR and its relation with the initial incision in endoscopic DCR has been described separately. Synechiae formation between the anterior attachment of the middle turbinate and the lateral wall leads to the ostia closure and failure in DCR surgery (Fig.  2.8). Middle turbinate therefore should be handled with care and all exposed bone should be covered with mucosal flap as described in the chapter on surgical technique of endoscopic DCR. The inferior turbinate is important from endoscopic probing and irrigation or balloon dacryoplasty point of view in children. A gentle medial rotation of the inferior turbinate is required for examining the inferior meatus for any pathology over the valve of Hasner (Fig. 2.9).

2.3 Puncta Fig. 2.3 Schematic diagram showing various parts of nasal septum

11

Cribriform plate

Perpendicular plate of ethmoid

Sphenoid sinus

Nasal bone

Vomer Quadrangular cartilage

Palatine bone

Fig. 2.5  Endoscopic view of the left nasal cavity demonstrating a grossly deviated septum. LW lateral wall, IT inferior turbinate

2.3

Fig. 2.4  A skull photograph showing a high posterior deviation of the septum(star)

Puncta

The lacrimal punctum is an opening at the medial end of the eyelid and forms the first part of the upper lacrimal pathway. (Fig.  2.10). There are two lacrimal puncta one each on the upper and the lower eyelid in the medial and inner part.

12

Fig. 2.6  Sagittal section of a cadaver head specimen showing the turbinates and sac with NLD in a sagittal cut. NLD Nasolacrimal duct

Fig. 2.7 Computed tomographic scan of paranasal sinuses demonstrating right concha (star)

Tears are produced by the lacrimal gland, collected by puncta, carried through the lacrimal canaliculi to the lacrimal sac and drain through the NLD into the inferior meatus of the nose [1]. The diameter of the puncta is 0.2–0.3 mm in diameter and are known as the upper and lower

2  Anatomy of Lacrimal Drainage System

Fig. 2.8  Endoscopic view of the left nasal cavity demonstrating the synechiae between the anterior attachment of middle turbinate and the ostia on the lateral wall

Fig. 2.9  Endoscopic view of the left nasal cavity demonstrating the gentle lifting up of the inferior turbinate needed to visualize the inferior meatus and distal NLD opening

lacrimal puncta [1]. During embryologic development maxilla grows more rapidly than the frontal bone, it thus pulls the inferior canaliculus laterally. As a result, the lower punctum is located slightly lateral to the upper punctum [12]. When eyelids close, puncta meet each other and both puncta hide in the lacrimal lake and when eyelids

2.4 Canaliculi

13 Common canaliculus

0.5–0.6mm Horizontal canaliculus

Vertical canaliculus

2mm

Fig. 2.10  Clinical photograph demonstrating left lower punctum by gently pulling the lid down

open, the lower punctum is seen to lie approximately 1 mm lateral to the upper one [12].

2.3.1 Clinical Relevance The positioning of the puncta is important for the effective functioning of the lacrimal drainage system thus abnormally located puncta can lead to epiphora [1].

2.4

Canaliculi

The lacrimal canaliculi start from puncta and are present one in each eyelid. They are seen on the margins of the lids [13]. The lacrimal canaliculi have a horizontal part and a vertical part. The first part of the lacrimal canaliculi run about 2 mm vertically, get dilated to form the ampulla of the lacrimal canaliculus and then turn medially into the horizontal part. The length of the horizontal segment varies from 6 to 10 mm [14, 15] (Fig. 2.11). The upper and lower canaliculi join to form a common canaliculus, which is 3–5 mm long and opens into the lateral wall of the sac [15] (Fig.  2.11). The upper canaliculus is smaller in

6mm

Ampulla

3–5mm

Fig. 2.11  Schematic diagram demonstrating canalicular system and its dimensions

length than the lower one and is straighter. It runs at an angle of 25–30 deg down towards the lacrimal sac. The lower canaliculus, however, lies in a more horizontal position and bends down at the angle of 10–15 deg [1]. The upper and lower canaliculi open into the sac in different ways [1, 16]. They can join to form a common canaliculus that opens in the lacrimal sac in 94% cases while in the rest of the cases they either join in the sac wall without a common canaliculus or open separately in the sac [1]. Although the diameter of the canaliculi lumen is about 0.5– 0.6  mm but it can increase by up to three times owing to the elastic walls, lined by orbicular eye muscle fibres known as Riolan’s muscle [17]. Due to this elastic tendency of the walls of the canaliculi as well the lacrimal sac alters there is an alteration in their diameter that assists the drainage of tears and contribute to the lacrimal pump [15]. During eyelid closure, the distal part of the canaliculi lumen constricts by Horner’s muscle and compresses the tear fluid by the Venturi effect. When eyelids open the lumen dilates, causing the absorption of fluid creating a suction effect called the Bernoulli effect [1].

2  Anatomy of Lacrimal Drainage System

14

Common canalicular cavity opens into a laterally bulged portion of the sac, called the sinus of Maier. Sinus of Maier is the area of the sac around the common internal opening of the common canaliculus [18]. An expanded common canaliculus can also be labelled as the sinus of Maier [15]. Kakizaki demonstrated morphological characteristics of two different types of the sinus of Maier, one with a lacrimal sac diverticulum that was supplied by separate canalicular openings, and the other that showed terminal dilatation of the common lacrimal canaliculus [18, 19]. The functional valve between the common canalicu-

lus and the lacrimal sac has been described as two folds of mucosa that are formed by a sharp turn of the common canaliculus at its entry into the sac [1]. The upper fold is called the valve of Rosenmuller, (Figs. 2.12 and 2.13) while the lower fold was labelled as the valve of Huschke [20]. However, a recent study has questioned the presence of the valve of Hushke and has reported the findings of in vivo presence of two different types of valve of Rosenmuller [21].

2.4.1 Clinical Relevance Lacrimal sac gets distended due to the accumulation of tears in the sac due to an obstructed NLD, the hydrostatic pressure in the sac increases, leading to folding of the valve of Rosenmuller and closure of the common canaliculus ostium [1] as is also seen in congenital dacryocystocele formation. Canalicular anatomy is important for performing lacrimal drainage system surgeries and also helps in accurate preoperative assessment.

2.5

Fig. 2.12  Endoscopic view of the right nasal cavity demonstrating valve of Rosenmuller (arrow)

Fig. 2.13  Valve of Rosenmuller opened up with the passage of probe (arrow)

 ony Lacrimal Fossa B and Lacrimal Sac

The lacrimal fossa is a depression in the inferomedial orbital rim between anterior and posterior lacrimal crest [1] with a vertical length of 10–17 mm [22–25]. Anterior lacrimal crest is a groove on the frontal process of maxilla while the posterior lacrimal crest is a ridge on the lacrimal bone [18, 26] (Fig.  2.14). The lacrimo-maxillary suture, i.e. a vertical line that marks the articulation of the maxillary bone to the lacrimal bone runs almost midway in the lacrimal fossa between the ­anterior and posterior lacrimal crests and divides it into two almost equal parts [22] (Figs 2.11, 2.14 and 2.18). Intranasally, this suture corresponds to the maxillary line which is an important landmark for endoscopic DCR [22, 27] (as depicted in the chapter on the surgical technique of endoscopic DCR) (Fig.  7.1). A lacrimo-maxillary suture located more anteriorly would indicate predominance of the lacrimal bone (Fig. 4.9) while more posteriorly

2.6  Lacrimal Bone

15

Posterior lacrimal crest

fies the importance of preoperative imaging in primary acquired nasolacrimal duct obstruction.

2.6 Anterior lacrimal crest Frontal process of maxilla Lacrimal sac fossa Lacrimal bone

Fig. 2.14  Schematic diagram of the enlarged view of the lacrimal bone elaborating various parts

placed suture indicates predominance of the maxillary bone (Fig. 4.10) [26]. Computed dacryocystography (CT DCG) is an excellent investigation to know the type of dominance in the lacrimal fossa. Axial cuts on CT DCG can demonstrate the thickness of the bony boundaries of the fossa as described in the chapter on the radiological anatomy of the lacrimal drainage system (Figs. 4.8, 4.9, 4.10 and 4.11).

2.5.1 Clinical Relevance The lacrimal bone dominant fossa is a favourable situation as the bone is thin and removal with Kerrison punch is possible, while maxillary bone dominant fossa is a difficult situation. Endoscopic DCR in a maxillary bone dominant fossa should preferably be done by a more experienced surgeon as the bone is hard and cannot be removed by Kerrison punch. The complete bone needs to be drilled right from the beginning. Preoperative knowledge of this anatomic variation helps in predicting the intraoperative difficulty, can guide about the estimated duration of surgery and signi-

Lacrimal Bone

The lacrimal bone is a thin bone with a mean thickness of 106 microns, (Figs.  2.14 and 2.15) and thus can be easily removed to expose the lower part of the sac and NLD [28]. The lacrimal bone is divided into two parts (anterior and posterior) by a vertical ridge known as posterior lacrimal crest. The anterior part contributes to the formation of the posterior boundary of the lacrimal fossa and the posterior part articulates with the lamina papyracea (Figs. 2.14 and 2.16). The posterior part continues below into a lacrimal hamulus. Hamulus is a hook-like projection that articulates with the lacrimal tubercle of the maxilla. Both these structures form the upper opening of the NLD [12]. A longitudinal grove called lacrimal sulcus lies in front of the posterior lacrimal crest. The inner border of the lacrimal sulcus joins with the frontal process of maxilla to form lacrimal fossa. The upper part of the fossa lodges lacrimal sac, the lower part of the nasolacrimal duct [2]. A fine groove called sutura notha runs parallel to the anterior lacrimal crest [26] (Fig. 2.16). It is a vascular groove through which small branches of the infra orbital artery pass to supply the bone and nasal mucosa and may bleed during surgery. It lies on the frontal process of the maxilla just anterior to the lacrimal sac fossa.

2.6.1 Clinical Relevance Frontoethmoidal suture forms an important landmark and the dissection during lacrimal surgeries should be limited inferior to this suture to avoid intracranial complications [29]. The anterior and posterior ethmoidal foramina carry branches of the ophthalmic artery and the nasociliary nerve. Injury to these vessels may lead to torrential haemorrhage therefore the location should be known. The anterior and posterior ethmoidal foramina lie at 24- and 36-mm posterior to the anterior lacrimal crest, respectively [26] (Fig. 2.16).

16 Fig. 2.15  Location of the lacrimal bone marked in yellow in a skull photograph

Fig. 2.16  A skull bone photograph showing bony lacrimal fossa and various structures in relation to the fossa and the lacrimal bone

2  Anatomy of Lacrimal Drainage System

2.8  Nasolacrimal Duct

2.7

17

Lacrimal Sac

The sac is about 12.5 mm (6–14 mm) in length, 2.5  mm (1–4  mm) in diameter [1]. The oblique AP diameter is about 4 mm (1–6 mm). The lacrimal sac expands during eyelid closure and contracts when the eyelids open. The lacrimal sac is enclosed by a lacrimal fascia that is formed from the orbital periosteum which divides into two layers at the posterior lacrimal crest to envelope the lacrimal sac and NLD.  The lacrimal sac is thus a preseptal structure [18]. Surrounding the lacrimal fascia is a muscular envelope composed of the orbicularis oculi muscle that surrounds the lacrimal fascia. Orbicularis Oculi muscle has three parts; an orbital part (Fig. 4.20), that surrounds the orbit and a palpebral part that lies in the eyelids and it is attached medially to the anterior lacrimal crest by the medial palpebral ligament. It is also known as the superficial head. A third part of the orbicularis oculi muscle passes deep to attach to the posterior lacrimal crest also known as the deep head or lacrimal part of orbicularis oculi or Horner’s muscle [12, 18]. (Figs. 4.4, 4.5 and 4.7) However, a recent publication suggested that Horner’s muscle should be named as HornerDuverney’s muscle as the first description of this muscle was published by Duverney in 1745 and later as Horner in 1805 [30]. Thus, the central part of the lacrimal sac is covered by the medial palpebral ligament on its anterior and posterior aspect [1] (Fig.  2.17) (Figs.  4.22, 4.23, 4.24 and 4.25). The ligament divides into two parts and the part of the sac that lies above the level of the medial canthus is known as the fundus of the sac and measures about 5 mm, the part below is 10 mm in length [26] (Fig.  2.17) (Fig. 4.25). The sac below the level of medial palpebral ligament is a week site as it is not covered by a muscular layer and can be a site of spread of infection to the orbit [18].

2.7.1 Clinical Relevance The anterior attachment of the medial canthal tendon is often detached from the anterior lacrimal

F B

Fig. 2.17  A schematic diagram to demonstrate medial canthal ligament. The part of the lacrimal sac above the medial canthal ligament is known as the fundus(F) and the part below is known as body of the lacrimal sac(B)

crest during external DCR [26, 31] and that is why endoscopic DCR is considered more physiological as the medial canthal tendon is preserved.

2.8

Nasolacrimal Duct

The nasolacrimal duct (NLD) is the caudal extension of the lacrimal sac and is located within the nasolacrimal canal (Fig. 2.1). It has an upper orbital part, located in the bony lacrimal sac fossa and the lower part, located in the bony canal of the nasolacrimal duct. The length of the orbital part of NLD varies from 5–7 mm though the sac position can be high or low in the fossa and the length of the orbital part of NLD varies accordingly [1, 32] depending on the location of the lacrimal sac. If the sac is located high, the duct measures up to 10 mm, while if the sac position is low, the duct starts in the bony canal and the usual length of the orbital part of NLD is 5–7 mm [1]. The proximal bony opening of

2  Anatomy of Lacrimal Drainage System

18

the NLD is formed by the articulation of the hamulus (a small hook-like projection of the lacrimal bone) with the maxilla [22] (Figs. 4.16, and 4.17). It runs along the lateral wall of the nasal cavity and enters the inferior meatus below the anterior end of the inferior turbinate. During its course here it runs inferolateral and posteriorly [1]. Bony NLD is formed anterolaterally by maxillary bone and posteromedial by lacrimal bone superiorly and inferior turbinate inferiorly [26, 29, 33]. It has an average length of 21–22 mm, an average transverse diameter of 2.3 mm and oblique diameter of 2.8 mm [1]. Rest of the nasolacrimal duct has two parts: the intra-osseous part, about 12  mm in length, within the bony nasolacrimal canal of the maxilla; and the membranous or meatal part, which is 5  mm long and runs beneath the nasal mucosa before ending beneath the inferior nasal turbinate [26, 29, 33] (Fig. 2.18). NLD opens into the inferior meatus with a funnel-shaped opening. NLD continues for few millimetres under the nasal mucosa after leaving its bony canal and its distal opening is marked by a mucosal valve called valve of Hasner [34]. The mean distance of the natural ostium of the maxillary sinus to the NLD is 5.5 mm. The shortest distance between the NLD and the natural ostium of the maxillary sinus was found to be 4.8 mm [35]. Inadvertent removal of the thick bone surrounding the NLD may occur during the anterior widening of maxillary sinus ostium using backbiting forceps. Thus, middle meatal antrostomy should be done in the posteroinferior direction to minimize the chance of nasolacrimal duct damage [36, 37]. The NLD opening may have shapes varying from a small pin point orifice to a slit or a triangular opening [38] (Figs. 2.19, 2.20, 2.21, and 2.22). Irrespective of the size or shape, the ostium remains patent and functioning. A patent NLD allows tear flow into the nose however in cases of congenital nasolacrimal duct obstruction, there is a membranous obstruction at the distal end of NLD over the valve of Hasner [34, 39] (Fig. 2.23). This is typically a mucous membrane obstruction at the lower end of the nasolacrimal duct, seen in up to 20% of newborn infants [34, 39]. Spontaneous resolution occurs in the majority of the cases by 1 year of age.6.

Fig. 2.18  Schematic diagram demonstrating dimensions of the bony and membranous parts of NLD

In cases with persistent obstruction, this membrane is perforated by probing under nasal endoscopic guidance and the refractory cases undergo dacryocystorhinostomy [39, 40].

2.9

 alve and Mucosal Folds V in NLD

The mucous membrane folds in the lacrimal sac and NLD were earlier considered a type of valve that blocks the backward flow of tear. They were also supposed to limit the spread of disease in the lacrimal system [1]. Various such valves were, the valves of Bochdalek and Foltz associated

2.9  Valve and Mucosal Folds in NLD

Fig. 2.19  A pin head circular NLD orifice in a cadaveric specimen

19

Fig. 2.21  A well-formed large elliptical NLD opening and the area of valve of Hasner can be visualized on nasal endoscopy in a cadaver. IT Inferior turbinate

Fig. 2.20  A patent rounded NLD opening with free flow of dye on nasal endoscopic visualization of inferior meatus

Fig. 2.22  Inferior meatal endoscopy demonstrating a triangular NLD opening

with puncta, the valves of Rosenmuller and Huschke as the valve of common canaliculus formed near its entry into the lacrimal sac, valve of Krause lied at sac duct junction, Valve of Teileffer were thought to be formed at the mid part of the NLD and the valve of Hasner lying at the distal opening of the NLD into the inferior meatus [1]. However further studies have mentioned that these valve-like structures are actually the vascu-

lar system embedded in the wall of the lacrimal sac and nasolacrimal duct. It was also stated that the variations in the conditions of swelling of the cavernous tissue may have led to the mistaken description of valves in the lacrimal passage [41]. While all other valves were said to be impermanent mucosal folds that created a partial barrier to the tear reflux valve of Rosenmuller and the valve of Hasner are the most consistent valves. The valve of Hasner is the functional

20

Fig. 2.23  Intact membrane over the valve of Hasner in a child with congenital nasolacrimal duct obstruction

valve that prevents the backward flow of tears and also the nasal contents. The valve of Rosenmuller prevents back flow of the lacrimal sac content into the conjunctival sac. It is responsible for mucocele or dacryocele formation. Most of the obstructions are found at the sac duct junction that was called as sac duct junction [1]. Key Points • Knowledge of the anatomy of the nasal structures and bony lacrimal fossa is crucial to a successful lacrimal sac procedure. • Anatomical differences between lacrimal bone dominant fossa and maxillary bone dominant fossa can be studied on preoperative CT DCG. • A thorough understanding of the anatomy of the lacrimal drainage system facilitates a successful surgical outcome.

References 1. Maliborski A, Różycki R. Diagnostic imaging of the nasolacrimal drainage system. Part I.  Radiological anatomy of lacrimal pathways. Physiology of tear secretion and tear outflow. Med Sci Monit. 2014;20:628–38.

2  Anatomy of Lacrimal Drainage System 2. Janki S, Roxbury CR, Sindwani R.  Techniques in septoplasty traditional versus endoscopic approaches. Otolaryngol Clin N Am. 2018;51:909–17. 3. Măru N, Rusu MC, Săndulescu M. Variant anatomy of nasal turbinates: supreme, superior and middle conchae bullosae, paradoxical superior and inferior turbinates, and middle accessory turbinate. Romanian J Morphol Embryol. 2015;56(3):1223–6. 4. Felix V, Veerasigamani NK. Unilateral absence of ethmoid sinus and nasal turbinates: a rare case report. J Clin Diagn Res. 2017;11(4):MD01–2. 5. Ozcan KM, Selcuk A, Ozcan I, Akdogan O, Dere H.  Anatomical variations of nasal turbinates. J Craniofac Surg. 2008;19(6):1678–82. 6. Neskey D, Eloy JA, Casiano RR.  Nasal, septal, and turbinate anatomy and embryology. Otolaryngol Clin N Am. 2009;42(2):193–205, vii. 7. San T, Erdoğan B, Taşel B. Bilateral superior concha bullosa: a rare case overlooked. Kulak Burun Bogaz Ihtis Derg. 2014;24(5):292–4. 8. Ozturan O, Yenigun A, Degirmenci N, Yilmaz F. ‘Conchae bullosis’: a rare case with bilateral triple turbinate pneumatisations. J Laryngol Otol. 2013;127(1):73–5. 9. Tiwari R, Goyal R. Study of anatomical variations on CT in chronic sinusitis. Indian J Otolaryngol Head Neck Surg. 2015;67(1):18–20. 10. Kaygusuz A, Haksever M, Akduman D, Aslan S, Sayar Z.  Sinonasal anatomical variations: their relationship with chronic rhinosinusitis and effect on the severity of disease  – a computerized tomography assisted anatomical and clinical study. Indian J Otolaryngol Head Neck Surg. 2014;66(3):260–6. 11. Stallman JS, Lobo JN, Som PM.  The incidence of concha bullosa and its relationship to nasal septal deviation and paranasal sinus disease. AJNR Am J Neuroradiol. 2004;25(9):1613–8. 12. Gray H.  The complete anatomy of the human body, published. 20th U.S. ed. NB. Philadelphia: Warreh H Lewis; 1918. 1028p. 13. Hurwitz JJ.  Embryology of the lacrimal drainage system. In: Hurwitz JJ, editor. The lacrimal system. Philadelphia: Lippincott-Raven; 1996. p. 9–13. 14. Olver J.  Colour atlas of lacrimal surgery. Oxford: Butterworth-Heinemann; 2002. p. 2–23. 15. Kassel EE, Schatz CJ.  Lacrimal apparatus. In: Som PM, Curtin HD, editors. Head and neck imaging. St. Louis, MO: Mosby; 2003. p. 672–4. 16. Yazici B, Yazici Z.  Frequency of common cana liculus: a radiological study. Arch Ophthalmol. 2000;118:1381–5. 17. Bochenek A, Reicher M. Anatomia Człowieka T. V. Warszawa: PZWL; 1989. p. 558–68. 18. Russell EJ, Czervionke L, Huckman M, Daniels D, McLachlan D.  CT of the inferomedial orbit and the lacrimal drainage apparatus: normal and pathologic anatomy. AJNR. 1985;6:759–66. 19. Kakizaki H, Takahashi Y, Kang H, Nakano T, Asamoto K, Ikeda H. Two types of the sinus of Maier: an anatomic study. Orbit. 2015;34(5):253–6.

References 20. Yazici B, Yazici Z.  Anatomic position of the common canaliculus in patients with a large lacrimal sac. Ophthal Plast Reconstr Surg. 2008;24(2):90–3. 21. Ali MJ.  Endoscopic real-time analysis of two subtypes and potential functional implications. Ophthal Plast Reconstr Surg. 2020;36(1):94–7. 22. Massegur H, Lorenzo JG, Gras-Cabrerizo JR.  Nasal anatomy and evaluation. In: Cohen AJ, et  al., editors. The lacrimal system: diagnosis, management, and surgery. 2nd ed. Cham: Springer International Publishing; 2015. p.  15. https://doi. org/10.1007/978-3-319-10332-7_2. 23. Shams PN, Abed SF, Shen S, Adds PJ, Uddin JM. A cadaveric study of the morphometric relationships and bony composition of the caucasian nasolacrimal fossa. Orbit. 2012;31(3):159–61. 24. Lang J. Clinical anatomy of the nose, nasal cavity and paranasal sinuses. New York: Thieme; 1989. 25. Bisaria KK, Saxena RC, Bisaria SD, Lakhtakia PK, Agarwal AK, Premsagar IC.  The lacrimal fossa in Indians. J Anat. 1989;166:265–8. 26. Burkat CN, Lucarelli MJ.  Anatomy of the lacrimal system. In: Cohen AJ, Brazzo B, editors. The lacrimal system: diagnosis, management, and surgery. New York: Springer; 2006. p. 3–19. 27. Chastain JB, Cooper MH, Sindwani R.  The maxillary line: anatomic characterization and clinical utility of an important surgical landmark. Laryngoscope. 2005;115(6):990–2. 28. Hartikainen J, Aho HJ, Seppa H, Grenman R. Lacrimal bone thickness at the lacrimal sac fossa. Ophthalmic Surg Lasers. 1996;27(8):679–84. 29. Lemke BN, Della RR.  Surgery of the eyelids and orbit: an anatomical approach. East Norwalk, CT: Appleton & Lange; 1990. 30. Ali MJ, Paulson F.  Horner’s muscle or Horner-­ Duverney’s muscle. Ophthal Plast Reconstr Surg. 2020;36(2):208. 31. Whitnall SE.  Anatomy of the human orbit and accessory organs of vision, vol. 164–165. 2nd ed. New York: Krieger Publishing Company; 1979. p. 2.

21 32. Groell R, Schaffler GJ, Uggowitzer M.  CT-anatomy of the nasolacrimal sac and duct. Surg Radiol Anat. 1997;19:189–91. 33. Ali MJ, Nayak JV, Vaezeafshar R, Li G, Psaltis AJ.  Anatomic relationship of nasolacrimal duct and major lateral wall landmarks: cadaveric study with surgical implications. Int Forum Allergy Rhinol. 2014;4:684–8. 34. Vagge A, Desideri LF, Nucci P, Serafino M, Giannaccare G, Lembo A, Traverso CE.  Congenital nasolacrimal duct obstruction (CNLDO): a review. Diseases. 2018;6(4):96. 35. Unlü HH, Gövsa F, Mutlu C, Yücetürk AV, Senyilmaz Y.  Anatomical guidelines for intranasal surgery of the lacrimal drainage system. Rhinology. 1997;35(1):11–5. 36. Kim KR, Park CW, Choi SJ, Park IB. Surgical anatomy around the maxillary sinus ostium in cadavers. J Rhinol. 1998;5(1):19–22. 37. Serdahl CL, Berries CE, Chole RA.  Nasolacrimal duct obstruction after endoscopic sinus surgery. Arch Ophthalmol. 1990;108:391–2. 38. Tatlisumak E, Aslan A, Cömert A, Ozlugedik S, Acar HI, Tekdemir I. Surgical anatomy of the nasolacrimal duct on the lateral nasal wall as revealed by serial dissections. Anat Sci Int. 2010;85(1):8–12. 39. Gupta N, Neeraj C, Smriti B, Das S.  A comparison of the success rates of endoscopic-assisted probing in the treatment of membranous congenital nasolacrimal duct obstruction between younger and older children and its correlation with the thickness of the membrane at the valve of Hasner. Orbit. 2018;37(4):257–61. 40. Gupta N, Singla P, Kumar S, Ganesh S, Dhawan N, Sobti P, Aggarwal S.  Role of dacryoendoscopy in refractory cases of congenital nasolacrimal duct obstruction. Orbit. 2020;39(3):183–9. 41. Paulsen F, Thale AB, Hallmann UJ, Schaudig U, Tillmann BN.  The cavernous body of the human efferent tear ducts: function in tear outflow mechanism. Invest Ophthalmol Vis Sci. 2000;41(5):965–70.

3

Endoscopic Anatomy of the Lacrimal Drainage System

There is a wide range of anatomic variations in the nose between two individuals as well as on the two sides of the same individual. It is therefore important to understand the complex nasal anatomy in relation to the lacrimal drainage system. Paranasal sinuses drain in the osteomeatal complex on the lateral wall. Therefore, basic knowledge of sinuses will help in understanding the important landmarks on the lateral wall.

3.1

The Lateral Wall of Nose

The lateral wall is the most important structure of the nose in relation to the endoscopic lacrimal and orbital surgery and also from endoscopic sinus surgery point of view. It has a complex anatomical structure comprising of three turbinates, inferior, middle and superior. Each turbinate has its own meatus known as inferior, middle and superior meatus running below each turbinatea [1]. Endoscopic anatomy of the nose can be described in terms of various structures visualized during nasal endoscopy in a sequential manner [2].

between the inferior turbinate and the septum to look for any septal deviation or spur and condition of the nasal mucosa is examined (Fig. 3.1). The scope is then rotated laterally and is advanced under the inferior turbinate to enter into the inferior meatus [2]. As described earlier, for easy negotiation, the endoscope is first passed along the floor of nose medially to reach nasopharynx and then withdrawn gradually to enter the inferior meatus at the posterior end of inferior turbinate [3] (Figs. 3.2 and 3.3). This step can be safely performed without any manipulation of the inferior turbinate and is especially helpful in children undergoing nasal endoscopy guided probing and irrigation for congenital nasolacri-

3.1.1 First Pass Diagnostic endoscopy is performed using a 4 mm 00 endoscope. During first pass the endoscope is gently passed along the floor of the nasal cavity

Fig. 3.1  Endoscopic view of the left nasal cavity during first pass demonstrating the inferior turbinate and septum

© Springer Nature Singapore Pte Ltd. 2021 N. Gupta, Endoscopic Dacryocystorhinostomy, https://doi.org/10.1007/978-981-15-8112-0_3

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Inferior turbinate

lateral wall of the inferior meatus. A mucosal fold at the lower end of NLD prevents reflux into the NLD and this fold is known as valve of Hasner. In cases of CNLDO, this distal opening is covered by a membrane. After examination of the inferior meatus, the endoscope is then withdrawn from the inferior meatus and advanced towards the nasopharynx. Eustachian tube openings, torus tubarius and adenoid tissue are visible. Secretions may be seen flowing from the sinuses into the nasopharynx

Fig. 3.2  Endoscope is passed along the floor of the nose till the posterior end of inferior turbinate

Inferior turbinate

Fig. 3.4  Distal NLD opening is seen in the left inferior meatus with the presence of air bubbles indicating a patent NLD

Fig. 3.3  Endoscope is then withdrawn and rotated laterally under the inferior turbinate to visualize the inferior meatus

mal duct obstruction (CNLDO). Using this technique of posterior entry into the inferior ­ meatus, gentle lifting up of the inferior turbinate is sufficient and out fracturing may not be required for endoscopic probing and irrigation in CNLDO. The nasolacrimal duct (NLD) opening in the inferior meatus is examined and on pressing below the medial canthus area the transmitted movement along with air bubbles with secretion can be seen egressing through the NLD opening (Fig. 3.4). The NLD may open into the axilla of inferior meatus or well below the axilla on the

Fig. 3.5  Nasopharynx is examined by negotiating the endoscope along the floor. Posterior part of the middle and inferior turbinates come in view and the septal bulge can be seen medially

3.1  The Lateral Wall of Nose

Fig. 3.6  Eustachian tube orifice and torus tubarius can be visualized

25

Fig. 3.7  The second pass demonstrating superior turbinate as the scope is advanced between the middle turbinate and the septum

(Figs. 3.5 and 3.6). The patient is asked to swallow to note the movement of the eustachian orifice and palatal muscles [2].

3.1.2 Second Pass The second pass involves negotiating the endoscope between the inferior and the middle turbinate. The inferior portion of the middle turbinate, middle meatus, fontanelle or any accessory ostium is examined [2]. The scope is then rotated superiorly at the posterior border of the middle turbinate and sphenoethmoid recess is examined. In this pass sphenoid ostium and the superior t­urbinate are visible (Fig. 3.7). This step however is painful as the middle turbinate needs to be gently manipulated and mucosal oedema may obscure the view of sphenoid sinus opening and therefore, topical anaesthesia with decongested solution is applied.

3.1.3 Third Pass In the third and the final pass as the endoscope is withdrawn from the nasopharynx, it is rotated laterally under the posterior end of the middle turbinate to get a complete view of the middle meatus including bulla ethmoidalis, hiatus semilunaris and infundibular area. The third pass can also be performed from anterior to posterior i.e. uncinate

Fig. 3.8  The third pass to examine the middle turbinate and the structure in the middle meatus

process, bulla ethmoidalis and hiatus semilunaris etc. [2] (Figs. 3.8 and 3.9). This procedure again needs good topical anaesthesia and decongestion as middle turbinate is pushed medially to examine the contents of the middle meatus. The anterior attachment of the middle turbinate is examined. This part of the middle turbinate gets attached to the roof of the cribriform plate. The site of its attachment with the lateral wall is known as the axilla of the middle turbinate. It forms an important landmark in lacrimal surgery and may show a prominence anteriorly, indicating the location of agger nasi.

3  Endoscopic Anatomy of the Lacrimal Drainage System

26

Fig. 3.9  Middle turbinate is pushed medially to visualize uncinate process, bulla ethmoidalis and middle meatus (UP Uncinate process, B Bulla, MT Middle turbinate)

Fig. 3.10  Agger nasi impression is seen at the anterior attachment of the middle turbinate on the lateral wall (UP Uncinate Process, MT Middle turbinate)

After all steps of nasal endoscopy are complete let us have a look at various relevant anatomical structures in detail.

3.2

Agger Nasi

Agger nasi is the anterior-most ethmoid air cells. It is a prominent landmark in endoscopic dacryocystorhinostomy. It lies anterosuperior to the insertion of the anterior end of the middle turbinate on the lateral wall [also known as the axilla of the middle turbinate (Fig. 3.10)]. These can invade the lacrimal bone or the ascending process of the maxilla. Agger nasi cells were found to be present in 40–98.5% [2–5]cases [1]. Agger nasi is related anteriorly to the frontal process of maxilla, posteriorly to the ethmoid infundibulum, superiorly to the frontal recess, inferiorly and medially to the uncinate process [1]. Nasolacrimal duct runs parallel, anterior and lateral to agger nasi often in the same frontal plane or 1–2 mm anterior to it [1]. Studies of the ethmoid air cells have described the location of the agger nasi cells in relation to the superior part of lacrimal sac fossa [4–9] (Fig. 3.11). Blaylock et al. reviewed the relative anatomic positions of the ethmoid air cells and the lacrimal sac fossa in 190 normal orbits from computed tomographic scans [4]. The bony landmarks of the lacrimal sac fossa were defined and the loca-

Fig. 3.11  Agger nasi opened up during left dacryocystorhinostomy and its relation with the lacrimal sac with probe insitu can be visualized. AN Agger nasi

tion of the most anterior ethmoid sinus was described into three categories [4]. In category 1 there were no sinuses anterior to the posterior lacrimal crest. In category 2 sinuses extended anterior to the posterior lacrimal crest but remained behind the suture at the anterior edge of the lacrimal bone. In category 3 sinuses extended into the frontal process of the maxilla, anterior to

3.3  Uncinate Process

the lacrimal bone [4].Thus the bony lacrimal fossa and lacrimal drainage system are closely related anatomically to the ethmoid sinuses [6, 8, 10, 11].

3.2.1 Clinical Relevance Liang et al. studied 25 revision endoscopic DCRs and found that the viable agger nasi cell indicates an inappropriate lacrimal sac localization and inadequate sac exposure during the primary surgery leading to surgical failure [12]. This is a very important point that emphasizes the need for identifying and opening the agger nasi during primary surgery. Agger nasi lies in close relation to the fundus of the sac and opening up agger nasi ensures complete sac exposure leading to better outcomes [12].

3.3

Uncinate Process

27

Posteroinferior part of the uncinate process gets attached to the perpendicular process of palatine bone and the ethmoid process of the inferior turbinate. The superior attachment of the uncinate process is variable and determines the frontal sinus drainage pathway. In the majority of the cases, the uncinate process turns laterally to get attached to the lamina papyracea and the ethmoid infundibulum ends blindly into a terminal recess. In this situation, the frontal recess opens directly into the middle meatus. Alternatively, it may get attached to the middle turbinate or to the skull base lateral to the lateral lamella of lamina cribrosa. In these situations, frontal recess opens into the ethmoid infundibulum [1].

3.3.1 Clinical Relevance

The uncinate process is a sickle or boomerang shaped structure on the lateral wall of the nose and is composed of a thin bone [1]. It lies in a sagittal plane and has two borders, the anterior border that is convex and is attached to the lateral nasal wall and a free border that is concave and runs parallel to the bulla ethmoidalis (Fig. 3.12).

The lacrimal sac lies anterior to the uncinate process and uncinectomy is not needed in endoscopic DCR. However, an enlarged ballooned out uncinate process may push the maxillary line more anteriorly needing resection of the uncinate process (Fig. 3.13). The DCR incision is placed more anteriorly in such cases. An accidental entry into the orbit may occur due to loss of landmarks.

Fig. 3.12  Uncinate process in view with its free concave margin (white arrow) and convex anterior margin (black arrow). UP Uncinate process, B Bulla

Fig. 3.13  An enlarged uncinate process encroaching the maxillary line (in pink)

3  Endoscopic Anatomy of the Lacrimal Drainage System

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3.4

Bulla Ethmoidalis

The name bulla has been derived from a latin word ‘bulla’ means a hollow and prominent thin-­walled structure [1]. Bulla lies posterior to the uncinate process in the osteomeatal complex and has been grouped into the category of anterior ethmoid cells by some authors while the others have included it into middle ethmoid group [1, 13, 14] (Figs. 3.12 and 3.14). However, there are only two groups of ethmoid air cells present that are separated by basal lamella as was proposed by the international conference on sinus disease (1993) [1]. Bulla is attached laterally to the lamina papyracea. It is related anteriorly to infundibulum that separates it from the uncinate process, superiorly to the suprabullar recess that separates bulla from fovea ethmoidalis, posteriorly to the retrobullar recess that separates it from the basal lamella of the middle turbinate and medially to the hiatus semilunaris superioris. In some patients, the ethmoidal air cells extend to the entire length of the lacrimal sac fossa [15, 16].

3.4.1 Clinical Relevance Any anatomical abnormalities in bulla should be identified and if needed should be corrected. If

polyposis of the ethmoidal cells involving bulla is encountered during endoscopic DCR, an ethmoidectomy should be performed. The dissection should stay medially as the lateral wall is thin with high chances of orbital injury following breech in the lamina papyracea.

3.5

Hiatus semilunaris is divided into hiatus semilunaris superioris and hiatus semilunaris inferioris [1]. Hiatus semilunaris inferioris is a crescent-­ shaped structure that lies between the bulla and the free concave margin of the uncinate process and it is a two-dimensional structure (Fig. 3.14). Hiatus semilunaris superioris is a cleft between ethmoid bulla and middle turbinate and it leads posteriorly into retrobullar recess.

3.6

Ethmoid Infundibulum

The term infundibulum was given by Boyer who derived it from a latin word infundere meaning to pour into [1, 17]. It is a three-dimensional space that can be clearly visualized after the removal of the uncinate process. It is situated on the lateral nasal wall between ethmoid bulla and the uncinate process and is 4  cm long and 5–6  mm wide [1]. Maxillary sinus opens into infundibulum.

3.7

Fig. 3.14  Hiatus semilunaris; an area between the free border on uncinate process and bulla ethmoidalis marked by an arrow UP Uncinate process

Hiatus Semilunaris

Fontanelle

Fontanelle is the area on the lateral wall of the nose where the maxillary sinus and the nasal cavity are separated only by the mucosa [18] (Fig. 3.15). The portion of the medial wall of the maxillary antrum that is devoid of bone and is lined only by mucosa is the area of fontanelle. Fontanelle is separated into anterior and posterior by the uncinate process. The natural ostium of the maxillary sinus is located in the posterior fontanelle. There may be one more accessory ostium in the anterior fontanelle [18] (Fig. 3.16).

3.8  Middle Turbinate

29

Middle turbinate is a very stable structure and has three parts. The first part lies in the sagittal plane and is attached to the skull base between the cribriform plate and the lateral lamella (Fig.  3.17). The second part lies in the coronal plane and is attached to the lamina papyracea in an oblique pattern. This part of the middle turbinate is called basal lamella (Fig. 3.18). The third part of the middle turbinate lies in an axial plane and has an attachment to the perpendicular plate of palatine bone [1] (Figs.  3.19 and 3.20). The anterior attachment of the middle turbinate on the lateral nasal wall is called axilla of the middle

Fig. 3.15  Endoscopic view of left nasal cavity demonstrating fontanelle

Fig. 3.17  First part of the middle turbinate in the sagittal plane with its attachment to the skull base (SB) between the cribriform plate and the lateral lamella; White arrow

Fig. 3.16  An accessory osteum on the right side

Since the area of fontanelle is devoid of bone, there are high chances of orbital injury in case the instruments are directed superiorly and laterally.

3.8

Middle Turbinate

Middle turbinate is a bony projection from the ethmoids on the lateral wall of the nose. It is the most reliable and constant landmark for doing any kind of endoscopic surgery of the nose [1].

Fig. 3.18  Second part of the middle turbinate in the coronal plane also known as basal lamella (MT Middle turbinate)

30

Fig. 3.19  Transition from the second to the third part. (MT MIddle turbinate)

3  Endoscopic Anatomy of the Lacrimal Drainage System

Fig. 3.21  Lameller and bulbous part of the first part of the middle turbinate (MT)

(Fig. 3.22b), a double middle turbinate (Fig. 3.22c) or a polypoidal middle turbinate (Fig.  3.22d). Normally the middle turbinate has a concave surface facing the lateral wall. If this concave surface of the middle turbinate faces the septum, it is called a paradoxical middle turbinate [5]. A pneumatized middle turbinate is known as concha bullosa and is a common finding [19–25].

3.8.1 Clinical Relevance Fig. 3.20  Third part of the middle turbinate in the horizontal plane attached to the perpendicular plate of ethmoids. (MT MIddle turbinate)

turbinate that forms an important landmark in DCR surgery. The first part of the middle turbinate is divided into two parts. The upper part is thin and is called the lamellar portion that forms anterior one third of the middle turbinate. The lower portion is broad and is called the bulbous portion of the middle turbinate [1] (Fig. 3.21). The anterior attachment of the middle turbinate on the lateral wall is called axilla of the middle turbinate. Axilla forms an important landmark in DCR surgery. There are certain anatomical variations found in middle turbinate like a concha bullosa (Fig.  3.22a), paradoxical middle turbinate

A pneumatized MT blocks the access to the maxillary line and needs to be handled before endoscopic DCR.  Therefore, conchoplasty should be performed to gain access to the proposed neo ostium site. If not corrected, mucosal injuries may occur during instrumentation intraoperatively leading to synechiae formation later. Post-­operative care also gets compromised due to limited access. Similarly, a polypoidal middle turbinate needs to be handled to gain access to the maxillary line and also for better outcomes of endoscopic DCR.

3.9

Paranasal Sinuses

Paranasal sinuses are grouped into the anterior and posterior groups. Frontal sinus, maxillary sinus and anterior ethmoid sinuses have been labelled as the anterior group (Fig. 3.23a, b) and they open into the

3.9  Paranasal Sinuses

31

a

b

c

d

Fig. 3.22  Anatomical variations of the middle turbinate, (a) concha bullosa, (b) Paradoxical middle turbinate, (c) a double middle turbinate, (d) a polypoidal middle turbinate. (MT MIddle turbinate)

a

b

Fig. 3.23  Anterior group of sinuses, (a) frontal sinus, (b) maxillary sinus

32

a

3  Endoscopic Anatomy of the Lacrimal Drainage System

b

Fig. 3.24  Posterior group of sinuses, (a) posterior ethmoids opened up, (b) sphenoid sinus with dehiscent optic nerve in a case of extensive fungal sinusitis

middle meatus. Posterior group of sinuses includes posterior ethmoids cells that drain into superior meatus and the sphenoid sinuses, that open into the spheno-ethmoidal recess [1] (Fig. 3.24a, b). Widely opened sinuses can be seen in post-operative and intraoperative cases. In the sphenoid sinus dehiscent optic nerve can be visualized in an extensive fungal sinusitis case (Fig. 3.24a).

3.9.1 Clinical Relevance Sinus infection, inflammation, any mass or polyposis should be ruled out as concomitant presence of sinus pathology may compromise the results of endoscopic DCR.

3.10 Meatuses The middle meatus is the most important structure in relation to nasal and sinus surgery. It lies deep to the middle turbinate and is in relation to the lacrimal sac fossa [15, 16]. The inferior meatus lies between the inferior turbinate and the medial wall of the maxillary sinus. It houses the distal opening of the nasolacrimal duct, covered by a valve known as the valve of Hasner [26].

3.10.1 Clinical Relevance The middle meatus is the most common area involved in rhinosinusitis. The inferior meatal examination helps in the diagnosis and management of CNLDO.

3.11 L  acrimal Sac and NLD with Their Relation to the Different Structures on the Lateral Wall Lacrimal sac location and dimensions have been mentioned in the chapter on the anatomy of lacrimal drainage system. Endoscopically the most important landmark for lacrimal sac is the maxillary line. It is a mucosal crease that marks the lacrimomaxillary suture [27] (Fig. 3.25). Unlu did a cadaveric study and found that the distance between the natural ostium of the maxillary sinus to NLD was 5.5 + 1.9 mm (3–9 mm), distance of NLD from the anterior surface to bulla ethmoidalis was 10.2 ± 2 mm (7–16 mm), from the free edge of uncinate process to was 8.8  + 2.1 mm (7–15 mm) and from the anterior attachment of middle turbinate on the latera wall was 5.4 + 1.4 mm (3–8 mm) [28]. On complete marsu-

3.11  Lacrimal Sac and NLD with Their Relation to the Different Structures on the Lateral Wall

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Fig. 3.25  Lacrimo-maxillary suture (LMS) also known as maxillary line seen on endoscopic view of the left nasal cavity (pink line) with parallel depiction on CT DCG and a skull photograph

the middle turbinate will lead to incomplete marsupialization as only the lower part of the sac will be opened and leaving the upper portion of the sac unopened and resultant failure. Key Points

pialization, lacrimal sac can be appreciated lying anterior to the uncinate process and therefore, uncinectomy is not required in endoscopic DCR. Superiorly on an average, the lacrimal sac lies 8.8 mm above the anterior attachment of the middle turbinate and 4.1 mm of the sac lies below it [29]. The average length of the sac above the common canaliculus is 5.3 mm and below it is 7.7 mm as was found in a CT DCG study [29] (Fig. 3.26).

• Since the lacrimal sac and nasolacrimal duct are located in the nose, it is important to understand the endoscopic anatomy of the nose. • In majority of the cases fundus of the lacrimal sac is located above the axilla of the middle turbinate. It is therefore important to understand its relation with other structures in the nose. • Agger nasi cell lies in relation to the fundus of the sac and in most of the cases opening up the agger nasi ensures complete sac exposure. Variations in ethmoid cell are important and should be identified intraoperatively. • Endoscopic lacrimal surgery involves correction of associated nasal pathologies like concha, a gross septal deviation or polyps limiting the access to the maxillary line. Thus, a thorough understanding of nasal anatomy helps in achieving better outcomes.

3.11.1 Clinical Relevance

References

Knowledge of anatomic dimensions acts as an important guideline to ensure complete sac exposure. Opening up the sac just up to the axilla of

1. Singh AP. Functional endoscopic sinus surgery. Atlas and comprehensive review of basic, clinical and surgical considerations. New Delhi: Aditya Medical Publisher; 2002. p. 17–37.

Fig. 3.26  Endoscopic view of the left nasal cavity demonstrating the superior border of the marsupialized sac located much above the probe seen through common canalicular opening indicatiing a good exposure and complete marsupialization

34 2. Gleeson M, Browning GG, Burton M, Clark R, Hibbert J, Jones NS, Lund VJ, Luxon LM, Wakinson JC.  Nasal endoscopy chapter 105. In: Schlosser RJ, Kennedy DW, editors. Scott-Brown’s otorhinolaryngology: head and neck surgery. 7th ed. London: Hodder Arnold; 2008. 3. Gupta N, Neeraj C, Smriti B, Sima D. A comparison of the success rates of endoscopic-assisted probing in the treatment of membranous congenital nasolacrimal duct obstruction between younger and older children and its correlation with the thickness of the membrane at the valve of Hasner. Orbit. 2017;37:257–61. https:// doi.org/10.1080/01676830.2017.1383483. 4. Blaylock WK, Moore CA, Linberg JV. Anterior ethmoidal anatomy facilitates dacryocystorhinostomy. Arch Ophthalmol. 1990;108:1774–7. 5. Mosher HP. The surgical anatomy of the ethmoid labyrinth. Ann Otol Rhinol Laryngol. 1929;38:869–901. 6. Whitnall SE. The relations of the lacrimal fossa to the ethmoid cells. Ophthalmic Rev. 1911;30:321–5. 7. Bagatella F, Guirado CR. The ethmoid labyrinth: an anatomical and radiological study. Acta Otolaryngol Suppl (Stockh). 1983;403(Suppl):1–19. 8. Terrier F, Weber W, Ruefennacht D, Porcellini B. Anatomy of the ethmoid: CT, endoscopic and macroscopic. Am J Radiol. 1985;144:493–500. 9. Mattox DE, Delaney RG.  Anatomy of the ethmoid sinus. Otolaryngol Clin N Am. 1985;18:3–42. 10. Hengerer AS.  Surgical anatomy of the paranasal sinuses. Ear Nose Throat J. 1984;63:137–43. 11. Miller AJ, Amedee RG.  Functional anatomy of the paranasal sinuses. J La State Med Soc. 1997;149:85–90. 12. Liang J, Hur K, Merbs SL, Lane AP. Surgical and anatomic considerations in endoscopic revisions of failed external dacryocystorhinostomy. Otolaryngol Head Neck Surg. 2014;150(5):901–5. 13. Rice DH, Schaefer SD.  Endoscopic paranasal sinus surgery. 2nd ed. New York: Raven Press; 1992. 14. Schaefer JP.  The nose, paranasal sinuses, naso lacrimal passageways and olfactory organ in man. Philadelphia: Blakiston; 1920. p. 125–9. 15. Shaik KV & Haripriya. Management of NasolacrimalCutaneous Fistula – A Maxillofacial Review and Sharing Experience. Annals of International Medical and Dental Research, 2016;2(6):10–13. https://doi. org/10.21276/aimdr.2016.2.6. DE2ISSN (O):2395– 2822; ISSN (P):2395–2814. 16. Mauriello JA, Rosen A.  Surgical anatomy of the lacrimal drainage system. In: Mauriello JA, editor. Unfavorable results of eyelid and lacrimal surgery. Prevention and management. Boston: Butterworth Heinemann; 2000. p. 361–80.

3  Endoscopic Anatomy of the Lacrimal Drainage System 17. Boyer (1805): cited by E. Zuckerkandl, 1893. Cited by Singh AP. Functional endoscopic sinus surgery. Atlas and comprehensive review of basic, clinical and surgical considerations. New Delhi: Aditya Medical Publisher; 2002:17–37. 18. Yoon JH, Kim KS, Jung DH, Kim SS, Koh KS, Oh CS, DDS HJK, Lee JW, Chung IH.  Fontanelle and uncinate process in the lateral wall of the human nasal cavity. Laryngoscope. 2009;110(2):281. 19. Ozcan KM, Selcuk A, Ozcan I, Akdogan O, Dere H.  Anatomical variations of nasal turbinates. J Craniofac Surg. 2008;19(6):1678–82. 20. Neskey D, Eloy JA, Casiano RR.  Nasal, septal, and turbinate anatomy and embryology. Otolaryngol Clin N Am. 2009;42(2):193–205, vii. 21. San T, Erdoğan B, Taşel B. Bilateral superior concha bullosa: a rare case overlooked. Kulak Burun Bogaz Ihtis Derg. 2014;24(5):292–4. 22. Ozturan O, Yenigun A, Degirmenci N, Yilmaz F. ‘Conchae bullosis’: a rare case with bilateral triple turbinate pneumatisations. J Laryngol Otol. 2013;127(1):73–5. 23. Tiwari R, Goyal R. Study of anatomical variations on CT in chronic sinusitis. Indian J Otolaryngol Head Neck Surg. 2015;67(1):18–20. 24. Kaygusuz A, Haksever M, Akduman D, Aslan S, Sayar Z. Sinonasal anatomical variations: their relationship with chronic rhinosinusitis and effect on the severity of disease  – a computerized tomography assisted anatomical and clinical study. Indian J Otolaryngol Head Neck Surg. 2014;66(3):260–6. 25. Stallman JS, Lobo JN, Som PM.  The incidence of concha bullosa and its relationship to nasal septal deviation and paranasal sinus disease. AJNR Am J Neuroradiol. 2004;25(9):1613–8. 26. Vagge A, Desideri LF, Nucci P, Serafino M, Giannaccare G, Lembo A, Traverso CE.  Congenital nasolacrimal duct obstruction (CNLDO): a review. Diseases. 2018;6(4):96. 27. Massegur H, Lorenzo JG, Gras-Cabrerizo JR. Nasal anatomy and evaluation. In: Cohen AJ, et  al., editors. The lacrimal system: diagnosis, management, and surgery. 2nd ed. Cham: Springer International Publishing; 2015. p.  15. https://doi. org/10.1007/978-3-319-10332-7_2. 28. Unlü HH, Gövsa F, Mutlu C, Yücetürk AV, Senyilmaz  Y.  Anatomical guidelines for intranasal surgery of the lacrimal drainage system. Rhinology. 1997;35(1):11–5. 29. Wormald PJ, Kew J, Van Hasselt CA. The intranasal anatomy of the nasolacrimal sac in endoscopic dacryocystorhinostomy. Otolaryngol Head Neck Surg. 2000;123:307–10.

4

Radiological Anatomy of the Lacrimal Drainage System

Radiological anatomy encompasses the structure, location, normal anatomical variation and interrelation of various parts of the lacrimal drainage system. Epiphora is a common ophthalmic problem that can compromise visual acuity [1]. Epiphora occurs due to an obstruction to the tear flow from functional or anatomical causes. Anatomical nasolacrimal duct (NLD)obstruction could be congenital, primary acquired NLD obstruction or secondary acquired NLD obstruction. The diagnosis can be made by clinical evaluation along with irrigation of the lacrimal system but this does not help in detecting the site and type of obstruction [1–5]. Computed tomographic dacryocystography with the instillation of contrast material into the canaliculi can identify the site and type of obstruction in the nasolacrimal system and can demarcate adjacent soft tissue and bony abnormalities [1, 6]. However, before studying the abnormal scans, a clear understanding of the lacrimal pathway including the bony framework, membranous conduit and the surrounding soft tissue structures is essential to understand how various pathologies can alter the functioning of Lacrimal drainage system [1].

4.1

Computed Tomographic Dacryocystography (CT DCG)

Ewing et al performed the first contrast-enhanced radiographs of the lacrimal pathways using bismuth subnitrate solution to demonstrate a lacrimal abscess in 1909 [7–9].

There are two types of contrast materials available, water-soluble material and oil-soluble material. Oil-soluble contrast material should not be used as it fails to mix with the secretions and may result in artefacts looking like polycystic sac [7, 10]. Moreover, any leakage into the subcutaneous tissue leads to reaction and granuloma formation [11]. Water-soluble contrast material is preferable as its pH and viscosity are similar to tears and thus, they provide a more real image. The dye disappears fast, unlike oil-soluble contrast that remains in tissues for a longer time [10–12]. We prefer Bilateral CT DCG in the same sitting as recommended [10, 12]. It allows a comprehensive evaluation of the bilateral lacrimal drainage system as well as nasal cavities and is useful in patients with prominent nasal symptoms. The ability to detect and correct associated nasal and sinus pathology during endoscopic DCR leads to better outcomes. According to Fabiano et al bilateral evaluation allows comparison with the contralateral lacrimal drainage system and helps in detecting any alteration [7]. In experienced hands, cannulation is fast and safe and allows early detection of contralateral ­pathology and saves a second radiation exposure of the patient [7]. Comparison with the contralateral side is always useful and alteration in asymptomatic contralateral lacrimal drainage system was found in 8.3% cases [10]. Although non-contrast CT scan alone is a useful investigation as it gives excellent bony

© Springer Nature Singapore Pte Ltd. 2021 N. Gupta, Endoscopic Dacryocystorhinostomy, https://doi.org/10.1007/978-981-15-8112-0_4

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36

details and can outline the lacrimal drainage system [13, 14], it fails to diagnose the exact site of NLD obstruction. Hence a CT DCG is better suited for a complete evaluation of the lacrimal system.

4.2

Procedure

The sac secretions are flushed to avoid the artefacts as inspissated secretions may look like filling defects and may obstruct the flow of contrast leading to false observations. The lower punctum was dilated with a punctal dilator, the cannula was placed and stabilized into the lower canaliculus. Two millilitres of contrast material iopromide was diluted with saline in 1:1 ratio and was injected on both sides. Toshiba Alexion Multidetector computed tomography (MDCT) scanner was used. Patients scanning was done in a supine position. The lacrimal drainage system was studied from punctum till the valve of Hasner and various anatomic landmarks were noted in relation to the complete lacrimal drainage system on CT DCG. Transverse axial sections through orbit and paranasal sinuses were obtained in all the patients in 5mm slice with retro reconstruction at 1mm (CT Slice position 1&2). The sections were labelled from superior to inferior. Coronal, sagittal and 3D reformations of the axial images were done to get a complete view of the lacrimal drainage system. Patients with normal lacrimal drainage pathways were studied for the normal anatomical landmarks. Study of normal radiological anatomy of lacrimal drainage system helps in improving our diagnostic accuracy [14]. Various schematic diagrams and skull photographs were used to mark the level of cuts through the lacrimal drainage pathway and to study their relation with the surroundings. The normal anatomical landmarks were studied on CT dacryocystography and were correlated with abnormal findings described in the subsequent chapter on abnormal conditions.

4.3

Various Structures of Lacrimal Drainage System on CT DCG

The lacrimal drainage system is divided into proximal and distal parts [15]. The proximal part consists of punctum, upper and lower canaliculi and common canaliculus [15–18]. The distal lacrimal drainage system include the lacrimal sac and the NLD that runs in the lateral wall of the nose to open into the inferior meatus [1]. Since the lower lacrimal drainage system lies in the nose, it is important to have knowledge of anatomy of the lacrimal drainage system. Figures 4.1–4.58 demonstrate complete anatomy including normal variations of all the structures. Most of the description has been given as legend below each figure and for more details please refer to the chapter on anatomy and endoscopic anatomy of the lacrimal drainage pathway. Key Points  Knowledge of the normal radiological anatomy of the lacrimal drainage pathway is essential for a clear understanding of the lacrimal drainage system including the bony framework,

Fig. 4.1  CT DCG coronal sections showing proximal canalicular system, superior canaliculus (SC) and inferior canaliculus (IC)

4.3  Various Structures of Lacrimal Drainage System on CT DCG

Fig. 4.2  Temporal location of lower punctum (LP) relative to the upper punctum (UP) can be appreciated by drawing vertical lines through upper and lower puncta

Fig. 4.3  Superior (SC) and inferior canaliculi (IC) joining to form common canaliculus (CC) which in turn enters the lacrimal sac

37

Fig. 4.4  Axial sections CT DCG through the central part of the lacrimal sac showing relations of canaliculi with orbicularis oculi

Fig. 4.5  The lateral part of the lacrimal canaliculus is covered with the Horner's muscle

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4  Radiological Anatomy of the Lacrimal Drainage System

Fig. 4.6  Medial part of lacrimal canaliculus that is the common canaliculus is covered anteriorly by orbital part of orbicularis oculi muscle on its anterior surface. Common canaliculus bends behind the medial canthal tendon before entering the lacrimal sac at an angle

Fig. 4.8  Axial sections CT DCG at the level of mid lacrimal fossa formed anteriorly by articulation of frontal process of maxilla (outlined in blue) and posteriorly by thin lacrimal bone (outlined in yellow). This section shows a balanced type of left lacrimal fossa with equal contribution from both the bones (Grade 2). Lacrimomaxillary suture can be seen lying in the center of the fossa. This is the most common clinical presentation seen during endoscopic DCR

Fig. 4.7  Axial section CT DCG through the central part of the lacrimal sac demonstrating the Horner’s muscle, (a third part of the orbicularis oculi muscle) getting attached to the posterior lacrimal crest. It is also known as the deep head or lacrimal part of orbicularis oculi

4.3  Various Structures of Lacrimal Drainage System on CT DCG

Fig. 4.9  Shows dominance of lacrimal bone with anteriorly placed lacrimomaxillary suture in the left lacrimal fossa (Grade 1). This is a favorable situation as the thin lacrimal bone makes bone removal easy during endoscopic DCR

39

Fig. 4.10  Dominance of the frontal process of maxilla in a maxillary dominant right lacrimal fossa with posteriorly placed lacrimomaxillary suture (Grade 3). This is a difficult situation as the thick frontal process of maxillary predominantly covering the lacrimal sac needs to be drilled right from the beginning

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4  Radiological Anatomy of the Lacrimal Drainage System

Fig. 4.11  Axial scans through lacrimal fossa demonstrating the contrast opacified lacrimal sac bounded anteriorly by anterior lacrimal crest that is frontal process of maxilla and posteriorly by posterior lacrimal crest that is lacrimal bone, both in equal proportion making it a Grade 2 type of lacrimal fossa. Lacrimomaxillary suture lies between the frontal process of maxilla and the lacrimal bone. It produces a ridge in the nasal mucosa and is known as maxillary line, that forms an important landmark for endoscopic DCR. Anteriorly frontal process of maxilla is seen articulating with nasal bone. Posteriorly lacrimal crest can be seen lying in the center of the lacrimal bone

Fig. 4.12  Relation and the distance of the lacrimal sac with the uncinate process and bulla ethmoidalis. It serves as an important landmark during endoscopic sinus surgery

Fig. 4.13  Coronal section through the anterior part of the lacrimal fossa demonstrating lacrimal tubercle of maxilla. It is a continuation of the anterior lacrimal crest (a groove on the frontal process of maxilla) that articulates with the lacrimal hamulus, which is a hook-like projection from the lacrimal bone. Both these structures complete the upper orifice of the nasolacrimal canal

Fig. 4.14  Coronal section through mid lacrimal fossa demonstrating the thick posterior border of the frontal process of maxilla. Superonasally It Is related to agger nasi and part of the frontal recess. Inferomedially it is related to middle meatus and turbinate. Lateral to lacrimal fossa is ipsilateral orbital soft tissues

4.3  Various Structures of Lacrimal Drainage System on CT DCG

Fig. 4.15  Coronal section demonstrating the relation of the lacrimal sac with agger nasi

Fig. 4.16  Coronal section through the inferior part of the lacrimal fossa corresponding with the sac duct junction and the proximal part of NLD demonstrating lacrimal hamulus, which is a hook-like projection from the lacrimal bone. It articulates with the lacrimal tubercle a part of the frontal process of maxilla to complete the upper orifice of the nasolacrimal canal

41

Fig. 4.17  Coronal section at the mid-NLD level demonstrating intraosseous part of NLD descends within the nasolacrimal canal of the maxilla reinforced by the bony inferior nasal turbinate; Here it is inferiorly related to the palatine bone and inferior nasal turbinate; superiorly to the uncinate process and inferomedial orbital wall. Medial to the canal is the middle meatus of the nasal cavity and lateral to it is maxillary sinus

Fig. 4.18 Coronal section at the mid-NLD level Membranous part of NLD (5 mm): runs in the nasal mucosa; terminates below the inferior nasal meatus as a slit-like opening where it is covered by a mucosal fold called the valve of Hasner (or plica lacrimalis). This part of nasolacrimal canal is related medially to the inferior nasal turbinate and laterally to the medial wall of maxillary sinus. In superior relation to it is the uncinate process and inferior relation is the palatine bone

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4  Radiological Anatomy of the Lacrimal Drainage System

Fig. 4.19  Coronal section showing proximal part of NLD along with orbicularis oculi and inferior oblique muscle

Fig. 4.20  Upper end of NLD just below the formation of its proximal opening and orbital part of orbicularis oculi in view

Fig. 4.21  Axial scan demonstrating the anterior most part of the muscle; orbital part of orbicularis oculi attaches to frontal process of maxilla and covers medial aspect of canaliculi

Fig. 4.22  Axial sections of lacrimal sac showing medial palpebral ligament (MPL). The medial palpebral ligament comprises of two heads. The superficial head (regarded as palpebral part of orbicularis oculi by some) attaches to the anterior lacrimal crest and the deep head (also known as Horner’s muscle / lacrimal part of orbicularis oculi) attaches to posterior lacrimal crest

4.3  Various Structures of Lacrimal Drainage System on CT DCG

43

Fig. 4.23  Axial section demonstrating medial palpebral ligament (black star)

Fig. 4.25  Fundus and the body of the sac can be clearly demarcated in a dilated and contrast opacified lacrimal sac. (F: fundus, B:body)

Fig. 4.24  Oblique coronal reformed sections demonstrating the lacrimal drainage system. The part of the sac above the medial palpebral ligament (MCL) is known as the fundus of the sac and the part of the sac that lies below the MCL is known as the body and is uncovered weak part of the sac Fig. 4.26  Sagittal section through lacrimal drainage system showing the relation of sac and NLD with respect to the free edge of uncinate process and anterior wall of bulla ethmoidalis

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4  Radiological Anatomy of the Lacrimal Drainage System

Fig. 4.27  Sagittal section through lacrimal drainage system showing the relation of the most medial section of the lacrimal sac with respect to the free edge of uncinate process and anterior wall of bulla ethmoidalis

Fig. 4.29  Section through Distal NLD showing inferior meatus and distal NLD opening on the left side

Fig. 4.30  Coronal oblique reformation through LDS demonstrating bony structures forming NLD and its relations with nasal turbinates and maxilla. Free flow of contrast material is seen into the left inferior meatus. The right sac is dilated with obstruction at the sac duct junction Fig. 4.28  Section through mid-canal level of NLD showing NLD in complete length

4.3  Various Structures of Lacrimal Drainage System on CT DCG

Fig. 4.31  Coronal CT DCG section through sac- NLD junction showing orbital part of bony NLD. Medial relation of lacrimal sac to Agger nasi (AN) and anterior aspect of middle turbinate (MT) is depicted on the left side. Lacrimal hamulus is the inferior extension of lacrimal bone which forms posteromedial wall of bony NLD can be seen reaching up to the inferior turbinate

Fig. 4.32  Axial section through inferior meatus at the level of distal end of NLD showing valve of Hasner on right side

45

Fig. 4.33  Sagittal CT section showing relations of bulla ethmoidalis. Antero inferior to the bulla lies the ethmoid infundibulum that separates uncinate process from bulla. Posterior to the bulla is retrobullar recess that separates it from the basal lamella of the middle turbinate

Fig. 4.34 Axial sections through mid lacrimal fossa showing relation of ethmoidal air cells and their anterior extent with respect to lacrimal fossa, category 1, the anterior ethmoid cells are confined posterior to the posterior lacrimal crest

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4  Radiological Anatomy of the Lacrimal Drainage System

Fig. 4.35  Category 2, the anterior ethmoid cells are sinuses extend anterior to the posterior lacrimal crest but remain behind the suture at the anterior edge of the lacrimal bone

Fig. 4.37  Further anterior extension category 3 anterior ethmoid cells on the right side

Fig. 4.36  In category 3, sinuses extend into the frontal process of the maxilla, anterior to the lacrimal bone on the right

Fig. 4.38  Axial CT DCG at mid-NLD level showing relation of NLD with the uncinate process, ethmoidal bulla, middle turbinate

4.3  Various Structures of Lacrimal Drainage System on CT DCG

Fig. 4.39  Coronal CT section showing ethmoidal bulla and ethmoidal infundibulum

47

Fig. 4.41  Sagittal CT DCG image showing uncinate process (UP) as a hook-like thin bony structure on the lateral nasal wall (marked in yellow dotted line) with convex anterior border and concave free border running parallel to the bullae ethmoidalis (marked in orange line)

Fig. 4.40  Sagittal CT section through ethmoidal bulla showing retrobullar recess posterior to ethmoidal infundibulum, basal lamella attachment of middle turbinate Fig. 4.42  Coronal CT images showing the commonest variant of superior attachment of uncinate process (marked in yellow) to the lamina papyracea on both sides. The ethmoid infundibulum ends blindly into a terminal recess. In this situation, the frontal recess opens directly into the middle meatus (marked in blue)

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4  Radiological Anatomy of the Lacrimal Drainage System

Fig. 4.43  Enlarged right coronal section to show the same pattern of uncinate attachment to the lamina papyracea

Fig. 4.44  Enlarged view of the left coronal section showing the same most common attachment of uncinate process with terminal recess

4.3  Various Structures of Lacrimal Drainage System on CT DCG

49

Fig. 4.47  Coronal CT showing variant superior attachment of uncinate process to the skull base lateral to the lateral lamella of lamina cribrosa

Fig. 4.45  Coronal CT showing superior attachment of the uncinate process to the middle turbinate (variant). In these situations, frontal recess opens into the ethmoid infundibulum

Fig. 4.48  Coronal section showing superior attachment of middle turbinate to the skull base between the lamina cribrosa and the lateral lamella of cribriform plate

Fig. 4.46  Coronal cut showing the same arrangement

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4  Radiological Anatomy of the Lacrimal Drainage System

Fig. 4.49  Axial section through mid-NLD shows the posterior attachment of middle turbinate to the lateral nasal wall

Fig. 4.51 Axial section CT DCG showing anterior attachment of middle turbinate at the axilla

Fig. 4.50  Axial sections CT DCG showing basal lamella of middle turbinate formed by lateral attachment of middle turbinate to lamina papyracea

Fig. 4.52  Coronal sections CT DCG demonstrating the relationship of axilla and lacrimal fossa

4.3  Various Structures of Lacrimal Drainage System on CT DCG

Fig. 4.53  Various measurements of the position of lacrimal fossa in relation to the axilla of middle turbinate

Fig. 4.54  Coronal CT section showing bilateral concha lamella

51

Fig. 4.55  Coronal CT image showing various patterns of the pneumatized of the middle turbinate, lamellar (green dot) and bullous (yellow dot) parts of middle turbinate

Fig. 4.56 Sagittal CT section showing right concha bullosa

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4  Radiological Anatomy of the Lacrimal Drainage System

membranous conduit and the surrounding soft tissue to understand how various pathologies can alter the functioning of the lacrimal drainage system. • CT DCG is the most useful radiological investigation from anatomical landmarks point of view and helps in preoperative assessment in cases of complex obstructions in the lacrimal drainage pathway. Acknowledgement I am extremely thankful to Dr. Vandana Kalra, Senior Consultant radiologist at Banwarial charitable diagnostic centre Delhi and Delhi Heart and lung institute for spending long hours on extensive discussion for selection of photographs, and for preparing the manuscript with me.

References

Fig. 4.57  Coronal CT section through middle turbinate shows bifid/lobulated middle turbinate

Fig. 4.58  Coronal CT section demonstrating left paradoxical middle turbinate. (LP: Lower punctum, UP: upper punctum, SC: superior canaliculus, IC: inferior canaliculus, MPL: medial palpebral ligament, MCL: medial canthal ligament, AN: agger nasi, LDS: lacrimal drainage system)

1. Eldesoky S, Farouk H, Moustafa AN, El-noueama K, Elsabaaa A.  The role of multi-detector CT dacryocystography in the assessment of naso-lacrimal duct obstruction. The Egyptian Journal of Radiology and Nuclear Medicine. 2012;43(3):397–405. 2. Kassel EE, Schatz CJ.  Lacrimal apparatus. Head and neck imaging, 3, St Louis, Mo, Mosby (2003), pp. 1129–1153. [Google Scholar] 3. Steindler P, Mantovani E, Incorvaia C, Parmeggiani F.  Efficacy of probing for children with congenital nasolacrimal duct obstruction: a retrospective study using fluorescein dye disappearance test and lacrimal sac echography. Graefes Arch Clin Exp Ophthalmol. 2009;247:837–46. 4. Blackmore K, Ainsworth G, Robson A. Epiphora: an evidence based approach to the 12 min consultation. Clin Otolaryngol. 2010;35:210–4. 5. Amanat L, Wraight E, Watson P, Hawkins T.  Role of lacrimal scintigraphy and subtraction macrodacryocystography in the management of epiphora. Br J Ophthalmol. 1979;63:511–9. 6. Tanenbaum M, Mccord J. Lacrimal drainage system Duane’s ophthalmology. Philadelphia, PA: Lippincott Williams & Wilkins 2010;4(13):358–360. 7. Francisco FB, Carvalho ACP, Neto GT, Francisco VFM, de Souza AM, Francisco MC, Fonseca LMB, Gutfilen B, Júnior AAM.  Evaluation of the lacrimal system by radiological methods. Radiol Bras 2007;40(4), São Paulo July/Aug. 8. Schellini SA, Hercules LA, Padovani CR, Nascimento SM, Lopes PS, Schellini RC.  Dacriocistografia na propedêutica da via lacrimal excretora de adultos. Arq Bras Oftalmol. 2005;68:89–92. 9. Ewing AE. Roentgen ray demonstrations of the lacrimal abscess cavity. Am J Ophthalmol. 1909;24:1–4.

References 10. Takano BA, Mendonça-Júnior AA. Dacriocistografia: aspectos radiológicos nas alterações das vias lacrimais—análise de 24 casos. Radiol Bras. 1996;29:23–9. 11. Munk PL, Burhenne LW, Buffam FV, Nugent RA, Lin DT.  Dacryocystography: comparison of water-­ soluble and oil-based contrast agents. Radiology. 1989;173:827–30. 12. Patrão ALS.  Dacriocistografia. Rev Bras Oftalmol. 1983;XLII:68–72. 13. Mukherjee B, Dhobekar M.  Traumatic nasolacrimal duct obstruction: clinical profile, management, and outcome. Eur J Ophthalmol. 2013;23(5):615–22. 14. Russell EJ, Czervionke L, Huckman M.  CT of the inferomedial orbit and the lacrimal drainage apparatus: normal and pathologic anatomy. Am J Radiol. 1985;145:1147–54.

53 15. Kashkouli MB, Pakdel F, Kiavash V.  Assessment and management of proximal and incomplete ­symptomatic obstruction of the lacrimal drainage system. Middle East Afr J Ophthalmol. 2012;19(1):60–9. https://doi.org/10.4103/0974-9233.92117. 16. Basic and clinical course. Section 7, Orbit, eyelids and lacrimal system. American Academy of Ophthalmology. 2008–2009:259–64. [Google Scholar] 17. Basic and clinical course. Section 2, Fundamentals and principles of ophthalmology. American Academy of Ophthalmology. 2008–2009:36. [Google Scholar] 18. Tucker NA, Tucker SM, Linberg JV.  The anatomy of the common canaliculus. Arch Ophthalmol. 1996;114:1231–4.

5

Imaging in Disorders of the Lacrimal Drainage System

Various imaging modalities have been described for the anatomical and functional assessment of the lacrimal drainage system. Computed tomography (CT) and computed tomographic dacryocystography (CT DCG) are the most useful investigations. There are other investigations for the functional integrity of the lacrimal drainage system. This chapter presents an overview of all available modalities with special emphasis on CT DCG. The available modalities described in the literature include computed tomography, computed tomographic dacryocystography, ultrasound, magnetic resonance imaging, magnetic resonance dacryocystography, scintigraphy and digital subtraction dacryocystography [1–5]. Although in complex situations like post-­ traumatic NLD obstruction imaging of the lacrimal system is often indicated [6] but in primary acquired nasolacrimal duct obstruction (PANDO), radiological investigations are generally not advised. This is because the diagnosis can often be reached through a battery of clinical tests including regurgitation test, probing syringing and the fluorescein dye test [7, 8]. However, in certain selective cases of PANDO (mentioned below), radiological evaluation must be done to avoid failures. CT DCG is a widely used imaging modality and is considered a gold standard method for the evaluation of the lacrimal drainage system [9, 10].

5.1

Computed Tomography (CT)/ Computed Tomographic Dacryocystography (CT DCG)

Computed tomography is suitable for delineating the bony details of the lacrimal drainage system along with the presence of fluid or air in the sac and nasolacrimal duct (NLD). CT is also suitable for assessing the lacrimal sac tumours [1, 4] and in post-traumatic involvement of the lacrimal drainage system. CT however, fails to detect the exact site of obstruction with poor soft tissue visualization [1, 4] and the canalicular system can-not be visualized on plain CT. Since CT dacryocystography is considered the gold standard for evaluating the patency of lacrimal drainage system [11] we will be describing its application in various indications. CT DCG is performed by cannulating the canaliculi for the administration of water-soluble contrast material to visualize the site of obstruction. CT DCG has been described under the following heads 1. CT DCG in primary acquired nasolacrimal duct obstruction (PANDO) 2. CT DCG in primary acquired nasolacrimal duct obstruction (PANDO) with medial canthal swelling to demonstrate following differential diagnosis

© Springer Nature Singapore Pte Ltd. 2021 N. Gupta, Endoscopic Dacryocystorhinostomy, https://doi.org/10.1007/978-981-15-8112-0_5

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(a) Ethmoidal mucocele mimicking lacrimal sac mucocele (b) Lacrimal sac diverticulum (c) Dacryocystocele verses meningocele (d) Dacryocystitis with periorbital inflammation and oedema 3. CT DCG in post-traumatic dacryocystitis 4. CT DCG in failed cases of DCR

5.1.1 CT DCG in PANDO CT DCG in a routine case of PANDO may not add any value over and above clinical assessment. However, before we discuss its application in specific conditions of PANDO, let us have a look at the basic CT DCG findings in a case of PANDO. In most of PANDO cases, there is a dilated and contrast opacified lacrimal sac with obstruction lying at the sac duct junction. Based on the involvement of the other sites Eldosky et  al. divided the level of obstruction in three categories [12]. Obstruction located at the common canalica

5  Imaging in Disorders of the Lacrimal Drainage System

ulus was labelled as high obstruction, obstruction in the region of lacrimal sac neck to lower third of bony canal was labelled as mid-­level obstructions and obstruction at the lower end of NLD was labelled as low-level obstructions [12]. The site of obstruction can be judged by comparing the presence of contrast in serial imaging with coronal, axial and sagittal sections (Figs. 5.1a–c, 5.2a–c, and 5.3). Coronal oblique reformatted image helps in delineating the complete lacrimal drainage passage (Fig.  5.4). CT DCG is thus a valuable tool for the assessment of LDS and helps in the management of NLDO.

5.1.2 C  T DCG in Primary Acquired Nasolacrimal Duct Obstruction (PANDO) with Medial Canthal Mass A medial canthal swelling in the lacrimal sac area with epiphora is not always lacrimal sac mucocele. The differential diagnosis includes ethmoid b

c

Fig. 5.1  (a) CT DCG, coronal section at the level of the superior part of the lacrimal fossa demonstrating a contrast opacified dilated lacrimal sac due to obstruction at the proximal opening of NLD on the right while the left lacrimal sac is normal. (b) CT DCG, coronal section at the level of proximal NLD demonstrating the absence of con-

trast on the right side indicating an obstruction. The presence of contrast on the left side indicates a patent NLD. (c) CT DCG, coronal section at the level of distal NLD demonstrating the absence of contrast in the right inferior meatus indicating an obstruction. The presence of contrast on the left side indicates a patent NLD

5.1  Computed Tomography (CT)/Computed Tomographic Dacryocystography (CT DCG)

a

57

b

c

Fig. 5.2 (a) CT DCG, axial section with a superior cut showing a dilated contrast opacified sac on the right and a normal sac on the left side. (b) Axial scan through the midpart of the fossa showing dilated sac on the right and nor-

mal sac on the left. (c) Axial scan taken through the proximal NLD demonstrating the absence of contrast into the right NLD and presence of contrast in the left NLD indicating an obstructed right system and a patent left system

Fig. 5.3  Sagittal section demonstrating a patent nasolacrimal system

mucoceles, lacrimal sac diverticulum, encephalocele, dermoid cysts and malignancy of lacrimal sac [13–19]. CT scan of paranasal sinuses should be performed if any nasal pathology is suspected [13, 14]. The relevance of CT DCG in all these cases have been mentioned below.

5.1.2.1 Ethmoidal Mucocele Mimicking Lacrimal Sac Mucocele Ethmoidal cell mucocele like lacrimal sac mucocele, presents as a medial canthal mass and can be differentiated on clinical examination.

Fig. 5.4  Coronal oblique reformatted approach on CT DCG demonstrating an obstructed system on right and a patent system on the left

Diagnostic difficulty arises in cases of an ethmoidal mucocele with associated nasal polyp involving the lacrimal sac. In the absence of a preoperative CT DCG, the diagnosis is missed leading to failure of DCR as depicted in Fig. 5.5. Ethmoidal mucocele is seen as a homogeneously expansile lesion involving ethmoid air cell. There might be an extension of the ethmoidal mucocele into the lacrimal fossa involving the lacrimal sac (Fig.  5.5). In lacrimal sac

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5  Imaging in Disorders of the Lacrimal Drainage System

Fig. 5.5  A case of failed external DCR showing right ethmoidal mucocele communicating with the lacrimal sac. Bony defect in the bony lacrimal fossa and breach in lamina papyracea seen from previous surgery

Fig. 5.7  A well-defined cystic lesion of the left lacrimal sac with intact walls and a dilated sac. Right side nasolacrimal system is normal

Fig. 5.6  CT DCG showing a left lacrimal sac mucocele filled with secretions and the contrast material

mucocele the swelling is more centred on the lacrimal sac fossa (Figs. 5.6 and 5.7). Thus, a preoperative CT DCG in lacrimal sac mucocele allows confirmation of diagnosis and management of ethmoidal mucocele as well as dacryocystitis. Patients of PANDO having a history of nasal and sinus symptoms must be investigated for any nasal and sinus pathology as these patients have high chances of associated nasal polyposis [20]. Polyps may obscure the lacrimal sac landmarks and pose difficulty in sac exposure and marsupialization leading to failure. A dilated lacrimal sac with soft tissue densities in the sinuses can be seen on CT DCG in such failed

Fig. 5.8  CT DCG in a failed case of endoscopic DCR demonstrating a dilated right lacrimal sac with soft tissue densities due to polyps filling the nose and sinus

cases (Fig.  5.8). Involvement of the lacrimal drainage system in allergic fungal sinusitis is a very rare occurrence but should be suspected in all the patients with epiphora due to recurrent dacryocystitis and history of recurrent sinusitis [20, 21]. Sometimes other associated pathologies line an osteoma may be found in association with nasal polyps leading to the failure of primary surgery.

5.1  Computed Tomography (CT)/Computed Tomographic Dacryocystography (CT DCG)

59

Fig. 5.10  CT DCG sagittal section demonstrating lacrimal sac diverticulum as an outpouching from the lacrimal sac filled with contrast in a case of dacryocystocele that presented with medial canthal swelling

Fig. 5.9  CT DCG axial section demonstrating a lacrimal sac diverticulum as an outpouching lying separate from the lacrimal sac but communicating with sac lumen and opacified with the passage of contrast. Dilated sac can be seen below

Findings of nasal polyps in failed cases indicate that the polyps were missed during previous surgery. This also suggests that either a preoperative nasal endoscopy was not done, or the polyps were missed due to inadequate nasal cavity decongestion, gross septal deviation concha or grade 1 polyps. As per Lund, Kennedy ­endoscopic classification (0 = Absence of polyps; 1 = Polyps in middle meatus only; 2 = Polyps beyond middle meatus but not blocking the nose; 3  =  Polyps completely obstructing the nose) [22]. could have been missed in cases of severe deviation of nasal septum or presence of concha. CT DCG is very helpful in these cases to allow a meticulous primary surgery involving endoscopic DCR with the management of polyp, septal deviation, etc.

5.1.2.2 Lacrimal Sac Diverticulum Diverticulum is an abnormal sac or pouch formed at a weak point in the wall of a hollow organ. Lacrimal sac diverticulum clinically mimics other medial canthal masses and appears as a tense, fluctuant mass in the medial canthus fixed to the underlying structures, but not the overlying skin [23]. It often remains undetected and the incidental discovery is made either on dacryocystography or during

surgery [24]. On dacryocystography contrast material can be observed accumulating in a second space below the lacrimal sac (Figs. 5.9 and 5.10). NLD may be patent or obstructed and a diverticular pooling with relatively irregular contour can be seen on dacryocystography [25] (Figs. 5.9 and 5.10). Thus, dacryocystography is necessary for the diagnosis of a diverticulum. Surgical treatment involves excision of diverticulum alone if the NLD is patent and excision with endoscopic DCR if NLD obstruction is present [25–27].

5.1.2.3 Dacryocystocele Verses Meningocele Dacryocystocele and meningocele can be differentiated clinically however in absence of typical features of both the entities, imaging may be needed to confirm the diagnosis [28]. MRI is a preferred modality but in centres where MRI facility is not available a CT scan can be done with low dose radiation setting (Figs. 5.11, 5.12 and 5.13). 5.1.2.4 Dacryocystitis with Periorbital Inflammation and Oedema Clinically dacryocystitis presents with inflammation and oedema around the medial canthal area and with lacrimal sac dilatation, it may mimic an orbital abscess. CT scan helps in differentiating an orbital abscess from dacryocystitis as lacrimal sac is a pre-septal structure and an abscess limited to this area with no post-septal spread indicates dacryocystitis. A mass involving the lacrimal sac with peripheral enhancement con-

60

Fig. 5.11  Congenital dacryocele seen as a homogeneous soft tissue mass at inferomedial part of the orbit in the area of the lacrimal fossa. The sac is expanded, with the erosion of the fossa. This medial canthal mass represents dilated lacrimal sac, enlarged due to obstructed NLD

5  Imaging in Disorders of the Lacrimal Drainage System

Fig. 5.13 Encephalocele can be seen as a well-­ circumscribed expansile mass present in the extracranial area communicating with the intracranial space

5.1.3 C  T/CT DCG in Post-Traumatic Dacryocystitis

Fig. 5.12  CT scan of a patient with encephalocele in case of mass at the root of the nose extending up to the medial canthal area

firms dacryocystitis. CT thus helps in differentiating a medial orbital lesion (Fig.  5.14) from lacrimal sac pathology [7, 29, 30].

Although the incidence of injury to lacrimal drainage system following a road traffic accident is low but in severe blunt trauma to facial structures, the fracture line may extend further to involve the thin bony NLD that is week and vulnerable [7, 31–33]. Dacryocystography (DCG) is an important diagnostic procedure in post-traumatic NLDO cases as it demonstrates the fractured NLD (Fig.  5.15), impacted thickened and overlapping bones along with plates and screws from previous repair and their relation with the lacrimal drainage system [33]. Any severe scarring leading to the stenosis of the anterior nares and the location and size of the lacrimal sac as well as canaliculi can be delineated [33]. Axial cuts are better suited for delineating the fracture lines involving bony lacrimal fossa and bony NLD (Fig.  5.16) [7]. CT scan helps in  locating any fracture fragments impinging on the lacrimal drainage pathway [7]. Fracture of the frontal process of maxilla with postero-

5.1  Computed Tomography (CT)/Computed Tomographic Dacryocystography (CT DCG)

a

61

b

Fig. 5.14  a Right dacryocystitis showing area of enhancement around a lacrimal sac, b Soft tissue thickening with areas of enhancement posterior to the orbital septum is seen in a case of right orbital abscess

Fig. 5.15  CT DCG sagittal section demonstrating left fractured NLD with callus formation and bone remodelling

medial displacement of the fractured segment and its impaction into the ethmoids can be a challenging surgical situation (Figs. 5.17, 5.18, and 5.19). Preoperative assessment with CT DCG helps in proper planning and preventing complications. Although the sac duct junction is the most common site of obstruction seen in 85% cases [34] Dacryocystography may help in differentiating a high obstruction from lower obstructions that occurs in the mid NLD following fractures of

Fig. 5.16  CT DCG, axial scan demonstrating left NLD fracture with deformed proximal opening of NLD. Concha can also be seen

Fig. 5.17  Fractured and impacted the right frontal process of maxilla, fracture ethmoids and involvement of the superior portion of the sac

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5  Imaging in Disorders of the Lacrimal Drainage System

Fig. 5.18  CT DCG coronal section showing fracture right frontal sinus in a case of epiphora due to right lacrimal fossa fracture involving fundus of the sac

Fig. 5.20  Axial section showing the absence of contrast in the NLD on the right in a failed external DCR case indicating an obstructed system. The left side is patent with the passage of contrast on the left side

Fig. 5.19  CT DCG sagittal section showing fractured frontal sinus and frontal process of maxilla involving lacrimal drainage system

Fig. 5.21  Bony defect from previous surgery with remnant of sac

the NLD [7]. This localization of the site of fracture is important in planning endoscopic DCR surgery so that a lower, infected, ductal part is not left after surgery and should be marsupialized [34] (Fig. 5.15).

5.1.4 C  T DCG in Failed Cases of External or Endoscopic DCR In failed cases, CT DCG provides useful information about the site and status of the bony window from previous surgery. An intact agger nasi or any remnant of the sac may also be visible (Figs.  5.20, 5.21 and 5.22). Sometimes associated nasal polyps are found in failed cases indicating the lack of preoperative detection

Fig. 5.22  CT DCG sagittal section demonstrating a bony window from the previous surgery with remnant of the sac seen as a small contrast opacified area in the lacrimal fossa

(Fig.  5.23). Radiological investigations in these cases facilitate meticulous surgery that helps in avoiding further recurrence.

5.2 Ultrasonography

63

5.2

Fig. 5.23  Failed previous endoscopic DCR with distorted anatomy of the lacrimal fossa, intact sac and soft tissue densities. The nose was found full of polyps on nasal endoscopy

a

Ultrasonography

Ultrasonography is a non-invasive method of evaluating the lacrimal sac and can differentiate between the normal sac from the sac in chronic dacryocystitis by picking up the changes [35, 36]. It can be used as an adjunct to the clinical examination. It helps in detecting the abnormal dilatation of the sac, presence of diverticula and inflammatory exudates within the lacrimal sac (Fig. 5.24a–c) [35–38]. It is also useful in the visualization of DCR osteum and the flow of tear through the osteum It is however not a physiological test as the sac needs to be inflated with saline to obtain good images [5, 39] and the ultrasound probe when placed over the sac exerts pressure exerts pressure over the medial canthal area.

b

c

Fig. 5.24  (a) Ultrasound of the lacrimal sac demonstrating the dilated part of the lacrimal sac with collection of thick fluid and dirty echoes seen medial to the orbit and deep to the nasal bone in a case of dacryocele. (Photo courtesy; Dr. Gyan Prakash Aggarwal). (b) Ultrasound of

an enlarged lacrimal sac showing its dimensions in a case of dacryocele. (Photo courtesy; Dr. Gyan Prakash Aggarwal). (c) Dilated sac is seen on ultrasound in a case of primary acquired nasolacrimal duct obstruction. (Photo courtesy; Dr. Gyan Prakash Aggarwal)

5  Imaging in Disorders of the Lacrimal Drainage System

64

5.3

Magnetic Resonance Imaging (MRI) of Lacrimal Drainage System

MRI of the lacrimal drainage system can be performed by instillation of gadolinium drops into the conjunctival sac on both sides allowing the functional assessment of the lacrimal drainage system [40, 41]. It can also be performed by cannulating the canaliculi for diluted gadolinium administration to obtain T1 weighted images [40] (Figs. 5.25 and 5.26). The sensitivity of CT and MRI has been reported to be similar in some studies [4, 41]. The MRI provides adjacent soft tissue details, facilitates the acquisition of 3D images and it does not utilize ionizing radiation but it is an expensive procedure and lacks bony details.

5.4

Lacrimal Scintigraphy

Lacrimal scintigraphy is a physiological test as it is not performed under the pressure of canalicular injection of the saline or contrast material [42]. It has been used widely in the assessment of

Fig. 5.25  Contrast-enhanced magnetic resonance imaging study revealed an ovoid lesion in the left lacrimal sac region appearing hyperintense on T2W images. It measures 11 × 9 mm in size and shows peripheral enhancement on post-contrast image suggesting dacryocystocele. Left globe is grossly small in size due to Phthisis bulbi

the lacrimal drainage system obstructions [42– 45]. Lacrimal scintigraphy can be performed with a variety of gamma cameras [1] with patient blinking normally. One drop of 99mTc-sodium pertechnetate is instilled in each eye. Patients are made to sit in front of a gamma camera and his head is stabilized and the passage of tracer through the lacrimal drainage system is detected by a gamma camera to obtain DSG images [46]. Sequential images are taken at specific intervals [43, 44] specific intervals of 2.5, 5, 7.5, and 10 min [43]. The eyes are flushed with saline to help clear the remaining radioactivity. Dacryocystography demonstrates the passage of tracer into the lacrimal sac, NLD and then inferior meatus. In case of delayed passage of tracer into the NLD, the sac can be seen filled with the tracer. A post-sac delay is diagnosed by early filling of the sac, but it continues to remain full of contrast at the end of the study [47] (Fig. 5.27a–g). Thus, physiological dysfunctions with post-sac delay can cause functional obstruction of lacrimal drainage system [47]. Dacryocystography is a

Fig. 5.26  Contrast-enhanced magnetic resonance imaging study revealed an ovoid lesion in the left lacrimal sac region appearing hypointense on T1W

5.4  Lacrimal Scintigraphy

65

a

b

c

d

e

f

Fig. 5.27  (a) Dynamic anterior images were acquired on lacrimal scintigraphy after instillation of 100 microcurie of Tc99 pertechnetate solution in the lateral canthus of both eyes. Delayed static images were acquired till 90 min. In the first image right eye tracer activity is seen in the interpalpebral fissure and is seen to collect immediately at the medial canthus. (b) In the second image tracer can be seen flowing through canaliculi into the lacrimal sac on the right with no flow on the left side. (c) In this image on lacrimal scintigraphy, tracer is seen in proximal nasolacrimal duct at 4 min on the right side with the no flow on the left side indicating a delay. (d) Tracer seen in the nasal cavity by 8 min on the right indicating a patent

system while the delay was noted on the left side. (e) The tracer activity in the interpalpebral fissure is seen to diminish with time on the right side while the pooling of tracer can still be noted in the left interpalpebral fissure after 15  min indicating a delayed transport on left. (f) Tracer can be seen in the nasal cavity on the left side as well at the end of 90 min indicating a delayed flow in an atonic left lacrimal sac. (g) Lacrimal scintigraphy showing the complete set of dynamic anterior images depicting a normal lacrimal drainage system of the right eye with patent nasolacrimal duct and slow drainage of tracer on the left indicating an atonic left lacrimal sac

5  Imaging in Disorders of the Lacrimal Drainage System

66

g

Fig. 5.27 (continued)

5.5  Digital Subtraction Dacryocystography

a

67

b

c

Fig. 5.28  (a) Digital subtraction dacryocystography in process with a contrast media filled in syringe placed in one of the puncta. Opacified upper and lower canaliculi are seen along with a dilated lacrimal sac. (b) Digital subtraction angiography of the left lacrimal system demonstrating complete obstruction at the level of sac duct junction. The structures that can be identified are 1 inferior canaliculus, 2 superior canaliculus, 3 common canaliculus, 4 distended lacrimal sac, 5 obstruction at sac duct

junction, extravasated contrast material. (c) Digital subtraction angiography of the right lacrimal system showing a free flow of contrast indicating a morphologically normal system. Various structures seen are 1 Inferior canaliculus, 2 superior canaliculus, 3 common canaliculus, 4 lacrimal sac, 5 normal nasolacrimal duct, 6 patent valve of Hasner, 7 contrast material between lateral wall of nose and inferior turbinate, 8 Syringe with needle containing contrast

sensitive method for lacrimal drainage system evaluation but the useful clinical information is only possible by supplementing it with CT DCG to localize any obstruction [46].

bony structures and the dynamic tear flows [48] (Fig. 5.28a–c).

5.5

Digital Subtraction Dacryocystography

Digitally subtracted DCG (DS-DCG) provides a good view of the lacrimal drainage system but it fails to provide information about the ­surrounding

Key Points • CT DCG is a gold standard investigation for all complex obstructions of the lacrimal drainage system. Most of the PANDO cases can be diagnosed by clinical evaluation but imaging does play an important role in diagnosis and improving results in a select group of PANDO patients presenting with a medial canthal mass.

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13. do Nascimento SB, Rodrigues AB, Jurity TP, de Sá JC, Castelo Branco AN. Lacrimal sac mucocele. Braz J Otorhinolaryngol. 2014;80:540–1. 14. Katarzyna EK, Harpreet A.  Chronic dacryocystitis with spontaneous resolution of sac mucocele: fact or fiction. Ophthal Plast Reconstr Surg. 2011;27:e90–2. 15. Xiao MI, Tang LS, Zhu H, Li HJ, Li HL, Wu XR. Adult nasolacrimal sac mucocele. Ophthalmologica. 2008;222:21–6. 16. Yip CC, McCulley TJ, Kersten RC, Bowen AT, Alam S, Kulwin DR.  Adult nasolacrimal duct mucocele. Arch Ophthalmol. 2003;121:1065–6. References 17. Perry LJP, Jakobiec FA, Zakka FR, Rubin PAD. Giant dacryocystomucopyocele in an adult: a review of 1. Detorakis ET, Zissimopoulos A, Ioannakis K, lacrimal sac enlargements with clinical and histoKozobolis VP.  Lacrimal outflow mechanisms and pathologic differential diagnoses. Surv Ophthalmol. the role of scintigraphy: current trends. World 2012;57:474–85. J Nucl Med. 2014;13(1):16–21. https://doi. 18. Woo KI, Kim YD.  Four cases of dacryocystocele. org/10.4103/1450-1147.13856. Korean J Ophthalmol. 1997;11:65–9. 2. Detorakis ET, Drakonaki EE, Bizakis I, Papadaki E, 19. Lindberg JV, McCormick SA.  Primary acquired Tsilimbaris MK, Pallikaris IG.  MRI evaluation of nasolacrimal duct obstruction. A clinicopatholacrimal drainage after external and endonasal daclogic report and biopsy technique. Ophthalmology. ryocystorhinostomy. Ophthal Plast Reconstr Surg. 1986;93:1055–63. 2009;25:289–92. 20. Pao KY, Yakopson V, Flanagan JC, Eagle RC Jr. 3. Detorakis ET, Drakonaki E, Papadaki E, Pallikaris IG, Allergic fungal sinusitis involving the lacrimal sac: a Tsilimbaris MK.  Watery eye following patent extercase report and review. Orbit. 2014;33(4):311–3. nal DCR: an MR dacryocystography study. Orbit. 21. Kim C, Kacker A, Chee R-I, Gary J. Lelli allergic fun2010;29:239–43. gal sinusitis causing nasolacrimal duct obstruction. 4. Manfrè L, de Maria M, Todaro E, Mangiameli A, Orbit. 2013;32(2):143–5. Ponte F, Lagalla R. MR dacryocystography: compari- 22. Lund V. Quantification for staging sinusitis. The stagson with dacryocystography and CT dacryocystograing and therapy group. Ann Otol Rhinol Laryngol. phy. AJNR Am J Neuroradiol. 2000;21:1145–50. 1995;167:17–21. 5. Pavlidis M, Stupp T, Grenzebach U, Busse H, Thanos 23. Aswani RG, Meyer DR.  Surgical Management S. Ultrasonic visualization of the effect of blinking on of Acquired Lacrimal sac diverticula M.D.  Am J the lacrimal pump mechanism. Graefes Arch Clin Exp Ophthalmol. 1994;117(6):814. Ophthalmol. 2005;243:228–34. 24. Demorest B, Milder B.  Dacryocystography II.  The 6. Mukherjee B, Dhobekar M.  Traumatic nasolacrimal pathologic lacrimal apparatus. Arch Ophthal Mol. duct obstruction: clinical profile, management, and 1955;54:410. outcome. Eur J Ophthalmol. 2013;23(5):615–22. 25. Akcay EK, Cagil N, Yulek F, Yuksel D, Simsek 7. Russell EJ, Czervionke L, Huckman M, David Daniels S.  Congenital lacrimal sac diverticulum as a cause D, McLachlan D. CT of the inferomedial orbit and the of recurrent orbital cellulitis. Can J Ophthalmol. lacrimal drainage apparatus: normal and pathologic 2009;44:e29–30. anatomy. AJNR. 1985;6:759–66. 26. Bullock JD, Goldberg SH.  Lacrimal sac diverticuli. 8. Flach A. The fluorescein appearance test for lacrimal Arch Ophthalmol. 1989;107:756. obstruction. Ann Ophthalmo. 1979;11:237–42. 27. Adjemian A, Burnstine MA.  Lacrimal canalicular 9. Munk PL, Burhenne LW, Buffam FV, Nugent RA, diverticulum: a cause of epiphora and discharge. Lin DT.  Dacryocystography: comparison of water-­ Ophthal Plast Reconstr Surg. 2000;16:471–2. soluble and oil-based contrast agents. Radiology. 28. Wei IBA. Congenital disorders of the lacrimal system. In: 1989;173:827–30. Milder B, BA WI, editors. The lacrimal system. Norwalk, 10. Malik SRK, Gupta AK, Chaterjee S, Bhardwaj OP, Saha CT: Appleton-Century-Crofts; 1983. p. 95–104. M. Dacryocystography of normal and pathological lac- 29. Schramm VL Jr, Curtin HD, Kennerdell rimal passages. Br J Ophthalmol. 1969;53:174–9. JS. Evaluation of orbital cellulitis and results of treat11. Milder B, Demorest BH.  Dacryocystography. The ment. Laryngoscope. 1982;92:732–8. pathologic lacrimal apparatus. Arch Ophthalmol. 30. Harr DL, Quencer RM, Abrams GW.  Computed 1955;54(3):410–21. tomography and ultrasound in the evaluation of 12. Salah Eldesoky S, Hisham Farouk H, Moustafa AN, orbital infection and pseudotumor. Radiology. El-noueam K, Elsabaa A. The role of multi-detector 1982;142:395–401. CT dacryocystography in the assessment of naso-­ 31. Fernbach SK, Naidich TP.  CT diagnosis of lacrimal duct obstruction. Egyptian J Radiol Nucl orbital inflammation in children. Neuroradiology. Med. 2012;43(3):397–405. 1981;22:7–13.

• Detection of ethmoid mucocele, nasal polyposis and lacrimal sac diverticulum in failed cases emphasize the importance of preoperative imaging. • CT DCG is a valuable investigation prior to endoscopic DCR in all complex cases as well as selective cases of PANDO.

References 32. Linberg JV. Disorders of the lower excretory system. In: Milder B, Weil BA, editors. The lacrimal system. Norwalk, CT: Appleton-Century-Crofts; 1983. p. 133–43. 33. Gruss JS, Hurwitz JJ, Nik NA, Kassel EE. The pattern and incidence of nasolacrimal injury in naso-orbital-­ ethmoid fractures: the role of delayed assessment and dacryocystorhinostomy. Br J Plast Surg. 1985;38:116–21. 34. Milder B. Dacryocystography. In: Milder B, Weil BA, editors. The lacrimal system. Norwalk, CT: Appleton-­ Century-­Crofts; 1983. p. 79–91. 35. Machado MAC, Silva JAF, Garcia EA, Allemann N.  Ultrasound parameters of normal lacrimal sac and chronic dacryocystitis. Arq Bras Oftalmol. 2017;80(3):172–5. 36. Végh M, Németh J. Use of ultrasound diagnostics in lacrimal sac diseases. Int Ophthalmol. 1991;15(6):397–9. 37. Tan S, Özcan AS, Akçay E, Süngü N.  Sonographic appearance of primary sac lymphoma. J Ultrasound Med. 2011;30(4):574–5. 38. Jedrzynski MS, Bullock JD.  Lacrimal ultrasonography. Ophthal Plast Reconstr Surg. 1994;10(2):114–20. 39. Ezra E, Restori M, Mannor GE, Rose GE. Ultrasonic assessment of rhinostomy size following external dacryocystorhinostomy. Br J Ophthalmol. 1998;82:786–9. 40. Francisco FC, Carvalho ACP, Neto GT, Francisco VFM, Souza LAM, Francisco MC, Fonseca LMB, Gutfilen B, Mendonça Júnior AA.  Evaluation of the lacrimal system by radiological methods*. Radiologia Brasileira. Radiol Bras. 2007;40(4):273–8.

69 41. Karagulle T, Erden A, Erden I, Zilelioglu G. Nasolacrimal system: evaluation with gadolinium-­ enhanced MR dacryocystography with a three-­ dimensional fast spoiled gradient-recalled technique. Eur Radiol. 2002;12:2343–8. 42. Rossomondo RM, Carlton WH, Trueblood JH, Thomas RP.  A new method of evaluating lacrimal drainage. Arch Ophthalmol. 1972;88:523–5. 43. Detorakis ET, Zissimopoulos A, Katernellis G, Drakonaki EE, Ganasouli DL, Kozobolis VP. Lower eyelid laxity in functional acquired epiphora: evaluation with quantitative scintigraphy. Ophthal Plast Reconstr Surg. 2006;22:25–9. 44. Hurwitz JJ, Maisey MN, Welham RA.  Quantitative lacrimal scintillography. I. Method and physiological application. Br J Ophthalmol. 1975;59:308–12. 45. Hanna IT, MacEwen CJ, Kennedy N. Lacrimal scintigraphy in the diagnosis of epiphora. Nucl Med Commun. 1992;13:416–20. 46. Barna S, Garai I, Kukuts K, et  al. Clinical util ity of SPECT/CT and CT-dacryocystographyenhanced dacryoscintigraphy in the imaging of lacrimal drainage system obstruction. Ann Nucl Med. 2019;33:746–54. 47. Delaney YM, Khooshabeh R.  External dacryocys torhinostomy for the treatment of acquired partial nasolacrimal obstruction in adults. Br J Ophthalmol. 2002;86:533–5. 48. Singh S, Ali MJ, Paulsen F. Dacryocystography: from theory to current practice. Ann Anat. 2019;224:33–40.

6

Preoperative Evaluation in Endoscopic Dacryocystorhinostomy

Epiphora is the most common symptom of nasolacrimal duct obstruction in patients needing endoscopic dacryocystorhinostomy (DCR). However, there are several etiological factors causing epiphora and their treatment differs according to the cause. Therefore, a comprehensive evaluation of patients presenting with epiphora is needed [1]. The term ‘epiphora’ originates from the Greek word ‘epifora’, which is derived from phérein (to bring) and epi (upon) [2]. Thus, the term epiphora means ‘to bring upon’, or an overflow of tears [2–6]. In ancient Greece, time epiphora was described as an overflow of tears due to excessive tear production or impaired drainage. In 1960 the term epiphora was redefined to include only the inadequate drainage of tears [2]. Kuriakose et al. suggested that the new definition does not include the term reflex epiphora and gustatory epiphora that are still used in literature. They, therefore, suggested that epiphora as a broad term should include symptoms of tear overflow for any reason, as the term was used or thousands of years. There can be modifications like obstructive epiphora and hypersecretory epiphora [2]. We believe that this clear demarcation between obstructive and hypersecretion pathology will simplify the epiphora as an entity and will allow an easy compilation of symptomatology and investigations that would facilitate appropriate management.

Although a battery of tests is available to reach a diagnosis in epiphora not all of them are needed in each case. History plays an important role and can localize the site of obstruction in most of the cases and allows the surgeon to decide which tests are needed in a particular circumstance [7]. Most cases of epiphora are secondary to an obstruction or non-patency in the lacrimal outflow pathway [8–13]. Other causes such as eyelid and adnexal disorders, and corneal and ocular surface pathologies can also cause watering [8]. A list of various causes of epiphora has been given below [14]. A. Reflex watering or Hypersecretion 1. Dry eye 2. Inflammation 3. Ocular surface disorders 4. Allergy B. Reduced tear outflow 1. Obstructive pathology (a) Punctal or canalicular obstructions (b) NLD obstruction Congenital nasolacrimal duct obstruction (CNLDO) Primary acquired nasolacrimal duct obstruction Secondary acquired nasolacrimal duct obstruction 2. Eyelid laxity 3. Eyelid malposition 4. Lacrimal pump insufficiency

© Springer Nature Singapore Pte Ltd. 2021 N. Gupta, Endoscopic Dacryocystorhinostomy, https://doi.org/10.1007/978-981-15-8112-0_6

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6.1

History

6.1.1 Epiphora in Children 6.1.1.1 Onset of Symptoms and Type of Epiphora History of onset of symptoms is especially important in children as probing and syringing is not possible in them like adults. Epiphora in children present since birth is often due to a membranous obstruction at the valve of Hasner [7, 15–19]. The discharge is generally mucoid or mucopurulent and is continuous (Fig.  6.1). Intermittent watering with exacerbation during the attack of cold indicates a partial NLD obstruction (Fig.  6.2). Therefore, a history of nasal symptoms should also be taken. Children with late-onset continuous epiphora need to be investigated further to know the causes of epiphora. 6.1.1.2 History of Swelling in Medial Canthal Area Swelling in the medial canthal area present since birth indicates a congenital dacryocele [20] (Fig. 6.3). CNLDO is a common condition with obstruction at the valve of Hasner. A concomitant obstruction at the opening of the common canaliculus in the lacrimal sac leads to the accumulation of fluid followed by the distension of the lacrimal sac at birth. This condition is known as congenital lacrimal amniotocele, or dacryocele [20] (Fig.  6.3). The swelling appearing after a few months or later is due to a secondary infection resulting in dacryocystitis. 6.1.1.3 History of Conservative Treatment History of improvement following massage over the lacrimal sac area in a case of CNLDO is a favourable sign and the child can be observed till he turns one year before any intervention. However persistent thick mucopurulent discharge despite regular massage and instillation of antibiotic eye drops point towards a complex CNLDO needing early intervention.

Fig. 6.1  Clinical photograph of a child with complete NLD obstruction in CNLDO

Fig. 6.2 Partial NLD obstruction demonstrated by delayed fluorescein dye clearance in a child during acute exacerbation of upper respiratory tract infection

6.1.1.4 History of Previous Intervention History of conventional or endoscopic probing should be elicited. A failed conventional probing warrants an endoscopic check and repeat probing  is needed with or without dacryoendoscopy assistance. A simultaneous planning of endoscopic DCR avoids multiple general anesthesia sittings.

6.1 History

73

Fig. 6.3  Congenital dacryocele in a 1-month old child

6.1.1.5 Syndromic Association Lacrimal anomalies have been found to be associated with a variety of syndromes like Down syndrome and blepharophimosis epicanthus inversus syndrome [21, 22]. The management depends on the type of defect and associated malformations. The parents should be explained the need for endoscopic DCR in the event of any bony dysgenesis of NLD or refractory NLD obstruction.

Fig. 6.4  Mucopurulent discharge in nasolacrimal duct obstruction

6.1.2 E  valuation of Adults Based on History 6.1.2.1 History of Discharge Epiphora could be in the form of simple watering, mucoid or mucopurulent discharge. In non-­ obstructive pathology, the discharge could be unilateral or bilateral. Unilateral occurs due to any corneal injury, abrasion or corneal foreign body or keratitis. Bilateral hypersecretion is seen in recurrent conjunctivitis, blepharitis and dry eye. Obstructive pathologies would often have an infected discharge (Fig. 6.4) while simple punctal or canalicular obstructions present with simple watering (Fig. 6.5). Persistent blockage of the lacrimal drainage system leads to chronic dacryocystitis causing drainage of mucopurulent discharge from the corner of the eye. Inflammation of the skin in the region of the medial canthus overlying the

Fig. 6.5  Clear fluid accumulation in the left eye in a case of canalicular obstruction

obstructed sac may occur, particularly during acute infection (Fig. 6.6).

6.1.2.2 History of Nasal Symptoms History of nasal symptoms should be elicited in detail especially in cases of epiphora with medial canthal swelling. There are chances of associated

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Fig. 6.7  Clinical photograph of a patient demonstrating a scar from high osteotomy during previous left external DCR

Fig. 6.6  Long-standing infection leading to skin inflammation and fistula formation

nasal polyposis with ethmoidal mucocele extending into the lacrimal sac in some of these cases. Strong history of nasal symptoms indicates the need for imaging in addition to nasal endoscopy to allow complete clearance of nasal and sinus disease during endoscopic DCR.

Fig. 6.8  Clinical photograph of a patient with fullness in the left lacrimal sac area indicating a dilated sac

6.1.2.3 History of Trauma or Any Previous Surgery History of trauma or previous sinus or sac surgery must be taken. Inadvertent damage to NLD may occur during endoscopic sinus surgery and knowing this, one can anticipate the site of NLD injury.

6.1.3 Examination 6.1.3.1 Local Eye Examination The examination involves the presence of discharge, matting of the eye lashes and any excoriation of periorbital skin (Fig. 6.1). 6.1.3.2 Examination of the Medial Canthal Area Medial canthal area is the next area that comes in view and is looked for any scar, fullness, redness, rounded bulge, cystic swelling with inflamed skin or fistula (Figs. 6.7, 6.8, 6.9, 6.10, 6.11, and

Fig. 6.9  Clinical photograph of a patient demonstrating inflamed skin with induration indicating an acute on chronic dacryocystitis

Fig. 6.10   Right lacrimal sac mucocele

6.1 History

6.12). The presence of scar indicates some previous surgery, fullness indicates a dilated sac due to long-standing infection, rounded bulge is often due to lacrimal sac mucocele, a cystic bulge with inflamed skin indicates a lacrimal sac abscess. Though the most common cause of the swelling in the medial canthal area in patients presenting with epiphora is lacrimal sac mucocele, the

Fig. 6.11  Left acquired dacryocystocele

Fig. 6.12  Right lacrimal sac abscess

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differential diagnosis includes dacryocystitis, lacrimal sac diverticulum, encephalocele, ­ethmoid mucoceles, dermoid cysts and malignancy of the lacrimal sac [23–29]. Lacrimal sac mucocele can be differentiated from ethmoidal mucocele as the ethmoidal mucocele is located in the medial canthal area and extends along the medial orbital wall and roof depending on the extent of involvement and may be associated with telecanthus, epiphora, diplopia and eye displacement [30]. Lacrimal sac mucocele often lies below the medial canthal ligament and can be differentiated from neoplastic mass lesions as the latter can extend above the medial canthal ligament [23–29]. CT or CT dacryocystography (DCG) provides useful information in cases of medial canthal swelling. Differential diagnosis of cases presenting with medial canthal swelling has been depicted with the help of four collages. Collage 1 demonstrates left dacryocystocele with displaced maxillary line on endoscopy and a cystic lesion  on CT DCG (Fig. 6.13), Collage 2 depicts an ethmoidal mucocele with extension into the lacrimal sac and nasal polyposis (Fig. 6.14), Collage 3 shows Lacrimal sac diverticulum (Fig. 6.15), Collage 4 demonstrates an atonic lacrimal sac with extensive nasal polyposis (Fig. 6.16). All these cases had presented with epiphora and medial canthal swelling.

6.1.3.3 Lacrimal Sac Fistula Medial canthal area may also show a fistula that could be congenital or acquired [31]. congenital

Fig. 6.13  Clinical photograph of a left dacryocystocele with endoscopic view showing a bulge on the lateral wall encroaching the maxillary line and a CT DCG demonstrating a fluid-filled large cyst with enhancement

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Fig. 6.14  A failed  right external DCR with persistent medial canthal swelling due to ethmoidal mucocele with extension into the lacrimal sac (mimicking simple lacri-

mal sac mucocele), with polyps on endoscopic visualization and opaque sinuses on CT Scan

Fig. 6.15  Left lacrimal sac diverticulum presenting as a medial canthal mass in an eye with phthisis bulbi, normal nasal endoscopy and a diverticulum on CT DCG

Fig. 6.16  Left atonic sac is seen as a mass below the inner corner of the lower lid, no epiphora, patent syringing, nose full of polyp with ROPLAS positive. CT DCG

showed a dilated sac with opaque sinuses due to nasal polyps along with a post-operative endoscopic view of the left nasal cavity

lacrimal fistulae are located below and lateral to the medial canthal area and are often asymptomatic [32] (Fig. 6.17). Acquired fistulas occur at the site of a ruptured abscess, they have no fixed place and are often symptomatic (Fig. 6.18).

6.1.3.4 Regurgitation Test Regurgitation of mucopurulent discharge on pressing the lacrimal sac area (ROPLAS) through one or both the punctum is diagnostic of NLD obstruction [33, 34] (Fig. 6.19).

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77

The regurgitation is positive only if the valve of Rosenmuller is patent [9]. If the regurgitation test is positive the nature of discharge is judged. It is mostly mucoid or mucopurulent but could be blood stained as seen in malignancy, rhinosporidiosis of the lacrimal sac [35] and canaliculitis. In cases where the valve of Rosenmuller gets blocked due to the pressure exerted by a large lacrimal sac swelling, the regurgitation test may be negative like in dacryocele or an encysted mucocele.

Fig. 6.17  Left congenital lacrimal sac fistula

6.1.3.5 Punctal Examination The normal location of the lacrimal puncta is important for maintaining the patency of the lacrimal drainage system. When eyelids close, the puncta should contact each other and get immersed in the lacrimal lake [32]. The punctum is examined by everting the lid (Fig.  6.20) and abnormality in the punctum like congenital absence of punctum, punctal stenosis or supernumerary punctum in upper or the lower lid should be documented. Slit lamp examination should be performed to grade the severity of punctal stenosis and institute appropriate management. Slit lamp examination nicely delineates a normal punctum and also helps in confirmation of cases

Fig. 6.18  Right acquired lacrimal sac fistula

Fig. 6.19  Regurgitation test revealing mucopurulent discharge on pressing over the lacrimal sac fossa, confirming NLD obstruction

Fig. 6.20  The right lower lid is retracted to examine the lower punctum

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a

b

Fig. 6.21  (a) Slit lamp examination shows a normal punctum. (b) Slit lamp photograph demonstrating an absent right lower punctum

also affected in cases of eyelid laxity due to facial palsy (Fig. 6.22). The ageing process or following maxillectomy for carcinoma of the maxilla (Fig. 6.23).

6.1.3.6 Probing and Irrigation Irrigation is the most reliable method to check the patency of lacrimal drainage system [36]. Fig. 6.22  Left facial paralysis showing lid eversion and epiphora

Fig. 6.23  Right retained dye with lid eversion following right maxillectomy

where punctum is stenotic or missing on clinical examination (Fig.  6.21a, b). Punctal position is

Steps • Topical anaesthetic drops are instilled into the eye. The lower eyelid is retracted down with the index finger and punctum is dilated with a Nettleship’s punctum dilator (Figs.  6.24 and 6.25). • Irrigation is done with an appropriate size, partially curved or straight canula on a 2cc syringe. The irrigation canula is first inserted vertically as the eyelid is pulled vertically down (Fig.  6.26). The canula is then tilted horizontally as the eyelid is pulled laterally to straighten the canaliculi and the saline is flushed (Fig. 6.27). Regurgitating fluid may be clear or mucopurulent (Fig.  6.28). Forceful irrigation should be avoided as it will give false results and may also cause injury to the canaliculi. The interpretation of the results of irrigation has been mentioned in the flow chart given below.

6.1 History

79 Irrigation of lacrimal drainage system

Regurgitation of turbid fluid through opposite punctum

Regurgitation of clear fluid through the opposite Punctum

Regurgitation of clear fluid through same (lower) Punctum on syringing through lower punctum Lower Canalicular Block (CB)

NLD Block

Common Canalicular obstruction

Endoscopic DCR

Check Probing

Hard stop

Soft Stop

Repeat syringing through upper punctum

Patent with free flow of saline into nose

Regurgitation of turbid or mucoid/mucopurulent discharge through the upper punctum with hard stop

Regurgitation of clear fluid through upper punctum with a soft block at tip of canula

No Intervention

NLD obstruction lower CB)

Upper CB (with already present Lower CB)

Common Canalicular obstruction Trephination with Endoscopic DCR Endoscopic DCR with minimonka through upper punctum

Probing to Mmasure the site of CB separately by probing

Proximal CB Endoscopic conjunctival DCR/ Botox Inj. In lacrimal gland

Distal CB Trephination + Endoscopic DCR

Flow Chart

Fig. 6.24 Right lower lid is retracted down and a Nettleship punctal dilator is inserted vertically Fig. 6.25  The dilator is then tilted horizontally and gentle dilatation is continued

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Fig. 6.28  Regurgitation of mucopurulent discharge indicates NLD obstruction

not indicate a normal tear draining pathway [3] and should be correlated with the fluorescein dye test findings [9, 11, 12]. irrigation should not be done in cases of acute or acute on chronic dacryocystitis.

Fig. 6.26  Irrigation is done with fluorescein dye into a 2  ml syringe with a canula. The canula is first inserted vertically down while the lid in stretched down

Fig. 6.27  The canula is then tilted horizontally and the lid is retracted laterally to allow smooth passage of the canula

The hydrostatic pressure is higher in irrigation than the normal tear flow, therefore it is not a physiological test. Thus, a patent syringing does

6.1.3.7 Probing Probing is indicated only if irrigation findings point towards a canalicular obstruction. Topical anaesthesia is achieved by instilling paracaine eye drops into the eyes. Punctum is dilated and a Bowman’s probe is passed through the punctum first vertically into the vertical canaliculus while the lid is stretched down and then tilting the probe medially and horizontally (Fig. 6.29a, b). As the probe is advanced into the sac lumen, a hard stop signifies an NLD obstruction (Fig.  6.29c, d). The hard stop is felt when the probe enters the sac and hits the bone covering the medial wall of the lacrimal sac. Hard stop rules out canalicular obstruction. The technique of probe insertion and lid traction have been depicted with the help of schematic diagrams (Fig. 6.29e–h). A soft stop at the tip of the probe indicates a canalicular obstruction, however, a false soft stop must be ruled out. False soft stop can be due to the faulty technique of probing in which there is kinking of the canaliculus and the probe hits one of the walls of the canaliculus. False soft stop can also be felt in the patent canalicular system due to the presence of canalicular/lacrimal sac mucosal folds (CLS-MFS folds) at the opening of the

6.1 History

81

a

b

c

d

e

f

g

h

Fig. 6.29  In clear fluid regurgitation with a soft stop at the tip of the canula canalicular obstruction should be ruled out by probing. (a) The probe is inserted vertically. (b) It is then tilted horizontally while the lid is stretched laterally. (c) Canaliculi is straightened and the probe is advanced further till a hard stop is felt. (d) Incorrect technique of probing by pulling the lid in a way that it leads to kinking of the canaliculus. (e) Schematic diagram to demonstrate steps of probing by first vertical insertion of the

probe. (f) Horizontal tilting of the probe. Note the direction of finger over the lower lid as it pulls the lid inferiorly and laterally to straighten the horizontal canaliculus. (g) Hard stop indicating that the probe has reached into the sac and as it goes and hits the bone covering the medial wall of the sac that feels like a hard stop. (h) Kinking of one of the canaliculi occurs due to faulty technique and it gives a spongy feeling that appears as a soft stop

common canaliculus that obstruct the tip of the probe. A slight manoeuvering the probe under endoscopic visualization can easily overcome the obstruction [37–39]. Probing should be done through both the upper and the lower canaliculi and the site of canalicular obstruction is measured. The point at which a soft stop is felt, the probe is held close to the punctum and is placed against a scale to measure the site of the block as described in the chap. 10 on upper lacrimal drainage system disorders (Figs. 10.14 and 10.15). The differentiation between the hard stop and soft stop is essential because an obstruction at the sac or duct junction is treated by DCR while canalicular obstructions require trephination or conjunctival DCR depending on the length of canaliculus at which the obstruction is present (Fig. 10.16).

6.1.3.8 Lid Examination The lid condition is generally obvious on the preliminary examination. In cases of doubt, special tests should be performed [8]. The lid muscle tonicity can be assessed by snap-back test as described earlier [13, 33]. In this test, the lower lid is pulled down and away from the globe and then released and its ability to return to its original position is checked. The horizontal lid laxity is tested by the pinch test [13] in which the lid is pulled away from the globe and the distance between the lid and the eye is measured. If the distance is more than 8 mm between it indicates lid laxity. Olver described lateral distraction test to check ectropion or the medial canthal tendon laxity [5, 13]. In this test, the lid is pulled laterally and a movement of 1–2 mm in adults and up to 3–4 mm in the elderly is taken as normal [13].

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6.1.4 Fluorescein Dye Test Fluorescein dye test is a very reliable test to check the patency of lacrimal drainage system [40]. This is done by holding a saline soaked strip of fluorescein close to the medial canthus or by pouring few drops of saline over the strip placed in conjunctival fornix  (Figs. 6.30, 6.31, 6.32, 6.33 and 6.34).

Fig. 6.30  A fluorescein strip is shown Fig. 6.33  The dye can also be instilled by pouring saline over the  fluorescein  strip placed  in the conjunctival fornix

Fig. 6.31  Fluorescein strip is soaked in normal saline

Fig. 6.32  The lower conjunctival fornix is touched with fluorescein strip to instill few drops of dye

Fig. 6.34  Dye can be seen in the right eye

The presence of the dye can be confirmed in the nose with the help of the endoscope or cotton tip applicator (Figs. 6.35 and 6.36). If no dye is visible in the nose, the canaliculus is irrigated with saline to assess the patency of NLD with pressure irrigation. If there is reflux of saline or dye, the canaliculi are probed for the sign of stenosis or obstruction. This test provides useful information in children and is done by instilling fluorescein into the conjunctival fornix and a cotton tip applicator is placed in the nose. In a normal NLD, cot-

6.1 History

83

6.1.5 Nasal Endoscopy

Fig. 6.35  A cotton tip applicator is gently introduced into the nose to check the presence of dye into the nose

Nasal endoscopy is routinely performed in all the patients of lacrimal drainage obstruction before surgical intervention. Endoscopy is done in a structured manner as described in the chap. 3 on the endoscopic anatomy of the lacrimal drainage system. Special focus lies on the maxillary line as this is the area of the lacrimal sac. Difficult access to this area may occur as a result of a deviated nasal septum (Fig. 6.37), an enlarged middle turbinate (concha) (Fig. 6.38), edema of the middle meatus (Fig.  6.39), nasal polyposis (Fig.  6.40) and infected nasal mucosa with crusting and erosions over the turbinate (Fig. 6.41) and septum. Knowledge of all these findings helps in planning a meticulous primary surgery and sometimes gives us an idea of the associated granulomatous systemic disease like tuberculosis [41]. Preoperative endoscopy is a must in all the failed cases posted for revision surgery. Endoscopy helps us to decide our plan of management based on the presence or absence of previous ostium (Fig. 6.42), synechiae, granulations, a damaged middle turbinate with adhesion with the lateral wall of the nose. Many failed cases were found to have gross septal deviation and

Fig. 6.36  Staining of the cotton tip shows free flow of dye into the nose indicating a patent NLD

ton tip of the applicator turns green indicating the presence of dye in the nose, while in cases of NLD obstruction no dye appears in the nose Examination of child under general anaesthseia is needed for probing and irrigation or endoscopic DCR depending on the complexity of the obstruction.

Fig. 6.37  Endoscopic view of the left nasal cavity demonstrating a deviated nasal septum

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Fig. 6.38  Right concha bullosa Fig. 6.40  Endoscopic view of the left nasal cavity showing nasal polyposis

Fig. 6.39  Oedematous mucosa in the right osteomeatal complex

moderate to Extensive nasal polyposis that was missed during primary surgery probably because nasal endoscopy was not done. Radiological investigations in the form of CT DCG may help to pick up these defects well before surgery.

6.1.5.1 Schirmer Test This is an important test to diagnose dry eye that can lead to reflex tear formation. There are two types of Schirmer test. This test was first described by Schirmer in 1903, Schirmer 1 and

Fig. 6.41  Severely infected nasal mucosa with right nasolacrimal duct obstruction

Schirmer 2 [42] Schirmer 1 test is done without anaesthesia and it measures both basal and reflex secretion and Schirmer 2 with anaesthesia measures only the reflex tear secretion. Schirmer 1 test is done by using Whatman filter paper strip measuring 35  ×  5  mm [42]. The strip is bent and hooked into the lower conjunctival sac at the temporal side in both eyes and is kept for 5 min (Fig. 6.43). Wetting of the strip is measured and a value of more than 10 mm is

6.3  Optical Coherence Tomography (OCT)

85

conditions like lacrimal sac diverticulum are often discovered on the operating table and can be managed but in cases, with associated ethmoiditis and polyps there are high chances of failure. CT DCG helps in the detection of the associated pathology and helps in better planning leading to improved outcome.

6.3

Fig. 6.42  Cicatrized osteum from the previous surgery

Optical Coherence Tomography (OCT)

It is a very suitable modality for the assessment of the proximal canaliculus system [44].OCT is an emerging technology for performing high-­ resolution cross-sectional imaging [44]. The absence of both puncta is often thought to be associated with the absence of canaliculi as well [26]. However, detection of an epithelial lined canalicular lumen may be seen on anterior segment OCT (ASOCT) and this finding is very helpful as such patients respond well to punctoplasty [45]. If not detected these patients are often labelled as the cases of refractory epiphora. OCT thus plays an important diagnostic role in upper lacrimal pathway disorder.

Fig. 6.43  Schirmer test

taken as normal. The same test can be performed after instilling anaesthetic drops into the conjunctival sac. Test with anaesthesia is more reliable but if a clinician prefers Schirmer 1 without anaesthesia, patients with eye closed give more reliable results [42, 43]. Schirmer 2 test measures only the reflex secretion and is performed by instilling anaesthetic drops into the eye and stimulating the nasal mucosa by a cotton tip applicator to facilitate reflex tearing [42].

6.2

Radiological Investigations

CT or CT dacryocystography provides useful information in cases of medial canthal swelling. As described above there are multiple causes of epiphora with medial canthal swelling. Some

Key Points • Preoperative assessment of cases undergoing endoscopic DCR plays an important role in achieving excellent results. • Obstructive pathology is the most common cause of epiphora. • Probing and Irrigation forms the main stay of diagnosis and remains the single most ­important investigation to check the status of the lacrimal drainage system. • Correct technique of probing needs to be learnt with complete knowledge of false stops that can often mislead the surgeon. • Nasal endoscopy must be done preoperatively in all the cases. • There is a definitive role of CT and CT DCG in medial canthal swelling and post-traumatic cases. Through assessment facilitates the correction of associated nasal pathology.

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6  Preoperative Evaluation in Endoscopic Dacryocystorhinostomy

References 1. Ulusoy MO, Kıvanç SA, Atakan M, Akova-Budak B.  How important is the etiology in the treatment of epiphora? J Ophthalmol. 2016; https://doi. org/10.1155/2016/1438376. 2. Kuriakose RK, Leffler CT.  The new definition of epiphora should be rejected. Hist Ophthal Intern. 2017;2:109–13. 3. Epiphora, N.  OED online. Oxford University Press, June 2016. Web. 22 August 2016. 4. Maheshwari R. Management of congenital nasolacrimal duct obstruction. J Bombay Ophthalmol Assoc. 2005;14(1):44–7. 5. Hirschberg J.  The history of ophthalmology: renaissance of ophthalmology in the eighteenth century, vol. 3. Bonn: JP Wayenborgh; 1984. 6. Murube J. Concepts of the origin and physiology of tears: from prehistoric times through the XVIII century. Ocul Surf. 2011;9(4):191–6. 7. Dutton JJ, White JJ.  Imaging and clinical evaluation of the lacrimal drainage system. In: Cohen AJ, Mercandetti M, Brazzo BG, editors. The lacrimal system. New York, NY: Springer; 2006. 8. Tovilla Canales JL, Morales OO, Velasco y Levy A.  Stem the tide of excessive tearing expert tips for diagnosing and managing patients who present with epiphora. Review Ophthalmology. 7 April 2017. 9. Komínek P, Della Rocca CD, Rosenbaum S. Chapter 3. Diagnostics. In: Weber RK, Keerl R, Schaefer SD, Della Rocca RC, editors. Atlas of lacrimal surgery. Berlin; Heidelberg: Springer; 2007. p. 29–51. 10. Hurwitz JJ, Welham RAN. Radiography in functional lacrimal testing. Br J Ophthalmol. 1975;59:323–31. 11. Kanski JK.  Clinical ophthalmology. Oxford: Butterworth Heinemann; 1999. 12. Komínek P, Červenka S, Müllner K. The lacrimal diseases. Diagnosis and treatment. Prague: Maxdorf; 2003. 13. Olver J.  Colour atlas of lacrimal surgery. Oxford: Butterworth-Heinemann; 2002. 14. Guang-Lin Shen GL, Ng JD, Ma X-P. Etiology, diagnosis, management and outcomes of epiphora referrals to an oculoplastic practice. Int J Ophthalmol. 2016;9(12):1751–5. 15. Vagge A, Ferro Desideri L, Nucci P, Serafino M, Giannaccare G, Lembo A, Traverso CE.  Congenital nasolacrimal duct obstruction (CNLDO): a review. Diseases. 2018;6(4):96. 16. Olitsky SE.  Update on congenital nasolacrimal duct obstruction. Int Ophthalmol Clin. 2014;54:1–7. 17. Petris C, Liu D.  Probing for congenital nasolacrimal duct obstruction. Cochrane Database Syst Rev. 2017;7:CD011109. 18. Gupta N, Neeraj C, Smriti B, Das S.  A comparison of the success rates of endoscopic-assisted probing in the treatment of membranous congenital nasolacrimal duct obstruction between younger and older children and its correlation with the thickness of the membrane at the valve of Hasner. Orbit. 2017;37(4):257–61.

19. MacEwen CJ, Young JDH, Barras CW, Ram B, White PS. Value of nasal endoscopy and probing in the diagnosis and management of children with congenital epiphora. Br J Ophthalmol. 2001;85:314–8. 20. Moon SK, Kim SD, Kim JD.  A case of congenital lacrimal amniotocele. J Korean Ophthalmol Soc. 1996;37(2):356–9. 21. Ali MJ, Paulsen F.  Syndromic and nonsyndromic systemic associations of congenital lacrimal drainage anomalies: a major review. Ophthal Plast Reconstr Surg. 2017;33(6):399–407. 22. Gupta N, Ganesh S, Singla P, Kumar S. A rare association of blepharophimosis–ptosis–epicanthus inversus case with congenital nasolacrimal duct obstruction. Eur J Ophthalmol. 2019. 23. Nascimento SB, Rodrigues AB, Jurity TP, de Sá JC, Castelo Branco AN.  Lacrimal sac mucocele. Braz J Otorhinolaryngol. 2014;80:540–1. 24. Perry LJP, Jakobiec FA, Zakka FR, Rubin PAD. Giant dacryocystomucopyocele in an adult: a review of lacrimal sac enlargements with clinical and histopathologic differential diagnoses. Surv Ophthalmol. 2012;57:474–85. 25. Katarzyna EK, Harpreet A.  Chronic dacryocystitis with spontaneous resolution of sac mucocele: fact or fiction. Ophthal Plast Reconstr Surg. 2011;27:e90–2. 26. Xiao MI, Tang LS, Zhu H, Li HJ, Li HL, Wu XR. Adult nasolacrimal sac mucocele. Ophthalmologica. 2008;222:21–6. 27. Yip CC, McCulley TJ, Kersten RC, Bowen AT, Alam S, Kulwin DR.  Adult nasolacrimal duct mucocele. Arch Ophthalmol. 2003;121:1065–6. 28. Woo KI, Kim YD.  Four cases of dacryocystocele. Korean J Ophthalmol. 1997;11:65–9. 29. Lindberg JV, McCormick SA.  Primary acquired nasolacrimal duct obstruction. A clinicopathologic report and biopsy technique. Ophthalmology. 1986;93:1055–63. 30. Chirag G, Jose N, Javier SJ, Geoffrey JG, FACS. Telecanthus as a presenting sign of a Fronto-­ Ethmoidal Mucocele in an eleven year-old. J Clinic Experiment Ophthalmol. 2011;S5:003. https://doi. org/10.4172/2155-9570.S5-003. 31. Welham RA, Bates AK, Stasior GO. Congenital lacrimal fistula. Eye. 1992;6(Pt 2):211–4. 32. Maliborski A, Różycki R. Diagnostic imaging of the nasolacrimal drainage system. Part I.  Radiological anatomy of lacrimal pathways. Physiology of tear secretion and tear outflow. Med Sci Monit. 2014;20:628–38. 33. Hurtwiz JJ.  The lacrimal system. Philadelphia: Lippincott-Raven Publishers; 1996. 34. Weber RK.  Atlas of lacrimal surgery. New  York: Sringer; 2007. 35. Gupta N, Singla P, Pradhan B, Gurung U. Lacrimal sac rhinosporidiosis: case report and review of literature with a new grading system to optimize treatment. Saudi Journal of Ophthalmology. 2019;33:283–90.

References 36. Thomas R, Thomas S, Braganza A, et al. Evaluation of the role of irrigation prior to cataract surgery. Indian J Ophthalmol. 1997;45(4):211–4. 37. You Y, Cao J, Zhang X, Wu W, Xiao T, Tu Y. In vivo and cadaver studies of the canalicular/lacrimal sac mucosal folds. J Ophthalmol. 2016;2016(2):1–6. 38. Aubaret E. The valves of the lacrymo-nasal passages. Arch Ophthalmol. 1908;28:211–36. 39. Ali MJ. Endoscopic evidence of canalicular-­lacrimal sac mucosal folds mimicking common canalicular obstructions. Otolaryngol Head Neck Surg. 2020;162(2):261– 2. https://doi.org/10.1177/0194599819896353. 40. Kashkouli MB, Mirzajani H, Jamshidian-Tehrani M, Shahrzad S, Sanjari MS.  Fluorescein dye disappearance test: a reliable test in assessment of success after dacryocystorhinostomy procedure. Ophthalmic Plast Reconstr Surg. 2015;31(4):296–9.

87 41. Gupta N, Janaki VR, Ali MJ. Primary nasal tuberculosis with lacrimal drainage involvement. Int J Pediatr Otorhinolaryngol Extra. 2017;17:1–3. https://doi. org/10.1016/j.pedex.2017.03.001. 42. Zeev B, Miller DD, Latkany R. Diagnosis of dry eye disease and emerging technologies. Clin Ophthalmol. 2014;8:581–90. 43. Serin D, Karsloglu S, Kyan A, Alagoz G.  A simple approach to the repeatability of the Schirmer test without anesthesia: eyes open or closed. Cornea. 2007;26(8):903–6. 44. Wawrzynski JR, Smith J, Sharma A, Saleh GM.  Optical coherence tomography imaging of the proximal lacrimal system. Orbit. 2014;33:428–32. 45. Timlin HM, Keane PA, Rose GE, Ezra DG.  Characterizing the occluded lacrimal Punctum using anterior segment optical coherence tomography. Ophthalmic Plast Reconstr Surg. 2018;34(1):26–30.

7

Surgical Technique of Endoscopic Dacryocystorhinstomy

Endoscopic Dacryocystorhinostomy (DCR) is now a well-established procedure for the treatment of nasolacrimal duct obstruction with a success rate as high as 95.7% [1]. It involves creating a passage of the lacrimal sac into the nose by bypassing the obstruction in the nasolacrimal duct (NLD). It as is a safe, fast and effective method to relieve stenosis distal to the common canaliculus [2]. The endonasal technique for endoscopic DCR was described by West more than a century ago but could not gain popularity because of the compromised visualization and poor exposure of the lacrimal sac in narrow dimensions of the nasal cavity [3, 4]. Bleeding and lack of good instruments further complicated the procedure. Advent of high definition camera and monitor unit provided excellent visualization within the nasal cavity and it was felt that the endoscopic instrumentation is a safe technique that facilitates the lacrimal sac marsupialization without the need for an external incision. A better understanding of the anatomy facilitated complete sac exposure with excellent results. A variety of approaches have described for performing endoscopic DCR [5] like endonasal laser DCR [5–7], endocanalicular laser DCR [8– 10], powered mechanical endonasal DCR, or DCR with or without drills [11–13]. Bone removal in endoscopic DCR can be achieved by laser [14, 15], punches [16] radiofrequency electrodes [17] and powered drills [11]. The origin of the term powered comes from powered instruments that were devised for sinus surgery in late

1980 [9]. Powered instruments are widely used in otorhinolaryngology for sinus surgeries, skull base surgeries and otology surgeries. These include high-speed drills, pneumatic drills and sinus debrider. The advantage of using powered instruments is that they facilitate a better precision, good surgical access and better outcomes for a variety of ENT surgeries. The drilling burrs attached to microdebrider handle are used for a number of endoscopic sinus surgeries and when used for endoscopic DCR, were named as powered endoscopic DCR or mechanical powered endoscopic DCR [1, 5]. Thus, the highly efficient safe drilling is desirable during endoscopic DCR to remove the residual bone (in cases where it can not be removed by a punch) covering the fundus of the lacrimal sac and depending on the surgeon’s expertise as well as the availability of the instruments different drills can be used. The options are a 15° coarse diamond endoscopic DCR burr attached to a microdebrider handpiece (Medtronic Xomed, Jacksonville, FL), a Karl Storz microdebrider with a drill using a coarse diamond burr (UNIDRIVE® S III ENT Karl-­ Storz, Tutlingen, Germany), an otology drill (with shaft covered), a stylus drill. Stylus High-­ Speed Drill (Medtronic Inc USA) is a small, lightweight drill that offers adjustable speeds from 200 to 75,000 rpm. It works with the curved burs for access in narrow anatomic regions and helps in faster removal of superior bone. This is especially helpful in posttraumatic NLD obstruction where extensive drilling is required.

© Springer Nature Singapore Pte Ltd. 2021 N. Gupta, Endoscopic Dacryocystorhinostomy, https://doi.org/10.1007/978-981-15-8112-0_7

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7.1

I ndications of Endoscopic DCR

Indications of Endoscopic DCR: Acquired nasolacrimal duct obstruction is the most common indication of DCR. DCR is also indicated in refractory cases of complex congenital nasolacrimal duct obstruction not amenable to endoscopic intervention [18]. Acquired lacrimal drainage obstruction may be primary acquired nasolacrimal duct obstruction (PANDO) or secondary acquired nasolacrimal duct obstruction (SALDO) [19] PANDO is defined as an inflammation of unknown cause that eventually leads to occlusive fibrosis [19, 20]. SALDO occurs secondary to various causes like infection, inflammation, neoplastic, traumatic or mechanical causes [19].

7.2

Surgical Technique

7.2.1 Optimization of Surgical Field Nasal mucosa is very vascular and troublesome intraoperative bleeding may occur leading to the compromised quality of surgery with an increased risk of complications. Optimization of the surgical field is therefore very important in any endoscopic nasal surgery. Adequate time should be spent in preparation of the nose before surgery starts. Using the reverse Trendelenburg position (RTP) [21], total intravenous anaesthesia (TIVA) [22] and local infiltration of saline adrenaline solution are the three most important steps in achieving the improved surgical field. RTP is a safe and effective method to reduce intraoperative blood loss [21]. TIVA provides a better field with less bleeding due to the effect on mean blood pressure and heart rate [22]. Surgery of the lacrimal sac starts with the identification of the landmarks. The key landmark is the maxillary line which is a ridge formed by the frontal process of the maxilla and the root of the middle turbinate on the lateral nasal wall (Fig. 7.1).

This landmark for lacrimal sac surgery is found to be obstructed in some cases due to the high posterior deviation of the septum, hypertrophied uncinate process or intervening ethmoids. This septal deviation poses difficulty in the visualization of the proposed neo osteum site and smooth passage of the scope beyond the deviation. Endoscopic limited septoplasty can be performed in such cases to gain access to the lacrimal sac area.

7.2.2 Preparation of Nose The surgery is performed using Karl Storz IMAGE1 S™ camera unit with 4 mm, 0° endoscope. The nose is packed with pledgets soaked in 1:1000 adrenaline solution. Local infiltration is done using a 26 gauge, 1.5-in-long needle on a 2  cc syringe. Saline adrenaline solution is infiltrated on the lateral wall in a concentration of 1:80,000. The area on the lateral wall above the anterior attachment of the middle turbinate and at the upper insertion of the inferior turbinate is infiltrated till complete blanching of the mucosa is obtained (Figs. 7.2, 7.3 and 7.4). Incision • Since around 8mm of the sac extends above the axilla of MT [5, 23], the Incision using Bard-Parker knife with 15# blade is given

Fig. 7.1 Endoscopic view of the left nasal cavity demonstrating maxillary line as the landmark for lacrimal sac with a view of the axilla of middle turbinate and uncinate process

7.2  Surgical Technique

Fig. 7.2 Local infiltration with xylocaine adrenaline solution is done anterosuperior to the axilla of the middle turbinate on the lateral wall

Fig. 7.3  The area on the lateral wall just above the superior attachment of the inferior turbinate is also infiltrated

around 8–10 mm superior to the axilla of the middle turbinate and runs approximately 1 cm horizontally on the lateral wall (Fig. 7.5). • The incision is taken vertically down till the upper insertion of the inferior turbinate and is then extended horizontally up to the uncinate process to complete a posteriorly based ‘U’ shaped incision (Figs. 7.6, 7.7, 7.8 and 7.9).

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Fig. 7.4  Blanching of the nasal mucosa over the lateral wall is seen following complete infiltration

Fig. 7.5  ‘U’ shaped incision line marked on the lateral wall with two horizontal limbs and a vertical limb needed to create a posteriorly based flap

Raising Mucosal Flaps • A suction Freer elevator is used to lift the mucoperiosteal flap (Fig.  7.10). The suction elevator keeps the field clear and allows the surgeon to expose the underlying bone. • A full-thickness incision should be ensured before lifting the flap by scoring the incision with the dissector and then firm pressure is

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Fig. 7.6  A 15 no blade is used to give incision on the lateral wall with horizontal incision starting 8–10  mm above the axilla

Fig. 7.7  Superior horizontal limb of the incision runs up to 8mm on the anterior wall

Fig. 7.8  The blade is then tilted vertically down to create vertical limb of the incision that extends till the superior border of inferior turbinate

Fig. 7.9  Incision then turns horizontally to complete a posterior based ‘U’ shaped flap

Fig. 7.10  Mucoperiosteal flap is lifted using a blunt dissector

applied over the bone while the flap is lifted. This provides a clear surgical plane and facilitates bone exposure. • Lacrimomaxillary junction starts getting visible after the flap is lifted (Fig. 7.11). Lower part of the lacrimal fossa is formed by the lacrimal bone and the frontal process of the maxilla is thin here thus it is easy to start bone removal inferiorly. This area also marks the beginning of an uncinate process that lies immediately posterior to the lacrimal bone. The gap between the lacrimal bone and the uncinate process is palpated with a blunt ­dissector. This provides a cleavage to insert our Kerrison’s punch.

7.2  Surgical Technique

Fig. 7.11  Lacrimal bone can be visualized (arrow) with lacrimo-frontal suture, black dotted line

Fig. 7.12  Kerrison punch is engaged at the lower end of the lacrimal sac fossa

Exposure of the Lacrimal Sac• In cases where the thin lacrimal bone is prominently visible, it can be simply peeled off the NLD otherwise a Kerrison punch can be used right from the beginning. • Kerrison punch is engaged at the lower end of the fossa and bone removal starts from here (Fig.  7.12). Nasolacrimal duct starts getting visible after the first punch (Fig. 7.13). It can be confirmed by pressing over the medial ­canthal area to note the transmitted movement over the NLD. • Careful bone removal is continued up with the help of Kerrison punch (Figs  7.14 and 7.15)

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Fig. 7.13  Nasolacrimal duct starts getting visible after the first punch

Fig. 7.14  Bone removal continues up to expose the lacrimal sac

without causing any injury to the sac wall. Any tear in the sac wall can compromise the sac flaps and may have a bearing on the outcome. • As the bone removal proceeds superiorly the bone becomes hard and the removal with Kerrison’s punch becomes difficult (Fig.  7.16). In some cases where the upper part of the frontal process of the maxilla is thin and the bony ledge is favourable, it may be possible to remove the entire bone by Kerrison punch alone (as described below) but it is not feasible in all the cases. Thus,

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Fig. 7.15  The exposed lacrimal sac can be seen with thin lacrimal bone posteriorly (arrow)

Fig. 7.16  Kerrison punch is further engaged to remove as much as bone is possible to minimize drilling

most of the patients need drilling in the superior part of the frontal process that houses the fundus of the sac. • Drilling can be done by the available drills or the powered endoscopic sinus surgery instruments like 15° endoscopic DCR burr attached to a microdebrider handpiece (Medtronic Xomed, Jacksonville, FL, USA) or a Karl Storz microdebrider with (UNIDRIVE® S III ENT Karl-Storz, Tutlingen, Germany) a coarse diamond burr. Complete bone over the frontal process of maxilla is drilled to expose the fundus of the sac (Fig. 7.17). • The superior limit of bone removal needs to be checked to ensure that the fundus of the sac is

Fig. 7.17  Drilling is carried superiorly to expose the fundus of the sac

Fig. 7.18  Complete lacrimal sac exposure with  agger nasi in view

exposed completely. Agger nasi is an important landmark to ensure this. Agger nasi lies in intimate relation with the thick bone covering this superior part of the sac [5] and therefore opening up the agger nasi ensures complete bone removal (Fig. 7.18). However, this is not the only parameter as the adequacy of the bone removal needs to be further confirmed by probing and common canalicular opening (CCO) visualization. • Some people advocate regular uncinectomy as the first step to endonasal DCR [24]. This is not necessary as the lacrimal sac lies much anterior to the uncinate process and the frontal

7.2  Surgical Technique

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process of the maxilla is a consistent landmark for finding the lacrimal sac. Lacrimal Sac Marsupialization • Bowman’s probe (Visitec, Warwickshire, UK) is passed through the punctum and tenting of the sac is noted (Fig.  7.19). An incision is given at the tip of the probe using a crescent knife. Crescent knife has three side cutting edges, a tip and two sides (Fig. 7.20). The tip is gently inserted into the lumen without going too deep into the sac as it may damage the CCO (Fig. 7.21). A complete vertical incision Fig. 7.21  Crescent knife is gently introduced into the into the sac lumen through its medial wall

Fig. 7.19  Tenting of the lacrimal sac can be seen following probing (arrow) Fig. 7.22  A vertical incision is given on the medial sac wall

Fig. 7.20  A crescent knife with three cutting sides is used for lacrimal sac incision

is given over the medial wall of the lacrimal sac in a way that it creates a large anterior flap and a small posterior flap (Fig. 7.22). Superior and inferior horizontal cuts are given over both anterior and posterior lacrimal sac flaps to open it like a book and to be able to reflect the flaps on the lateral nasal wall as described earlier [5] (Figs. 7.23 and 7.24). The probe can be visualized coming out of the common canalicular opening (Fig. 7.25). • In cases with canalicular obstruction, the probe may not be seen in the lumen of the sac. This may be a true canalicular obstruction that

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Fig. 7.23  Superior release incision is given horizontally over the sac flap

Fig. 7.24  Inferior release incision is given horizontally over the lower end of the lacrimal sac flaps to open the sac like a book

needs to be diagnosed and managed or it could be a false canalicular obstruction due to canalicular/lacrimal sac mucosal folds and can be overcome with the right technique of probing as described earlier. Fashioning the Flaps • Having created two flaps, the large anterior lacrimal sac flap is reflected on the lateral wall and to cover the bare bone and the posterior flap goes posteriorly towards the uncinate process (Fig. 7.26). • Once the lacrimal sac is marsupialized the nasal mucosal flap is examined. The nasal

Fig. 7.25  The anterior lacrimal sac flap is reflected over the lateral wall and a probe can be seen coming out of the sac lumen

Fig. 7.26  Anterior lacrimal sac flap is reposited anteriorly and the posterior lacrimal sac flap is reposited along the floor. (AN: Agger nasi)

mucosal flap is divided into two parts using Westcott scissors, an upper smaller flap and the lower larger flap (Fig. 7.27). The upper flap is reflected superiorly over the raw edge of the superior osteotomy (Figs.  7.28 and 7.29) and the inferior flap is pulled inferiorly, and  is trimmed to prevent cul-de-sac formation over NLD. It is then rotated laterally to cover the exposed bone on the lateral wall. Some amount of intervening area of the bone on the lateral wall may remain bare after repositing the superior and inferior

7.2  Surgical Technique

Fig. 7.27  Nasal mucosal flap is examined and is divided into two part with an endoscopic scissor

Fig. 7.28  The superior smaller portion is lifted up on a dissector and reposited up

flap. This is taken care of by reflecting the large anterior lacrimal sac flap on the lateral wall and thus a 360° mucosal coverage is achieved (Fig.  7.30a, b). If the flaps are nicely apposed, it prevents granulation formation and provides excellent long-term results. Mitomycin C and Bicanalicular Silicone Stenting • Any Blood clots from the field are cleared followed by topical application of 0.2mg/ml mitomycin C for 3 min as per published protocols [25] (Figs. 7.31 and 7.32).

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Fig. 7.29  A well reposited superior flap is seen over the superior edge of the bony ostium. The inferior large part of the nasal mucosal flap is pulled down, trimmed and reposited on the lateral wall inferiorly

• Intubation is done using silicone Stents, mounted on a metallic probe that is passed through the upper and the lower puncta (Figs.  7.33 and 7.34). The metallic guard is retrieved into the nose and is pulled out by holding it at its tip to avoid injury to the nasal mucosa (Fig. 7.35). • The metallic probe attached to the silicone tube is cut and removed. The two ends of the tube are tied together in the nose (Figs. 7.36 and 7.37). The knot is reposited along the floor of the nose behind the posterior end of the middle turbinate. The tube should not be too tight or else it may cause cheese wiring of the punctum and canaliculi and at the same time it should not be too loose to carry the risk of prolapse through the eye (Fig. 7.38). Although the role of intubation in endoscopic DCR is debatable [10, 26], we perform intubation in all our cases. The pros and cons of intubation have been described in more detail in chap. 8.

7.2.3 Final Inspection The flaps get displaced during stent placement and should therefore be inspected after intubation to ensure proper placement. Any displacement noted is corrected and the flaps are adjusted and secured with gel foam and the nose is packed gently.

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98

a

b

Fig. 7.30 (a) A 360° mucosal lined ostium is seen with no exposed bone. (b) Schematic diagram of a well mucosal lined ostium 1; Superior part of the nasal mucosal flap,

2; Inferior large part of the nasal mucosal flap, 3; Anterior lacrimal sac flap, 4; Posterior lacrimal sac flap. (Photo courtesy: Dr Amrit Pal Singh)

Fig. 7.31  Blood and secretions are cleared from the lumen of the sac

Fig. 7.32  Mitomycin C soaked merocel is placed over the surgical area for 2 minutes

7.3

threatening granulations or the synechiae that can be managed timely. 5. The dynamic movement of the stent is noted by asking the patient to blink with simultaneous visualization of the stent movement on nasal endoscopy. It indicates a patent and functional nasal ostium. 6. The stent is removed after 4weeks in primary endoscopic DCR with post-saccal ­obstruction. In cases where canalicular trephination has been performed as an adjuvant procedure, the

Postoperative Instructions: Post-Operative Instructions

1. Patients are discharged the same day and the packing removal is done after 48 hours. 2. Oral antibiotics are given for a week and topical antibiotic and steroid eye drops are given for 2 weeks. 3. Saline nasal wash is started after 1 week 4. Regular check endoscopy is done at 1 week, 2 weeks, 4 weeks and 8 weeks to look for any

7.3  Postoperative Instructions: Post-Operative Instructions

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Fig. 7.34 The metallic guard of the tube is passed through the upper and lower puncta

Fig. 7.33  Bicanalicular silicone stent with metallic guard at both the ends is used for intubation

stent duration is prolonged to 6weeks based on the symptoms and the intranasal condition of the ostium.

7.4

Additional Points

7.4.1 E  ffective Use of Kerrison Punch Kerrison bone punch is an excellent instrument for fast bone removal and in some cases leads to effective and complete bone removal. In situation where powered drills are not available, or the surgeon is not comfortable with the drilling, Kerrison’s punch can be used differently to

Fig. 7.35  Two ends are pulled into the nose. Metallic probe is removed and tube is tied into the nose

expose the complete sac. In this technique, initial bone removal starts from the lower part of the lacrimal sac fossa (Figs. 7.39 and 7.40). In thin built elderly patients complete bone removal can be accomplished with Kerrison punch. This is done by taking initial few small punches and then by sliding the complete lower jaw of Kerrison punch under the bone in the mid part of the bony fossa, grasping a larger chunk of bone and

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Fig. 7.36  The flaps are secured using gel foam

Fig. 7.39  An alternate technique of bone removal using Kerrison punch alone. The punch is engaged in the inferior part of the lacrimal fossa

Fig. 7.40  Initial bone removal is done at the inferior border and NLD starts getting visible (arrow). Fig. 7.37  During post-operative follow up the stent is seen with well healed ostium

t­wisting it medially. This creates a vertical fracture line along the superior part of the frontal process of the maxilla (Figs. 7.41 and 7.42). A large piece of bone is dislodged and removed in one piece (Fig.  7.43). A complete sac exposure is achieved up to the fundus (Fig. 7.44). However, this technique may not work in all the cases and in those cases, drilling is needed.

7.4.2 Uncinectomy and Endoscopic DCR Fig. 7.38  Endoscopic view of the medial canthus showing the loop of the silicone stent in view

Some studies have recommended regular uncinectomy (ref above) in endoscopic DCR [24] but

7.3  Postoperative Instructions: Post-Operative Instructions

101

Fig. 7.43  A large piece of bone is dislodged and removed Fig. 7.41  Kerrison punch is engaged again with its jaw wide open and the lower jaw is slid under the bone as far posteriorly as possible, without grasping the sac or NLD mucosa. The punch is then closed and firmly twisted medially. This creates a fracture line along the frontal process covering the sac (arrow)

Fig. 7.44  Complete sac exposure is achieved with agger nasi in view

Fig. 7.42  A large chunk of bone is mobilized

this is not necessary. The frontal process of the maxilla is always a constant landmark and its junction with the lacrimal bone is the first landmark that comes in view after the mucoperiosteal flap is reflected [5]. Posteriorly the lacrimal sac lies adjacent to the uncinate process [27, 28] (Fig. 7.45). The uncinate process does not need to be disturbed. Sometimes, there might be confusion on the status of the uncinate process, a question  often asked in teaching workshops. This is

because a posteriorly based flap is reflected over the middle turbinate obscuring the uncinate process, it becomes a little difficult to correlate the sac position with the uncinate process. Figure 7.46 demonstrates relationship of the lacrimal sac with the uncinate process after reflecting the mucoperiosteal flap inferiorly. Uncinate process is posterior, the lacrimal sac is anterior and in between there is thin lacrimal bone (Fig. 7.46). Thin lacrimal bone can be removed easily without disturbing the uncinate process. This step, however, needs to be performed carefully as only half of the lacrimal bone (part anterior to the posterior lacrimal crest) is involved in the formation of the bony lacrimal fossa, the rest half contributes in the formation of the medial orbital wall along with lamina papyracea (as described in the chaps. 2 and 3).

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Fig. 7.45  Endoscopic view of the left nasal cavity demonstrating the relationship of the lacrimal bone with the uncinate process. uncinate process can be seen lying posterior to the lacrimal bone

Fig. 7.46  Lacrimal sac can be seen lying anterior to the uncinate process and in between lies the thin lacrimal bone. (UP: Uncinate process, LB: Lacrimal bone, FP: Frontal process of maxilla, MT: Middle turbinate)

There for, further dissection posterior to this landmark leads to an increased risk of orbital fat prolapse or haematoma [11] especially if the instruments are directed laterally [27, 28].

7.5

Difficulties During Endoscopic DCR

1. Associated nasal conditions like a deviated nasal septum blocking access to middle turbinate and lateral wall, concha bullosa, anatom-

Fig. 7.47  A small contracted sac visualized with light pipe

ical variations of uncinate process, ethmoid bullae and nasal polyposis may pose a challenge as the anatomy is altered. 2. Maxillary bone dominant fossa is a difficult situation that requires more expertise. 3. Intraoperative bleeding may obscure the vision, hamper completion of surgery and may lead to complications. This could be due to multiple factors like inadequate preparation of the surgical field, lack of proper positioning, high blood pressure, high pulse rate or mucosal injury. 4. The small contracted sac may pose difficulty in marsupialization. The light pipe can be used in such cases to locate the sac intranasally (Fig. 7.47).

7.6

Advantages of Endoscopic DCR

1. The primary advantage of an endoscopic approach to the lacrimal sac is the ability to identify the abnormal intranasal anatomy and to correct it in the same sitting. 2. There is no external skin incision, thus no scar as seen in external DCR (Fig. 7.48). The tissue dissection is less with decreased post-­ operative morbidity [15–17, 23, 24]. 3. Bilateral endoscopic DCR can be done in the same sitting (Fig. 7.49).

7.9  Causes of Failure in Endoscopic DCR

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7.7

Disadvantages

Endoscopic DCR is a very safe procedure and has no disadvantages. Its limitations are a steep learning curve and need for expensive equipment.

7.8

Fig. 7.48  Scar from an external DCR surgery right side

Fig. 7.49  A post-operative case of bilateral endoscopic DCR done in the same sitting along with bicanalicular intubation both sides (arrow)

Fig. 7.50  A case of acute dacryocystitis with abscess formation, where external DCR cannot be performed, endoscopic DCR can safely be done by endoscopic approach during this acute phase

4. Revision surgery is easy as we get an excellent endoscopic view of the failed ostium and an effective revision is possible. 5. Endoscopic DCR can be safely performed in acute dacryocystitis [29] where external DCR is contraindicated in the acute phase as the skin is fragile (Fig. 7.50).

Results

The success of endoscopic DCR is indicated by a completely asymptomatic patient with an endoscopically confirmed patent nasolacrimal system [5]. Although there has been scepticism in the past regarding the results of endoscopic DCR in comparison to external DCR [30–33] in the current literature the success of endoscopic DCR has been proven beyond doubt [1, 34]. The success rate reported in different studies varied from 91 to 95.7% [1, 5]. A meta-analysis compared both endoscopic and external DCR and found that the success rates of both routes were comparable [35]

7.9

Causes of Failure in Endoscopic DCR

• Inadequate removal of the thick bone above the insertion of the middle turbinate has been cited as one of the main reasons for the failure of the external DCR technique [5]. • Inadequate bone removal in the lower part of the sac can lead to Sump syndrome [32]. • Uncorrected nasal pathology like a deviated septum and concha bullosa can lead to synechiae formation and failure in post-operative period. • Scarring at the ostium site following the inability of the flaps to cover bare bone Ways to handle these difficulties have been described in the chapter on improving results in endoscopic DCR. Key Points  Endoscopic Dacryocystorhinostomy is a well-established procedure for the treatment of nasolacrimal duct obstruction with a high success rate at par with the external DCR. • Owing to the availability of high definition camera with endoscopes and increased train-

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ing opportunities, endoscopic DCR is fast becoming widely accepted across both the specialties. • There is no external skin incision, thus no scar as seen in external DCR and the morbidity is less and bilateral endoscopic DCR can be done in the same sitting. • It is superior over external dacryocystorhinostomy in acute dacryocystitis as endoscopic marsupialization of the sac can be done along with intranasal drainage of an abscess in the same sitting. • Highly efficient safe drilling is desirable during endoscopic DCR to remove the bone covering the fundus of the lacrimal sac. Depending on the surgeon’s expertise as well as the availability of the instruments curved diamond burr on a microdebrider or different drills can be used.

References 1. Wormald PJ. Powered endoscopic dacryocystorhinostomy. Laryngoscope. 2002;112(1):69–72. 2. Shun Shin GA. Endoscopic dacryocystorhinostomy: a personal technique. Eye. 1998;12:467–70. 3. Yoon SW, Yoon YS, Lee SH, MD.  Clinical results of endoscopic DCR using a microdebrider. Korean J Ophthalmol. 2006;20(1):1–6. 4. Caldwell GW. Two new operations of obstruction of the nasal duct with preservation of the canaliculi. Am J Ophthalmol. 1893;10:189. 5. Tsirbas A, Wormald PJ.  Mechanical endonasal DCR. Br J Ophthalmol. 2003 Jan;87(1):43–7. 6. Gonnering RS, Lyon DB, Fisher JC.  Endoscopic laser-assisted lacrimal surgery. Am J Ophthalmol. 1991;111:152–7. 7. Hehar SS, Jones NS, Sadiq SA, et al. Endoscopic holmium: YAG laser dacryocystorhinostomy—safe and effective as a day-case procedure. J Laryngol Otol. 1997;111:1056–9. 8. Pearlman SJ, Michalos P, Reib ML, et al. Translacrimal transnasal laser-assisted dacryocystorhinostomy. Laryngoscope. 1997;107:1362–5. 9. Rosen N, Barak A, Rosner M. Transcanalicular laser-­ assisted dacryocystorhinostomy. Ophthal Surg Lasers. 1997;28:723–6. 10. Caversaccio M, Frenz M, Schar P, et  al. Endonasal and transcanalicular Er;YAG laser dacryocystorhinostomy. Rhinology. 2001;39:28–32. 11. Lun Sham C, van Hasselt AC. Endoscopic terminal dacryocystorhinostomy. Laryngoscope. 2000;110:1045–9. 12. Sprekelsen MB, Barberan MT.  Endoscopic dacryocystorhinostomy: surgical technique and results. Laryngoscope. 1996;106:187–9.

13. Cokkeser Y, Evereklioglu C, Hamdi E.  Comparative external versus endoscopic dacryocystorhinostomy: results in 115 patients (130 eyes). Otolaryngol Head Neck Surg. 2000;123:488–91. 14. Bakri SJ, Carney AS, Downes RN, et  al. Endonasal laser-assisted dacryocystorhinostomy. Hosp Med. 1998;59:210–5. 15. Muellner K, Bodner E, Mannor GE, et  al. Endolacrimal laser assisted surgery. Br J Ophthalmol. 2000;84:16–8. 16. McDonogh M.  Endoscopic transnasal dacryocystorhinostomy. S Afr J Surg. 1992;30:107–10. 17. Javate RM, Campornanes BS, Nelson D, et  al. The endoscope and the radiofrequency unit in DCR surgery. Ophthal Plastic Reconstr Surg. 1995;11:54–8. 18. Gupta N, Singla P, Kumar S, Ganesh S, Dhawan N, Sobti P, Aggarwal S.  Role of dacryoendoscopy in refractory cases of congenital nasolacrimal duct obstruction. Orbit. 2019; https://doi.org/10.1080/016 76830.2019.1668434. 19. Bartley GB.  Acquired lacrimal drainage obstruc tion: an etiologic classification system, case reports, and a review of the literature: Part 1. Ophthal Plastic Reconstr Surg. 1992;8(4):237–42. 20. Linberg JV, McCormick SA.  Ophthalmology. 1986;93(8:1055–63. 21. Gan EC, Habib AR, Rajwani A, Javer AR. Five-degree, 10-degree, and 20-degree reverse Trendelenburg position during functional endoscopic sinus surgery: a double-blind randomized controlled trial. Int Forum Allergy Rhinol. 2014 Jan;4(1):61-68. https://doi. org/10.1002/alr.21249. Epub 2013 Nov 26 22. Ahn HJ, Chung SK, Dhong HJ, Kim HY, Ahn JH, Lee SM, Hahm TS, Kim JS. Comparison of surgical conditions during propofol or sevoflurane anaesthesia for endoscopic sinus surgery. BJA. 2008;100(1):50–4. 23. Wormald PJ, Kew J, Van Hasselt A.  Intranasal anatomy of the nasolacrimal sac in endoscopic dacryocystorhinostomy. Otolaryngol Head Neck Surg. 2000;123(3):307–10. 24. Fayet B, Racy E, Assouline M.  Systematic unciformectomy for a standardised endonasal dacryocystorhinostomy. Ophthalmology. 2002;109:530–6. 25. Feng YF.  Debates in dacryology: the Mitomycin C dilemma. In: M Javed Ali, editor. Principles and practice of lacrimal surgery. p. 341–6. 26. Chong KKL.  Primary endoscopic dacryocystorhinosomy. In Mohammad Javed Ali (Ed.) Principles and practice of lacrimal surgery. New Delhi: Springer; 2015. p. 195–201. 27. Unlu HH, Govsa F, Mutlu C, et al. Anatomical guidelines for intranasal surgery of the lacrimal drainage system. Rhinology. 1997;35:11–5. 28. Unlu HH, Goktan C, Aslan A, et al. Injury to the lacrimal apparatus after endoscopic sinus surgery; surgical implications from active transport dacryocystography. Otolaryngol Head Neck Surg n.d.;124:308–12. 29. Madge SN, Chan W, Malhotra R, Ghabrial R, Floreani S, Wormald PJ, Tsirbas A, Selva D. Endoscopic dacryocystorhinostomy in acute dacryocystitis: a multicenter case series. Orbit. 2011 Jan;30(1):1–6.

References 30. Hartikainen J, Jukka A, Matti V, et  al. Prospective randomised comparison of endonasal endoscopic dacryocystorhinostomy and external dacryocystorhinostomy. Laryngoscope. 1998;108:1861–6. 31. Ibrahim HA, Batterbury M, Banhegyi G, et  al. Endonasal laser dacryocystorhinostomy and external dacryocystorhinostomy outcome profile in a general ophthalmic service unit; a comparative retrospective study. Ophthalmic Surg Lasers. 2001;32:220–7. 3 2. Welham RA, Wulc AE.  Management of unsuccessful lacrimal surgery. Br J Ophthalmol. 1987;71:152–7.

105 33. Hurwitz JJ, Merkur S, DeAngelis D. Outcome of lacrimal surgery in older patients. Can J Ophthalmol. 2000;35:18–22. 34. Kong YJ, Choi HS, Jang JW, Kim SJ, Jang SY.  Surgical outcomes of canalicular trephination combined with endoscopic dacryocystorhinostomy in patients with distal or common canalicular obstruction. Korean J Ophthalmol. 2015 Dec;29(6):368–74. 35. Huang J, Malek J, Chin D, Snidvongs K, Wilcsek G, Tumuluri K, Sacks R, Harvey RJ.  Systematic review and meta-analysis on outcomes for endoscopic versus external dacryocystorhinostomy. Orbit. 2014;33(2):81–90.

8

Improving Results in Endoscopic Dacryocystorhinostomy

There are various factors that affect the outcome of endoscopic dacryocystorhinostomy (DCR) and the first and foremost being the proper case selection. One must rule out punctal stenosis, canalicular obstructions, associated nasal pathologies and conditions mimicking nasolacrimal duct (NLD) obstruction. Radiology has a definite indication in selective cases of primary acquired NLD obstruction and has been described separately in chap. 5. A detailed preoperative work up has been described in the chapter on preoperative assessment  chap. 6 and only some of the important points will be highlighted here. Probing and irrigation should be done by self (the operating surgeon) through both the upper and the lower punctum, especially in cases where the regurgitation test is negative and the irrigation result suggests canalicular obstruction. Probing needs to be done very carefully as the natural axis of the canaliculi can get distorted during probing [1, 2] and presence of canalicular/ lacrimal sac mucosal folds (CLS-MFS folds) at the opening of common canaliculus that regulates the opening and closing of the orifice may give a false sensation of soft stop [3–5] (Fig. 8.1). Any attempt of trephination in such cases can jeopardize the integrity of common canaliculus [ 5]. Therefore, the right technique of the probing should be used and the results

should be interpreted correctly as described earlier. An endoscopic view of some of the failed cases reveals an inadequate, inappropriate or absent bony window along with the synechiae, distorted anatomy of the middle turbinate and nasal polyposis (Figs. 8.2, 8.3 and 8.4). There are granulomas at the ostium site with collection of mucopurulent discharge and a stent lying in the false passage (Figs. 8.5 and 8.6). All these findings help us to develop an understanding of the causes of failure and devise strategy to minimize failures in the primary surgery. Various such factors that need to be kept in mind during primary surgery are as follows 1. Various aspects of bone removal (a) Site of bone removal (b) Importance of initial incision in bone removal (c) Adequacy of bone removal i. By identification and opening up of agger nasi ii. By assessing superior osteotomy in relation to common canalicular opening (CCO) 2. Advantage of Common canaliculus opening (CCO) visualization (d) Effective marsupialization of the portion of the sac lying above the level of CCO

© Springer Nature Singapore Pte Ltd. 2021 N. Gupta, Endoscopic Dacryocystorhinostomy, https://doi.org/10.1007/978-981-15-8112-0_8

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Fig. 8.3  Endoscopic view of the right nasal cavity in a Fig. 8.1  Endoscopic view of the right nasal cavity dem- case of failed endoscopic DCR demonstrating a probable onstrating canalicular/lacrimal sac mucosal folds (CLS-­ site of work during the previous surgery MFS folds) at the opening of common canaliculus that regulates the opening and closing of the orifice may give a false sensation of soft stop (arrow)

Fig. 8.4  Failed right external DCR with turbino-ostial synechiae and nasal polyposis

Fig. 8.2 Right nasal cavity demonstrating synechiae between the distorted middle turbinate and the lateral wall in a failed case of DCR. No ostium is visible from previous surgery. (LW; Lateral wall, MT; Middle turbinate)

(e) Identification of intrasac septation and detection of hidden diverticulum (f) Identification and management of canalicular obstructions

3. Intrasac granulomas 4. Flap creation and role of mucosal coverage of the raw area 5. Identification and correction of associated nasal pathologies 6. Mitomycin C 7. Intubation 8. The role of regular post-operative nasal endoscopy

8.1  Bone Removal

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or anterior to the anterior attachment of the middle turbinate with minimal extension above [6– 9], however, the current literature suggests that much of the sac lies above the level of the axilla of the middle turbinate [6, 10]. The bone overlying this superior portion needs to be removed to prevent failure.

8.1.2 I mportance of Initial Incision in Bone Removal

Fig. 8.5  Infected granuloma at the nasal ostium site in a failed case of Right endoscopic DCR

Correct incision is the first step towards achieving adequate bone exposure. The correct and incorrect site of incision have been depicted in (Fig.  8.7). An incision starting at the axilla of middle turbinate will fail to expose the superior bone resulting in inadequate sac exposure. Thus, the superior incision needs to be placed at approximately 8–10 mm above the axilla of the middle turbinate (Fig. 8.7). Exposure is followed by the technique of bone removal which can be done by Kerrison punch alone in some cases as described earlier while the majority of  cases  need powered instruments in the form of drill, debrider with coarse diamond burr, etc. In post-traumatic cases, with healed fracture and callus formation it becomes difficult to remove hard bone. Extensive drilling is needed

Fig. 8.6  Mucopurulent collection around the stent lying in a false passage in a failed case of left external DCR

8.1

Bone Removal

8.1.1 Site of Bone Removal The bone covering the superior part of the sac is very thick and difficult to remove [6] . It thus remains as the most common site of inadequate bone removal. Earlier studies on the intranasal anatomy of the lacrimal sac suggested that the sac lies below

Fig. 8.7  Correct site of superior incision marked by orange line, and incorrect by blue line as the an inferiorly placed incision will hamper the superior bone removal

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in these cases especially in those presenting with telecanthus and lateral displacement of the sac. Thus, a high speed stylus drill with a coarse diamomd burr may reduce the surgical time.

8.1.3 Adequacy of Bone Removal

inadequate sac exposure during the primary surgery leading to surgical failure [11]. chap. 4 on preoperative CT DCG explains how these ethmoid cells are graded into into 3 categories (Figs. 4.34, 4.35 and 4.36) by which the encroachment can be detected preoperatively and once identified, they should be addressed intraoperatively.

8.1.3.1 By Identification and Opening Up of Agger Nasi Agger nasi has an intimate relation with the superior portion of the frontal process of the maxilla that lies over the fundus of the sac. Therefore, the anterolateral wall of the agar nasi cell  needs  to be  removed for complete sac exposure (Figs.  8.8 and 8.9). Agger nasi cell was found to overlap the medial part of the lacrimal fossa in 95% of the cases [ 11] (Fig. 8.10). The presence of ethmoid cells encroaching the medial aspect of the sac was found to be more in failed cases (78%) then in successful cases (24%) [12, 13] and the difference was statistically significant. Thus, a viable agger nasi cell indicates an inappropriate lacrimal sac localization and

Fig. 8.9  variable relation of the right lacrimal sac and agger nasi with the superior border of the lacrimal sac extending above the level of agger nasi (arrow). AN; Agger nasi, LS; Lacrimal sac

Fig. 8.8  Endoscopic view of the right nasal cavity showing a well opened Agger Nasi and the marsupialized lacrimal sac. LS; Lacrimal Sac, AN; Agger Nasi, MT; Middle turbinate

Fig. 8.10  Fundus of the left lacrimal sac opening into a large pneumatized agger nasi

8.1  Bone Removal

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8.1.3.2 B  y Assessing Superior Osteotomy In Relation To Common Canalicular Opening (CCO) The osteotomy should also be assessed in relation to the position of CCO.  The situation presented here shows  a completely exposed sac showing tenting with the probe and an opened up agger nasi (Fig. 8.11). The sac is incised to release the thick mucopurulent discharge (Figs.  8.12 and 8.13) and the lumen is examined. The probe can be visualized in the nose in a horizontal plane closely abutting the bone superiorly, (Fig. 8.14A and 8.14B) the superior movement of the probe is Fig. 8.13  Mucopurulent discharge draining out of the sac indicates a satisfactory surgery

Fig. 8.11  Complete lacrimal sac exposure with agger nasi in view and the uncinate process can be seen lying posterior to the lacrimal sac. AN; Aggr nasi. MT; Middle turbinate, UP; Uncinate process, LS; Lacrimal sac, LW; Lateral wall

Fig. 8.12 Sac is incised using a crescent knife as described earlier also

restricted and the CCO could not be clearly visualized (Fig. 8.15A and 8.15B). Probe when tilted down can be seen in the nasal cavity (Fig. 8.16A and 8.16B). Since approximately 5.3 mm of the sac length lies above common canaliculus [10], the inability to see any sac portion above the level of the probe indicates incomplete bone removal around and above the CCO (Fig. 8.16B). If the bone is left near the common canaliculus closure of the newly created ostium may occur [14]. This bone acts as a scaffold leading to scarring and obliteration of the ostium. Removal of the bone surrounding the common canaliculus, at the upper one third of the lacrimal sac, prevents the bone to act as a scaffold for fibroblast ingrowth, and obliteration [14]. Thus, the bone overlying the probe is drilled (Fig. 8.17) and the residual sac hidden under the superior bony ledge comes in view (Fig.  8.18). This portion of the sac is also opened up using a 12 no blade and the lacrimal sac flap is reflected anteriorly (Figs. 8.19 and 8.20). The lumen of the sac now looks favourable with a good portion of the sac exposed above the level of CCO (Fig. 8.21). The lacrimal sac is open like a book with its flaps reflected flat on the surrounding surface with an excellent view of CCO (Fig. 8.22). Thus, visualization of agger nasi is an indicator of meticulous surgery but the portion of the lacrimal sac above the  and CCO should ­ be exposed visualized in each case.

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a

b

Fig. 8.14  A. Clinical photograph demonstrating the confirmation of the superior osteotomy. Probe is passed horizontally through the lower punctum; B. Endoscopically the probe can be seen abutting the bony wall superiorly

a

b

Fig. 8.15  A. Probe is passed through the lower punctum and is tilted superiorly; B. Endoscopically the probe movement is restricted superiorly indicating inadequate bone removal

8.2

Advantages of Common Canaliculus Opening (CCO) Visualization

8.2.1 Effective Marsupialization of the Portion of the Sac Lying Above the Level of CCO A study on in vivo measurement of the length of the lacrimal sac fundus above the CCO concluded that CCO serves as a guideline to expose the lacrimal sac [15] and at least 3 mm of the sac above the CCO should be visible to ensure complete fundus marsupialization [15]. This mean that the distance between the superior-most aspect of

the fundus of the sac and the CCO was found to be 3.2 mm, varying from 1.2 to 4.8  mm [15] (demonstrated in Fig. 3.26 chap. 3 on endoscopic anatomy of the lacrimal drainage system). Thus, visualization of CCO allows examination of the superior portion of the sac and facilitates its effective marsupialization.

8.2.2 Identification of Intrasac Septation and Detection of Hidden Diverticulum CCO visualization may help in detecting a lacrimal sac diverticulum. This can be done by ensur-

8.2  Advantages of Common Canaliculus Opening (CCO) Visualization

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a

b Fig. 8.18  The residual part of the sac that was hidden under the bone can now be seen lying exposed above the CCO as shown by a ball pointer

Fig. 8.16  A. Probe is passed through the upper punctum and is tilted inferiorly. B.  Endoscopically the portion of the sac above the common canaliculus is still hidden under the bone as pointed out by a ball pointer, though agger nasi is seen medially Fig. 8.19  The portion of the sac above the common canaliculus is incised with a 12-number blade

Fig. 8.17  More bone is drilled superiorly for complete sac exposure

Fig. 8.20  The sac flaps are lifted using a ball pointer

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Fig. 8.23  Another case with sac lumen full of inflamed tissue. Restriction of probe movement inferiorly Fig. 8.21  A significant portion of the sac can be seen lyig above the CCO. A marked difference can be seen when compared from Fig. 8.14b 

Fig. 8.24  Teasing the inflamed tissue in an attempt to create a common and clean cavity through which a clear CCO could be visualized

Fig. 8.22  Sac can be seen nicely marsupialized with CCO in view and adequate portion of sac lying above CCO with the flaps resposited over the surrounding area

ing that the area of the sac around and below the probe results in a common cavity at the end of surgery. Restriction of probe movement inferiorly (Fig. 8.23) and the presence of infected tissue covering the probe (Fig. 8.24) are the factors that indicate incomplete surgery. Teasing the inflamed tissue in an attempt to create a common cavity through which a clear CCO could be visu-

alized, resulted in discovery of a large diverticulum (Fig. 8.25). Timely detection of the associated diverticulum present as a separate outpouching helped in preventing failure.

8.2.3 Identification and Management of Canalicular Obstructions Common canalicular opening visualization helps in examining and managing canalicular obstruction lying at CCO or in the distal segment of the upper and lower canaliculi. The identification and man-

8.3  Intrasac Granulomas

agement of these obstructions help in improving outcome in primary surgery and has been described in greater detail in the chap. 10 on the management of upper lacrimal pathway obstruction.

8.3

Intrasac Granulomas

The presence of intrasac granuloma and inflammatory tissue occupying the sac lumen in the superior part (Fig. 8.26A) explain why certain

Fig. 8.25  A large diverticulum was found in the inferolateral area after cleaning the inflamed tissue filling the sac. A deep diverticulum with CCO in view with probe insitu

a

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cases fail without removing superior bone while others may do well. This is because cases with granulomas in sac extending up to the fundus are likely to fail if complete bone removal is not done, while those cases where the sac is filled with mucopurulent discharge without any granulation tissues are likely to do well despite limited bone removal (Fig. 8.26B). Cases with the absence of granulomas and the presence of simple mucopurulent discharge may still do well despite limited bone removal. This could also explain why some cases do well in laser DCR(Fig. 8.26B) despite the inability of laser to remove the superior hard bone. Preoperative CT DCG may help in identifying these granulomas as filling defects and helps in planning meticulous surgery. CT DCG could also help in proper case selection for laser DCR. Since preoperative imaging is not advised routinely in NLD obstruction, it is better to perform a comprehensive surgery in all the cases with complete bone removal. Histopathology of granulomas is often done to rule out chronic infections. This is followed by the topical application of Mitomycin C and bicanalicular silicone intubation.

b

Fig. 8.26  Intrasac granuloma filling the left lacrimal sac (a) and its comparison with a clean right sac lumen folowing transcanalicular laser DCR (b)

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8.4

 lap Creation and Role F of Mucosal Coverage of the Raw Area

The aim of flap creation and preservation is to provide complete mucosal coverage of the ostia as it improves the surgical outcome [16]. There are a number of ways the flaps can be fashioned varying from a posteriorly based flap to a bipedicle interlacing mucosal flaps [17]. We prefer a posteriorly based flap as described in the previous chapter. The flap is divided into a small superior part and a large inferior part (Fig.  8.27). These mucosal flaps are aligned with anterior and posterior lacrimal sac to gain a 3600 mucosal coverage as explained in the previous chapter on surgical technique (Fig. 8.28). The choice of incision and flap formation lies with the surgeon and the only prerequisite is that the flaps should be fashioned in a way that the complete mucosal coverage can be achieved so that the scarring can be prevented [18]. Thus, mucosal preservation and the avoidance of bone exposure are crucial for optimal results [19].

Fig. 8.28  A 3600 mucosal coverage of the ostium (orange circle)

8.5

Various nasal conditions like a septal deviation, concha or polyps, etc. need to be handled for a meticulous primary surgery. All these conditions have been described in detail in chap. 9.

8.6

Fig. 8.27  Posteriorly based flap divided into a small superior part (black star) and a large inferior part (white star). The intervening raw are on the lateral wall is covered by reflecting the anterior lacrimal sac anteriorly (white arrows)

Identification and Correction of Associated Nasal Pathologies

Mitomycin C

Mitomycin C (MMC) is an antitumor antibiotic derived from Streptomyces caespitosus. It was isolated in 1958. It inhibits DNA synthesis. MMC is active under anaerobic circumstances [20]. Though primarily mitomycin C is an antitumor drug but its role as a topical antifibrotic medicine has been proven in glaucoma surgery and another ocular pathologies [21–26]. The effect of MMC on nasal mucosa has been studied by various authors [27, 28]. Various concentrations were used by different authors and the growth suppression level was studied. Ali et al proposed that a concentration of 0.2 mg/ml for 3 minutes is the optimal dose to prevent fibro-

8.7 Intubation

blast formation in the nasal mucosa in vitro studies [28]. Circumostial injection of 0.02% MMC has been advocated in revision cases and post-­ traumatic NLD obstruction [29]. Safety and efficacy of mitomycin have been mitomycin C and concluded proven beyond doubt. MMC affects the ostium favourably and there is enough evidence to suggest an enhanced success rate with the use of MMC [30]. In a meta-analysis of 562 cases by Feng et  al. significantly higher success rate was found in mitomycin C group in comparison with the control group [31]. Cheng et al. compared results of DCR with and without mitomycin C and concluded that MMC  reduces osteotomy closure and enhances the success rate of primary as well as revision DCR [32].

8.7

Intubation

First silicone intubation was performed in external DCR in 1950 and in endoscopic DCR in 1960 [33, 34]. There is still a controversy on the use of silicone intubation during endoscopic DCR and the current opinion can be grouped into 3 categories. The first category of surgeons favour intubation stating that it is beneficial [35–37], the second group found it to be harmful [38–42] and the third group reported no difference in the success rate of endoscopic DCR with or without intubation [35]. The first group of authors who advocate the use of silicone stenting quote, that it increases the post-operative patency rate and helps in the maintenance of the ostial opening [35]. It corrects presaccal stenosis [36, 37] and helps in maintaining patency in cases with tight common canaliculus [43, 44]. Some surgeons found it to be beneficial in revision cases, small contracted sac, bleeding and poor mucosal flap formation [34]. Those who condemn intubation, quote a higher failure rate following silicone intubation due to granuloma formation, inflammation or injury to the canalicular system [39–42]. This observation however, was contradicted by other

117

authors saying that the silicone tubes do not incite granulation formation, it rather prevents fibrous closure of the ostia [45, 46]. The third group that reported no difference in the success rate of endoscopic DCR with or without intubation based their opinion on a metanalysis. Sequential cumulative data was collected from 2007 onwards and it was found that the initial year data did not show any difference but after 2012 an improved success rate was reported following intubation, indicating a change in trend towards favouring intubation. However, the difference was not statistically significant [ 34]. The optimal duration of silicone stenting is controversial, with the reported duration ranging from 4 weeks to 4 months [39] [47]. Comparative studies in the literature reported a success rate of 96.3% with intubation and 95.3% without intubation and the difference was not statistically significant. The odds ratio of failure without silicone intubation was 1.28 (95% confidence interval) [45]. Another study reported a success rate of 91.7% with intubation and 92.3% in cases, not intubated [48]. The other benefits of stenting in our experience were dilatation of stenotic puncta that was present in association with the NLD obstruction. Although it is not common to have bilateral punctal stenosis in a case of NLD obstruction as stasis of secretions and constant regurgitation keeps the punctum in a dilated state. In a case described here, the patient was found to have bilateral punctal stenosis with NLD obstruction. Such cases may keep having epiphora despite a good nasal ostium. Thus, punctal stenosis needs to be addressed. The severity of stenosis, in this case, was more in the upper punctum than the lower punctum (Fig. 8.29). The routine punctal dilator failed to dilate the punctum therefore a very fine dilator was used to make first entry into the lower punctum by gradually rotating the dilator between the thumb and the index finger (Figs. 8.30 and 8.31). Serial dilatation was done using larger size punctal dilators and both upper

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Fig. 8.29  Role of intubation in improving long-term results were noted in a case of both upper and lower punctal stenosis with nasolacrimal duct obstruction

Fig. 8.30  Lower punctum is dilated using a fine dilator first and then serial dilatation of the punctum

and lower puncta were dilated (Figs.  8.32 and 8.33). The patency was checked by irrigation (Fig. 8.34) and bicanalicular silicone stent was placed (Fig. 8.35). Silicone tube helped in dilating the punctum and kept it in that state till the punctal oedema or inflammation subsided. Tubes were removed after 4 weeks leading to complete resolution of symptoms. The inability to handle punctal stenosis leads to persistent epiphora despite good anatomic patency as the stenosed puncta hamper the tear flow into the nose. A meticulous endoscopic DCR with

Fig. 8.31  A successful dilatation of the lower punctum can be seen

Fig. 8.32  Upper punctum is also dilated in the same manner

s­ ilicone intubation leads to the complete resolution of epiphora in such cases. Some of our patients complained of epiphora after stent removal in primary surgery despite a patent osteum. Their comfort level with the stent in terms of no epiphora indicates some capillary action of the silicone stents. As per literature, lacrimal stenting is known to encourage lacrimal pump function. The exact mechanism by which lacrimal intubation relieves epiphora is not clear [49], however, a theory has been proposed to

8.8  The Role of Regular Post-Operative Nasal Endoscopy

Fig. 8.33  A well dilated upper punctum can also be visualized

119

Fig. 8.35  Bicanalicular stent is placed with endoscopic DCR in a case of NLD obstruction with associated punctal stenosis. Intubation helps in keeping the punctain dilated state leading to improved outcome

capillarity in patients who have the narrow capillary phenomenon [35]. Thus, having a number of advantages and no side effects, we routinely perform bicanalicular silicone intubation in all cases. Various observations during routine post-operative check endoscopies (described below) could demonstrate how intubating the canalicular  system prevented ­obliteration of ostium due to surrounding granulations and synechiae.

8.8

Fig. 8.34  Syringing is done to check patency

state two functions performed by silicone intubation; one that it controls the punctual position and improves lacrimal pump function; two, the canaliculi might act as capillary tubes, with strong

 he Role of Regular Post-­ T Operative Nasal Endoscopy

Various parameters assessed during regular post-­ operative nasal endoscopy are the dynamic movement of the stent, status of the ostium and flaps. Presence of synechiae, granulations and adhesions are noted and corrected simultaneously leading to a successful outcome. There are multiple causes of failed endoscopic DCR, one of them is the granuloma formation with scarring of the nasal ostium and its adhesion with the middle turbinate [51]. Placement of stent prevents the extension of adhesion and scarring over CCO as described in some of the cases here

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Fig. 8.36  Synechiae between the middle turbinate and the lateral wall can be seen with entrapment of stent

Fig. 8.38  The two raw areas are kept separate by placing gel foam pieces

Fig. 8.37  Synechiae is released with the help of a blunt dissector

Fig. 8.39  Adequate space is created between two raw areas following synechiae release

In the first situation here, there is almost complete fusion of the middle turbinate with the lateral wall along with stent entrapment (Fig.  8.36). Timely endoscopy allowed the release of adhesion using a blunt dissector (Fig. 8.37) and an antibiotic and steroid dressing were placed between the two raw areas (Fig.  8.38). This procedure created adequate space between two raw areas (Fig.  8.39). The

CCO however was functioning well with free flow of dye (Fig. 8.40). In the second situation again, there was granulation with synechiae between the middle turbinate and the lateral wall along with stent entrapment (Fig.  8.41). The synechiae were released using a blunt dissector and the ostium patency was restored (Figs. 8.42 and 8.43).

8.8  The Role of Regular Post-Operative Nasal Endoscopy

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Fig. 8.42  Synechiae is released using a blunt dissector Fig. 8.40  A patent ostium seen after stent removal

Fig. 8.41  Another case demonstrating a middle turbinate falling on the lateral wall leading to synechiae and granulation around the ostium. The presence of stent prevented the involvement of common canalicular opening by granulations and adhesions.

In the third situation, an infective granuloma can be seen on the lateral wall anterior to the stent (Fig. 8.44). The common canalicular area was protected by covering it and the granuloma was cauterized with tricarboxylic acid (TCA) ­followed by a steroid soaked gel foam dressing around the ostium (Fig.  8.45). The stent was kept for 6 weeks till complete heal-

Fig. 8.43  Middle turbinate was separated from the lateral wall and dynamic movement of the stent was restored

ing occurred (Fig.  8.46). Such granulomas have a tendency to involve CCO. Silicone tubes create a mechanical barrier and do not allow granuloma to reach CCO. Timely intervention with granuloma management prevents failure in such cases. In the fourth situation, a benign-looking granuloma noted over the lateral wall anterior to the stent (Fig. 8.47). The granuloma is treated with TCA application and steroid nasal spray was prescribed. Six weeks post-operatively a well-healed ostia can be seen (Fig. 8.48).

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Fig. 8.44  The third case shows a granuloma around the ostium in the right nasal cavity

Fig. 8.46  Four weeks post-operatively a clean ostium with dynamic movement of the stent is seen

Fig. 8.45  CCO is covered with a pledgets and granuloma is cauterized with tricarboxylic acid (TCA)

Fig. 8.47  Forth case showing a quiet granuloma over the anterior wall of the ostium

In the fifth situation, angry-looking granulations can be seen around the right nasal ostium (Fig. 8.49). The granulations are cauterized with tricarboxylic acid followed by the placement of antibiotic dressing (Fig.  8.50). In all the cases precaution was taken to cover CCO before applying TCA to prevent the trickling of TCA into CCO that can cause the sacring of CCO.  Fluorescein drops instilled into the eye

were seen freely flowing into the nose as seen on nasal endoscopy indicating a fully functional ostium (Fig. 8.51). All these cases carried a potential risk of failure but timely intervention took care of all minor yet important factors that could have contributed to the failure. Thus regular post-operative nasal endoscopy plays an important role in improving the outcomes of endoscopic DCR.

8.8  The Role of Regular Post-Operative Nasal Endoscopy

Fig. 8.48  Granuloma managed well leading to a patent ostium

Fig. 8.49  Multiple small granulomas seen  in the right nasal cavity

Key Points  • A proper case selection and a detailed preoperative analysis is a must for meticulous primary surgery. • Superior osteotomy is a crucial step and an adequate and appropriate bone removal leads to complete marsupialization. • Agger nasi should be identified and opened in all the cases and CCO should be visualized,

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Fig. 8.50  Tricarboxylic acid cauterization of the granulation is done

Fig. 8.51  Free flow of dye can be seen through the patent ostium

• A well-lined ostium covered with mucosa all around allows healing by primary intention and thus it must be achieved in all the cases. • Use of intubation and topical mitomycin C in primary cases and circumostial injection of mitomycin C in all revision cases leads to significant improvement in outcome.

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• Regular check endoscopies in post-operative period are as important as the primary surgery itself and should be performed for at least 4 weeks and then as and when needed based on the status of ostium.

15. Singh S, Curragh DS, Selva D. Successful endoscopic dacryocystorhinostomy: how high should the superior osteotomy be? International Forum of Allergy and Rhinology; 2019. 16. Kang MG, Shim WS, Shin DK, Kim JY, Lee JE, Jung HJ. A systematic review of benefit of silicone intubation in endoscopic dacryocystorhinostomy. Clin Exp Otorhinolaryngol. 2018;11(2):81–8. Published online 2018 Apr References 17. Muller SK, Freitag SK, Bleier BS. Endoscopic DCR using bipedicled flap interlacing mucosal flaps. Laryngoscope. 2018;128(4):794–7. 1. Yazıcı B, Yazıcı Z. Frequency of the common canaliculus: a radiological study. Arch Ophthalmol. 18. Longari F, Dehgani Mobaraki P, Ricci AL, Lapenna R, Cagini C, Ricci G. Endoscopic dacryocystorhinos2000;118(10):1381–5. https://doi.org/10.1001/ tomy with and without silicone intubation: 4 years archopht.118.10.1381. retrospective study. Eur Arch Otorhinolaryngol. 2016 2. Hecht S. Dacryocystorhinostomy. Guibor P, Smith B, Aug;273(8):2079–84. (eds.), Contemporary oculoplastic surgery. New York, NY, Stratton Intercontinental Medical Book Corp, 19. Knisely A, Harvey R, Sacks R. Long-term outcomes in endoscopic dacryocystorhinostomy. Curr Opin 1974;41–54. Otolaryngol Head Neck Surg. 2015 Feb;23(1):53–8. 3. You Y, Cao J, Zhang X, Wu W, Xiao T, Tu Y. In vivo and cadaver studies of the canalicular/lacrimal sac 20. Verweij J, Pinedo HM. Mitomycin C: mechanism of action, usefulness and limitations. Anticancer Drugs. mucosal folds. Journal of Ophthalmology, 2016 . 1990 Oct;1(1):5–13. 4. Aubaret E. The valves of the lacrymo-nasal passages. 21. Maestrini HA, Cronemberger S, Matoso HD, et  al. Archives of Ophthalmology. 1908;28:211–36. Late needling of flat filtering blebs with adjunctive 5. Ali MJ.  Endoscopic evidence of canalicular-­ mitomycin C: efficacy and safety for the corneal lacrimal sac mucosal folds mimicking comendothelium. Ophthalmology. 2011;118:755–62. mon canalicular obstructions. Otolaryngol Head Neck Surg. 2020;162(2):261–2. https://doi. 22. Reibaldi A, Uva MG, Longo A.  Nine year follow up of trabeculectomy with or without low dosage org/10.1177/0194599819896353. Epub 2019 Dec 17 mitomycin—C in primary open angle glaucoma. Br J 6. Tsirbas A, Wormald PJ.  Mechanical endonasal Ophthalmol. 2008;92:1666–70. DCR. Br J Ophthalmol. 2003;87(1):43–7. 7. Gonnering RS, Lyon DB, Fisher JC.  Endoscopic 23. Young AL, Jhanji V, et al. Ten-year results of a randomized control trial comparing 0.02% mitomycin C laser-assisted lacrimal surgery. Am J Ophthalmol. and limbal conjunctival autograft in pterygium sur1991;111:152–7. gery. Ophthalmology. 2013:1202390-5. 8. Bakri SJ, Carney AS, Downes RN, et  al. Endonasal laser assisted dacryocystorhinostomy. Hosp Med. 24. Diaz L, Villegas VM, Emanuelli A, et al. Efficacy and safety of intraoperative mitomycin C ad adjunct ther1998;59:210–5. apy for pterygium surgery. Cornea. 2008;27:1119–21. 9. Calhoun KH, Rotsler WH, Stiernberg CM.  Surgical anatomy of lateral nasal wall. Otolaryngol Head Neck 25. Chen SH, Feng YF, Stojanovic A, et al. Meta-analysis of clinical outcomes comparing surface ablation for Surg. 1990;102:156–60. correction of myopia with and without 0.02% mito10. Wormald PJ, Kew J, Van Hasselt CA.  The intra mycin C. J Refract Surg. 2011;27:530–41. nasal anatomy of nasolacrimal sac in endoscopic dacryocystorhinostomy. Otol Head Neck Surg. 26. Xue K, Mellington FE, Norris JH. Meta- analysis of the adjunctive use of mitomycin C in primary and 2000;123:307–10. revision external and endonasal dacryocystorhinos 11. Liang J, Hur K, Merbs SL, Lane AP. Surgical and anatomy. Orbit. 2014;33:239–44. tomic considerations in endoscopic revisions of failed 27. Hu D, Sires BS, Tong DC, et  al. Effect of brief external dacryocystorhinostomy. Otolaryngol Head exposure to mitomycin C on cultured human nasal Neck Surg. 2014;150(5):901–5. mucosa fibroblasts. Opthal Plast Reconstr Surg. 12. Gökçek A, Argin MA, Altintas AK.  Comparison of 2000;16:119–25. failed and successful dacryocystorhinostomy by using computed tomographic dacryocystography findings. 28. Ali MJ, Marriappan I, Maddileti S, et al. Mitomycin C in dacryocystorhinostomy: the search for the right Eur J Ophthalmol. 2005;15:523–9. concentration and duration—a fundamental study on 13. Orhan M, Saylam CY.  Anatomical analysis of the nasal mucosa and fibroblasts. Ophtha Plast Reconstr prevalence of agger nasi cell in the Turkish populaSurg. 2013;29:469–74. tion. Kulak Burun Bogaz Ihtis Derg. 2009;19(2):82–6. 14. Sprekelsen MB, Alobid I, Miret JM.  Complications 29. Kamal S, Ali MJ, Naik MN.  Circumostial injection of mitomycin C (COS-MMC) in external and endoof endoscopic DCR.  Chapter 8  in RK Weber, R scopic dacryocystorhinostomy: efficacy, safety proKeerl, SD Schaefer, RC Della Rocca (eds.), Atlas file, and outcomes. Ophthalmic Plast Reconstr Surg. of lacrimal surgery (pp.  87–90). Springer, Berlin, 2014;30(2):187–90. Heidelberg;2007

References 30. Nair AG, Ali MJ.  Mitomycin-C in dacryocysto rhinostomy: from experimentation to implementation and the road ahead: a review. Indian Journal of Ophthalmology. 31. Feng YF, Yu JG, Shi JL, Huang JH, Sun YL, Zhao YE.  A meta-analysis of primary external dacryocystorhinostomy with and without mitomycin C. Ophthalmic Epidemiol. 2012;19:364–70. 32. Cheng SM, Feng YF, Xu L, Li Y, Huang JH. Efficacy of mitomycin C in endoscopic dacryocystorhinostomy: a systematic review and meta-analysis. PLoS One. 2013;8:e62737. 33. Fayers T, Dolman PJ.  Bicanalicular silicone stents in endonasal dacryocystorhinostomy: results of a randomized clinical trial. Ophthalmology. 2016 Oct;123(10):2255–9. 34. Madge SN, Selva D.  Intubation in routine dacryocystorhinostomy: why we do what we do. Clin Exp Ophthalmol. 2009 Aug;37(6):620–3. 35. Kang MG, Shim WS, Shin DK, Kim JY, Lee JE, Jung HJ.  A systematic review of benefit of silicone intubation in endoscopic dacryocystorhinostomy. Clin Exp Otorhinolaryngol. 2018;11(2):81–88. [Published online 2018 Apr] 36. Metson R, Woog JJ, Puliafito CA.  Endoscopic laser dacryocystorhinostomy. Laryngoscope. 1994;104(3 Pt 1):269–74. [PubMed] [Google Scholar] 37. Griffiths JD.  Nasal catheter uses in dacryocysto rhinostomy. Ophthal Plast Reconstr Surg. 1991 Sep;7(3):177–86. 38. Longari F, Dehgani Mobaraki P, Ricci AL, Lapenna R, Cagini C, Ricci G. Endoscopic dacryocystorhinostomy with and without silicone intubation: 4 years retrospective study. Eur Arch Otorhinolaryngol. 2016 Aug;273(8):2079–84. 39. Al-Qahtani AS.  Primary endoscopic dacryocysto rhinostomy with or without silicone tubing: a prospective randomized study. Am J Rhinol Allergy. 2012;26(4):332–4. 40. Smirnov G, Tuomilehto H, Terasvirta M, Nuutinen J, Seppa J. Silicone tubing is not necessary after primary endoscopic dacryocystorhinostomy: a prospective randomized study. Am J Rhinol. 2008;22(2):214–7.

125 41. Liang J, Lane A. Is postoperative stenting necessary in endoscopic dacryocystorhinostomy. Laryngoscope. 2013;123(11):2589–90. [PubMed] [Google Scholar 42. Mohamad SH, Khan I, Shakeel M, Nandapalan V.  Long-term results of endonasal dacryocystorhinostomy with and without stenting. Ann R Coll Surg Engl. 2013 Apr;95(3):196–9. 43. Callejas CA, Tewfik MA, Wormald PJ. Powered endoscopic dacryocystorhinostomy with selective stenting. Laryngoscope. 2010;120(7):1449–52. [PubMed] [Google Scholar] 44. Walland MJ, Rose GE. The effect of silicone intubation on failure and infection rates after dacryocystorhinostomy. Ophthalmic Surgery. 1994;25(9):597–600. 45. Chong KKL.  Primary endoscopic dacryocystorhinosomy, 195–201. Principles and practice of lacrimal surgery. Mohammad Javed Ali. Springer, India 2015. 46. Caversaccio M, Hausler R. Insertion of double bicanalicular silicone tubes after endonasal dacryocystorhinostomy in lacrimal canalicular stenosis: a 10-year experience. ORL J Otorhinolaryngol Relat Spec. 2006;68:266–9. 47. Yeon JY, Shim WS.  Endoscopic dacryocystorhinostomy without silicone stent. Acta Otolaryngol. 2012 Jun;132(Suppl 1):S77–81. 48. Unlu HH, Aslan A, Toprak B, Guler C. Comparison of surgical outcomes in primary endoscopic dacryocystorhinostomy with and without silicone intubation. Annals of Otology, Rhinology & Laryngology. 2002;111(8):704–9. 49. Baek JS, Jeong SH, Lee JH, Choi HS, Kim SJ, Jang JW.  Cause and management of patients with failed endonasal dacryocystorhinostomy. Clinical and Experimental Otorhinolaryngology. 2017;10(1):85–90. 50. Kim NJ, Kim JH, Hwang SW, Choung HK, Lee YJ, Khwarg SI.  Lacrimal silicone intubation for anatomically successful but functionally failed external dacryocystorhinostomy. Korean J Ophthalmol. 2007 Jun;21(2):70–3. 51. Lee TS, Shin HH, Hwang SJ, Baek SH.  The results of revisional surgery for the failed endonasal DCR. J Korean Ophthalmol Soc. 2007 Feb;48(2):186–92.

9

Management of the Associated Nasal Conditions in Endoscopic Dacryocystorhinostomy

Anatomical variations in the nose like deviated nasal septum and concha bullosa are often found during endoscopic lacrimal surgery and sometimes polyps and may also be present. All these conditions need to be addressed simultaneously to get improved access to the surgical field as well as to obtain better outcomes. In reported literature adjunctive nasal procedures were required in 53.4% of the patients, including septoplasty in 47%, Middle turbinoplasty in 5.9% and septal papilloma excision in 0.49% with successful outcomes of DCR in 96.5% of patients [1]. Most of the procedures were performed to improve access to the lateral nasal wall including septoplasty, Conchoplasty [2–4] and endoscopic surgery for associated nasal polyposis.

9.1

Septoplasty

Deviated nasal septum causing nasal obstruction used to be a major indication of septoplasty before the introduction of endoscopic sinus surgery [5]. The procedure of septoplasty however has evolved over a period of time. In the late nineteenth century, deviated portion was removed routinely with the overlying nasal mucosa [6] Killian and Freer described submucosal resection in early twentieth century [7, 8]. It involves lifting the mucoperichondrial and mucoperiosteal flaps and resecting the deviated portion while keeping the flaps intact. During resection of the

deviated portion, a strip of caudal and dorsal strut of the septum is preserved to avoid causing any deformity of the nose. The disadvantage of the submucosal technique given by Killian and Freer is that it fails to correct the caudal deviation. Therefore, a hemi transfixion or caudal incision is used in cases of caudal deviation of the septum. Endoscopic nasal and sinus surgery led to a surge in the indications of septoplasty as septal correction is needed to gain access to the surgical area [5]. Thus, endoscopic septoplasty is now performed to improve access to the lacrimal sac area during endoscopic dacryocystorhinostomy (DCR) as well as other endoscopic procedures. Lanza et  al. and Stammberger initially described the application of endoscopic techniques to the correction of septal deformity in 1991 [9, 10]. They described a detailed endoscopic approach to the treatment of isolated septal spurs [8]. Limited septoplasty is primarily used when there is a specific deviation of the septum that limits the surgeon’s ability to adequate visualize the surgical site during surgery and also during postoperative period [5]. Endoscopic Septoplasty is now a fast-­ developing concept & gaining popularity with an increasing trend towards sinus endoscopic surgeries. It obviates the need for conventional headlight approach [11]. The primary advantage of endoscopic septoplasty is that the area of dissection is limited to the site of deviation leading to less postoperative swelling and morbidity.

© Springer Nature Singapore Pte Ltd. 2021 N. Gupta, Endoscopic Dacryocystorhinostomy, https://doi.org/10.1007/978-981-15-8112-0_9

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9.1.1 Types of Incisions • Killian incision is given 1–2centimeter (cm) posterior to the caudal border of the septum and is suitable for cases having deviation in the midpart of the septum. This incision has the limitation of not being able to correct the caudal deviation [7]. • Cottle in 1947 introduced the hemi transfixion incision that is given at the caudal-most point of the cartilaginous septum as it adjoins the membranous septum. It is a commonly used incision as it provides access to both anterior and posterior deviations [12–14]. • In endoscopic septoplasty, any of the above two incisions can be used or an incision can be given only over the deviated part of the septum. This incision allows limited resection of the cartilage obstructing access to the surgical area.

Fig. 9.1  Endoscopic view of the right nasal cavity demonstrating a deviated nasal septum on the left with inability to visualize the middle turbinate

9.1.2 Surgical Procedure • The surgery is performed using Karl Storz 4mm, O0 endoscope with a high definition camera. Topical decongestion is carried out to achieve adequate hemostasis. A clean surgical field is important for endoscopic septoplasty because even with minimal bleeding, the tip of the endoscope gets smeared. • The septum is infiltrated with 1:100,000 saline adrenaline solution, in the sub perichondrial plane from anterior to posterior till complete blanching occurs (Figs.  9.1 and 9.2). This infiltration reduces intraoperative bleeding, facilitates flap lifting and keeps the field clean. • An incision is given over the deviated portion of the septum and mucoperichondrial  flap is lifted up (Figs.  9.3 and 9.4). Gently scoring over the cartilage is essential as it ensures an avascular plane for dissection [12]. • Dissection is continued posteriorly till vomer and perpendicular plate of ethmoid (Fig. 9.4). The cartilage incision is given and the contralateral flap is also elevated (Fig. 9.5). The bony cartilaginous junction is separated and the deviated part of the septum is removed. Bony deviation is removed by first giving a sharp cut using

Fig. 9.2  Infiltration and blanching of the mucosa

turbinectomy scissors followed by mobilization and removal of the deviated part of the septum (Figs. 9.6, 9.7 and 9.8). Thus, limited resection of the cartilage is done here unlike the submucosal resection described by Killian and Freer in which major deviated portion of the septum is removed. Only a ‘L shape’ strip of the caudal and dorsal

9.1 Septoplasty

Fig. 9.3  Posterior deviated portion of the septum is identified and incision is marked 1cm anterior to the deviated portion

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Fig. 9.5  Contralateral flap is  raised and the cartilage is separated from the mucoperichondrial flaps on both the sides

Fig. 9.4  Mucoperichondrial flap is raised and the deviated portion of the cartilage is exposed and a partial-­ thickness incision is given over the septal cartilage. The Fig. 9.6  A sharp cut is given inferiorly and superiorly incision site is scored gently to reach under the contralat- over the cartilage eral mucoperiosteal flap

strut of the septum is preserved to avoid causing any deformity of the nose [7, 8] (Fig. 9.9). Once the septal correction is done the flaps are reposited, there is a significant improvement in the available space following septal correction (Fig. 9.10). The incision is sutured with an absorbable suture. Quilting sutures

can be applied to obliterate the dead space between the flaps. The nose is packed with Vaseline gauze or ribbon gauze for 48 hours. Antibiotics are given as long as the pack stays in the nose. Sometimes it may be possible to finish the complete endoscopic DCR surgery even in a

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Fig. 9.7  The deviated portion of septum is mobilized from the ipsilateral flap

Fig. 9.8  The deviated portion of septum is mobilized from the contralateral flap and is removed

grossly deviated septum by either injecting a vasoconstrictor solution over the septum or by pushing the septum to the contralateral side. This septal deviation returns at the end of decongestion and may lead to synechiae formation later, interferes with the postoperative examination and can lead to failure. Thus, limited endoscopic septoplasty should be done wherever needed.

Fig. 9.9  ‘L’ shaped strip of caudal and dorsal strut (arrow) of the septum is preserved to avoid causing any deformity of the nose

Fig. 9.10  The mucoperichondrial flaps are reposited and the middle turbinate comes in view with a good visualization of the site of neo ostium

9.1.3 Advantages of Endoscopic Septoplasty It provides a significantly improved field of view over the standard headlight technique [15, 16] especially in posterior deviations. Endoscope can be passed easily under septal mucoperchondrial flaps; minimal lifting of the flap is required to gain excellent visualization. The incision can be precisely placed more posterior, just anterior to

9.2  Endoscopic Conchoplasty

131

ficulty in handling the endoscope as there is not adequate support available in the nostrils when working anteriorly [6]. A conventional approach that allows caudal incision is preferable in such situations. • Endoscopic septoplasty alone is not suitable for complex septal deviations associated with a crooked nose or another deviated external nasal framework. Endoscopes can however be used in conjunction with the conventional technique in these cases.

9.1.5 Complications of Septoplasty Fig. 9.11  CT scan showing Pneumatisation of the middle turbinate also known as concha bullosa (star)

the deviated portion of the septum; the extent of mucoperichondrial  elevation anteriorly in the nose is minimized leading to less post-operative oedema. • The surgeon does not have to shift from the endoscope to headlight and then back to the endoscope. The surgical instrument can be introduced more precisely and the quilting sutures can be placed under direct observation [12]. • Endoscopes provide excellent visualization of the area of dissection and has an advantage of providing a magnified view. It also serves as an important teaching tool for the residents by providing a clear image on the monitor that enable’s better teaching [1]. • It helps in mucoperichondral flap elevation in revision cases in which the tissue planes are less obvious. Endoscopic septoplasty also helps to correct complex septal deviations when combined with the conventional approach.

9.1.4 Limitations of Endoscopic Septoplasty • Caudal septal deviations are difficult to correct because a caudal incision is needed for correcting the anterior deviation. There is dif-

• Various complications have been reported in conventional septoplasty like septal hematoma, toxic shock syndrome, cerebrospinal fluid (CSF) rhinorrhea and Septal perforation. However, these are not found in endoscopic septoplasty

9.2

Endoscopic Conchoplasty

Pneumatisation of the middle turbinate is called concha bullosa [16, 17]. It is a common anatomic variant of the middle turbinate and is best diagnosed on CT scan [17–19]. The incidence of concha bullosa varies from 8 to 53% [18, 20–23]. There are three types of pneumatization in the middle turbinate, (1). lamellar type pneumatization involving the vertical lamella, (2). bulbous type pneumatization of the inferior portion, (3). expanded type pneumatiza­ tion  that is a combination of types 1 and 2 [16, 17, 19]. If encountered during endoscopic sinus surgery or endoscopic DCR surgery, Conchoplasty should be done to create adequate working space. If not addressed it leads to synechiae formation between the concha and the lateral wall leading to a failure (Fig. 9.12) Various techniques have been described in the literature for correcting an enlarged turbinate. These include lateral or medial marsupialization, crushing, and transverse resection [17]. Some authors favour lateral excision of the middle

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Fig. 9.12  Endoscopic view of the left nasal cavity demonstrating concha bullosa. Adhesion with the lateral wall and discharge is seen

Fig. 9.13  Infiltration of saline adrenaline solution into the left concha

t­ urbinate [20], or  lateral lamella removal rather than excision of medial lamella or crushing of concha bullosa [21]. Radical resection of the turbinate may lead to severe functional disturbances leading to secondary atrophic rhinitis. The ‘empty nose’ syndrome is an entity within the secondary atrophic rhinitis where changes in the nasal airflow result in disturbed climatization and also interfere with pulmonary function [18]. The mucosal preservation technique of Conchoplasty is free of these complications and has been described below.

9.2.1 Surgical Technique Fig. 9.14  Incision over the anterior face of concha

Conchoplasty is performed in the following steps: • A zero-degree 4mm Karl Storz endoscope is used to visualize concha in the nose. A large concha can be seen in the left nasal cavity on nasal endoscopy in a failed case of endoscopic DCR.  The space is compromised and synechiae can be seen between the concha and the lateral nasal wall (Fig. 9.12). • Nasal Cavity is packed with merocele packs soaked in 1:1000 adrenaline solution. Submucosal infiltration into concha is done with 1:80,000 saline adrenaline solution (Fig. 9.13).

• A 15 no blade on Bard-Parker knife is used to make a vertical incision on the anterior face of the concha bullosa starting from the inferior to the superior border (Figs.  9.15 and 9.16). • The mucosal flaps are lifted on both sides using a suction Freer elevator (Figs.  9.16, 9.17, 9.18 and 9.19). • Straight scissors are used to divide the bony concha into lateral and medial lamellae. The bony lamella is removed while preserving the overlying mucosa (Figs. 9.20, 9.21 and 9.22).

9.2  Endoscopic Conchoplasty

133

Fig. 9.15  Incision is extended to expose the complete face of concha

Fig. 9.17  Media mucoperiosteal flap is lifted off the bony concha using a suction Freer elevator

Fig. 9.16  Lateral mucoperiosteal flap is lifted off the bony concha using a suction Freer elevator

Fig. 9.18  The bony concha can be seen lying free from the overlying mucosal flaps

• The mucosal flaps are opposed and the lateral wall of the nose is examined (Figs. 9.23 and 9.24). Synechiae can be seen between the ­turbinate and the lateral wall but the space created is adequate for the surgeon to work in the lacrimal sac area (Fig. 9.25). • The landmarks on the lateral wall are identified by pushing the middle turbinate medially and the uncinate process comes in view (Fig. 9.26).

• On pressing over the lacrimal sac mucopurulent discharge can be seen coming out from the probable previous ostium (Fig.  9.27). Thus, in a revision case, the reasonable clarity of the landmarks can be obtained by a simple procedure of Conchoplasty. Endoscopic turbinoplasty with preservation of mucous membrane and its superior attachment is a simple and effective technique for the treatment

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Fig. 9.19  Close up view of concha after lifting the mucoperiosteal flap

Fig. 9.21  Superior cut is given over the concha

Fig. 9.22  The bones of concha are separated Fig. 9.20  Inferior incision over the concha is given with sharp scissors

of concha bullosa [17]. It enables easy access to the maxillary line and allows identification of the proposed site of neo-ostium in endoscopic dacryocystorhinostomy.

9.3

Endoscopic Sinus Surgery

Involvement of the lacrimal drainage system in allergic fungal sinusitis is an unusual presentation [22] In patients presenting with epiphora,

allergic fungal sinusitis should be suspected in cases of  recurrent dacryocystitis and history of recurrent sinusitis [23]. Concomitant presence of nasal polyposis without allergic fungus may also be seen in cases of primary acquired nasolacrimal duct obstruction. In a study, CT scan in a case of recurrent dacryocystitis in a 54year old lady demonstrated the presence of multiple soft tissue masses along medial canthi [22] During Endoscopic DCR allergic mucin was detected in the sinuses with eosinophilia in the tissue from lacrimal sac suggestive of allergic fungal sinusitis [22].

9.3  Endoscopic Sinus Surgery

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Fig. 9.23  Lateral lamella of the bony concha is removed and an inner view of the concha shows a large lumen

Fig. 9.25  The corrected turbinate is then pushed medially to examine the lateral wall

Fig. 9.24  Mucosal flaps are reposited after removing the bony concha

Fig. 9.26  Middle turbinate is pushed medially to identify the uncinate process. MT: Middle turbinate, UP: Uncinate process/

Sometimes polyps are detected intraoperatively during revision endoscopic dacryocystorhinostomy (DCR). Those patients who have a history of recurrent sinus infection have high chances of associated nasal polyposis [23]. A thorough preoperative evaluation of cases ­undergoing DCR rules out any such gross nasal pathology. In a revision endoscopic DCR case described here (Fig. 9.28), the nose was found to be full of polyps with synechiae formation on the right side. The patient had a previous history of endoscopic

DCR but intraoperatively no nasal ostium could be identified    at the time of  revision surgery (Fig.  9.29). The overlying bone was intact with inflammation and polyps in the middle meatus. Endoscopic sinus surgery was done in a stepwise manner including widening of the maxillary ostium to drain mucopurulent discharge and clearance of polyps from ethmoid and other sinuses (Figs.  9.30, 9.31, 9.32, 9.33, 9.34, 9.35 and 9.36). The lacrimal sac  is subsequently

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Fig. 9.27  Mucopurulent discharge can be seen trickling from a point on the lateral wall indicating the probable site of the previous ostium  (arrow). MT: Middle turbinate, LW: Lateral wall

Fig. 9.29  No bony window can be seen after elevating the mucoperiosteal flap on the lateral wall

Fig. 9.30  Uncinate is palpated with a ball pointer before uncinectomy Fig. 9.28  Failed case of right  DCR with polyps and synechiae

exposed. (Figs. 9.37, 9.38 and 9.39). The sac is then incised and marsupialized and its lumen is examined (Figs. 9.40 and 9.41). In this case, polyps could be responsible for failure as the landmarks were obscured and the lacrimal fossa could not be exposed. This also suggests that preoperatively nasal polyps were missed. There are following causes of why polyps are likely to be missed during preoperative evaluation

1. Inability to elicit a complete history of nasal obstruction and recurrent sinus infections associated with epiphora and recurrent dacryocystitis. 2. Inability to perform a nasal examination prior to DCR due to the lack of a standard protocol or no available facility of nasal endoscopy in an eye set-up. 3. Anterior rhinoscopy alone provides limited access to the different areas of the nose and small polyps are likely to be missed.

9.3  Endoscopic Sinus Surgery

Fig. 9.31  Backbiting forceps is used to widen the maxillary sinus ostium

Fig. 9.32  Backbiting forceps is used to widen the maxillary sinus ostium

4. Absence of radiological findings as preoperative CT scan or CT DCG is not routinely done prior to DCR in primary acquired NLD obstruction. CT scan is likely to pick up sino nasal findings that were otherwise missed on diagnostic nasal endoscopy. CT DCG however is more useful. It is thus important to anticipate and detect nasal pathology by 1. Emphasising on the history of nasal symptoms with a careful nasal endoscopic examination of the relevant area.

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Fig. 9.33 Thick mucopurulent secretions filling the antrum are cleared

Fig. 9.34  More polyps come in view and are debrided

2. Computed tomography, preferably with dacryocystography should be done in all the cases with persistent nasal symptoms. 3. All medial canthal swelling with epiphora should have a radiological assessment to be able to perform a meticulous surgery and avoid failures. A meticulous surgery in concomitant presence of polyp in primary acquired nasolacrimal duct obstruction cases can be done only through the

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Fig. 9.35  In case of extensive polyposis larger chunk can be removed using forceps

Fig. 9.37  Lacrimal sac is exposed and the overlying thin lacrimal bone is removed

Fig. 9.36  Further debridement continues

internal route. Therefore, external DCR has a limited role in these conditions. Routine postoperative management is the same as in other cases of endoscopic DCR. Those with associated nasal polyps require longer follow-up. Key Points  • Associated nasal conditions if missed during primary surgery can lead to failure of endocsopic DCR. Therefore nasal endoscopy is an

Fig. 9.38  Posterior ethmoids are cleared of the polyps

important part of preoperative evaluation of patients undergoing endoscopic DCR • Anatomical variations in the nose like deviated nasal septum, concha bullosa and sometimes polyps are found during endoscopic lacrimal surgery. All these associated nasal conditions need to be addressed simultaneously to get an improved access to the surgical field and to obtain better outcomes

9.3  Endoscopic Sinus Surgery

Fig. 9.39  The lacrimal sac is fully exposed and the surrounding area is free of polyps

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Fig. 9.41  The sac lumen is examined with a ball pointer and the sac is completely marsupialized

• Special emphasis should be given on the history of nasal symptoms and it should alert the physician to conduct a comprehensive nasal endoscopic examination with focus on the middle meatal area. • Computed tomography, preferably with dacryocystography should be done in these selective cases with persistent nasal symptoms.

Fig. 9.40  A crescent knife is used to give incision over the lacrimal sac

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References 1. Ali MJ, Psaltis AJ, Wormald PJ.  The frequency of concomitant adjunctive nasal procedures in powered endoscopic dacryocystorhinostomy. Orbit. 2015;34(3):142–5. https://doi.org/10.3109/01676830 .2015.1014509. Epub 2015 Apr 22 2. Fradis M, Golz A, Danino J, et  al. Inferior turbinectomy versus submucosal diathermy for inferior turbinate hypertrophy. Ann Otol Rhinol Laryngol. 2000;109:1040–5. 3. Hamerschimidt R, Hamerschmit R, Moreira AT, et  al. Comparison of turbinoplasty surgery efficacy in patients with and without allergic rhinitis. Braz J Otorhinolaryngol. 2016;82:131–9. 4. Brunworth J, Psaltis AJ, Wormald PJ.  Adjunctive endonasal procedures with dacryocystorhinostomy. In: Ali MJ, editor. Principles and practice of lacrimal surgery. New Delhi: Springer; 2015. p. 267–78. 5. Cantrell H.  Limited septoplasty for endoscopic sinus surgery. Otolaryngol Head Neck Surg. 1997;116:274–7. 6. Janki S, Roxbury CR, Sindwani R.  Techniques in septoplasty traditional versus endoscopic approaches otolaryngol. Clin N Am. 2018;51:909–17. 7. Killian G.  The submucous window resection of the nasal septum. Ann Otol Rhinol Laryngol. 1905;14:363–93. 8. Freer OT.  The correction of deflections of the nasal septum with minimal traumatism. JAMA. 1902;38:636–42. 9. Lanza DC, Kennedy DW, Zinreich SJ. Nasal endoscopy and its surgical applications. In: Lee KJ, editor. Essential otolaryngology: head and neck surgery. 5th ed. New  York: Medical Examination; 1991. p. 373–87. 10. Stammberger H.  Special problems. In: Hawke M, editor. Functional endoscopic sinus surgery: the Messerklinger technique. Philadelphia: BC Decker; 1991. p. 432–3. 11. Gupta N. Endoscopic septoplasty. Indian J Otolaryngol Head Neck Surg. 2005 Jul;57(3):240–3.

12. Devaiah A, Keojampa B. Surgery of the nasal septum. In: Stucker F, de Souza C, Kenyon G, Lian T, Draf W, Schick B, editors. Rhinology and facial plastic surgery. Berlin, Heidelberg: Springer; 2009. 13. Cottle MH.  The ‘maxilla-premaxilla’ approach to extensive nasal septum surgery. Arch Otolaryngol Head Neck Surg. 1958;60:301. 14. Cottle MH, Loring RM.  Newer concepts of septum surgery: present status. Eye Ear Nose Throat Monthly. 1948;27:403. 15. Wormald PJ, Tsirbas A.  Powered endoscopic dacryocystorhinostomy. In: Cohen AJ, Mercandetti M, Brazzo BG, editors. The lacrimal system. New York, NY: Springer; 2006. 16. Scheithauer MO. Surgery of the turbinates and ‘empty nose’ syndrome. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2010;9:Doc03. https://doi. org/10.3205/cto000067. 17. Mehta R, Kaluskar SK. Endoscopic turbinoplasty of concha bullosa: long term results. Indian J Otolaryngol Head Neck Surg. 2013;65(Suppl 2):251–4. 18. Zinriech SJ, Mattox DE, Kennedy DW, et  al. Concha bullosa: CT evaluation. J Comput Assist Tomogr. 1998;12:778–85. https://doi. org/10.1097/00004728-198809010-00012. 19. Bolger EW, Butzin CA, Parsons DS.  Paranasal sinus body anatomic variations and mucosal abnormalties: CT analysis for endoscopic sinsus surgery. Laryngoscope. 1991;101:56–64. 20. Cannon CR. Endoscopic management of concha bullosa. Otolaryngol Head Neck Surg. 1994;110:449–54. 21. Braun H, Stammberger H.  Pneumatisation of turbinates. Laryngoscope. 2003;113:668–72. https://doi. org/10.1097/00005537-200304000-00016. 22. Kim C, Kacker A, Chee R-I, Lelli GJ. Allergic fungal sinusitis causing nasolacrimal duct obstruction. Orbit. 2013;32(2):143–5. 23. Pao KY, Yakopson V, Flanagan JC, Eagle RC Jr. Allergic fungal sinusitis involving the lacrimal sac: a case report and review. Orbit: The International Journal on Orbital Disorders, Oculoplastic and Lacrimal Surgery. 2014;33(169):311–3.

Upper Lacrimal Pathway Disorders

The lacrimal drainage apparatus is divided into the proximal and distal sections. The proximal section includes the punctum, canaliculus, and common canaliculus. The distal lacrimal drainage system consists of the lacrimal sac and the nasolacrimal duct that finally open into the lateral nasal wall, below the inferior meatus [1–4]. Disorders of the proximal lacrimal system involving punctal or canaliculi pose more challenges in terms of management as compared to the lower lacrimal drainage system. They may be present with or without nasolacrimal duct obstruction. Identification of these disorders is extremely important.

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Fig. 10.1  Slit lamp photography demonstrating a stenotic right upper punctum

10.1 Punctal Disorders The lacrimal drainage pathway begins at the superior and inferior puncta. The lacrimal punctum is approximately 0.3 mm in diameter [1]. An elevated area known as the papilla lies at the entrance of punctum and is supported internally by a ring of connective tissue [1] The puncta are the parts of tarsal plates and. the upper punctum lies at 6.0 mm from the medial canthus while the lower punctum lies at 6.5 mm [1, 3, 5]. Punctal stenosis is the most common disorder followed by punctal atresia with congenital absence of one or both the punctum along with canalicular atresia [6] (Figs.  10.1, 10.2, 10.3, and 10.4).

Fig. 10.2  Slit lamp photography demonstrating a stenotic left lower punctum

© Springer Nature Singapore Pte Ltd. 2021 N. Gupta, Endoscopic Dacryocystorhinostomy, https://doi.org/10.1007/978-981-15-8112-0_10

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Fig. 10.3  Slit lamp photography demonstrating an absent left upper punctum

Fig. 10.4  Slit lamp photography demonstrating an absent left lower punctum

Punctal stenosis is an important cause of epiphora [7, 8]. It could be congenital or acquired, may be seen in one punctum or both the puncta and can be unilateral or bilateral An associated NLD obstruction may be found in 8.5% cases of punctal stenosis [7]. Canalicular involvement is seen in 50% of the acquired punctal stenosis cases and the causative factors are trachoma [9], topical or systemic medication and chemotherapy [10–12] cicatricial lesion of the conjunctiva [13, 14] and ectropion [15].

10.1.1 Examination Punctal stenosis can be detected by direct clinical examination, endoscopic examination, slit lamp

Fig. 10.5  A high tear film is seen in a patient with stenosis of the punctum

examination and by optical coherence tomography (Figs. 10.1, 10.2, 10.3, and 10.4). Slit lamp examination is done to look for the status of the punctum, its shape, size, position, punctal stenosis, congenital absence of punctum and a supernumerary punctum (Figs.  10.1, 10.2, 10.3, and 10.4). Grading of the lacrimal punctum system helps in deciding the management. Kashkouli et  al. introduced a lacrimal punctal grading from 0–5 based on the shape of the punctum, slip lamp examination findings and insertion of the punctal dilator. The severity of epiphora can be judged by fluorescein tests showing a high tear film and Munk scoring (Fig. 10.5) [16]. Munk scoring for epiphora starts from. 0=no epiphora; 1=occasional epiphora requiring wiping less than twice a day (10 times per day or continuous tearing [16]. Munk scoring also provides important information about the severity of the punctal stenosis [1].

10.1.1.1

Optical Coherence Tomography (OCT) OCT is an emerging technology for performing high-resolution cross-sectional imaging using infra-red radiation. It is a safe, noninvasive technique that provides real time image of the tissue structure [17]. It is a very suitable modality for the assessment of the proximal lacrimal drainage system

10.1  Punctal Disorders

[17, 18]. OCT has unique capabilities and can significantly impact the diagnosis and clinical management of upper lacrimal pathway disorders [17]. Various findings regarding the height of tear film, punctal and canalicular configuration were seen and documented on Fourier domain anterior segment OCT (ASOCT) (Figs. 10.6, 10.7, 10.8, 10.9, and 10.10). The absence of both puncta is often thought to be associated with the absence of canaliculi as well [19]. However, an epithelial lined canalicular lumen may be seen on ASOCT in cases (Fig. 10.11). Timlin et al. did AS-OCT of 9 lower puncta that revealed the presence of canalicular lumen at 580micro meter depth from the margin of the eyelid. Two out of 4 eyes responded to punctoplasty with complete resolution of epiphora, the rest of the patients had associated NLD obstruction and required DCR [20]. In cases with complete absence of canaliculi often a bypass procedure is required [19]. OCT is thus an excellent modality for imaging the canaliculi in

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Fig. 10.7  ASOCT demonstrating a high tear film in reference to the lid margin (with colour coding). (Photography: Saptarshi Mukherjee)

Fig. 10.8  Increased tear film on ASOCT in reference to the sclera. (Photography: Saptarshi Mukherjee)

cases with complete punctal occlusion and helps in instituting appropriate management.

10.1.2 Management Fig. 10.6 Fourier Domain anterior segment optical coherence tomography (ASOCT) demonstrating a normal tear film. (Photography: Saptarshi Mukherjee)

The aim of treating a punctal stenosis is to create an adequate opening, maintaining the position of

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Fig. 10.9  Patent punctum on slit lamp with a cross-sectional image on OCT. (Photography: Saptarshi Mukherjee)

Fig. 10.10  Punctal stenosis on slit lamp with a cross sectional image on OCT. (Photography: Saptarshi Mukherjee)

Fig. 10.11  Optical coherence tomography demonstrating a patent canaliculus. (Photography: Saptarshi Mukherjee)

the puncta so that they get emerged in the lacrimal lake on closing the eye and thus maintain the integrity of the lacrimal pump [21, 22]. The surgical management of the punctal stenosis include 1-, 2- and 3-snip punctoplasty. However, a recent study compared the results of 3-snip punctoplasty with the punctal dilation with monocanalicular intubation and documented that the results of two procedures were comparable [23]. In their study punctum was dilated with punctum dilator and probing was done to ascertain the canalicular patency followed by monocanalicular intubation.

10.2  Canalicular Disorders

It was felt that the rate of restenosis was less in dilatation than 3-snip punctoplasty and the functional outcomes were better [23].

10.2 Canalicular Disorders Canalicular disorders include canalicular laceration (Fig.  10.12), canalicular stenosis and complete canalicular obstructions. Canalicular obstructions could be congenital or acquired. Congenital canalicular obstructions are seen in anophthalmous or severe microophthalmous [24]. Acquired canalicular obstructions occur secondary to dacryocystitis, Steven-Johnson syndrome, blepharitis, trachoma and lichen planus. Traumatic causes include burn injury, dog bite (Fig. 10.13) and sharp injuries. Iatrogenic injury due to repeated probing is one of the common causes of stenosis of the lacrimal canaliculi [19]. Prolonged use of medications both topical and systemic can also lead to canalicular obstructions [11]. Canalicular obstruction is a gradual process that often starts as canalicular inflammation and stenosis. Canalicular stenosis is the abnormal

Fig. 10.12  An old right lower canalicular laceration with epiphora (arrow)

Fig. 10.13  Rounding of medial canthus with left superior and inferior canalicular involvement following dog bite injury (arrow)

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narrowing of the canaliculi and is diagnosed on the basis of clinical examination or imaging modalities like digital subtraction dacryocystography, a computed tomographic dacryocystography, or a magnetic resonance dacryocystography [25]. Timely identification and treatment of canalicular stenosis prevent progression into a complete canalicular obstruction [25]. In cases of canalicular obstruction even if there is one functional canaliculus an endoscopic DCR should be done to remove the physiological resistance of NLD. The incidence of canalicular obstructions varies from 0.92% to 4.5% in all patients presenting with epiphora [1, 26, 27]. Canalicular agenesis leading to epiphora is seen in 4% cases [19]. Canalicular obstructions are one of the most difficult lacrimal conditions to treat [19].

10.2.1 Assessment of the Level of Canalicular Obstruction Canalicular obstructions are often missed during preoperative assessment and when detected the level of obstruction has a direct bearing on the surgical outcome. Probing is a useful adjuvant to syringing for the diagnosis of canalicular obstructions and it is recommended that no larger than 00 probe should be used to judge the site of canalicular obstruction [19]. A Bowman’s probe is passed through the punctum into the canaliculi. As soon as a soft block is felt at the tip of the probe, the probe is held close to the respective punctum with the help of forceps, is withdrawn and placed against a scale to measure the length of the blocked segment (Figs.  10.14 and 10.15). The canalicular obstruction is then classified into proximal, mid or distal depending on the availability of the patent segment of the canaliculi. The site of obstruction can also be examined with the help of dacryoendoscope. Canalicular obstruction can be divided into proximal, mid and distal canalicular obstructions. Obstruction at a distance of 2–3 mm from the puncta is labelled as proximal, at 3–8  mm from the punctum is labelled as mid and beyond

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8mm is labelled as distal and common canaliculus obstruction [19] (Fig.  10.16). Obstructions involving the distal ends of individual canaliculi may extend to common canaliculus and a demarcation may sometimes become difficult. In delayed closure of DCR ostia due to the chronic granulomatous disease, it was noted that the cicatricial tissue filling the lacrimal sac, had not only involved the common canaliculus but extended proximally to involve the distal part of both upper and lower canaliculi. Vesalios docu-

Fig. 10.14  A Bowman’s probe is passed through the lower canaliculi following the proper technique of probing as described in the chapter on preoperative assessment. A soft stop is felt at the tip in canalicular obstruction. The probe is held with a forceps close to the punctum and is withdrawn Fig. 10.15  The probe is placed next to the scale to measure the length at which the canalicular obstruction lies

10  Upper Lacrimal Pathway Disorders

mented that in distal obstructions, 6–8mm of the patent canaliculi is often present [19]. The congenital canalicular obstructions look whitish in colour and in the acquired obstructions the mucosa looks pinkish and inflamed. In canaliculitis also the mucosa looks reddish pink, inflamed and oedematous. A post trephination well-healed common canaliculus looks like a wide lumen well epithelized tunnel on dacryoendoscopy. Canalicular obstructions should be identified prior to surgery but the preoperative diagnosis remains a challenge and sometimes even radiological investigations fail to detect these obstructions [28]. Boboridis found a failed preoperative canalicular block detection in 43% of cases [28] but all these cases were correctly diagnosed intraoperatively [28]. A false perception of canalicular obstruction may be felt on probing despite a patent canalicular system [8] as the tip of the probe gets caught within the mucosal fold of common internal opening or lacrimal sac mucosa [29, 30, 31]. Preoperative detection of the false soft stop can often be differentiated from the true soft stop as they are often felt beyond 10–12mm from the punctum indicating that the probe has almost reached the common canaliculus level after crossing the total length of vertical canaliculus (2mm) + horizontal canaliculus (10mm,range 6–10mm) and common canaliculus (3mm, 3–5mm) [32, 33]. Additionally, the regurgitating fluid on syringing is often mucoid or mucopurulent indicating a distal obstruction. Sometimes distal or common canalicular obstructions are detected intraoperatively, rather than preoperatively [34]. Thus, when a distal or

10.2  Canalicular Disorders

Fig. 10.16 Classification of the site of canalicular obstruction into proximal, mid canalicular and distal

common canalicular obstruction is encountered during surgery, the surgeon has to immediately decide what technique to use in managing the obstruction.

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into the canaliculus through the punctum [19] (Fig. 10.17). The lid is stretched laterally and the trephine is placed parallel to the lid (Fig. 10.18). A piece of gauze piece can be placed under the finger while retracting the lid to avoid slippage of the finger. There are chances of creating a false passage therefore the procedure should be done slowly and carefully. As the trephine reaches the site of block the inner stylus pops out indicating that the site of obstruction has reached. The trephine is then gently advanced further till complete patency is achieved (Figs.  10.19, 10.20, and 10.21). Sometimes a cast like material is seen into the lumen of the trephine. The outcome of trephination depends on the experience of the surgeon as well as the site and type of obstruction. Mono canalicular distal obstructions have good results followed by distal bicanalicular, common canalicular and proximal obstructions [36].

10.2.2 Distal or common canalicular obstruction 10.2.2.1 Management Canalicular obstruction is a therapeutic challenge and the management depends on the site and type of obstruction. Various management options are canaliculoplasty with trephination of the blocked segment, balloon dacryoplasty, laser canaliculoplasty, trephination with DCR, membranectomy for distal and common canalicular obstructions. Proximal canalicular obstructions are treated with conjunctivodacryocystorhinostomy [35–51]. Out of all the options described for distal and common canalicular obstruction, canalicular trephination with or without endoscopic DCR is the most commonly adopted method for canaliculoplasty [35–42]. Canalicular Trephination Trephination was first described by Sisler and Allarakhia in 1990 [19, 43]. The trephine is a hollow steel tube with a cutting edge at one end and a plastic hub on the other end. It has stylus in its lumen and along with the stylus it is introduced

Fig. 10.17  Sisler’s trephine with a hollow steel tube with a plastic hub and a stylus

Fig. 10.18  Trephination of the blocked canalicular segment using Sisler’s trephine

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Fig. 10.19  The fibrous tissue obstructing the canaliculus is seen at the tip of the trephine

Fig. 10.22  Another case demonstrating scar tissue over the tip of the probe obstructing the common canaliculus (arrow)

Fig. 10.20  Some infected granulation tissue can be seen at the tip

Fig. 10.21  The trephine tip is cleaned with suction to complete the canaliculoplasty

Membranectomy Success rates for revision dacryocystorhinostomy vary from 76.5%–89% [28, 52]. Although canalicular obstruction is a risk factor for failed dacryocystorhinostomy surgery but concomitant canalicular obstructions found during revision endoscopic dacryocystorhinostomy often fail to get adequate attention [29]. Membranous obstruction at the common internal opening occurs due to the condensation or adhesion of the valve of Rosenmuller to the medial wall of the lacrimal sac mucosa [29] (Fig. 10.22). Identification and excision of these common canalicular obstructions in association with endoscopic dacryocystorhinostomy and lacrimal intubation are associated with a high anatomical (90%) and functional (83%) success [29]. The excision of the fibrotic tissue obstructing the common canaliculus is performed by endoscopic marsupialization of the sac. A Bowman’s probe is passed through one of the canaliculi into the sac lumen, dense fibrous condensation covering the common canaliculus can be visualized over the tip of the probe. Under endoscopic visualization, a sharp cut is given over the tip of the probe and canalicular patency is restored (Figs. 10.23 and 10.24). Dacryoendoscopic visualization of the various types of congenital canalicular obstructions,

10.2  Canalicular Disorders

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and bicanalicular silicone stenting is done. The surgical outcome can be significantly improved by endoscopic DCR with trephination of distal and common canalicular obstruction along with mitomycin C application [39].

10.2.3 Proximal Canalicular Obstructions

Fig. 10.23  A sharp cut is given over the scar tissue at the tip of the probe seen through the a marsupialized sac lumen

10.2.3.1 Conjunctivodacr­yoystorhinostomy Cases with proximal canalicular obstruction are managed with conjunctivodacryoystorhinostomy and placement of Lester Jones tube [53] However, this procedure has a high complication rates and thus Botox injection is an alternative therapy that can be used especially in the elderly population with multiple systemic illness. Botulinum toxin is a neurotoxin isolated from the bacterium Clostridium botulinum [53]. It blocks the release of the acetylcholine from presynaptic nerve terminals [54]. 10.2.3.2 Botulinum Toxin Botulinum toxin was first used in the treatment of functional epiphora in 2003 by Whittaker et  al. and then its use was extended in the treatment of punctal and canalicular disorders [53, 55–58].

Fig. 10.24  Bowman’s probe can be visualized through the lumen (arrow) with anterior lacrimal sac flap (black star) reposited over the lateral wall and the posterior lacrimal sac flap reflected back along the floor (white star). AN: Agger nasi

inflammatory canalicular lumen, acquired canalicular obstruction and 8 weeks post canaliculoplasty well-healed lumen has been depicted in Fig. 10.25. The rest of the tissue around the common canaliculus is cleared without causing any injury to the common canaliculus. Mitomycin C is applied

Technique Paracaine drops are instilled into the eye to anaesthetize the eye. The patient is asked to look down and towards the opposite shoulder side with the eye facing down, as described earlier [53] (Fig. 10.26). The upper eyelid is lifted gently without everting the lid and the palpebral part of the lacrimal gland is visualized. One ml syringe is used with a 26 G or 30G needle and 2.5unit Botox is injected slowly into the lacrimal gland (Figs. 10.27 and 10.28). The patient is asked not to rub his eye after the injection. Outcome Reduction in epiphora occurs within 1 week of injection and its effects were evaluated based on Munk scoring. Significant benefits were found lasting for a mean of 10–26  weeks [53, 57, 58].

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a

b

Congenital canalicular stenosis

Inflammatory canaliculitis

d

c

Common canalicular opening

Acquired canalicular obstruction

Probe trhough upper canaliculus

3 months post trephination common canaliculus

Fig. 10.25 Dacryoendoscopic visualization of the obstructed canaliculus: (a) Congenital canalicular obstruction. (b) inflamed canalicular lumen. (c) acquired

canalicular obstruction. (d) Eight weeks post trephination with endoscopic DCR showing a well-healed lumen of the common canaliculus

Side Effects Botox injection into the lacrimal gland may lead to temporary ptosis. It occurs due to the seepage of the toxin into the levator palpebrae superioris muscle. It lasts for 2–4 weeks [55, 56, 58].

• They may be present with or without nasolacrimal duct obstruction. • OCT is thus an excellent modality for imaging the canaliculi in cases with complete punctal occlusion and helps in instituting appropriate management. Identifying and managing common canalicular obstructions in association with endoscopic dacryocystorhinostomy is associated with a high degree of anatomical and functional success.

Key Points • Disorders of the proximal lacrimal system involving punctal or canaliculi pose more challenges in terms of management as compared to the lower lacrimal drainage system.

References

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Fig. 10.28  The area on injection is secured with a cotton tip applicator before the needle is removed. (Photo courtesy Dr Swati Singh)

Fig. 10.26  Clinical photograph demonstrating the technique of Botox injection in refractory epiphora

Fig. 10.27  Botox injection being given in the palpebral part of the lacrimal gland. (Photo courtesy Dr Swati Singh)

References 1. Kashkouli MB, Pakdel F, Kiavash V. Assessment and management of proximal and incomplete symptomatic obstruction of the lacrimal drainage system. Middle East Afr J Ophthalmol. 2012 Jan–Mar;19(1):60–9. 2. Basic and Clinical Course. Section 7, Orbit, Eyelids and Lacrimal System. Am Acad Ophthalmol. 2008–2009:259–64. 3. Basic and Clinical Course. Section 2, Fundamentals and Principles of Ophthalmology. Am Acad Ophthalmol. 2008–2009:36. 4. Tucker NA, Tucker SM, Linberg JV.  The anatomy of the common canaliculus. Arch Ophthalmol. 1996;114:1231–4. 5. Takahashi Y, Kakizak H, Nakano T, Asamoto K, Ichinose A, Iwaki M.  Anatomy of the vertical lacrimal canaliculus and lacrimal punctum: a macroscopic study. Ophthal Plast Reconstr Surg. 2011;27:384–6. 6. Shah S, Shah M, Khandekar R. Management of bilateral congenital lacrimal punctal and canalicular atresia and congenital fistula of the lacrimal sac. Middle East Afr J Ophthalmol. 2010 Apr–Jun;17(2):180–2. 7. Kashkouli MB, Beigi B, Murthy R, Astbury N.  Acquired external punctal stenosis: etiology and associated findings. Am J Ophthalmol. 2003;136:1079–84.

152 8. Mathew RG, Olver JM.  Mini-Monoka made easy: a simple technique for Mini-Monka insertion in acquired punctal stenosis. Ophthal Plast Reconstr Surg. 2011;27:293–4. 9. Tabbara KF, Bobb AA.  Lacrimal system complications in trachoma. Ophthalmology. 1980;87:298–301. 10. Hurwitz JJ.  The lacrimal system. Philadelphia, PA: Lippincott-Raven; 1996. p. 149–53. 11. Esmaeli B, Valero V, Ahmadi MA, Booser D.  Canalicular stenosis secondary to docetaxel (taxotere): a newly recognized side effect. Ophthalmology. 2001;108:994–5. 12. Seiff SR, Shorr N, Adams T.  Surgical treatment of punctal-canalicular fibrosis from 5-fluorouracil therapy. Cancer. 1985;56:2148–9. 13. Kristan RW, Branch L. Treatment of lacrimal punctal stenosis with a one snip canaliculotomy and temporary punctal plugs. Arch Ophthalmol. 1988;106:878– 9. [PubMed] [Google Scholar] 14. Schwab IR, Linberg JV, Gioia VM, Benson WH, Chao GM. Foreshortening of the inferior conjunctival fornix associated with chronic glaucoma medications. Ophthalmology. 1992;99:197–202. 15. O’Donnell FE Jr. Medial ectropion: association with lower lacrimal obstruction and combined management. Ophthalmic Surg. 1986;17:573–6. 16. Munk PL, Lin DT, Morris DC.  Epiphora: treatment by means of dacryocystoplasty with balloon dilation of the nasolacrimal drainage apparatus. Radiology. 1990;177:687–90. 17. Wawrzynski JR, Smith J, Sharma A, et  al. Optical coherence tomography imaging of the proximal lacrimal system. Orbit. 2014;33:428–32. 18. Fujimoto JG, Pitris C, Boppart SA, Brezinski ME.  Optical coherence tomography: an emerging technology for biomedical imaging and optical biopsy. Neoplasia. 2000 Jan;2(1–2):9–25. 19. Liarakosa VS, Boboridis KG, Mavrikakisa E, Mavrikakisa I.  Current opinion in ophthalmology. August 2009:395–400. 20. Timlin HM, Keane PA, Rose GE, Ezra DG.  Characterizing the occluded lacrimal punctum using anterior segment optical coherence tomography. Ophthal Plast Reconstr Surg. 2018 Jan/ Feb;34(1):26–30. 21. Ma’luf RN, Hamush NG, Awwad ST, Noureddin B.  Mitomycin C as adjunct therapy in correcting punctal stenosis. Ophthal Plast Reconstr Surg. 2002;18:285–8. 22. Konuk O, Urgancioglu B, Unal M. Long-term success rate of perforated punctal plugs in the management of acquired punctal stenosis. Ophthal Plast Reconstr Surg. 2008;24:399–402. 23. Singh S, Ali MJ, Mohamed A.  Comparison of outcomes of 3-Snip punctoplasty versus simple punctal dilatation with monocanalicular intubation for acquired punctal stenosis. Ophthal Plast Reconstr Surg. 2018;34(4):375–7. 24. Schittkowski MP, Guthoff RF.  Results of lacrimal assessment in patients with congenital clinical anoph-

10  Upper Lacrimal Pathway Disorders thalmos or blind microphthalmos. Br J Ophthalmol. 2007;91:1624–6. 25. Ali MJ, Paulsen F. Human lacrimal drainage system reconstruction, recanalization, and regeneration. Curr Eye Res. 2020;45(3):241–52. 26. Das AV, Rath S, Naik MN, Ali MJ. The incidence of lacrimal drainage disorders across a tertiary eye care network: customization of an indigenously developed electronic medical record system, eyeSmart. Ophthal Plast Reconstr Surg. 2018; (Epub). 27. Bukhari A.  Etiology of tearing in patients seen in an oculoplastic clinic in Saudi Arabia. Middle East Afr J Ophthalmol. 2013;20:198–200. https://doi. org/10.4103/0974-9233.114790. 28. Boboridis KG, Bunce C, Rose GE.  The outcome of external dacryocystorhinostomy combined with membranectomy of distal canalicular obstruction. Am J Ophthalmol. 2005;139:1051–5. 29. Shams PN, Pirbhai A, Selva D. A prospective outcome study of membranous and solid distal common canalicular obstructions. Eye (Lond). 2016;30(4):621–6. 30. Zoumalan CI, Joseph JM, Lelli GJ, Segal KL, Adeleye A, Kazim M, et  al. Evaluation of the canalicular entrance into the lacrimal sac: an anatomical study. Ophthal Plast Recostr Surg. 2011;27(4):298–303. 31. Yazici B. Outcome of external dacryocystorhinostomy combined with membranectomy of distal canalicular obstruction. Am J Ophthalmol. 2006;141(1):229–30. 32. Olver J.  Colour Atlas of lacrimal surgery. Oxford: Butterworth-Heinemann; 2002. p. 2–23. 33. Kassel EE, Schatz CJ.  Lacrimal apparatus. In: Som PM, Curtin HD, editors. Head and neck imaging: Mosby; 2003. p. 672–4. 34. Kong YJ, Choi HS, Jang JW, Kim SJ, Jang SY.  Surgical outcomes of canalicular trephination combined with endoscopic dacryocystorhinostomy in patients with distal or common canalicular obstruction. Korean J Ophthalmol. 2015;29(6):368–74. 35. Nathoo NA, Rath S, Wan D, Buffam F. Trephination for canalicular obstruction: experience in 45 eyes. Orbit. 2013;32:281–4. https://doi.org/10.3109/01676 830.2013.814685. 36. Khoubian JF, Kikawwa DO, Gonnering RS.  Trephination and silicone stent intubation for the treatment of canalicular obstruction: effect of the level of obstruction. Ophthal Plast Reconstr Surg. 2006;22:248–52. 37. Zadeng Z, Singh M, Singh U.  Role of lacrimal canalicular trephination and mini-monoka stent in the management of idiopathic distal canalicular obstructions: our experience of 23 cases. Asia-Pac J Ophthalmol. 2014;3:27–31. https://doi.org/10.1097/ APO.0000000000000002. 38. Paik JS, Cho W, Yang S.  Bicanalicular double silicone stenting in endoscopic dacryocystorhinostomy with lacrimal trephination in distal or common canalicular obstruction. Eur Arch Otorhinolaryngol. 2012;269:1605–11. https://doi.org/10.1007/ s00405-011-1845-y.

References 39. Nemet AY, Wilcsek G, Francis IC.  Endoscopic dacryocystorhinostomy with adjunctive mitomycin C for canalicular obstruction. Orbit. 2007;26:97–100. https://doi.org/10.1080/01676830601174627. 40. Baek BJ, Hwang GR, Jung DH, Kim IS, Sin JM, Lee HM.  Surgical results of endoscopic dacryocystorhinostomy and lacrimal trephination in distal or common canalicular obstruction. Clin Exp Otorhinolaryngol. 2012;5:101–6. https://doi. org/10.3342/ceo.2012.5.2.101. 41. Haefliger IO, Piffaretti JM.  Lacrimal drainage system endoscopic examination and surgery through the lacrimal punctum. Klin MonatsblAugenheilkd. 2001;218:384–7. https://doi. org/10.1055/s-2001-15907. 42. Ali MJ.  Canalicular and nasolacrimal duct recanalization. In: Ali MJ, editor. Principles and practice of lacrimal surgery. 2nd ed. Singapore: Springer; 2018. p. 349–53. 43. Sisler HA, Allarakhia L.  New minitrephine makes lacrimal canalicular rehabilitation an office procedure. Ophthal Plast Reconstr Surg. 1990;6:203–6. 44. Hwang SW, Khwarg SI, Kim JH, Choung HK, Kim NJ. Bicanalicular double silicone intubation in external dacryocystorhinostomy and canaliculoplasty for distal canalicular obstruction. Acta Ophthalmol. 2009;87:438–42. 45. Everman KR, Czyz CN, Kalwerisky K, Hill RH, Foster JA, Cahill KV.  Canalicular obstruction: a histopathological case series. Can J Ophthalmol. 2012;47:500–3. 46. Wilhelm KE, Hofer U, Textor HJ, Bóker T, Strunk H, Schild HH.  Non-surgical fluoroscopically guided dacryoplasty of common canalicular obstructions. Cardiovasc Intervent Radiol. 2000;23:1–8. 47. Yang SW, Park HY, Kikkawa DO. Ballooning canaliculoplasty after lacrimal trephination in monocanalicular and common canalicular obstruction. Jpn J Ophthalmol. 2008;52:444–9.

153 48. Wearne MJ, Beigi B, Davis G, Rose GE. Retrograde intubation dacryocystorhinostomy for proximal and mid-canalicular obstruction. Ophthalmology. 1999;106:2325–8. 49. Steinhauer J, Norda A, Emmerich KH, Meyer Rúsenberg HW.  Laser canaliculoplasty. Ophthalmologe. 2000;97:692–5. 50. Doucet TW, Hurwitz JJ.  Canaliculo dacryocystorhinostomy in the management of unsuccessful lacrimal surgery. Arch Ophthalmol. 1982;100:619–21. 51. Athanasiov PA, Madge S, Kakizaki H, Selva D.  A review of bypass tubes for proximal lacrimal drainage obstruction. Surv Ophthalmol. 2011;56:252–66. 52. Korkut AY, Teker AM, Yazici MZ, Kahya V, Gedikli O, Kayhan FT. Surgical outcomes of primary and revision endoscopic dacryocystorhinostomy. J Craniofac Surg. 2010 Nov;21(6):1706–8. 53. Singh S, Ali MJ, Paulsen F.  A review on use of botulinum toxin for intractable lacrimal drainage disorders. Int Ophthalmol. https://doi.org/10.1007/ s10792-017-0661-9. 54. Sellin LC, et al. Trends Pharmacol Sci. 1985;6:80–2. 55. Whittaker KW, Matthews BN, Fitt AW, Sandramouli S. The use of botulinum toxin A in the treatment of functional epiphora. Orbit. 2003;22:193–8. 56. Wojno TH.  Results of lacrimal gland botulinum toxin injection for epiphora in lacrimal obstruction and gustatory tearing. Ophthal Plast Reconstr Surg. 2011;27:119–21. 57. Ziahosseini K, Al-Abbadi Z, Malhotra R. Botulinum toxin injection for the treatment of epiphora in lacrimal outflow obstruction. Eye (Lond). 2015;29:656–61. 58. Kaynak P, Karabulut GO, Ozturker C, et  al. Comparison of botulinum toxin-A injection in lacrimal gland and conjunctivo dacryocystorhinostomy for treatment of epiphora due to proximal lacrimal system obstruction. Eye (Lond). 2016;30:1056–62.

Difficult Situations in Endoscopic Dacryocystorhinostomy

11

Although the advent of high definition camera unit and endoscopes has enabled the surgeons to handle complicated cases with ease and excellent outcomes. There are certain situations that need special attention as they are difficult to detect preoperatively for various reasons. Although some of them can be picked up on computed tomography (CT) scan and computed tomographic dacryocystography (CT DCG) but since most of the time radiological investigations are not done in primary acquired nasolacrimal duct (NLD)obstruction cases, these findings are often missed. Various such situations include maxillary bone dominant fossa, associated nasal conditions, lacrimal sac diverticulum, dacryolith, posttraumatic cases and bleeding, etc.

11.1 M  axillary Bone Dominant Fossa The Lacrimomaxillary suture is a vertical line that marks the articulation of the maxillary bone to the lacrimal bone. It runs almost midway in the lacrimal fossa between the anterior and posterior lacrimal crests and divides it into two almost equal parts [1] (Fig. 11.1). Intranasally, this suture corresponds to the maxillary line which is an important ­landmark for endoscopic dacryocystorhinostomy (DCR) [2]. A lacrimomaxillary suture located more anteriorly would indicate the predominance of the

Fig. 11.1  CT DCG axial section, demonstrating a lacrimomaxillary suture lying between the lacrimal bone and the maxillary bone. Dilated lacrimal sac can be seen with contrast opacification

lacrimal bone (Fig.  11.2) while more posteriorly placed suture indicates predominance of the maxillary bone [3] (Fig. 11.3). In cases with predominance of the lacrimal bone Kerrison punch can be engaged to remove the significant bone of the lacrimal fossa (Figs. 11.4, 11.5, and 11.6), while in cases with maxillary bone dominant fossa there is no groove or clear ledge of bone against which Kerrison punch can be engaged (Figs. 11.7 and 11.8). The bone is thick, hard and irregular with no visible

© Springer Nature Singapore Pte Ltd. 2021 N. Gupta, Endoscopic Dacryocystorhinostomy, https://doi.org/10.1007/978-981-15-8112-0_11

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Fig. 11.2  Endoscopic view of the right nasal cavity demonstrating lacrimal bone dominating fossa. Junction of lacrimal bone (LB) and the uncinate process is marked by arrows

Fig. 11.4  A favourable lacrimal sac fossa demonstrating the -engagement of Kerrison punch

Fig. 11.3  Endoscopic view of the left nasal cavity demonstrating maxillary bone dominating fossa with hard bone

Fig. 11.5  Initial bone removal starts inferiorly at the lower end of lacrimal fossa

lacrimal bone. It is thus difficult to create an osteotomy [4–6]. The overlying bone thus needs to be drilled right from the beginning (Fig. 11.9). This condition needs more expertise, adequate time and the right equipment. Preoperative CT DCG is helpful in predicting the thickness of bony lacrimal fossa as described in the chapter on the

radiological anatomy of the lacrimal drainage system (Fig. 11.1). The complete bone is drilled starting from the inferior part of the fossa till the fundus of the sac is completely exposed (Figs. 11.10 and 11.11). This is followed by the incision and marsupialization of the sac (Figs. 11.12 and 11.13). The lumen of the sac is visualized to get a good view of common canalicular opening (Fig. 11.14).

11.2  Associated Nasal Conditions

Fig. 11.6  Nasolacrimal duct starts getting visible (white arrow)

Fig. 11.7  A maxillary bone dominant fossa is seen with no lacrimal bone in view (Black box)

11.1.1 Interpretation The nature of the lacrimal fossa can be judged on CT DCG as described above. It helps is proper planning of surgery in terms of anticipating the total time needed and the possible intraoperative difficulties. Adequate time should be spent on meticulous drilling and complete marsupialization in a maxillary bone dominant fossa. The results of the surgery are on par with the routine endoscopic DCR.

157

Fig 11.8  There is no cleavage to engage the Kerrison punch

Fig. 11.9 Drilling the hard-maxillary bone starts inferiorly

11.2 Associated Nasal Conditions It is not uncommon to find associated nasal pathology in cases of PANDO. If missed during preoperative assessment it can become a cause of failure like a case described here. This patient continued to have troublesome epiphora following an external DCR.  The presence of sutures showed that it was a recently operated case of external DCR (Fig. 11.15a). On examination, the

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Fig. 11.10  Drilling is continued up to achieve adequate sac exposure

Fig. 11.12  Sac is incised with a crescent knife

Fig. 11.11  Complete sac exposure can be visualized

Fig. 11.13  Secretions are drained and the flaps are everted to examine the sac lumen

medial canthal swelling was present despite surgery (Fig.  11.15a). On nasal endoscopy, polyps were found in the nose (Fig.  11.15b) and a CT scan showed an ethmoidal mucocele involving the lacrimal sac, a bony window from the previous surgery with breach in lamina papyracea (Fig.  11.15c). All sinuses were hazy and there was an osteoma in the ethmoids impinging on the lamina papyracea (Fig. 11.15d). Ethmoid mucocele is an important differential diagnosis of lacrimal sac mucocele and should be considered in a case presenting with medial canthal swelling.

11.2.1 Interpretation This case emphasizes the need for preoperative endoscopy and CT DCG in cases with strong nasal symptoms, especially the ones presenting with medial canthal swelling. The nasal findings of polyps and osteoma were missed in this case prior to the surgery leading to failure. The comprehensive preoperative assessment followed by endoscopic DCR along with endoscopic sinus surgery results in better outcomes in such cases.

11.3  Lacrimal Sac Diverticulum

Fig. 11.14  A close up view demonstrates common canalicular opening with adequate portion of the sac above the probe being marsupialized

11.3 Lacrimal Sac Diverticulum Diverticulum is an abnormal sac or pouch formed at a weak point in the wall of a hollow organ. The sac below the level of the medial palpebral ligament is a week site as it is not covered by a muscular layer and can be a site of spread of infection to the orbit [7]. The lacrimal sac diverticulum could be congenital or acquired. The congenital lacrimal sac diverticulum is a rare congenital disorder that should be suspected in paediatric patients especially with non-resolving pre septal cellulitis or medial canthal mass [8–10]. The acquired type may result due to the traumatic or inflammatory weakening of the lacrimal sac wall [8, 11–13]. Lacrimal sac diverticulum is often an intraoperative diagnosis as preoperative imaging is not routinely done in PANDO cases. They present as a medial canthal swelling that is tense and is not fixed to the overlying skin [14]. The other differential diagnosis of medial canthal swellings centred on the lacrimal sac includes dermoid cysts, inflammatory sac swelling, encephaloceles and tumours impinging on the sac. The lacrimal sac diverticula in adults are often found to be associated with dacryocystocele (Fig. 11.16a). Dacryocystocele is a diffuse, centrifugal enlargement of the lacrimal sac that

159

occurs as a result of both proximal and distal obstructions in the lacrimal drainage system [14] and can be seen here on CT DCG in an anterior cut on the coronal section (Fig.  11.16a). The same dacryocystocele when traced posteriorly in an axial section demonstrates a diverticulum arising from the lacrimal sac and is in continuation with the sac lumen as seen by the passage of contrast into it (Fig. 11.16b). Often in the case of lacrimal sac diverticulum on dacryocystography contrast material can be seen getting accumulated in a second space below the lacrimal sac. A diverticular pooling with an irregular contour can be seen on dacryocystography [8] (Fig. 11.16c). Though dacryocystocele is rare in adults but in protracted cases, superadded infection and collection results in sac enlargement. This collection finds its way along the path of least resistance and that is why most of the lacrimal sac diverticula are often seen to arise from the inferolateral wall of the lacrimal sac [8, 15, 16] and can be marsupialized endoscopically (Fig. 11.16d). Cases of primary acquired nasolacrimal duct obstruction with associated dacryocele generally carry a good prognosis but failures do occur due to the inability to identify and marsupialize this additional outpouching from the lacrimal sac as described in the chapter on revision DCR. Preoperative CT DCG plays an important role in diagnosis and intraoperative management. Sometimes extensive dacryolithiasis with multiple large concretions can also result in an outpouching of one of the walls of the lacrimal sac leading to a diverticulum formation (Fig. 11.17). Dacryoliths are concretions formed in the lacrimal drainage system. Obstruction to the passage of tear leads to epithelial metaplasia and alteration of mucin and trefoil factor peptides leading to dacryolith formation [8]. CT DCG in cases of dacryolith may reveal filling defects. During endoscopic DCR these concretions are seen as large masses. The deposition takes shape of the sac and NLD with a large irregular superior part and the long narrow tail-­like cast of dacryolith (Fig. 11.17). In this particular case presented here, dacryolith was removed and the sac

11  Difficult Situations in Endoscopic Dacryocystorhinostomy

160

a

b

c

d

Fig. 11.15 (a) Clinical photograph of a patient with persistent medial canthal swelling with sutures following right external DCR a week ago (arrows). (b) On nasal endoscopic examination of case in 15A polyps were found. (c) CT scan in the case mentioned above demon-

strates a non-homogenous opacity in ethmoid sinuses with collection and expansion. Breach in lamina papyracea can be noted (arrow). (d) CT scan demonstrating an osteoma with opaque sinuses indicating polyposis

lumen was examined. The lumen looked clear and common canalicular opening could be identified. During bicanalicular stenting, the metallic guard could be successfully passed through the upper punctum (Fig. 11.18) but during intubation through the lower punctum (Fig.  11.19), a fold of lateral wall of the sac mucosa got pushed inside. A yellowish organized discharge like material was seen below the stent (Fig.  11.20). The area was  wiped gently with a  pledget, another piece of dacryolith

was seen emerging that was palpated with a ball pointer. The anterior lacrimal sac was further everted on the lateral wall, a big dacryolith was found to be lodged deep into a deep pouch (diverticulum) in the inferolateral wall of the lacrimal sac (Figs.  11.21 and 11.22). The dacryolith was  dislodged and removed with the ball pointer and the diverticulum was examined (Figs. 11.23 and 11.24). The diverticulum was marsupialized and the procedure was completed (Fig. 11.23).

11.3  Lacrimal Sac Diverticulum

a

161

c

d

b

Fig. 11.16 (a) CT DCG coronal section demonstrating left dacryocystocele in the anterior section. (b) Axial posterior section of the same patient, demonstrating a diverticulum arising from the lacrimal sac. (c) A diverticular

pooling with an irregular contour can be seen on dacryocystography in a sagittal section. (d) Endoscopic view of the marsupialized lacrimal sac diverticulum

11.3.1 Interpretation

ity of more than such concretions should be kept in mind. Dacryolith may be left behind in the presence of diverticulum of the lacrimal sac and may lead to persistent epiphora. Thus, a thorough examination of the lumen of the lacrimal sac should be done by everting both anterior and posterior lacrimal sac flaps.

Lacrimal sac diverticula should be kept as a differential diagnosis in cases presenting with medial canthal mass. They should be identified and completely marsupialized. Similarly, in the case of a dacryolith in the lacrimal sac, a possibil-

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Fig. 11.19  Intubation is performed smoothly through the upper canaliculus but while passing the other end of tube through the lower canaliculus, the lateral wall of the sac got pushed medially and a suspicious yellowish bulge was seen on the lateral wall as shown in Fig. 11.20 Fig. 11.17  A large dacryolith seen in the sac lumen with inferior extension, taking the shape of the lacrimal drainage pathway with a wider superior part lying in lacrimal sac and narrowing inferiorly taking shape of NLD (arrows)

Fig. 11.20  Manipulation of the lateral wall of the lacrimal sac during intubation shows a yellowish raised area on the lateral wall (arrow)

Fig. 11.18  A clear looking sac lumen is seen following dacryolith removal with metallic guard of the stent being inserted through the upper punctum

11.4 Post-Traumatic Cases The management of posttraumatic cases is often challenging due to multiple injuries, repair and plating, etc. (Fig.  11.25). The cases with the intracranial impact of injuries leading to a skull base defect pose a challenge during surgery (Fig. 11.26). Preoperative imaging must be done in these cases to know any herniation of intracranial tissue into the nose and also the position of

Fig. 11.21  The raised yellowish area was gently pressed with merocel and a second dacryolith was seen popping out from the lower part of the sac

11.4  Post-Traumatic Cases

163

Fig. 11.22  The dacryolith is dislodged using a ball pointer and removed

Fig. 11.24  A close view of the lacrimal sac diverticulum marked with an arrow (LS: Lacrimal sac)

Fig. 11.23  Another large dacryolith was found to be lodged in an inferolateral diverticulum (marked by a ball pointer) arising from the lacrimal sac. ALS; Anterior lacrimal sac, PLS; Posterior lacrimal sac

plate from the previous surgery. In such cases, endoscopic dacryocystorhinostomy is performed with full preparation to manage any inadvertent cerebrospinal fluid leak during surgery. Careful

Fig. 11.25  CT scan of a patient after repair of multiple fractures with metallic plates (arrows) after road traffic accident. The patient presented with delayed onset NLD obstruction

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Fig. 11.26  CT scan of the same patient as in Fig 25 demonstrating skull base defect in the left cribriform area with meningeal and brain tissue herniation through the defect

Key Points • Endoscopic DCR surgery has excellent results but failures do occur. Identifying difficult situations prior to surgery can significantly reduce failures. Maxillary bone dominant fossa, associated nasal condition, intraoperative findings of diverticulum, bleeding during surgery and a damaged lacrimal drainage system in posttraumatic cases are challenges that can be handled effectively with the modern-day technology and skill level. The key however lies in the proper identification of these difficult conditions by clinical assessment, nasal endoscopy and imaging wherever needed. • Preoperative planning and meticulous surgery by correcting all associated conditions during endoscopic DCR leads to excellent results.

drilling following a thorough radiological evaluation leas to excellent outcomes.

References

11.5 Concomitant Presence of Punctal and Canalicular Disorders Associated punctal and canalicular disorders in a case of NLD obstruction should be diagnosed and managed in the same sitting with a team approach for optimal outcome. The detailed description is given in the chapter on the management of upper lacrimal disorders.

11.6 Bleeding Intraoperative bleeding during endoscopic DCR can be a frustrating experience. Although the suction cautery and coblator are excellent instruments but some times a lot of time is spent on trying to control Intraoperative bleed. The bleeding is even more in revision cases. It is therefore important to spend adequate time in preparation of the patient. Reverse Trendelenburg position [17], using total intravenous anaesthesia [18], infiltration of vasoconstrictor solution along with other parameters described in preoperative preparation should be kept in mind.

1. Massegur H, Lorenzo JG, Gras-Cabrerizo JR.  Nasal anatomy and evaluation article. October 2015. AJ Cohen et al., editors. The lacrimal system: diagnosis, management, and surgery, second edition, 15. https:// doi.org/10.1007/978-3-319-10332-7_2. © Springer International Publishing Switzerland 2015. 2. Chastain JB, Cooper MH, Sindwani R.  The maxillary line: anatomic characterization and clinical utility of an important surgical landmark. Laryngoscope. 2005;115(6):990–2. 3. Burkat CN, Lucarelli MJ.  Anatomy of the lacrimal system. In: Cohen AJ, Brazzo B, editors. The lacrimal system: diagnosis, management, and surgery. New York: Springer; 2006. p. 3–19. 4. Yung MW, Logan BM. The anatomy of the lacrimal bone at the lateral wall of the nose: its significance to the lacrimal surgeon. Clin Otolaryngol Allied Sci. 1999;24:262–5. 5. Hartikinen J, Aho HJ, Seppa H, Grenman R. Lacrimal bone thickness at the lacrimal sac fossa. Ophthalmic Surg Lasers. 1996;27:679–84. 6. Olver J.  Colour atlas of lacrimal surgery. Oxford: Butterworth & Heinemann; 2002. p. 14–8. 7. Russell EJ, Czervionke L, Huckman M, Daniels D, McLachlan D.  CT of the inferomedial orbit and the lacrimal drainage apparatus: normal and pathologic anatomy. Am J Roentgenol. 1985;6:759–66. 8. Akcay EK, Cagil N, Yulek F, et al. Congenital lacrimal sac diverticulum as a cause of recurrent orbital cellulitis. Can J Ophthalmol. 2009;44:e29–30. 9. Adjemian A, Burnstine MA.  Lacrimal canalicular diverticulum: a cause of epiphora and discharge. Ophthal Plast Reconstr Surg. 2000;16:471–2.

References 10. Ali MJ, Naik MJ. Congenital lacrimal sac diverticulum. Saudi J Ophthalmol. 2017;31:199–200. 11. Aswani RG, Meyer DR.  Surgical management of acquired lacrimal sac diverticula. Am J Ophthalmol. 1994;117:814–5. 12. Bullock JD, Goldberg SH.  Lacrimal sac diverticuli. Arch Ophthalmol. 1989;107:756. 13. Duke-Elder S, MacFaul PA.  The ocular adnexa. Lacrimal, orbital and para-orbital diseases. In: Duke-­ Elder S, editor. System of ophthalmology, vol. 13, pt. 2. St. Louis: C. V. Mosby; 1974. p. 733–5. 14. Perry LJP, Jakobiec FA, Zakka FR, Rubin PAD. Giant dacryocystomucopyocele in an adult: a review of lacrimal sac enlargements with clinical and histopathologic differential diagnoses. Surv Ophthalmol. 2012;57:474–85. 15. Kim JH, Chang HR, Woo KI.  Multilobular lacrimal sac diverticulum presenting as a lower eyelid mass. Korean J Ophthalmol. 2012 Aug;26(4):297–300.

165 16. Sinnreich Z.  Lacrimal diverticula. Orbit. 1998;17:195–200. 17. Paulsen FP, Schaudig U, Fabian A, et  al. TFF peptides and mucin are major components of dacryoliths. Graefes Arch Clin Exp Ophthalmol. 2006;244:1160–70. 18. Gan EC, Habib AR, Rajwani A, Javer AR. Five-degree, 10-degree, and 20-degree reverse Trendelenburg position during functional endoscopic sinus surgery: a double-blind randomized controlled trial. Int Forum Allergy Rhinol. 2014 Jan;4(1):61–8. https://doi. org/10.1002/alr.21249. Epub 2013 Nov 26. 19. Ahn HJ, Chung SK, Dhong HJ, Kim HY, Ahn JH, Lee SM, Hahm TS, Kim JS. Comparison of surgical conditions during propofol or sevoflurane anaesthesia for endoscopic sinus surgery. BJA: Brit J Anaesth. January 2008;100(1):50–4.

Complications of Endoscopic Dacryocystorhinostomy

Endoscopic dacryocystorhinostomy (DCR) is a safe procedure, with an overall low rate of complications seen in up to 5% of the cases. Major complications were seen in less than 2% of all cases [1–7]. Following is the list of common complications that have been reported in cases of endoscopic DCR.

12.1 Bleeding Some amount of intraoperative bleeding is  usually seen as the nasal mucosa is very vascular but sometimes troublesome bleeding may occur during  endoscopic DCR [8, 9], especially in ­ revision  surgeries, uncontrolled hypertension, ­ patients on anticoagulants and infected nasal mucosa. In cases of hypertension, patient’s blood pressure should be adequately controlled and monitored. Mucosal bleed can be minimized by, adequate preparation of the nasal mucosa, preoperative oral antibiotics in suspected cases of nasal infection and use of bipolar cautery. In a series by Dolman 5.5% cases of bleeding nose required perioperative nasal packing [10]. Rarely in some cases, bleeding may be more severe because of the laceration of the anterior ethmoidal artery (AEA)located in anteriorly placed ethmoidal air cells [1, 8]. AEA is a branch

12

of the ophthalmic artery and it lies much posterior to the lacrimal sac. It is located at a distance of 20mm from the axilla of the middle turbintae [11] and is often covered with bone. it runs parallel to the ethmoid roof, forming a slight curve as it passes from the orbit to the cribriform plate [12]. It is not common to find AEA bleed during endoscopic DCR but may get damaged in cases where additional ethmoid surgery is performed [9]. AEA is more susceptible to injury in cases where supra ethmoid cell is present [13]. A large supraorbital cell can be seen on CT dacryocystography with a large dilated sac with nasolacrimal duct obstruction. In the presence of supraorbital cell, AEA crosses the ethmoid cavity at a much lower level as compared to when supraorbital cell is absent (Figs. 12.1 and 12.2). Injury to the AEA causes profuse haemorrhage and may result in a surgical eye emergency as an orbital hematoma may develop. Timely identification and coagulation using bipolar cautery effectively controls bleeding. If the artery gets severed close to the orbital end it may bleed into the orbit [11]. Endoscopic orbital decompression or a lateral canthotomy should be performed immediately to release the intraorbital pressure. If the pressure is not released timely it may lead to visual loss by stretching of the optic nerve and central retinal artery ischemia [14].

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potential area for granulation formation (Fig. 12.3) and their extension into the common canalicular area. The other reason could be, infected granuloma present around the internal common opening (Fig. 12.4) and in the superior portion of the sac with synechiae and polypoidal mucosa in a majority of long-standing sac infections (Fig.  12.5). If

Fig. 12.1  CT scan showing anterior ethmoidal artery (arrow) at the junction of superior and medial orbital wall with superior oblique muscle in view  in a case of nasal polyposis with NLD obstruction

Fig. 12.3  Endoscopic view of the right nasal cavity demonstrating an infected granuloma at the osteum site

Fig. 12.2  CT dacryocystography of paranasal sinuses of the same patient as in Fig. 12.1 demonstrating large right supra ethmoidal cell with dye filling the lacrimal sac and an obstructed and dilated right lacrimal drainage system

12.2 Surgical Failures Failure of surgery is  an  important complication of endoscopic DCR surgery. Inadequate bone removal is often the most common cause of failure [15]. The bone left intact in the superior portion over the fundus of the sac often becomes a

Fig. 12.4  Intrasac granulomas in the superior part of the sac and around the internal common opening (arrow)

12.3  Cerbrospinal fluid (CSF) Leak

Fig. 12.5  Multiple synechiae and polyps in a failed case of DCR

not marsupialized, they provide nidus for aggressive granulations and fibrosis. When persistent epiphora occurs due to the presence of residual lacrimal sac, it is known as ­lacrimal sump syndrome [16]. These patients have patent irrigation but complain of epiphora as the tears get collected in the residual sac [16]. The management includes wide opening of the lacrimal sac [16]. The detailed analysis of the causes of failure has been given in the chapter on revision DCR

12.3 Cerbrospinal Fluid (CSF) Leak Cerebrospinal fluid (CSF) leak is a very rare complication of dacryocystorhinostomy (DCR). Very few cases have been reported with an incidence is about 0.04% [1, 17]. Dolman reported a case of CSF leak following DCR [10]. CSF leak can lead to bacterial meningitis [18, 19]. CSF leakage following DCR is likely to occur due to a direct or indirect injury to the skull base. Direct damage may occur due to the extension of the osteotomy to the skull base. It has been documented that the distance between the upper limit of a DCR osteotomy and the skull base could get reduced in case of trauma or con-

169

Fig. 12.6    Endoscopic view of the right nasal cavity demonstrating NLD injury (white arrow) following megaantrostomy from previous surgery with a large recurrent polyp coming out of the maxillary sinus 

genital malformation such as the maldevelopment of the frontal sinus [2, 20–22]. This was also documented by other authors in a case of posttraumatic orbito-naso-ethmoid injury and in another case of meningoencephalocele (Fig. 12.6). In both cases, the frontal part of the brain was in direct contact with the nasal bone with meningeal prolapse [22, 23]. Indirect damage leading to CSF leakage has been reported following endoscopic sinus surgery.  In DCR surgery it may occur due to the pressure applied on a deviated septum to the move it out of the operative field without undertaking a septal correction. Middle turbinate and the perpendicular plate of ethmoid (Part of bony nasal septum) are inserted into the cribriform plate of the ethmoid and are located close to the lacrimal fossa [2, 10] (Fig. 12.7). Forceful manipulation of a deviated nasal septum leads to CSF leak [2] by causing a fracture in the cribriform plate (Fig. 12.7) and the chances are more in cases of posttraumatic dacryocystitis. Fayet reported a case of CSF leakage induced by the forced reclining of the nasal septum during endonasal DCR and was repaired endoscopically [2]. Friede reported a case of CSF leak during DCR in a woman affected by ozena, and a defect

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Fig. 12.7  Coronal CT section demonstrates middle turbinate and the nasal septum (perpendicular plate of ethmoid) are inserted into the cribriform plate of the ethmoid. On the right is an endoscooic picture of a failed DCR

demonstrating how CSF leak may occur due to the forceful manipulation of a deviated nasal septum causing a fracture in the cribriform plate

in the right side of cribriform plate was noted due to pre-existing area of bone resorption [17]. Neuhaus and Bayliss hypothesized that a twisting movement of the bone punch holding the maxillary bone during the osteotomy fracture can further spread to the base of the skull however there is no study published so far to prove this hypothesis [24]. Once the CSF leak occurs during surgery, it should be identified and repaired. The site of a leak in cases of primary endoscopic DCR is likely to be present at the cribriform plate. Though cases of posttraumatic NLD obstruction may have a different site of leak depending on the extent of skull base involvement. The bony defect is identified and sealed using fat and fascia graft depending on the size of the defect. An otorhinolaryngologist help can be sought in these cases if needed.

Dryden reported a case of meningitis on ninth day following endoscopic DCR [25]. Patient had posttraumatic NLDO following a road traffic accident. He first developed orbital cellulitis a week after the surgery and then meningitis [25]. Kurihashi reported another case of streptococcus meningitis in a 9-year-old girl, one day after DCR [19, 21]. Route of spread was hematogenous as no local signs like orbital cellulitis or ethmoiditis were present, the onset was faster and a single pathogen was isolated. In local invasion, there is more than one pathogen and it takes time to spread and has local signs.

12.4 Meningitis Bacterial meningitis may occur following DCR and it could be due to a local spread or a hematogenous spread [8, 21].

12.5 Pneumatoencephalocele Pneumatoencephalocele has been reported following an endoscopic DCR in an 80-year-old lady [2]. The risk factors reported were ethmoidal breech, insertion of the perpendicular plate of ethmoid directly onto the cribriform plate, meningeal prolapse and extensive osteoporosis of the skull base. There was an associated severe septal deviation that required forceful reclining. The use of Killian valve speculum to recline the nasal

12.6  Synechiae and Granulations

171

septum was probably the main cause of the anterior skull base fracture [2]. Endoscopic DCR is challenging in a narrow nasal cavity. The use of a Killian valve speculum to enlarge the nasal fossa may carry a risk for structural damage to the skull base. Prior to DCR endoscopic septoplasty in cases of narrow nasal fossa should be done to create adequate space.

12.6 Synechiae and Granulations Synechiae and granulation may form postoperatively between two raw areas and the most common site is the area between the anterior end of the middle turbinate and the lateral wall and was noted in 22.4% of cases [9] (Figs. 12.8, 12.9, and 12.10). Granulation tissue at the ostium site (Fig.  12.11) was reported to vary from 17.5 to 6.6% [9, 26]. Scar tissue was obliterating the window in 3.3% cases as seen during revision surgery [9]. Therefore, regular endoscopic checks help in addressing these factors and improve outcomes. Granulations are managed by steroid nasal spray, tricarboxylic acid cauterization, packing with steroid soaked gel foam, etc. In

Fig. 12.9  Another case with synechiae between the septum and the lateral wall

Fig. 12.10  Extensive synechiae obstructing the ipsilateral nasal cavity

Fig. 12.8  Synechiae between septum and the lateral wall

cases where infective granulomas develop, they need to be excised followed by topical application of antibiotic ointment and frequent checks to regulate the stent removal

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Fig. 12.11  Postoperative granulation formation at the osteum site

12.7 Injury to Lamina Papyracea Lamina papyracea is the orbital plate of the ethmoid bone and it forms the major portion of the medial wall of the orbit. It is a thin papery membrane separating the orbit from the content of the nasal cavity. The chances of injury to laminal papyracea are more in revision cases, posttraumatic nasolacrimal duct obstruction and in cases with unfavorable anatomy. Injury to the lamina papyracea was noted in a case of failed endoscopic DCR in which a stent had been forced through a false passage. The breach in the lamina papyracea was found in the posteroinferior part. The sac was found to be unopened, the patient had preoperative canalicular obstruction which was identified as proximal in the left lower canaliculi and distal in the left upper canaliculi. These canalicular obstructions were probably missed in primary surgery. The inability to open the sac further complicated the situation and thus the stent was forced into a blind path of least resistance leading to injury to lamina papyracea and fat prolapse (Fig.  12.12). Fat prolapse into the intraoperative area appears as a yellow globular tissue if this fat is pulled due

Fig. 12.12  Endoscopic view of the left nasal cavity demonstrating fat prolapse (star)  at the site of false passage (lamina papyracea breach) created by forced stenting during previous surgery

to missed identification it may traumatize the medial rectus muscle leading to diplopia.

12.8 Subcutaneous Emphysema Subcutaneous emphysema and haemorrhage around the eye and nose may develop after surgery [27] (Figs.  12.13 and 12.14). Patients are carefully instructed not to blow their nose after surgery to avoid emphysema [9]. The incidence of subcutaneous emphysema (9%) was more in earlier few cases reported by Sprekelsen in 1996 [28]. However, the further series reported by him had much less incidence of these complications [9].

12.9 Periorbita Breach, Ecchymosis and Diplopia Some of these complications have been mentioned in the old literature, however, the occurrence of these complications is not common these days [9]. Ecchymosis of the cheek has been

12.11  Complications Due To Stent

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12.11 Complications Due To Stent

Fig. 12.13  Subcutaneous haemorrhage around the operated left eye

Stent extrusion, breakage and entrapment may occur in the postoperative period. Sometimes blood may fill the lumen of the stent and its loop may appear red in the medial canthal area making patients apprehensive (Fig.  12.15). It may cause cheese wiring of the punctum if the stent is too tight. In cases of the loop of stent prolapsing in the medial canthal area, it can be reposited into the nose under endoscopic guidance. If the stent is broken it should be removed and repeat stenting can be done based on the need at that particular time (Fig.  12.16). Cheese wiring of both puncta may occur in cases where the stent is tied too tight in the nose (Fig. 12.17). Sometimes the knot of the

Fig. 12.15  Blood sucked into the lumen of the stent seen into the medial canthal loop Fig. 12.14  Subcutaneous emphysema  around the operated right eye

reported to be (44%) [29] in old literature. Inadvertent lesion of the periorbita, eyelid hematoma and eyelid odema may occur [9]. Periorbital ecchymosis indicates entry into the orbit. The eye should therefore be constantly examined [9].

12.10 Infections Postoperative infection following endoscopic DCR is rare. Oral antibiotics are routinely prescribed postoperatively, as nasal packing is done for 48 hours. However transient frontal sinusitis has been reported in past [2].

Fig. 12.16  Loop of the tube seen prolapsing out of the eye

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12  Complications of Endoscopic Dacryocystorhinostomy

Fig. 12.17  Cheese wiring of the punctum and canaliculi are seen due to the prolonged stenting

stent gets pulled into the common canaliculi and the stent may not be visible in those cases. The stent can be gently pulled through the canaliculi or pushed into the nose gently by probing the canaliculi by a fine Bowman probe. The knot can then be retrieved through the nose

12.12 False Passage in the Canaliculi False passage is likely to develop due to the wrong technique of probing. As the Bowman probe is passed through the canaliculi a false stop may be felt due to the kinking of the canaliculi. If this is not identified, one may end up pushing the probe through this soft block leading to a false passage formation. False passage may also form in cases of true canalicular obstructions where the probe is pushed hard and it may enter the nose through one of the walls of the canaliculi and bypasses the sac. Laceration of the puncta has been reported in 0.04% cases [14] and the inferior canalicular injury was found in 1.19% cases [7].

12.13 Air Reflux Post DCR surgery some patients reported significant air reflux during the use of CPAP [29]. Wrede reported an air leak through the eye fol-

lowing the use of CPAP in a patient with the history of John tube placement [29]. However, we came across the same complaints in our patients who were not on CPAP. Anatomically there are mucous membrane folds that form a type of valve in the lacrimal pathways and their main function is to block the backward tear outflow [29]. The valve of Rosenmuller prevents the outflow of the lacrimal sac content into the conjunctival sac [29]. There is a possibility that mucosal folds present in the lacrimal pathway get disturbed following lacrimal surgery [29]. Disruption of lacrimal system anatomy following DCR or stenting may lead to the air relax due to the retrograde air flow through the lacrimal pathway into the eye [30]. Key Points Endoscopic dacryocystorhinostomy (DCR) is a safe procedure, with few minor complications. Major complications are rare in simple primary acquired NLD obstruction. However posttraumatic cases with skull base injury or severe septal deviations should be handled carefully as complications occur in complex cases or in associated comorbidity. Preoperative assessment plays an extremely important role.

References 1. Mattavelli D, Lombardi D, Ferrari M, Nicolai P.  Complications of endoscopic DCR. 2016;91–9. Springer International Publishing Switzerland. 2. Fayet B, Racy E, Assouline M.  Complications of standardized endonasal dacryocystorhinostomy with unciformectomy. Ophthalmology. 2004;111:837–45. 3. Karim R, Ghabrial R, Lynch T, Tang B. A comparison of external and endoscopic endonasal dacryocystorhinostomy for acquired nasolacrimal duct obstruction. Clin Ophthalmol. 2011;5:979–89. 4. Tsirbas A, Wormald PJ.  Mechanical endonasal dacryocystorhinostomy with mucosal flaps. Otolaryngol Clin North Am. 2006;39:1019–36. 5. Hodgson N, Bratton E, Whipple K, Priel A, Sang-Rog O, Fante RG, Kikkawa DO, Korn BS.  Outcomes of endonasal dacryocystorhinostomy without mucosal flap preservation. Ophthal Plast Reconstr Surg. 2014;30:24–7. 6. Zenk J, Karatzanis AD, Psychogios G, Franzke K, Koch M, Hornung J, Velegrakis GA, Iro H. Long-term results of endonasal dacryocystorhinostomy. Eur Arch Otorhinolaryngol. 2009;266:1733–8.

References 7. Ali MJ, Psaltis AJ, Bassiouni A, Wormald PJ. Long-­ term outcomes in primary powered endoscopic dacryocystorhinostomy. Br J Ophthalmol. 2014;98:1678–80. 8. Beiran I, Pikkel J, Gilboa M, Miller B.  Meningitis as a complication of dacryocystorhinostomy. Brit J Ophthalmol. 1994;78:417–8. 9. Sprekelsen MB, Alobid I, Miret JM. Complications of endoscopic DCR.  In: Weber RK, Keerls SSD, Della Rocca RC, editors. Atlas of lacrimal surgery. Berlin, Heidelberg: Springer; 2007. 10. Dolman PJ.  Comparison of external dacryocystorhinostomy with nonlaser endonasal dacryocystorhinostomy. Ophthalmology. 2003;110:78–84. 11. Lee WC, Ku PKM, Hasselt CAV. New guidelines for localization of the anterior ethmoidal artery: a cadaveric study. The Laryngoscope. July 2000;110. 12. Yang YX, Lu QK, Liao JC, Dang RS. Morphological characteristics of the anterior ethmoidal artery in ethmoid roof and endoscopic localization. Skull Base. 2009 Sep;19(5):311–7. 13. Joshi A, Kshitiz D, Shah BR. Radiological correlation between the anterior ethmoidal artery and the supraorbital ethmoid cell. Indian J Otolaryngol Head Neck Surg. 2010 Sep;62(3):299–303. 14. Leong SC, Macewen CJ, White PS.  A systematic review of outcomes after dacryocystorhinostomy in adults. Am J Rhinol Allergy. 2010;24:81–90. 15. Gupta N.  Improving results in endoscopic DCR.  Indian J Otolaryngol Head Neck Surg. 2011 Jan;63(1):40–4. Published online 2011 Jan 18. 16. Migliori ME.  Endoscopic evaluation and manage ment of the lacrimal sump syndrome. Ophthal Plast Reconstr Surg. 1997;13:281–4. 17. Friedel ME, Earley MA, Eloy JA. Skull base defect in a patient with ozena undergoing dacryocystorhinostomy. Allergy Rhinol (Providence). 2011;2:36–9. 18. Beiran I, Pikkel J, Gilboa M, Miller B.  Meningitis as a complication of dacryocystorhinostomy. Br J Ophthalmol. 1994;78:417–8. 19. Usul H, Kuzeyli K, Cakir E, Caylan R, Imamoglu HI, Yazar U, et  al. Meningitis and pneuomocephalus. A

175 rare complication of external dacryocystorhinostomy. J Clin Neurosci. 2004;11:901–2. 20. Ritleng P, Caubet E, Fantin J.  Lacrimo-meningeal relations: anatomical study and practical aspects. Bull Soc Ophtalmol Fr. 1984;84:1205–8. 21. Kurihashi K, Yamashita A.  Anatomical consider ation for dacryocystorhinostomy. Ophthalmologica. 1991;203:1–7. 22. Botek AA, Goldberg SH. Margins of safety in dacryocystorhinostomy. Ophthalmic Surg. 1993;24:320–2. 23. Bagheri A, Naghibozakerin J, Yazdani S. Cerebrospinal fluid leakage during dacryocystorhinostomy in a patient with meningoencephalocele. Eur J Ophthalmol. 2005;15:500–3. 24. Neuhaus RW, Baylis HI.  Cerebrospinal fluid leakage after dacryocystorhinostomy. Ophthalmology. 1983;90:1091–5. 25. Dryden RM, Wulc AE.  Pseudoepiphora from cerebrospinal fluid leak: case report. Br J Ophthalmol. 1986;70:570–4. 26. Zilelioglu G, Tekeli O, Ugurba SH, Akiner M, Akturk T, Anadolu Y. Results of endoscopic endonasal non-­ laser dacryocystorhinostomy. Doc Ophthalmol. 2002;105:57–62. 27. Tanigawa T, Sasaki H, Nonoyama H, Horibe Y, Nishimura K, HoshinoT, Ogawa T, Murotani K, Ueda H, Kaneda M.  Outcomes of endoscopic endonasal dacryocystorhinostomy for intractable lacrimal dacryostenosis and associated factors. 28. Sprekelsen MB, Barberán MT.  Endoscopic dacryocystorhinostomy. Surgical technique and results. Laryngoscope. 1996;106:187–9. 29. Wrede JE, Parsons EC, Watson NF.  A novel treatment for nasolacrimal air regurgitation into the eye with CPAP: the total face mask. J Clin Sleep Med. 2018;14(8):1415–7. 30. Maliborski A, Różycki R. Diagnostic imaging of the nasolacrimal drainage system. Part I.  Radiological anatomy of lacrimal pathways. Physiology of tear secretion and tear outflow. Med Sci Monit. 2014;20:628–38.

Paediatric Endoscopic Dacryocystorhinostomy with Special Emphasis on Congenital Nasolacrimal Duct Obstruction and Approach to a Child with Epiphora

The Paediatric endoscopic dacryocystorhinostomy (DCR) in children is indicated in following conditions [1–5]: • Recalcitrant congenital nasolacrimal duct obstruction (CNLDO) • Primary acquired nasolacrimal duct (NLD) obstruction • Post-traumatic NLD obstruction • Cases with systemic anomalies and NLDO [1–4] The most common indication for DCR in the paediatric age group is CNLDO. However, conservative methods are used as the first line of treatment. These conservative methods of treatment include pressure on the lacrimal sac, topical antibiotics, probing, and silicone intubation if needed, leading to an effective relief in obstruction [1–4, 6–9]. DCR is required only rarely for recalcitrant cases. It is therefore important to understand CNLDO in detail. Since endoscopic DCR is not the first line of treatment in children with CNLDO, and is only indicated in cases that do not respond to probing, or are associated with recurrent dacryocystitis [7, 8]. it is important to understand CNLDO in detail. This will help us to know the cases that can be treated using minimally invasive ways and where the need for endoscopic DCR can be obviated.

13

13.1 Congenital Nasolacrimal Duct Obstruction (CNLDO) Congenital nasolacrimal duct obstruction (CNLDO) is the most common cause of epiphora in infants. It occurs due to the failure of canalization of the distal end of the nasolacrimal duct (NLD) [10]. There is a mucous membrane obstruction at the lower end of NLD, found in up to 20% of newborn infants [11]. Spontaneous resolution occurs in (>90%) during the first 12 months of life and the majority of children do not require surgical treatment [10]. In cases where the spontaneous opening of the membrane fails, persistent epiphora occurs [12] The prevalence of CNLDO has been quoted as 5% to 20% in the early childhood [13–15] and 95% of this population showed symptoms at one month of age [15]. CNLDO is generally unilateral but bilateral involvement is seen in 20% of cases [16] Children present with watering and discharge from the eye with lid oedema and excoriation (Fig. 13.1).

13.1.1 Symptoms The onset and severity of symptoms may vary, but the characteristic triad includes watering, discharge, and matting of eyelashes [13, 16]. Watering is usually unilateral but bilateral CNLDO occurs in 20% of cases [16, 18]

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a

b

c

d

e

f

Fig. 13.1  Clinical profile of children with CNLDO.  a. Epiphora right with high tear meniscus. b. Mucopurulent discharge left eye. c.  Right eye smeared with discharge

along with matting of the eye lashes. d. Down’s syndrome with lid cellulitis right eye with epiphora. e. and conjunctival congestion right. f. Congenital dacryocele left

Distal obstruction at the Hasner valve is more likely to cause a mucopurulent discharge, whereas, an obstruction at the valve of Rosenmueller, often leads to watery discharge [13, 16, 18]

NLD obstruction. FDT is a preferred tool for diagnosis of CNLDO [9, 19–21]. The test is performed by instilling 2% fluorescein drops in the eye and its appearance in the nose is checked after 5 minutes. The persistence of dye into the eye beyond 5 minutes indicates a blocked lacrimal drainage system. The fluorescein dye disappearance test is a non-invasive and reliable method to confirm lacrimal duct obstruction with a sensitivity of 90% and a specificity of 100% [22, 23] The following flow chart explains the approach to a child presenting with epiphora Flow chart; Approach to a child with epiphora due to CNLDO

13.1.2 Examination Preoperative assessment in children is different from adults as the routine probing, syringing and diagnostic nasal endoscopic tests are not possible. The surgeon has to rely on the history, local examination, regurgitation test and fluorescein dye test (FDT). Preoperative assessment includes a regurgitation test that if positive is confirmative of

13.1  Congenital Nasolacrimal Duct Obstruction (CNLDO)

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Approach to a Child with Epiphora

< 1 year

> 1 year

Simple Epiphora

ROPLAS +VE/ Discharge

No Relief

Intervention

No Associated Defect With Associated abnormality Congenital Dacryocele Congenital Lacrimal Sac Fistula Syndromic Child Recurrent infection Cranio facial Dysostosis Congenital cataract

Conservative Treatment-Crigler’s massage Topical Antibiotics-controversial

No Resolution

Massage 4 weeks/Immediate Intervention Endoscopic Probing & Irrigation

Endoscopic Probing & Irrigation

13.1.3 Conservative Management Crigler massage is the manoeuvre that was first described by Crigler in 1923 and involves compression over the lacrimal sac using a downward rotation of thumb over the tear sac [13]. Crigler massage is an important conservative method of treating membranous obstruction with high chances of resolution and its importance should be explained to parents. The success rate of resolution of symptoms with massage is high in comparison to the children who do not have lacrimal sac massage (96.2% vs. 77.7%) [13, 15]. Some authors advocate the use of high-­pressure irrigation, but despite being less invasive than probing it carries the risk of, damaging the lacrimal canaliculus with the canula [24]. Probing is indicated if the symptoms persist despite sac compression and is usually recommended beyond the age of one-year [25–27]. Probing of the nasolacrimal system is the most common procedure in the management of CNLDO [28–31].

Resolution complete/ or simple epiphora

Regular Follow Up

13.1.4 Probing and Irrigation The time of intervention in such children is still a matter of debate but most of the studies suggest waiting till 1 year of age [12]. Probing is undertaken in cases that fail to resolve with conservative treatment Intervention in the form of probing and irrigation is done. Conventional probing is usually the most commonly followed method of intervention. However, it carries the risk of false passage and failure as it is a blind procedure that mainly depends on the surgeon’s tactile sensation during probing [11, 17]. Endoscopic-assisted probing under general anaesthesia has now become the standard of care for children with persistent disease. Probing of the nasolacrimal system under endoscopic guidance allows direct visualization of the distal nasolacrimal duct and thus helps in increasing the success rate of the procedure as compared to blind probing [11, 12]. The advantages of nasal endoscopy assisted probing have been well recognized and has a much better outcome as compared to blind

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Fig. 13.2  The index finger is placed at the junction of the middle third and the lateral third of the upper lid and the lid is retracted up.

Fig. 13.3  Upper punctum is dilated using a punctal dilator with a rotatory movement

probing [32–37]. A success rate of 95.7% has been reported with endoscope assisted probing against 75.9% in conventional probing group [37].

13.1.4.1 S  teps of Nasal Endoscopic Guided Probing The nasal endoscopic guided probing is performed as per published protocols [3]: • The upper lid is retracted by keeping the index finger at the junction of medial third and the lateral two third (Fig. 13.2). A Nettleship punctal dilator is used to dilate the upper punctum by gentle rotatory movement (Fig. 13.3). • Fluorescein dye is taken in a syringe with a partially curved canula. The canula is first inserted vertically through the upper punctum and then tilted horizontally till a hard stop is felt. It is then withdrawn a little and again tilted vertically to reach the proximal NLD through the sac with a lateral traction on the lid. The canula is then tilted vertically up and is stabilized with the index finger (Figs. 13.3, 13.4, 13.5, 13.6). • The nasal cavity is decongested by placing merocel pledgets soaked in 1:1000 adrenaline

Fig. 13.4  A canula with a 2cc syringe is inserted through the upper punctum, it is first introduced horizontally

solution by placing them in the inferior meatus as well as between the inferior turbinate and the septum (Fig. 13.7). • A 2.7mm/4 mm, 0-degree nasal endoscope is passed along the floor of the nasal cavity to

13.1  Congenital Nasolacrimal Duct Obstruction (CNLDO)

Fig. 13.5  Canula is then tilted vertically at 90 degree to enter the sac

Fig. 13.6  The canula is stabilized with the index finger along the bone of the frontal process

reach nasopharynx. The scope is then gently withdrawn and rotated laterally to enter into the inferior meatus to visualize the NLD opening • The free edge of the inferior turbinate is gently lifted using a blunt dissector with careful handling of the nasal mucosa. The nasal mucosa is very vascular and any trivial trauma

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Fig. 13.7  Endoscopic view of the right nasal cavity showing cottonoid patties soaked in decongestant solution kept in the inferior meatus

can cause profuse bleeding. Therefore, adequate time should be spent in the decongestion of the nasal cavity (Fig. 13.8). • Syringing is done with fluorescein dye to check the patency of NLD. A free flow of dye is seen into the nose in cases of a patent NLD and in cases of membranous obstruction the greenish dye can be seen getting collected under the membrane (Fig. 13.9). • A Bowman’s probe is passed through the upper punctum under endoscopic visualization in a stepwise manner to overcome the membranous obstruction over the distal end of NLD. As the probe perforates the membrane, mucopurulent discharge starts flowing into the nose (Fig. 13.10). • The perforation can be enlarged by moving the probe in a different direction and if the membrane is thick a sharp cut can be given as described earlier [12]. The sac is emptied by applying pressure over the medial canthal area to push its content into the nose. The free flow of dye into the nose is seen on syringing (Fig. 13.11). There should be no resistance to check syringing and minimal or no regurgitation through the same punctum or the opposite punctum.

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Fig. 13.8  The free edge of the right inferior turbinate is gently lifted

Fig. 13.9  A membranous bulge with collection underneath can be visualized over the valve of Hasner

Fig. 13.10 The membrane is perforated using a Bowman’s probe and the mucopurulent discharge can be seen flowing into the nose

Fig. 13.11  Free flow of dye can be visualized in the right nasal cavity on irrigation

13.1  Congenital Nasolacrimal Duct Obstruction (CNLDO)

13.1.5 Classification of CNLDO CNLDO has been classified as simple, complex [38–40], complete complex and incomplete complex [9], membranous and firm [41]. While the definition of simple CNLDO is more or less uniform, the complex category still needs to be studied in more detail using dacryoendoscopy as an adjuvant to nasal endoscopy with or without radiological studies. Simple CNLDO is defined as a condition in which there is a lack of resistance in passing a probe through NLD until a point of membranous obstruction that can be easily perforated [39]. As per published studies, the complicated obstruction comprises of NLD variations, impacted inferior turbinate, bony obstruction, nondevelopment of NLD, anlages, syndromic association and craniofacial abnormality [39, 40]. However, this classified needs to be relooked as there is more clarity now in understanding various defects in NLD using a dacryoendoscopy (DEN) and labelling an impacted inferior turbinate as the cause of complex CNLDO seems to be subjective without any evidence. This is due to the fact that even if the inferior turbinate abuts the lateral nasal wall there is always some space below the axilla of the inferior turbinate where NLD drains. DEN allows an intraluminal examination of NLD and has a beneficial role in the diagnosis of refractory cases of CNLDO. Most of the studies classified CNLDO based on tactile feeling during blind probing [9, 41, 42] or inferior meatal visualization on nasal endoscopy (NE) guided probing [39]. Nasal endoscopy can effectively diagnose a number of conditions like a membranous bulge over the valve of Hasner, a buried probe, a thin-walled intra-nasal cyst and a thick-walled nasal component of congenital dacryocele (Fig. 13.2).

13.1.5.1 Membranous CNLDO: In membranous obstruction, a bulge is seen in the inferior meatus over the valve of Hasner. This can be a thin membrane that can be perforated with the probe itself or a thick membrane that needs to be cut with a sharp incision as described earlier

183

[12]. The schematic diagram along with the nasal endoscopic view shows a normal patent NLD in Fig.  13.12A and its comparison with membranous bulge over the valve of Hasner in Fig. 13.12B.

13.1.5.2 Buried Probe The nasolacrimal duct may have anatomical variations from the sac duct junction up to its opening in the inferior meatus. This variable course can contribute to false passage formation during probing [43, 44]. One such variation is the downward extension of NLD along the lateral wall of the nose up to the floor. The probe can be seen going down to the floor in the submucosal plane without perforating the mucosa and is labelled as buried probe [43] Fig. 13.12C. The probe is then tilted to perforate this mucosa successfully. 13.1.5.3 Nasal Cyst Nasal cyst is again a thin-walled cyst seen in the inferior meatus covering the valve of Hasner area. This thin-walled cyst can also be perforated with the probe alone. 13.1.5.4 Dacryoliths The presence of dacryoliths or concretions in the lacrimal drainage system can be suspected by a yellowish raised area in the inferior meatus without a bulging membrane (Fig.  13.12D). Nasal endoscopy guided probing in such cases shows the smooth passage of probe into the inferior meatus but the syringing is blocked. Dacryoendoscopy is done to confirm the findings of concretions which are then pushed through the lumen of the nasolacrimal system and retrieved through the nose followed by a check syringing. This allows a successful recanalization of NLD in cases of concretions associated with CNLDO. 13.1.5.5 Congenital Dacryocystocele Congenital dacryocystocele is a complex type of CNLDO.  It occurs as a result of a concomitant obstruction at the valve of Rosenmuller as well as at the valve of Hasner valve [19]. This leads to the accumulation of fluid in the lacrimal drainage system. The sac gets filled with mucoid discharge and

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13  Paediatric Endoscopic Dacryocystorhinostomy with Special Emphasis on Congenital Nasolacrimal…

a

b

c

d

Fig. 13.12 Schematic diagram along with the nasal endoscopic view of the corresponding pathology. a.  A normal patent NLD can be visualized opening into the right inferior meatus. b: An intact bulging membrane over the distal end of the NLD.  c. A lateral extension of the

NLD along the lateral wall of the IM seen as buried probe in the endoscopic view of the right nasal cavity. d. Dacryolith in the left inferior meatus seen to be bulging through an intact membrane over the valve of Hasner

looks like a grey-blue cystic swelling just below the medial canthus (Fig. 13.13). Ultrasound is a noninvasive and reliable method to differentiate dacryocystoceles from other conditions. Conservative methods like lacrimal sac massage may work but the neonates need to be watched regularly as they are obligatory nasal breathers so when the nose is obstructed by the cyst these patients will have respiratory distress during feeding and sleeping.

Nasal endoscopic examination can detect the size and extent of the intra-nasal cystic component and help in marsupialization (Fig.  13.14). The cyst wall is very thick in congenital dacryocystocele and for marsupialization, its wall is tented with a probe, a sharp cut is given over the cyst and the central portion of the cyst wall is removed. This is to ensure effective drainage with no chances of recurrence (Figs. 13.15, 13.16

13.1  Congenital Nasolacrimal Duct Obstruction (CNLDO)

Fig. 13.13  Probing in a case of left congenital dacryocele demonstrating regurgitation of thick discharge following rupture of its wall during probing

185

Fig. 13.15  Endoscopic view of the left nasal cavity demonstrating an incision over the intranasal cystic part of congenital dacryocele

Fig. 13.16  Marsupialized cyst with probe insitu Fig. 13.14  Incising the large nasal cystic part of dacryocele using a sickle knife Endoscopic view of the left nasal cavity demonstrating a large intranasal cystic part of congenital dacryocele

and 13.17). Free flow of dye is seen following irrigation (Fig. 13.18)

13.1.5.6 Dysgenesis of NLD NLD dysgenesis is considered in patients with CNLDO having difficulty in cannulating nasolac-

rimal canal during probing due to a malformed NLD. In such cases on nasal endoscopy, no NLD opening is seen and nasal mucosa looks tightly draped in the inferior meatus. On DEN the sac is normal with blind bottom and missing NLD opening as described in the chapter of dacryoendoscopy. Such cases cannot be treated by probing and syringing and thus endoscopic DCR is the only definitive treatment

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Fig. 13.17  Irrigation through upper punctum in process

obstruction and thus has an added advantage over nasal endoscopy assisted probing in refractory cases of CNLDO. Membranous obstructions in simple CNLDO can be overcome by nasal endoscopic guided probing. DEN is indicated when no free flow of dye is seen into the nose despite probing. There is an absence of membranous bulge or no NLD area is demarcated with stretched out nasal mucosa in the inferior meatus. A partial flow of dye into the nose is seen with significant regurgitation through both the puncta. Concretions/dacryolith in the nasolacrimal system, complete bony dysgenesis, an incomplete bony dysgenesis and fibrosis of the lower segment of NLD are difficult to diagnose on nasal endoscopy. The definite diagnosis of these conditions can be made only on DEN as it allows an intraluminal examination of NLD. Role of  DEN in refractory cases of CNLDO has already been published [45]. Those with dacryolith can be recanalized using both DEN and nasal  endoscopic (NE) assisted probing while those with bony dysgenesis need endoscopic DCR. DEN has been described in details in the chapter on current concepts in the management of nasolacrimal pathway obstructions

13.2 Endoscopic DCR

Fig. 13.18  Free flow of dye is seen in the nose

13.1.5.7 Complicated CNLDO CNLDO can present with associated upper lacrimal pathway disorders like punctal or canalicular disorders. The management depends on the associated pathology and has been explained in the chapter on upper lacrimal pathway disorders.

13.1.6 Dacryoendoscopy Dacryoendoscopy (DEN) facilitates direct examination of the nasolacrimal system and helps in accurate localization of the site and type of

DCR in children has its own set of challenges irrespective of the route used. Endoscopic DCR in children can be performed using a paediatric 2.7mm endoscope, that may be more suitable in younger children but in the hands of an experienced surgeon with good vasoconstriction of the nasal mucosa a 4mm endoscope can be used comfortably. Owing to the narrow nasal cavity, micro ear surgery instruments can be used in very young children needing endoscopic DCR.  Mucosal injury should especially be avoided in children as it can become an additional factor responsible for failure. This is due to the fact that rigorous post-­ operative nasal endoscopic checks are possible in adult and allow us to release synechiae and handle granulations but this  is not possible in children.

13.3  Surgical Technique

187

Not every child referred for endoscopic DCR may necessarily need surgery, some do respond to nasal endoscopic or dacryoendoscopic guided probing [45], thus a proper case selection is very important. The following flow chart explains the approach to a child who is referred for endoscopic DCR.

adrenaline solution in adults). Merocel packs are placed in the nasal cavity in between nasal septum and the middle turbinate, septum and inferior turbinate and in the inferior meatus. • Adrenaline infiltration is performed in the 1:100,000 concentration over the lateral wall

Approach to a Child Referred for Endoscopic DCR

Discharge

Watering

ROPLAS Test

Positive

FDDT Negative Patent

H/O Intervention Present

Obstructed

No Intervention • Functional Epiphora NLD Obstruction

H/O Conventional Probing

Plan

Unilateral

Inferior Meatal Endoscopy

Favorable Situation

Unfavorable Situation

Tightly draped membrane over VH

Probe can not be seen in 1M

Minimal mucosal movement seen in 1M on pressing over medial canthus

Endoscopic DCR

Punctal atresia

• Nasal allergy with oedema of NLD Mucosa

H/O Endoscopic Probing

Blocked

VH: Valve of Hasner, IM: Inferior meatus, FDDT: Fluorescein dye disappearance test, DEN: Dacryoendoscopy, NE: Nasal endoscopy

13.3 Surgical Technique The technique of the endoscopic DCR in children is similar to that of an adult in primary acquired NLD obstruction. In cases of refractory CNLDO complete sac and NLD should be exposed to observe the defects that led to the failure of probing and persistent epiphora. A missing NLD and a small sac point towards complete dysgenesis of NLD like described below. • Decongestion is done with merocel packs soaked in 1:30,000 adrenaline (unlike 1:1000

Bulging membrane over VH

Bilateral

Reassurance Conjunctival DCR later

Occasionally Dacryolith Probing DEN assisted recanalization or pushing the concretions by probing and syringing

Check Patency Freely patent

in children more than 2 years and in the concentration of 1:200,000  in children younger than 2 years of age (Fig. 13.19). • Nose is examined with 4mm/2.7mm paediatric endoscope for any septal deviation or concha bullosa blocking the proposed site of neo ostium. Inferior meatal examination in cases of CNLDO needing DCR is an important step. This is just to look for any possibility of the recanalization of the NLD with adjuvant use of dacryoendoscopy in addition to nasal endoscopy and also to understand the likely cause of failed previous intervention. • Deviated nasal septum can be infiltrated with lignocaine adrenaline to allow it to move out of the operative field or it can be generally pushed to the opposite side with a blunt dissector. Severe septal deviation in cases of

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13  Paediatric Endoscopic Dacryocystorhinostomy with Special Emphasis on Congenital Nasolacrimal…

Fig. 13.19  Endoscopic DCR in process on the left step with demonstration of infiltration as the first step

•

•

•

•

failed DCR, post-traumatic dacryocystitis and nasal and facial defects should be corrected by a limited endoscopic septoplasty. An incision is given over the lateral wall with horizontal and vertical limbs to create an inferior based ‘U’ shaped flap of the nasal mucosa (Figs.  13.20, 13.21, 13.22). This incision allows a complete sac and NLD exposure that enables examination of the NLD area. Any maldevelopment or dysgenesis of NLD in this area can be identified. The incision can also be given with micro ear surgical instruments like a circular knife, a side knife or a sickle knife in cases where the nasal cavity is narrow as seen in very young children. The frontal process of maxilla is not as hard in children as in adults. Therefore, gentle force is applied to the underlying bone while lifting the mucoperiosteal flap (Figs.  13.23, 13.24, 13.25). There are more chances of injury to the uncinate process and easy entry into lamina papyracea is possible in children in the absence of good control over the instruments. The bone removal starts with Kerrison punch (Karl Storz, Germany) to expose the lower part of the nasolacrimal system (Fig.  13.26). The superior portion of the frontal process of

Fig. 13.20  Endoscopic view of the left nasal cavity demonstrating an incision on the lateral wall

Fig. 13.21  DCR incision on the lateral wall in process

maxilla covering the fundus of the sac is drilled for complete exposure of the lacrimal sac. In cases of bony agenesis of NLD, the NLD cannot be seen, the sac looks small and can be seen ending blindly in one of the walls of the maxilla (Figs. 13.27, 13.28, 13.29). • This finding is not seen in acquired NLD obstruction in children where the obstruc-

13.3  Surgical Technique

189

Fig. 13.22  Lower horizontal limb of the incision to make a complete U shaped inferior based flap

Fig. 13.24  Reflecting the mucoperiosteal flap over the middle turbinate

Fig. 13.23  Lifting up of the left mucoperiosteal flap

Fig. 13.25  The frontal process of maxilla is seen with thin lacrimal bone seen (arrow)

tion lies at the distal end of NLD and the bony NLD is normal. In such cases  complete  sac and NLD can be visualized after bone removal unlike in NLD malformation described above. • DEN is an excellent tool to confirm this finding preoperatively. If DEN is not available, this defect should be identified during surgery

by drilling to search for the inferior extension of the sac and NLD. • The sac is tented with a probe and incised, flaps are created and the sac is marsupialized in the same way as in adults by giving superior and inferior horizontal incisions over the flap to open it like a book (Figs. 13.30, 13.31 and 13.32).

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Fig. 13.26  Lower part of the bony lacrimal fossa and lacrimal bone is removed using Kerrison punch to expose NLD and the lower part of the sac

Fig. 13.28  A fully exposed lacrimal sac looks small and can be seen ending blindly into the bone of the frontal process of maxilla

Fig. 13.29  The lacrimal sac looks small due to congenital absence of NLD in this child Fig. 13.27  Lacrimal sac is exposed and the lower part is drilled to search for NLD.

• Visualization of the probe through the common canaliculus is followed by a free flow of dye (Figs.  13.33 and 13.34).

Mitomycin C is applied and intubation  is performed. • Post-operatively, Tobramycin and Fluromethlone eye drops are used for 2 weeks. Stent removal is done after 4 weeks.

13.3  Surgical Technique

Fig. 13.30  Tenting of the sac can be seen with probe in-situ

Fig. 13.31  Incision being given over the lacrimal sac with a crescent knife

191

Fig. 13.32  Lacrimal sac lumen is palpated with ball probe and the sac flaps are reflected

Fig. 13.33  Probe can be seen into the nose after sac marsupialization

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13  Paediatric Endoscopic Dacryocystorhinostomy with Special Emphasis on Congenital Nasolacrimal…

is severe like in post-traumatic cases or in a syndromic association, a limited endoscopic septoplasty can be done. Limited septoplasty in young children does not negatively affect the growth of the face [46]. Elevation of nasal floor mucosa should not be done to avoid damage to the incisive nerves. Limited excisions of the cartilaginous part of the septum can be done [46]. Septal cartilage should not be separated from the perpendicular plate of the ethmoid especially near the dorsum as it may affect the height of the dorsum of the nose [46].

13.4.3 Success Rate Fig. 13.34  Fluorescein dye into the left nasal cavity indicating a successful procedure

Various studies published on endoscopic DCR in children have recorded high success rate of 88 and 100 % in post-saccal CNLDO [47].

13.4 Challenges in Paediatric Endoscopic DCR and Its Success Rate:

13.4.4 Complications of Paediatric Endoscopic DCR

13.4.1 Narrow Dimensions of the Nasal Cavity: Paediatric endoscopic DCR needs more expertise as compared to the adults due to narrow nasal pathway, less working space, more bleeding due to the limitation on the permiscible concentration of vasoconstrictor solution and high chances of mucosal injury.

13.4.2 Handling the Septal Deviations in Children Severe nasal septum deviation obscuring the proposed site of neo ostium in young children may pose challenges as the septoplasty is not encouraged in them. Any attempt to create space by pushing the septum to the opposite side with the elevator may fracture the bony cartilaginous junction. If the deviation is mild it can be handled by injecting vasoconstricting agent over the deviated area of the septum. However, if the deviation

Complications of endoscopic DCR have been reported in up to 8.6% of the patients and include haemorrhage, granulomas, emphysema, sinusitis, and rare complications such as orbital and intracranial traumas [53–57]. Failure in paediatric DCR occurs due to the aggressive healing responses resulting in cicatricial closures of ostia and granuloma formation [53–57]. • Key Points  The most common indication of endoscopic DCR in children is recalcitrant CNLDO.  Other indications include primary and secondary acquired NLD obstructions. • Paediatric size endoscope and micro-­ instruments may be needed in young children • Paediatric endoscopic DCR requires more expertise due to small dimensions of the nasal cavity • Case selection is crucial in children and the possibility of associated punctal disorder should be kept in mind. • Careful evaluation and use of dual endoscopy can obviate the need for endoscopic DCR in selected few cases.

References

References 1. Kominek P, Cervenka S.  Pediatric endonasal acryocystorhinostomy: a report of 34 cases. Laryngoscope. 2005;115:1800–3. 2. Cunningham MJ, Woog JJ.  Endonasal endoscopic dacryocystorhinostomy in children. Arch Otolaryngol Head Neck Surg. 1998;124:328–33. 3. Woog JJ.  Endonasal dacryocystorhinostomy. A report by the American academy of ophthalmology. Ophthalmology. 2001;108:2369–77. 4. Freitag SK, Woog JJ. Congenital nasolacrimal obstruction. Ophthalmol Clin North Am. 2000;13:705–18. 5. Celenk F, Mumbuc S, Durucu C, et  al. Pediatric endonasal endoscopic dacryocystorhinostomy. Int. J. Pediatr. Otorhinolaryngol. 2013;77:1259–62. 6. Nemet AY, Fung A, Martin PA, Benger R, Kourt G, Danks JJ & Tong JC Lacrimal drainage obstruction and dacryocystorhinostomy in children. Eye 2008;22:918–924. Cite this article. 7. Vanderveen DK, Jones DT, Tan H, Petersen RA.  Endoscopic dacryocystorhinostomy in children. J AAPOS. 2001;5:143–7. 8. Berlucchi M, Staurenghi G, Brunori P, Tomenzoli D, Nicolai P. Transnasal endoscopic dacryocystorhinostomy for the treatment of lacrimal pathway stenoses in pediatric patients. Int J Pediatr Otorhinolaryngol. 2003;67:1069–74. 9. Kashkouli MB, Kassaee A, Tabatabaee Z.  Initial nasolacrimal duct probing in children under age 5: cure rate and factors affecting success. J AAPOS. 2002;6:360–3. 10. MacEwen CJ, Young JDH, Barras CW, Ram B, White PS. Value of nasal endoscopy and probing in the diagnosis and management of children with congenital epiphora. Br J Ophthalmol. 2001;85:314–8. 11. Wallace EJ, Cox A, White P, MacEwen CJ. Endoscopic-assisted probing for congenital nasolacrimal duct obstruction. Eye. 2006;20:998–1003. https://doi.org/10.1038/sj.eye.6702049. 12. Gupta N, Chawla N, Bansal S, Das S. A comparison of the success rates of endoscopic-assisted probing in the treatment of membranous congenital nasolacrimal duct obstruction between younger and older children and its correlation with the thickness of the membrane at the valve of Hasner. Orbit. 2017:1–5. https://doi.org /10.1080/01676830.2017.1383483. 13. Aldo Vagge, Lorenzo Ferro Desideri, Paolo Nucci, Massimiliano Serafino, Giuseppe Giannaccare,Andrea Lembo, and Carlo Enrico Traverso. Diseases. Congenital Nasolacrimal Duct Obstruction (CNLDO): A Review. 2018;6(4): 96. 14. Sevel D.  Development and congenital abnormalities of the nasolacrimal apparatus. J. Pediatr. Ophthalmol. Strabismus. 1981;18:13–19. [PubMed] [Google Scholar] 15. Karti O, Karahan E, Acan D, Kusbeci T. The natural process of congenital nasolacrimal duct obstruction and effect of lacrimal sac massage. Int Ophthalmol. 2016 Dec;36(6):845–9.

193 16. Olitsky SE.  Update on congenital nasolacrimal duct obstruction. Int. Ophthalmol. Clin. 2014;54:1–7. https://doi.org/10.1097/IIO.0000000000000030. 17. Kamal S, Ali MJ, Gupta A, Naik MN. Lacrimal and nasal masquerades of congenital nasolacrimal duct obstructions: etiology, management, and outcomes. Int Ophthalmol. 2014; https://doi.org/10.1007/ s10792-015-0050-1. 18. Petris C., Liu D.  Probing for congenital nasolacrimal duct obstruction. Cochrane Database Syst. Rev. 2017;7:CD011109. 10.1002/14651858.CD011109. pub2. [PMC free article] [PubMed] [CrossRef] [Google Scholar] 19. Cavazza S, Laffi GL, Lodi L, Tassinari G, Dall’Olio D.  Congenital dacryocystocele: diagnosis and treatment. Acta Otorhinolaryngol Ital. 2008;28(6):298–301. 20. Kapadia MK, Freitag SK, Woog JJ.  Evaluation and management of congenital nasolacrimal duct obstruction. Otolaryngol Clin North Am. 2006;39:959–77. 21. Young JD, MacEwen CJ.  Managing congenital lacrimal obstruction in general practice. BMJ. 1997;315:293–6. 22. MacEwen CJ, Ogston SA.  Congenital nasolacrimal duct obstruction in the second year of life: a multicentre trial of management. Eye. 1996;10:485–91. 23. Zappa RJ, Milder B.  Lacrimal drainage function. 2. The fluorescein dye disappearance test. Am J Ophthalmol. 1972;74:160–2. 24. Alagoz G, Serin D, Celebi S, Kukner S, Elcioglu M, Gungel H. Treatment of congenital nasolacrimal duct obstruction with high-pressure irrigation under topical anesthesia. Ophthal. Plast. Recons. 2005;21:423–6. https://doi.org/10.1097/01.iop.0000183472.59203.48. 25. Eshragi B, Fard MA, Masomian B, Akbari M.  Probing for congenital nasolacrimal duct obstruction in older children. Middle East Afr J Ophthalmol. 2013;20(4):349–52. https://doi. org/10.4103/0974-9233.120018. 26. Takahashi Y, Kakizaki H, Chan WO, Selva D.  Management of congenital nasolacrimal duct obstruction. Acta Ophthalmol. 2010;88:506–13. 27. Olver J.  Colour atlas of lacrimal surgery. Oxford: Butterworth-Heinemann; 2002. Paediatric Lacrimal Surgery; pp. 69–89. 28. Baker JD. Treatment of congenital nasolacrimal system obstruction. J.  Pediatr. Ophthalmol. Strabismus. 1985;22:34–6. 29. Stager D, Baker JD, Frey T, Weakley DR Jr, Birch EE.  Office probing of congenital nasolacrimal duct obstruction. Ophthalmic. Surg. 1992;23:482–4. 30. Robb RM.  Probing and irrigation for congenital nasolacrimal duct obstruction. Arch. Ophthalmol. 1986;104:378–9. 31. Paul TO, Shepherd R.  Congenital nasolacrimal duct obstruction: natural history and the timing of optimal intervention. J. Pediatr. Ophthalmol. Strabismus. 1994;31:362–7. 32. Yasser HA.  Nasal endoscopy in the management of congenital nasolacrimal duct obstruction. Saudi J Ophthalmol. 2014;28:6–11.

194

13  Paediatric Endoscopic Dacryocystorhinostomy with Special Emphasis on Congenital Nasolacrimal…

33. Sener EC, Onerci M.  Reappraisal of probing of the congenital obstruction of the nasolacrimal system: is nasal endoscopy essential? Int J Pediatr Otorhinolaryngol. 2001;58:65–8. 34. Cakmak SS, Yildirim M, Sakalar YB, Keklikci U, Alakus F.  Is it necessary to accompany probing with endoscopy in cases of congenital nasolacrimal canal obstruction? Int J Pediatr Otorhinolaryngol. 2010;74(9):1013–5. 35. Ram B, Barras CW, White PS, MacEwen CJ.  The technique of nasal endoscopy in the evaluation of nasolacrimal obstruction in children. Rhinology. 2000;38:83–6. 36. Gardiner JA, Forte V, Pashby RC, Levin AV. The role of nasal endoscopy in repeat paediatric nasolacrimal duct. J AAPOS. 2001;5(3):148–52. 37. Galindo-Ferreiro A, Akaishi P, Cruz A, Khandekar R, et  al. Success Rates of conventional versus endoscope-­assisted probing for congenital nasolacrimal duct obstruction in children 12 years and younger. Journal of Pediatric Ophthalmology and Strabismus. 2016;53(5):292–9. 38. Kushner BJ.  The management of nasolacrimal duct obstruction in children aged between 18 months and 4 years. J AAPOS. 1998;2:57–60. 39. Ali MJ, Kamal S, Gupta A, Ali MH, Naik MN. Simple vs complex congenital nasolacrimal duct obstructions: etiology, management and outcomes. Int Forum Allergy Rhinol. 2015;5:174–7. 40. Jones LT, Wobig JL. Surgery of the eyelids and lacrimal system. Birmingham, AL: Aesculapius Publishing Co; 1976. p. 162–4. 41. Honavar SG, Prakash VE, Rao GN. Outcome of probing for congenital nasolacrimal duct obstruction in older children. Am J Ophthalmol. 2000;130:42–8. 42. Maheshwari R. Success rate and causes of failure for late probing for congenital nasolacrimal duct obstruction. J Pediatr Ophthalmol Strabismus. 2008; 43. Gupta N, Chawla N, Ganesh S, Das S, Dhawan N, Bansal S, Singla P.  Prevalence of buried probe in complex congenital nasolacrimal duct obstruction and evaluation of its success rate post ‘probing and irrigation’: a single-centre retrospective study. Orbit. 2018; https://doi.org/10.1080/01676830.2018.1435695. 44. Boger WP.  Congenital nasolacrimal duct obstruc tion. In: Albert DM, Jakobiec FA, editors. Principles and practice of ophthalmology, clinical practice. Philadelphia: WB Saunders; 1994. p. 2812–26. 45. Gupta N, Singla P, Kumar S, Ganesh S, Dhawan N, Sobti P, Aggarwal S.  Role of dacryoendoscopy in refractory cases of congenital nasolacrimal duct

obstruction. Orbit. 2019; https://doi.org/10.1080/016 76830.2019.1668434. 46. Cingi C, Muluk NB, Ulusoy S, Lopatin A, Sahin E, Passali D, et al. Septoplasty in children. Am J Rhinol Allergy. 2016;30:e42–7. 47. Cunningham MJ.  Endoscopic management of pediatric nasolacrimal Anomalies. Oper Tech Otorhinolaryngol. 2008;19:186–91. https://doi. org/10.1016/j.otot.2008.09.007. 48. Eloy P, Leruth E, Cailliau A, Collet S, Bertrand B, Rombaux P.  Pediatric endonasal endoscopic dacryocystorhinostomy. Int J Pediatr Otorhinolaryngol. 2009;73:867–71. https://doi.org/10.1016/j. ijporl.2009.03.006. 49. Cunningham MJ, Woog JJ.  Endonasal endoscopic dacryocystorhinostomy in Children. Arch Otolaryngol Head Neck Surg. 1998;124:328–33. 50. Cunningham MJ.  Endoscopic management of pediatric nasolacrimal anomalies. Otolaryngol Clin North Am. 2006;39:1059–74. https://doi.org/10.1016/j. otc.2006.07.004. 51. VanderVeen DK, Jones DT, Tan H, Petersen RA.  Endoscopic dacryocystorhinostomy in children. J AAPOS. 2001;5:143–7. https://doi.org/10.1067/ mpa.2001.114910. 52. Berlucchi M, Staurenghi G, Brunori PR, Tomenzoli D, Nicolai P. Transnasal endoscopic dacryocystorhinostomy for the treatment of lacrimal pathway stenoses in pediatric patients. Int J Pediatr Otorhinolaryngol. 2003;67:1069–74. 53. Komínek P, Cervenka S, Matousek P, Pniak T, Zeleník K. Primary pediatric endonasal dacryocystorhinostomy—a review of 58 procedures. Int J Pediatr Otorhinolaryngol. 2010;74:661–4. 54. Leibovitch I, Selva D, Tsirbas A, Greenrod E, Pater J, Wormald PJ. Paediatric endoscopic endonasal dacryocystorhinostomy in congenital nasolacrimal duct obstruction. Graefes Arch Clin Exp Ophthalmol. 2006;244:1250–4. 55. Limbu B, Katwal S, Lim NS, Faierman ML, Gushchin AG, Saiju R.  Comparing outcomes of pediatric and adult external dacryocystorhinostomy in Nepal: is age a prognostic factor? Orbit. 2017;36:237–42. 56. Chan W, Wilcsek G, Ghabrial R, Goldberg RA, Dolman P, Selva D, et al. Pediatric endonasal dacryocystorhinostomy: a multicenter series of 116 cases. Orbit. 2017:1–6. 57. Ali MJ, Paulsen F.  Syndromic and nonsyndromic systemic associations of congenital lacrimal drainage anomalies: a major review. Ophthal Plast Reconstr Surg. 2017;

Revision Endoscopic Dacryocystorhinostomy

Endonasal dacryocystorhinostomy (DCR) is an effective modality for treating patients of nasolacrimal duct obstruction (NLD). However, failures do occur for various reasons including cicatricial closure of the ostium, common canalicular obstruction, distal canalicular obstruction, granulomas and neo osteogenesis [1–14]. Intraoperative causes of failure include the difficulty in sac localization, inadequate and inappropriate bony window formation, uncorrected septal deviations and concha bullosa [1–14]. Success rates of endoscopic revision surgery range from 60% to 94% [15–23]. Although meticulously done revision surgery with complete sac marsupialization and mucosa to mucosa approximation leads to an enhanced success rate, it may be difficult in revision surgery due to the fibrosis and cicatrization. Therefore, all other factors like a deviated nasal septum, concha bullosa or nasal polyposis, responsible for crowding the space with a threat of synechiae formation should be corrected. In addition, an attempt should be made to cover as much as bone possible as there is an inflammatory reaction with the proliferation of capillaries leading to a pyogenic granuloma formation [24]. This leads to fibrosis and subsequent failure.

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14.1 I mportant Points in History of Failed Cases The failed cases of DCR should be assessed for the following parameters before revision surgery is performed. 1. Type of previous surgery 2. History of symptoms prior to the primary surgery 3. Examination findings 4. Time of failure of previous surgery: 5. Preoperative findings prior to primary surgery: 6. History of stent placement 7. Associated nasal abnormalities 1. Type of Previous Surgery: Previous surgery could be external DCR, endoscopic DCR or very rarely a laser DCR and conjunctival DCR history may be available. Commonly history of external or endoscopic DCR is the only factors that need to be looked into. a) External DCR: In cases operated by external route, there is generally a good bony window that can be palpated under the soft tissue but the site of

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bone removal is not always appropriate. Often a high bony window is found that is more anteriorly placed, leaving the sac unexposed. Sometimes there may be an associated indentation of the skin externally at the site of the bony window as described below in situation 1. Cicatrization of ostium is another factor that is more common in previous external DCR but overall, there is both inappropriate and inadequate bony window leaving a remnant of the sac behind as explained in the various situations described below. b ) Endoscopic DCR: In cases of failed endoscopic DCR, the cause of failure invariably is an inadequate bone removal. This is due to the inability to remove superior bone over the frontal process of the maxilla as the bone here is thick and sagittal. There is difficulty in engaging a straight Kerrison punch and the curved punches fail to transmit sufficient force at the tip. This superior bone drilling has a learning curve. The second common cause of failure found in endoscopic DCR is the adhesion between the middle turbinate and the lateral wall near the axilla of the middle turbinate. This is a crucial site as the mucosal incision extends above the axilla and any raw area left near the fundus of the sac leads to synechiae formation. Ensuring adequate drilling at this site, respecting the mucosa superiorly and covering the bare bone leads to a successful outcome. 2. History of Symptoms Prior To the Primary Surgery: History of sticky or mucopurulent discharge prior to the primary surgery indicates an NLD obstruction. Simple watering is often associated with canalicular obstruction and failure in such cases carries a possibility of having missed any punctal or canalicular stenosis during the previous surgery. The patient should therefore be thoroughly assessed using the correct technique of probing and syringing as described earlier in chap. 6.

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3. Time of Failure of Previous Surgery: Immediate failure indicates the inability to create a fistula between the sac and the nose. Intermediate failure occurring within the first 4  weeks could be due to an inadequate size of window or the ostium shrinkage as maximum shrinkage of the ostium occurs by the first 4 weeks and very little beyond that [25, 26]. Late failures in endoscopic DCR could be secondary to chronic granulomatous changes in the nose involving nasolacrimal system like tuberculosis as reported earlier [27]. 4. Preoperative Findings Prior To Primary Surgery: Though it is difficult to know preoperative details prior to the first surgery but if available can be very helpful in knowing the causes of failure. Details of preexisting nasal abnormalities and canalicular obstructions and whether they were managed or not will have a bearing on the outcome of revision surgery.

14.2 Preoperative Assessment in Failed Cases of DCR 1. External Examination: External examination of the nose, medial canthal area and the eye is performed to look for any swelling, scar, fistula or puckering of the skin. Regurgitation test is performed and a positive ROPLAS (Regurgitation on pressure over the lacrimal sac area) test is diagnostic of NLD obstruction. 2. Irrigation: On irrigation regurgitation of the turbid fluid through the opposite punctum always indicates NLD obstruction while regurgitation of the clear fluid through the opposite punctum suggests the possibility of either an NLD obstruction or a common canalicular obstruction. 3. Probing: Differentiation between a soft stop and hard stop is important and is done as described in chap. 6. If a soft stop is present, a comprehensive mangement plan is made for revision sur-

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gery including the management of canalicular obstruction. 4. Nasal Endoscopy: Nasal endoscopy forms an important part in the preoperative evaluation of failed DCR and includes evaluation of the site of the previous osteotomy. The area of the previous ostium is often marked by granulations, discharge and synechiae between the middle turbinate. There could be other associated nasal abnormalities like a grossly deviated nasal septum, stent embedded in granulations, a large unaddressed concha with synechiae and sometimes polyps.  A meticulous primary surgeryis planned based on the findings.

14.3 Surgical Steps Every case of a failed DCR is different and therefore needs to be dealt with differently. Following are some of the situations giving a detailed description of stepwise surgical ­correction of failed cases with analysis of possible causes of failure.

Fig. 14.1  Endoscopic view of the left nasal cavity in a failed case, demonstrating an organized granuloma with a stent embedded into it following an endoscopic DCR with intubation

14.3.1 Situation 1 • A 60-year-old lady presents with persistent epiphora following an endoscopic DCR with bicanalicular silicone stenting performed a month ago. • On nasal endoscopic examination, a stent was seen lying embedded in the infected granuloma with a significant high posterior deviation of the septum (Fig. 14.1). • Septal correction was done as the first step by a limited endoscopic septoplasty. The deviated portion was injected and an incision was given approximately 1  cm anterior to the deviated portion. The mucoperichondrial flap was lifted on both sides of the septum and the deviated portion of the cartilage was separated from the contralateral flap, and was excised and removed (Figs. 14.2, 14.3, 14.4, and 14.5). • The granuloma was excised and the stent was examined (Fig. 14.6). The stent was found to

Fig. 14.2  Gross septal deviation on the left side obstructing the view of the middle turbinate and its attachment on the lateral wall. The deviated septum is infiltrated with saline adrenaline solution

be coming out through the posteroinferior part of the uncinate process (Figs. 14.7 and 14.8). The stent was not removed at this stage considering that it may guide us to the lacrimal sac lumen.

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Fig. 14.3  An incision is given anterior to the deviated part of the septum

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Fig. 14.5  The deviated cartilage is separated on both sides and is removed

Fig. 14.4  The mucoperichondrial flap is lifted using a suction dissector

Fig. 14.6  Adequate space is created following septal correction and a large infected granuloma can be seen on the lateral wall with embedded stent

• The routine DCR incision was given over the lateral wall followed by lifting of the mucoperiosteal flaps (Figs. 14.9, 14.10, and 14.11). • An intact bone was found under the flaps indicating the inability to remove bone in the previous surgery. The bone was drilled and the lacrimal sac area was exposed (Fig.  14.12), sac walls were found to be adherent to the overlying mucoperiosteal flap (Fig. 14.13).

• The stent was examined and was found to be lying in a false passage created through the bone posterior to the uncinate process with a breach in the lamina papyracea (Figs.  14.14 and 14.15). The loop of the stent in the medial cantus was cut and was retrieved through the nose (Figs.  14.16, 14.17, and 14.18).

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Fig. 14.7  The granuloma is excised and the stent can be seen lying engulfed in mucosa with no nasal ostium in view

Fig. 14.9  An incision is given over the lateral wall using a 15no blade

Fig. 14.8  Stent is seen to be exiting from a false tract in the posteroinferior part of the uncinate process

Fig. 14.10  Mucoperiosteal flap is lifted without dislodging the stent

• Fat prolapse was seen at the site of stent removal indicating a breach in the periorbita (Fig. 14.19). • The lacrimal sac was opened and probing was done through both the upper and lower canaliculus but the probe could not be seen in the nose. The lower canaliculus had a soft stop at 3 mm indicating a proximal canalicu-

lar obstruction and the upper canaliculus had a soft block at 9  mm indicating a distal canalicular obstruction. • Upper canalicular trephination was done using Sisler’s trephine (Figs.  14.20, 14.21, 14.22, and 14.23). The lower canaliculus was left undisturbed as the trephination is not successful in cases of proximal obstruction.

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Fig. 14.11  The flap was found to be adherent to the underlying bone with the stent lying inferior to the mucoperiosteal flap

Fig. 14.13  Lacrimal sac is excised, thick mucosal flap adherent with the sac wall are seen

Fig. 14.12  Frontal process of maxilla is drilled to expose the lacrimal sac

Fig. 14.14  The stent is traced but is found to be exiting from a point much posterior to the sac

• The free flow of dye was seen in the nose on irrigating through the upper punctum (Fig. 14.24). • Mitomycin C was applied in a concentration of 0.2 mg/ml with circumostial injection of 0.02% in line with the published protocols [28, 29].

• A monocanalicular Mini Monoka stent was placed through the upper punctum and the stent was secured in the nose with gel foam (Figs. 14.25, 14.26, and 14.27).

14.3  Surgical Steps

Fig. 14.15  A close-up view of the stent demonstrating the exit point of the stent

Fig. 14.16  The loop of silicone stent from medial canthal area is cut with scissors

14.3.1.1 Interpretation This patient was found to have both upper and lower canalicular obstruction at the time of revision surgery. There is a possibility that this canalicular obstruction existed even before the primary surgery and might have been missed during preoperative evaluation. An accurate diagnosis helps in proper planning involving the correction of cana-

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Fig. 14.17  Endoscope is placed in the nose and the knot is held with the forceps

Fig. 14.18  The cut ends of the stent are seen into the nose (arrow)

licular obstructions, p­redicting outcome and explaining the prognosis to the patient.

14.3.2 Situation 2 • A 52-year-old male presented with persistent epiphora following two attempts of right exter-

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Fig. 14.19  Fat prolapse can be seen after stent removal indicating a breech in periorbita due to the false passage created during stenting (arrow)

Fig. 14.20 A Sisler’s trephine is placed through the upper punctum

nal DCR.  On examination, a scar with a depression was seen in the medial canthal area (Fig. 14.28). The nasal endoscopy on the right side showed granuloma formation anterosuperior to the location of the fundus of the sac on the lateral wall and no nasal ostium could be located (Fig. 14.29). A computed tomographic dacryocystography (CT DCG) was done. ­Coronal and axial cuts revealed a bony win-

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Fig. 14.21  The level of obstruction is confirmed as described in the chapter on the upper lacrimal pathway and the trephine is gently rotated between the thumb and the index finger. Simultaneous nasal endoscopy is done to view the passage of trephine

Fig. 14.22  The trephine finally enters the nose by overcoming canalicular obstruction

dow made very high close to the nasal bones and a contrast opacified remnant of the sac (Figs. 14.30, 14.31, and 14.32). • Infiltration and incisions were given and the mucoperiosteal flaps were lifted (Fig. 14.33). A lot of fibrosis was seen in the superior part indicating a probable site of the previous osteotomy (Fig. 14.34). Bone over the major part of the lacrimal sac was intact. This bone was drilled and continued superiorly to

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Fig. 14.23  A close view of the common canalicular opening seen after trephination

Fig. 14.25  A monocanalicular Mini Monoka stent was passed through the upper punctum and was secured into the nose

Fig. 14.24  On irrigating the upper canalicular system dye can be seen flowing freely indicating a successful trephination

expose the complete sac including the fundus (Figs. 14.35 and 14.36). The sac was opened using a crescent knife (Figs.  14.37 and 14.38). Probe was seen coming out of the common canaliculus (Fig.  14.39). Mucosal tags around common canalicular opening were cleared and mitomycin C was applied topically as well as circumostial injection of mitomycin C was given, followed by a stent placement (Fig. 14.40). Dynamic movement of the stent was checked and fluorescein dye

Fig. 14.26  The other end of the stent is pulled out through the nose

test demonstrated free flow at 4  weeks (Figs. 14.41, 14.42, and 14.43)

14.3.2.1 Interpretation This is a case of an inappropriate location of the bony osteum. Despite a good amount of bone removal during previous surgery, as is evident

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Fig. 14.29  Endoscopic view of the right nasal cavity demonstrating granuloma and discharge with closed ostia Fig. 14.27  Collar of the Mini Monoka stent seen over the upper punctum (arrow)

Fig. 14.28  A small depression in the skin over the medial canthus area can be seen at the scar site from previous surgery Fig. 14.31  CT DCG Coronal section demonstrate a contrast opacified remnant of the sac

Fig. 14.30  CT DCG Coronal section demonstrates a right bony window from previous surgery

14.3  Surgical Steps

Fig. 14.32  CT DCG axial section demonstrates a small bony window (arrow) with no contrast into the NLD

Fig. 14.33  Incision over the lateral wall is followed by lifting the mucoperiosteal flaps with previous site of osteotomy marked (star)

from CT also, the sac could not be opened. Endoscopic identification of landmarks followed by bone removal led to a successful marsupialization of the sac.

14.3.3 Situation 3 • A 35-year-old lady complained of persistent epiphora following an external DCR. The preoperative diagnosis prior to external DCR was

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Fig. 14.34  The bone over the lacrimal sac is intact and a previous bony window is seen lying anteriorly and superiorly (star) with fibrosis of the overlying flap

Fig. 14.35  Drilling of the frontal process of the maxilla is done

a lacrimal sac mucocele. Such cases generally, have good outcome but this patient remained symptomatic and the regurgitation test was positive (Fig. 14.44). • On nasal endoscopic examination, granulations were seen on the lateral wall of the nose at the root of the middle turbinate and no ostium could be seen (Fig. 14.45). • During revision surgery, an incision was given and the mucoperiosteal flap was lifted (Figs. 14.46 and 14.47). A small bony window

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Fig. 14.36  Bone over the fundus of the sac is checked

Fig. 14.37 The exposed lacrimal sac area is examined  with fibrosed and thickened walls (B; Bone, LS; Lacrimal sac, MT; Middle turbinate)

was seen in the superior part of the fossa indicating the previous site of osteotomy ­ (Fig. 14.48). The rest of the bone covering the lacrimal sac and NLD was found to be intact. • The bone was drilled to expose the sac in its full length. The sac walls were adherent to the overlying mucosal flaps (Fig. 14.49), and the lumen was occupied with a lot of inflammatory tissue (Fig. 14.50). • The thick flaps were trimmed with microdebrider and the inflammatory tissue was cleaned. A Bowman’s probe was passed through the upper punctum into the nose. The

14  Revision Endoscopic Dacryocystorhinostomy

Fig. 14.38  Crescent knife is used to give incision over the medial wall of the lacrimal sac along its whole length

Fig. 14.39  Sac is opened and a probe can be visualized coming out of the common canaliculus

probe could be moved freely in and out of the nose but the sac appeared small and contracted and the common canalicular opening could not be visualized (Fig. 14.51). • Thus, the area inferior to the probe was cleared by sharp cut as well as by debriding the inflammatory tissue. A large inferolateral outpouching of the sac was found as a hollow tubular structure extending down from the lacrimal sac (Figs.  14.52 and 14.53). The diverticulum was marsupialized along with ­ sac leading to a favourable outcome.

14.3  Surgical Steps

Fig. 14.40  Bicanalicular silicone stent is placed through the upper and the lower punctum and the two ends of the stent are tied in the nose

Fig. 14.41  Four weeks postoperatively dynamic movement of the stent can be seen in the nose

14.3.3.1 Interpretation In this case during external DCR, a large dacryocele was marsupialized during previous surgery and the surgery was considered as complete while a pouch was left behind. Since preoperative CT DCG was not performed this hidden diverticulum was missed during previous external DCR. Diverticula are often better visualized during endoscopic DCR as an enlarged view is obtained on the screen. Thus if

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Fig. 14.42  Fluorescein dye is instilled into the eye

Fig. 14.43  A nicely formed ostium with free flow of dye can be seen

an external DCR is planned in a case of acquired dacryocystocele a possibility of lacrimal sac diverticulum should be kept in mind.

14.3.4 Situation 4 • A 45-year-old lady presented with persistent epiphora, conjunctival chemosis, redness and

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Fig. 14.46  An incision is given over the lateral wall with a15no blade Fig. 14.44  Clinical photograph of a patient with persistent epiphora and a positive ROPLAS test following an external DCR for left lacrimal sac mucocele

Fig. 14.47  Mucoperiosteal flaps are lifted and the bony defect is seen superiorly with overlying flap adherent to it Fig. 14.45  Endoscopic view of the left nasal cavity demonstrating granulations over the lateral wall near the anterior attachment of the middle turbinate with a closed ostium

discharge from her left eye despite one endoscopic DCR and two external DCR with fistulectomy in the second attempt (Fig. 14.54). • Nasal endoscopy showed granulations on the lateral wall of the nose with oedematous mucosa and no ostium from previous surgery could be visualized (Fig. 14.55). • Incision was given over the lateral wall and the mucoperiosteal flap was raised (Fig. 14.56). Intact bone was found covering the upper two third of the sac with only a lower small portion of the sac exposed, which

could be identified by pressing the medial canthal area (Figs.  14.57 and 14.58). The bone was drilled leading to complete sac exposure (Fig. 14.59). • The sac was incised using a crescent knife and thick pus was drained. A bicanalicular intubation was done (Figs.  14.60, 14.61, and 14.62).

14.3.4.1 Interpretation The sac remained unexposed despite three surgeries. The major portion of the sac was still covered under the thick bone leading to recurrent infections. Endoscopic bone removal, complete sac exposure and marsupialization led to complete recovery.

14.4  Analysis of the Causes of Failure

Fig. 14.48  A small bony window was seen in the superior part of the fossa indicating the previous site of the osteotomy (arrow). The rest of the bone covering the lacrimal sac and NLD was found to be intact.

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Fig. 14.51  A probe is passed through the upper punctum and can be seen surrounded by thick inflamed tissue and intrasac synechiae

Fig. 14.49  Bone removal starts from the inferior part of the frontal process of the maxilla Fig. 14.52  The area around inferior to the probe is cleaned to open the sac fully and to visualize the common canalicular opening

14.4 Analysis of the Causes of Failure

Fig. 14.50  The exposed lacrimal sac has distorted walls adherent to the overlying nasal mucosa

Although inadequate bone removal is the most common cause of failure, most cases have multiple aetiologies for the previous failure [31]. The causes vary from a blocked ostium due to membranous scarring, sump syndrome, small ostium, a too high ostium and common canalicular obstruction [30].

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Fig. 14.53  A Bowman’s probe can be seen coming out of the common canalicular opening Fig. 14.55  Endoscopic view of the left nasal cavity demonstrating granuloma on the lateral wall and no ostia can be seen

Fig. 14.54  Clinical photograph of a patient who presented with persistent epiphora following 3 attempts at DCR surgeries before, 2 external DCR, one endoscopic DCR with fistulectomy. A scar can be seen below the medial canthus with conjunctival chemosis and an eye full of watering. External DCR scar is seen over the left medial canthus area

Additional procedures like septoplasty, synechiae release and canalicular trephination were performed in some of the cases at the time of revision DCR. Literature reports causes of failure in the hands of an experienced surgeon verses inexperienced surgeons. It was found that the granulation tissue was the common cause of failure among experienced surgeons while inappropriate ostium location was the common cause among the inexperienced surgeons [4].

Fig. 14.56  Incision is given and the mucoperiosteal flap is lifted

We found inadequate osteotomy as the most common cause of failure in line with the published reports [1]. Uncorrected nasal pathologies like significant septal deviations and middle turbinate hypertrophies are more in cases of previous external DCR when compared with endoscopic DCRs [12].

14.4  Analysis of the Causes of Failure

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Fig. 14.57  A bony defect seen in the inferior part of the frontal process of the maxilla (arrow), showing a partially exposed sac (star) with most of the bone lying intact

Fig. 14.59  The intact bone is drilled and the sac is fully exposed

Fig. 14.58  The bony defect is palpated with a blunt dissector

Fig. 14.60  The sac is incised using a crescent knife

Liang et al. [2] studied 25 revision endoscopic DCRs and found that the viable agger nasi cell reflects inappropriate sac localization and inadequate sac exposure during the primary surgery and hence contributes to the surgical failure [2]. This is a very important point that emphasizes the need for identifying and opening the agger nasi during primary surgery. Agger nasi lies in close

relation to the fundus of the sac and opening up agger nasi ensures complete sac exposure leading to better outcomes. A better understanding of the intranasal anatomy of the lacrimal sac [31] helps in complete sac exposure and marsupialization. A complete mucosa to mucosa approximation of the newly created ostium helps in healing without granulation formation and minimizes the chances of synechiae formation.

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• Lacrimal sac diverticulum should be looked for on CT DCG in cases of acquired dacryocystocele to prevent failure. • Correction of associated nasal pathologies must be done during revision endoscopic DCR primary surgery involving complete sac marsupialization, opening up of agger nasi, mucosa to mucosa approximation leads to better outcome.

References

Fig. 14.61  Thick mucopurulent discharge can be seen flowing out of the sac

Fig. 14.62  Bicanalicular silicone intubation is done

Key Points • Inadequate bone removal is the most common cause of failure in endoscopic DCR and inappropriate bone removal is commonly seen in external DCR. • Revision surgeries are challenging and each case is different. A thorough preoperative evaluation with proper surgical planning results in a successful surgery.

1. Dave TV, Mohammed FA, Ali MJ, Naik MN. Etiologic analysis of 100 anatomically failed dacryocystorhinostomies. Clin Ophthalmol. 2016;10:1419–22. 2. Liang J, Hur K, Merbs SL, Lane AP. Surgical and anatomic considerations in endoscopic revisions of failed external dacryocystorhinostomy. Otolaryngol Head Neck Surg. 2014;150(5):901–5. 3. Elmorsy SM, Fayk HM. Nasal endoscopic assessment of failure after external dacryocystorhinostomy. Orbit. 2010;29(4):197–201. 4. Onerci M, Orhan M, Ogretmenoglu O, Irkec M. Long-­ term results and reasons for failure of intranasal endoscopic dacryocystorhinostomy. Acta Otolaryngol. 2000;120(2):319–22. 5. Welham RAN, Wulc AE. Management of unsuccessful lacrimal surgery. Br J Ophthalmol. 1987;71(2):152–7. 6. Demarco R, Strose A, Araujo M, et  al. Endoscopic revision of external DCR.  Otolaryngol Head Neck Surg. 2007;137(3):497–9. 7. Ari S, Kürşat Cingü A, Sahin A, Gün R, Kiniş V, Caça I.  Outcomes of revision external dacryocystorhinostomy and nasal intubation by bicanalicular silicone tubing under endonasal endoscopic guidance. Int J Ophthalmol. 2012;5(2):238–41. 8. El-Guindy A, Dorgham A, Ghoraba M.  Endoscopic revision surgery for recurrent epiphora occurring after external dacryocystorhinostomy. Ann Otol Rhinol Laryngol. 2000;109(4):425–30. 9. Narioka J, Ohashi Y.  Transcanalicular-endonasal semiconductor diode laser-assisted revision surgery for failed external dacryocystorhinostomy. Am J Ophthalmol. 2008;146(1):60–8. 10. Choussy O, Retout A, Marie JP, Cozlean A, Dehisdin D.  Endoscopic revision of external dacryocystorhinostomy failure. Rhinology. 2010;48(1):104–7. 11. Hull S, Lachlan SA, Olver JM. Success rates in powered endonasal revision surgery for failed dacryocystorhinostomy in a tertiary referral center. Ophthal Plast Reconstr Surg. 2013;29(4):267–271.1. 12. Paik JS, Cho WK, Yang SW.  Comparison of endoscopic revision for failed primary external versus endoscopic dacryocystorhinostomy. Clin Experiment Ophthalmol. 2013;41(2):116–21.

References 13. Joshi RS.  Conventional dacryocystorhinostomy in a failed trans-canalicular laser-assisted dacryocystorhinostomy. Indian J Ophthalmol. 2011;59(5):383–5. 14. McMurray CJ, McNab AA, Selva D. Late failure of dacryocystorhinostomy. Ophthal Plast Reconstr Surg. 2011;27(2):99–101. 15. Baek JS, Jeong SH, Lee JH, Choi HS, Kim SJ, Jang JW.  Cause and management of patients with failed endonasal dacryocystorhinostomy. Clin Exp Otorhinolar. 2017;10(1):85–90. 16. Mathew MR, McGuiness R, Webb LA, Murray SB, Esakowitz L. Patient satisfaction in our initial experience with endonasal endoscopic non-laser dacryocystorhinostomy. Orbit. 2004 Jun;23(2):77–85. 17. Metson R.  Endoscopic surgery for lacrimal obstruction. Otolaryngol Head Neck Surg. 1991 Apr;104(4):473–9. 18. Ragab SM, Elsherif HS, Shehata EM, Younes A, Gamea AM.  Mitomycin C-enhanced revision endoscopic dacryocystorhinostomy: a prospective randomized controlled trial. Otolaryngol Head Neck Surg. 2012 Nov;147(5):937–42. 19. Weidenbecher M, Hosemann W, Buhr W. Endoscopic endonasal dacryocystorhinostomy: results in 56 patients. Ann Otol Rhinol Laryngol. 1994 May;103(5 Pt 1):363–7. 20. El-Guindy A, Dorgham A, Ghoraba M.  Endoscopic revision surgery for recurrent epiphora occurring after external dacryocystorhinostomy. Ann Otol Rhinol Laryngol. 2000 Apr;109(4):425–30. 21. Zeldovich A, Ghabrial R.  Revision endoscopic dacryocystorhinostomy with betamethasone injection under assisted local anaesthetic. Orbit. 2009;28(6):328–31. 22. Korkut AY, Teker AM, Ozsutcu M, Askiner O, Gedikli O. A comparison of endonasal with external

213 dacryocystorhinostomy in revision cases. Eur Arch Otorhinolaryngol. 2011 Mar;268(3):377–81. 23. Choussy O, Retout A, Marie JP, Cozlean A, Dehesdin D.  Endoscopic revision of external dacryocystorhinostomy failure. Rhinology. 2010 Mar;48(1):104–7. 24. Jordan DR, Brownstein S, Lee-Wing M, Ashenhurst M. Pyogenic granuloma following oculoplastic procedures: an imbalance in angiogenesis regulation? Can J Ophthalmol. 2001 Aug;36(5):260–8. 25. Mann BS, Wormald PJ. Endoscopic assessment of the DCR ostium after endoscopic surgery. Laryngoscope. 2006;116:1172–4. 26. Chan W, Selva D.  Ostium shrinkage after endo scopic dacryocystorhinostomy. Ophthalmology. 2013;120:1693–6. 27. Gupta N, Janaki RV, Ali MJ. Primary nasal tuberculosis with lacrimal drainage involvement. Int J Paediatr Otorhi Extra. September 2017;17:1–3. 28. Ali MJ, Mariappan I, Maddileti S, Ali MH, Naik MN.  Mitomycin C in dacryocystorhinostomy: the search for the right concentration and duration  – a fundamental study on human nasal mucosa fibroblasts. Ophthal Plast Recontr Surg. 2013;29:496–74. 29. Kamal S, Ali MJ, Naik MN.  Circumostial injection of mitomycin C (COS-MMC) in external and endoscopic dacryocystorhinostomy: efficacy, safety profile, and outcomes. Ophthal Plast Reconstr Surg. 2014 Mar–Apr;30(2):187–90. 30. Hull PS, Lalchan SA, Olver JM. Optimising success in endoscopic revision surgery for failed dacryocystorhinostomy. Invest Ophthalmol Vis Sci. April 2009;50:4830. 31. Wormald PJ, Kew J, Van Hasselt CA.  The intranasal anatomy of nasolacrimal sac in endoscopic dacryocystorhinostomy. Otolaryngol Head Neck Surg. 2000;123(3):307–10.

An Overview of Nasolacrimal Duct (NLD) Encountered in Different Situations; Identification, Prevention and Management of NLD Injuries

Nasolacrimal duct (NLD) is a very important structure on the complex lateral nasal wall. It forms an integral part of the lacrimal drainage pathway. It is encountered during various endoscopic surgical procedures like functional endoscopic sinus surgery, endoscopic median maxillectomy, extended maxillary mega antrostomy, inferior meatal antrostomy, inferior turbinectomy, rhinoplasty and faciomaxillary trauma [1–5]. NLD is a downward continuation of the lacrimal sac with a bony component that is approximately 12mm in length and a membranous part of approximately 5mm [6, 7]. It is directed laterally, posteriorly and downward [6, 7]. To identify NLD during nasal and sinus surgery it is important to know the distances between the lacrimal drainage pathway and various anatomical structures on the lateral wall of the nose [8]. NLD anatomy has been studied by various authors radiologically [9–11] as well as by cadaveric studies [12–15] and has been described in detail in the chapter on anatomy and radiology of lacrimal drainage system (LDS). The aim of including NLD overview as a separate chapter is to

15

3. Ways of handling NLD in pre-lacrimal approaches.

15.1 M  ode of NLD Injury in Endoscopic Sinus Surgery

NLD injury in functional endoscopic sinus surgery has been documented by various authors [8, 16–21]. Some authors have reported no symptoms stating  that the nasolacrimal duct injury does not always lead to epiphora [8] but others found symptomatic NLD injury following functional endoscopic sinus surgery in 8 cases and all patients were treated with dacryocystorhinostomy (DCR) [16]. As described in the chapter on anatomy, the mean distance of the natural ostium of the maxillary sinus to the NLD is 5.5 mm. The shortest distance between the NLD and the natural ostium of the maxillary sinus was found to be 4.8 mm [8]. The cause of injury in a series by Serdahl et al was the inadvertent removal of the thick bone surrounding the NLD during the anterior widening of maxillary sinus ostium using a backbiting forceps [16] (Figs. 15.1 and 15.2). They thus sug1. Highlight the vulnerable site and mode of gested that, performing middle meatal antros NLD injury in endoscopic sinus surgery. tomy in the posteroinferior direction minimizes 2. Emphasize the importance of focussing on the the chance of nasolacrimal duct damage8(Fig. status of sac and NLD during preoperative CT 15.3). evaluation of cases posted for  endoscopic In this case of recurrent antrochoanal polyp sinus surgery. This helps in detecting any pre-­ (Fig. 15.4), a wide middle meatal antrostomy can existing dehiscence of NLD. be seen on a CT scan (Fig. 15.5). Intraoperatively

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Fig. 15.1  A backbiting punch demonstrating wrongly directed in the antero-superior direction 

Fig. 15.3 A posteroinferiorly directed punch facing away from the NLD indicating a safe direction for widening of the maxillary sinus ostium

Fig. 15.2  A backbiting punch demonstrating wrong  in the antero-superior portion

a large polyp was seen coming out of a wide ostium with the anterior widening of the ostium that had led to entrapment and injury of NLD as described above (Fig. 15.6). The chances of NLD damage are high in revision surgery like in this case, the patient was operated twice before and presented with epiphora following the second surgery. This patient underwent a revision endoscopic sinus surgery with endoscopic DCR in the same sitting with a successful outcome (Fig.  15.7). The sac was

Fig. 15.4  A case of iatrogenic right NLD injury following endoscopic sinus surgery for an antrochoanal polyp with recurrence of a large polyp. Patient presented with epiphora

small and the site of NLD injury was identified in the proximal part of NLD near the anterior border of the mega antrostomy (Figs.  15.8 and 15.9). The direction of punch is important as mentioned in Fig. 15.3 and one needs to be more cautious in revision surgery.

15.2  Importance of Preoperative CT DCG in Lacrimal Drainage Disorders

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Fig. 15.5  CT scan of paranasal sinus showing a large right maxillary sinus ostium with complete opacity of the right maxillary antrum

Fig. 15.7  Lacrimal sac is exposed

Fig. 15.6  First step of endoscopic DCR in such cases involves endoscopic sinus surgery. The large polyp is pulled down to see its attachment. A wide maxillary ostium is seen and also the site of NLD injury during previous surgery is marked

15.2 Importance of Preoperative CT DCG in Lacrimal Drainage Disorders The chances of the injury to NLD are more in cases with radiological evidence of preoperative bony NLD dehiscence [1, 19]. Preoperative presence of this NLD dehiscence was found on radio-

Fig. 15.8  Sac is incised and a probe is passed through the lumen

logical studies in 3.3% to 20% cases [1, 19]. Thus a CT scan  must be ordered prior to endoscopic DCR in cases with severe nasal symptoms, widening of the nasal dorsal framework (Fig. 15.10) and presence of nasal polyposis on endoscopy (Fig.  15.11). Other associated  conditions like fungal sinusitis and  bone erosion must be confirmed on CT scan (Fig. 15.12). CT scan demonstrates opaque sinuses filled with polyps and

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Fig. 15.9  Site of NLD injury could be visualized(star)

Fig. 15.11  Endoscopic view of the left nasal cavity of same patient in Fig. 15.9, demonstrates large polyps filling the nasal cavity

Fig. 15.10  Clinical photograph of a patient with widening of the dorsum along with crooked nose to the left due to the polyps filling the left nasal cavity

secretions (Fig. 15.13). Axial cuts demonstrated dehiscent NLD on the left side (Fig.  15.12). Extensive polyps were seen involving the uncinate process as well the lacrimal bone with thinning of the frontal process of maxilla. On clearing the polyps, the posterior part of the nasolacrimal system could be seen indicating the dehiscence of the bony canal (Fig.  15.14). This was confirmed by pressing the medial ­canthal area. A close look revealed a major portion of sac and NLD lied exposed (Fig.  15.15). Endoscopic sinus surgery was completed

Fig. 15.12  CT scan axial section of the paranasal sinuses demonstrating a dehiscence in the bony NLD (arrow)

c­arefully keeping the lacrimal drainage system intact. Having the radiological impression,  a dehiscent bony NLD was anticipated and it thus made intraoperative identification easy. Thinned out the frontal process of the maxilla was seen covering the anterior half of the sac and NLD. Careful identification of the lacrimal drainage system assisted by prior ­knowledge of bony breach on CT scan helped in preventing injury.

15.3  NLD in Pre-Lacrimal Approaches

Fig. 15.13  All sinuses are completely opaque due to the polyps filling all the sinuses

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Fig. 15.15  A close up view shows complete posterior border of the left  nasolacrimal system exposed (arrow), due to the pressure  erosion  of lacrimal bone and thinning  of frontal process of maxilla due to long standing polyposis

15.3 NLD in Pre-Lacrimal Approaches

Fig. 15.14  Endoscopic view of the left nasal cavity showing the dehiscent bone over the nasolacrimal system. NLD is lying exposed (arrow)

In patients posted for endoscopic sinus surgery often the surgeon pays more attention to the sinuses and ignores the study of the lacrimal pathway. This particular situation explains how preoperative LDS assessment on imaging can be helpful in preventing injury to sac and NLD. The use of debrider in extensive polyposis may inadvertently damage NLD in this particular scenario. Therefore, it is important to evaluate the nasolacrimal system on a computed tomographic scan prior to endoscopic sinus surgery.

NLD is encountered in pre-lacrimal approach to the maxillary sinus lesions. in a case of inverted papilloma, the exposure of the lesion involves removal of the medial wall of the maxilla, that can be done using chisel and hammer or drill. The first step in endoscopic median maxillectomy to cauterize or coblate the mucosa over the lateral wall and the inferior turbinate to achieve good haemostasis (Fig. 15.16). This is followed by the lifting of mucoperiosteal flap on both sides and removal of the medial wall of the maxilla (Figs. 15.17 and 15.18). Complete representation of the NLD can be seen (Fig. 15.19). To approach the lesion in the maxillary sinus, the LDS is severed by a sharp oblique cut at the sac duct junction (Fig. 15.20). NLD may be separated from the bony fragments (Fig.  15.17, 15.18 and 15.19) or may be sacrificed during bone removal. Resection of NLD should be in an oblique fashion without the need for endoscopic DCR (Figs. 15.19 and 15.20). In medial maxillectomy dacryocystorhinostomy is recommended by some authors owing to the fre-

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Fig. 15.16  A case of inverted papilloma getting operated through pre-lacrimal approach via endoscopic median maxillectomy. First step is coblation of the mucosa over the inferior turbinate and the lateral wall

Fig. 15.18  Mucoperiosteal flaps are lifted in subperiosteal plane over the lateral wall of the maxilla

Fig. 15.19 NLD representation after removing the medial wall of maxilla Fig. 15.17  Mucoperiosteal flaps are lifted in subperiosteal plane over the medial wall of the maxilla

quent damage caused to the lacrimal system [5, 20]. However, a study by Imre et al reported that the transection of NLD in endoscopic medial maxillectomy does not lead to epiphora. It has been proven that epiphora following nasolacrimal duct resection in patients with sinus tumours is not common [21]. Therefore, there is no need for simultaneous sac marsupialization

(DCR) or stenting in these patients. The situation is different in cases where patient presents with significant epiphora that  occurs after accidental injury to NLD while working on the lateral wall of the nose for tumour removal (Figs. 15.21 and 15.22). This is because in pre-lacrimal approach the NLD is cut with a sharp incision but in accidental injury, NLD gets severed, crushed or cauterized during surgery leading to obstructive

15.4  NLD Damage in Endoscopic Extended Maxillary Mega Antrostomy

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Fig. 15.22  Landmarks on the lateral wall are distorted and turbinates are absent. Patient developed epiphora immediately following surgery indicating intraoperative injury to NLD Fig. 15.20  Close up view of the NLD with a sharp and clean oblique cut near the sac duct junction. The duct is severed to approach the maxillary sinus. An oblique cut provides a wider outlet  to the lacrimal  sac that allows smooth drainage of tears in postoperative period without causing any epiphora 

Fig. 15.23  Patient was managed by endoscopic DCR and the sac can be visualized. Medial to the sac the middle turbinate is seen as a thin strand

Fig. 15.21  Endoscopic view of the right nasal cavity in a case operated for right nasal tumour

symptoms later and has to be managed by endoscopic DCR (Fig. 15.23). The intraoperative injury should be suspected in all such cases that involve working on the lateral nasal wall and inferior meatus. Therefore, the integrity of NLD should be checked by syringing as well as endoscopic visualization during surgery. If needed sac patency can be accomplished by clean resection of sac NLD junction or complete sac marsupialization in the same sitting.

15.4 N  LD Damage in Endoscopic Extended Maxillary Mega Antrostomy Endoscopic extended maxillary mega antrostomy is a modification of median maxillectomy [5]. In this procedure, the maxillary sinus ostium is widened and connected to inferior meatal antrostomy after removing the inferior turbinate. In this technique, NLD is spared and the inferior meatal antrostomy is created posterior to the valve of Hasner [5]. • Key Points  Nasolacrimal duct (NLD) is a very important structure on the complex lat-

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•

•

•

•

15  An Overview of Nasolacrimal Duct (NLD) Encountered in Different Situations; Identification, Prevent…

eral nasal wall. It forms an integral part of the lacrimal drainage pathway. NLD is encountered during various surgical procedures. Understanding the NLD anatomy plays an important role in preventing injury. The cause of injury in endoscopic sinus surgery is the inadvertent removal of the thick bone surrounding the NLD during the anterior widening of maxillary sinus ostium using backbiting forceps. Performing middle meatal antrostomy in the posteroinferior direction minimizes the chances of nasolacrimal duct damage. In pre-lacrimal approach to the tumours of nose and sinuses, there is no epiphora following nasolacrimal duct resection therefore, there is no need for simultaneous sac marsupialization (DCR) or stenting in these patients.

References 1. Shoshani Y, Samet N, Ardekian L, Taicher S. Nasolacrimal duct injury after Le-Fort I osteotomy. J Oral Maxillofac Surg. 1994;52:406–7. 2. Osguthorpe JD, Hoang G.  Nasolacrimal injuries: evaluation and management. Otolaryngol Clin North Am. 1991;24:59–78. 3. Demas PN, Sotereanos GC. Incidence of nasolacrimal injury and turbinectomy–associated atrophic rhinitis with Le-Fort I osteotomies. J Craniomaxillofac Surg. 1989;17:116–8. 4. Lauritzen C, Lilja J.  Nasolacrimal obstruction in craniofacial surgery. Scand J Plast Reconstr Surg. 1985;19:269–72. 5. Sarber KM, O’Connor PD, Doellman MS, Dagucon MJ, Chen PG, Kevin C, KC MM, Weitzel EK. Surgical relationship of the nasolacrimal system to the maxillary line: Performing safe mega antrostomy. Allergy Rhinol (Providence). 2015 Fall;6(3):e158–61. 6. Whitnall SE. Anatomy of the human orbit and accessory organs of vision. 2nd ed. New  York: Krieger Publishing Company; 1979. p. 164–5. 7. Burkat CN, Lucarelli MJ.  Anatomy of the lacrimal system. In: Cohen AJ, Brazzo B, editors. The lacrimal system: diagnosis, management, and surgery. New York: Springer; 2006.

8. Unlü HH, Gövsa F, Mutlu C, Yücetürk AV, Senyilmaz Y.  Anatomical guidelines for intranasal surgery of the lacrimal drainage system. Rhinology. 1997;35(1):11–5. 9. Takahashi Y, Kakizaki H, Nakano T.  Bony nasolacrimal duct entrance diameter: gender difference in cadaveric study. Ophthal Plast Reconstr Surg. 2011;27:204–5. 10. Fasina O, Ogbole GI. CT assessment of nasolacrimal canal in a black African population. Ophthal Plast Reconstr Surg. 2013;29:231–3. 11. McCormick A, Sloan B.  The diameter of nasolacrimal canal measured by computed tomography: gender and racial differences. Clin Exp Ophthalmol. 2009;37:357–61. 12. Orhan M, Ikiz ZAA, Saylam CY.  Anatomical features of the opening of nasolacrimal duct and the lacrimal fold for intranasal surgery. Clin Anat. 2009;22:925–31. 13. Ipek E, Ezin K, Amac K, et  al. Morphological and morphometric evaluation of lacrimal groove. Anat Sci Int. 2007;82:207–10. 14. Takahashi Y, Nakamura Y, Nakano T, et  al. The narrowest part of the bony nasolacrimal canal:an anatomical study. Ophthal Plast Reconstr Surg. 2013;29:318–22. 15. Park J, Takahsahi Y, Nakano T, et al. The orientation of the lacrimal fossa to the bony nasolacrimal canal: an anatomical study. Ophthal Plast Reconstr Surg. 2012;28:463–6. 16. Serdahl CL, Berries CE, Chole RA.  Nasolacrimal duct obstruction after endoscopic sinus surgery. Arch Ophthalmol. 1990;108:391–2. 17. Kennedy DW, Zinreich SJ, Shaalan H, Kuhn F, Naclerio R, Loch E.  Endosocopic middle meatal antrostomy: theory, technique, patency. Laryngoscope. 1987;97:1–9. 18. Bolger WE, Parsons DS, Mair EA, Kuhn FA. Lacrimal drainage system injury in functional endoscopic sinus surgery. Arch Otolaryngol Head Neck Surg. 1992;118:1179–84. 19. Ali MJ, Murphy J, Wormald PJ, Psaltis AJ. Bony nasolacrimal duct dehiscence in functional endoscopic sinus surgery: radiological study and discussion of surgical implications. The Journal of Laryngology & Otology. 2015;129(Suppl. S3):S35–40. 20. Sadeghi N, Joshi A. Management of the nasolacrimal system during trans nasal endoscopic medial maxillectomy. Am J Rhinol Allergy. 2012;26:e85–8. 21. Imre A, Imre SS, Pinar E, Ozkul Y, Songu M, Ece AA, Aladag I.  Transection of nasolacrimal duct in endoscopic medial maxillectomy: implication on epiphora. J Craniofac Surg. 2015;26(7). Annals of Maxillofacial Surgery. Wolters Kluwer—Medknow Publications

Transcanalicular Laser Assisted Dacryocystorhinostomy

Transcanalicular endoscopic laser dacryocystorhinostomy (DCR) involves the creation of an opening between the lacrimal sac and the nasal cavity using a transcanalicular laser fibre [1]. Transcanalicular or the endocanalicular approach was first described by Jack in 1963. He introduced a probe through the lower punctum via the canaliculus into the lacrimal sac [2, 3]. The laser DCR was first described by Massaro et  al in 1990  in an attempt to achieve precise bone removal with meticulous hemostasis [4]. He did a cadaveric study to prove that the lacrimal bone osteotomy can be performed by means of laser energy delivered through an optic fibre by trans nasal or endocanalicular approach [2, 4, 5]. The prefix endo- or trans are used as synonyms and it means the insertion of an optic fibre inside the lumen of lacrimal canaliculus and the sac [2]. Brigita et al. suggested the term transcanalicular laser DCR is more suitable as the endoscope and laser fibre is inserted into the lumen of canaliculus and is used to bypass the obstruction across the lacrimal sac wall (trans) and not to remove an obstruction inside(endo) the lacrimal system [2]. Various lasers have been used in the past for performing laser DCR [6–13]. The type of laser appropriate for a DCR would allow delivery via flexible optic fibres, achieve effective bone ablation and provide good haemostasis with a shallow depth of penetration; therefore, the potassium titanyl phosphate (KTP/532), diode, and holmium: yttrium aluminium garnet (Ho: YAG) are suitable. The carbon dioxide (CO2) laser is not ideal

16

due to its cumbersome delivery system, poor haemostatic properties, poor bone ablation [4]. We used diode laser for transcanalicular laser DCR as it is easily available, can be delivered through a fibre tip as well as a rigid vitreoretinal probe. Diode laser (980  nm infrared) using fibre-­ optic cable was used because it offers high absorption in water and oxyhemoglobin, achieves optical coagulation with very efficient vaporization of bone and soft tissue, and ensures almost bloodless surgery. Diode laser-assisted DCR was first reported by Eloy et  al. and then by Fernande [2, 14].

16.1 Indications of Laser DCR The laser has been used in the following conditions • Primary acquired nasolacrimal duct (NLD) obstruction • Failed DCR due to ostia closure • Complex congenital NLD obstruction

16.2 Mode of Delivery The laser beam can be delivered through a 0.5 mm optic fibre which is inserted into a canalicular probe. The laser fibre can be directly inserted into the punctum and the canaliculi or a rigid 20 gauge vitreoretinal probe can be used. The advantage of using a vitreoretinal probe is that it is rigid and as

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the probing is done a hard stop is felt. The probe can be just held at this point, sensing the hard block all the time and keep firing the laser till an osteotomy can be visualized through the nose. The hard stop, felt constantly during the surgery ensures that the tip of the laser probe is in the sac and does not slip into the canaliculi when the laser is fired and it thus, ensures canalicular safety. The smoke from the osteotomy site can be evacuated using suction.

16.3 Steps of Laser DCR • It can be done under local anaesthesia with topical application of four percent lignocaine with adrenaline followed by local infiltration of two percent lignocaine with adrenaline. • In the case of general anaesthesia saline adrenaline packs are used for topical anaesthesia. The nasal mucosa is decongested using merocele pack soaked in 1:1000 adrenaline solution. • The lateral wall is infiltrated with 1:80,000 saline adrenaline solution (Fig. 16.1) • Middle turbinate and septum positions are checked (Fig. 16.2). In case of a situation with concha bullosa (pneumatized middle turbi-

Fig. 16.2  Right Concha bullosa can be visualized with compromised access to the maxillary line

Fig. 16.3  Middle turbinate is infiltrated with 2% xylocaine adrenaline solution

Fig. 16.1  Endoscopic View of the right nasal cavity demonstrating infiltration of 1:80,000 saline adrenaline solution into the lateral wall of the nose

nate) blocking the access to the site of the lacrimal sac, a conchoplasty is done (Figs. 16.3, 16.4, 16.5, 16.6 and 16.7) • Punctum is dilated using punctal dilator and the laser probe is passed through the upper canaliculi in the same fashion as the Bowman’s probe. As the probe enters the sac, a hard block is felt (Figs. 16.8 and 16.9). The probe is kept in place to ensure it touches the bone all the time.

16.3 Steps of Laser DCR

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Fig. 16.4  A vertical incision is given over the anterior face of the middle turbinate using a 15number blade.

Fig. 16.6  The bony middle turbinate is divided into the medial and lateral part using endoscopic scissors

Fig. 16.5  The incision starts inferiorly and is taken up superiorly

Fig. 16.7  Medial portion of the middle turbinate is removed leading to the improved access to the maxillary line and a prominent bulla can be visualized

• The illumination of the light into the nose is checked using 0°, 4 mm Storz endoscopes. • Thermal injury to the middle turbinate is avoided by covering the middle turbinate with a moist pack that separates it from the lateral wall (Figs. 16.10 and 16.11). • The location of the aiming beam is checked into the nose using an endoscope. Once the

beam is located in a position anterior to the middle meatus, the probe is first tilted down and a 980 nm diode laser is first fired in pulsed mode (Fig. 16.12). It is easy to create a lower window as the lower part of the fossa is formed by the lacrimal bone and the frontal process of the maxilla is thin here (Fig. 16.13). The osteotomy is extended further up by

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Fig. 16.8  Right upper punctum is dilated before the insertion of the laser probe

Fig. 16.10  Endoscopic view of the right nasal cavity demonstrating the transillumination from the laser tip into the nose

Fig. 16.9  20 G vitreoretinal diode laser tip-is inserted through the upper punctum

Fig. 16.11  Once the tip of the laser probe hits the bone covering the medial wall of the lacrimal sac, the laser is fired

moving the laser tip up and firing the laser in a continuous mode (Figs. 16.14 and 16.15). • The continuous back and forth motions are made with the laser fibre until a bony ostium of 10  mm diameter is made. As the bone is ablated the mucosa can be entered easily and the flow of pus can be seen into the nose (Figs. 16.16 and 16.17).

• Once an adequate size window is made the lacrimal sac lumen is examined (Figs. 16.18 and 16.19). A favourable case is the one where the lumen is clear and the obstruction lies distally at the sac duct junction (Figs. 16.20 and 16.21). • Clean and smooth lacrimal sac mucosa can be visualized through the lumen of the sac (Fig. 16.22). Incomplete partitions can be seen

16.3 Steps of Laser DCR

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Fig. 16.12  The laser probe is first tilted down towards the lower part of the lacrimal fossa as this is the thinnest part of the fossa and a window in the lacrimal bone can be easily ablated using a laser

Fig. 16.14  A slit-like bony window is seen along the maxillary line with transillumination from the laser under the intervening intact mucosa

Fig. 16.13  The bony window is gradually widened superiorly by moving the laser tip superiorly along the maxillary line

Fig. 16.15  Inferior window is widened to expose the sac and NLD

in the lacrimal sac lumen made up of prominent mucosal thickening (Fig. 16.22). There is no inflammation of mucosa lining the sac lumen and no organized discharge or granulations. Such cases are favourable cases and they do well post-operatively.

• In favourable cases once the sac is opened the patency is checked by syringing, a free flow of dye is seen (Fig. 16.23). • Bicanalicular silicone stenting is performed (Figs. 16.24, 16.25 and 16.26). A light pack is kept for 24 hours.

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16  Transcanalicular Laser Assisted Dacryocystorhinostomy

Fig. 16.16  Mucopurulent secretions start flowing into the nose through the ostium created by the laser beam

Fig. 16.18  The lumen of the sac seen with discharge at the tip of the laser probe

Fig. 16.17  The laser pipe is moved up towards the fundus of the sac to create a high osteotomy to enable complete sac marsupialization

Fig. 16.19  The laser probe is moved up and down to widen the bony window

• Antibiotic steroid eye drops are advised for 2 • The stent is kept for 4 weeks and the dynamic weeks. movement of the stent is checked in the post-­ • Regular nasal endoscopy is done in post-­ operative period. Follow up is done at 1week, operative period to look for any synechiae and 2 weeks, 4 weeks, 3 months and 6 months. granulation. Appropriate treatment is instituted in case of any adhesions.

16.4 Advantages of Laser DCR

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Fig. 16.20  The bone overlying the superior portion of the sac is mobilized using a ball probe

Fig. 16.22  Lacrimal sac lumen is seen with an incomplete septum dividing the lacrimal sac into two parts with laser probe tip in-situ

Fig. 16.21  The window is further widened by removing the ablated bone using a ball pointer

Fig. 16.23  Free flow of fluorescein dye can be seen into the nose

16.4 Advantages of Laser DCR

3. A relative indication for laser DCR is revision surgery for a failed external DCR [4, 16]. Failure in external DCR is presumably due to excessive scarring with a thin membrane blocking the rhinostomy. It can be revised using transcanalicular laser DCR however the results cannot be predicted.

1. It can be performed under local anaesthesia as a day-case procedure [15]. Elderly patients who are unfit for general anaesthesia due to their systemic disease and are troubled with their symptoms of epiphora can be operated using laser DCR. 2. The laser DCR is useful when a patient is on anticoagulants as it can be performed without discontinuing the anticoagulants [4, 15].

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16  Transcanalicular Laser Assisted Dacryocystorhinostomy

Fig. 16.24 A bicanalicular silicone stent is passed through the upper and lower punctum

Fig. 16.26  A loop of silicone tube can be seen in the right medial canthal area

• A fistula may form between the canalicular system and the skin over the corner of eye [14]. • Three cases had tissue necrosis on medial canthal area and a case of nasocutaneous fistula has been reported [17]. • Sump syndrome due to inadequate bony ostium leaving a lower portion that was not opened. There is post-operative collection leading to discharge on pressing below the medial canthal area. • Granulation tissue and synechia with stent migration may occur • A decrease in olfactory function following transcanalicular laser DCR has been reported [18]. Fig. 16.25  Both ends of the tube are retrieved into the nose

16.5 Disadvantages of Laser DCR • High failure rate • High rate of complications • High cost of the laser

16.6 Complications • Laser-induced pericanalicular inflammation and canalicular burns may occur [1] along with Partial canalicular stenosis [14].

16.7 Success Rate The success rate of laser-based transcanalicular DCR varies from 73.3% to 95.77% [1, 6, 14, 19]. Transcanalicular laser DCR should be done in a select group of patients in whom the bone is thin and can be ablated with laser. Preoperative CT DCG may help in case selection. The success rates following non-laser endoscopic DCR are higher than laser DCR due to the feasibility of a wider bony ostium and it avoids thermal damage caused by the laser which produces more fibrosis and occlusion at the rhinostomy site [4].

References

16.8 Contraindications of Transcanalicular Laser DCR 1. Acute dacryocystitis and acute exacerbation of chronic dacryocystitis 2. Cases with lacrimal abscess or fistula 3. Mucocele of the lacrimal sac or dacryocystocele 4. Posttraumatic NLD obstruction 5. Multiple intra sac synechiae or diverticula if detected on CT DCG 6. Associated nasal conditions like nasal polyposis with NLD obstruction

16.9 Causes of Failure in Conventional Endoscopic DCR and Its Relation to the Laser DCR 1. Incomplete marsupialization owing to difficult superior osteotomy as the bone is hard in the superior part. 2. Excessive scarring in the post-operative period due to increasing local temperature, tissue heating and charring with collateral damage. This leads to scarring and fibrosis and finally closure of the ostium [6]. 3. Undetected lacrimal sac diverticula need careful identification and marsupialization.

16.10 Advantage of Vitreoretinal Probe with Diode Laser 1. It is a rigid probe in which the laser energy is directed along the axis of the laser fibre with a blunt tip for the laser energy exit point. This there is no collateral damage. The tip is directed towards the nose away from the orbital structures and thus carries no risk to the medial canthal structures. 2. The chances are more with a flexible laser pipe as the control is less and the exact judgement of the position of the fire tip may be misleading. Perception of the light into the nose may not necessarily indicate that the fibre’s

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tip is in the lacrimal sac. It may still be at the common canaliculus. Firing the laser at this point may damage the canalicular system. 3. In the case with a rigid light pipe, the tip of the rigid pole hits the bone and a good tactile sensation of the tip touching the bone is a safe finding. This ensures that the laser tip is in the lacrimal sac and the bone can be safely ablated using the laser.

16.11 Key Points • Transcanalicular laser-assisted dacryocystorhinostomy is a relatively safe, effective simple and elegant procedure when performed under nasal endoscopic guidance. • In view of high cost, high prevalence of minor complications, many contraindications, and the higher reported failure rate, an endonasal endoscopic DCR is favoured over this approach.

References 1. Wali U, Sabt B, Al Badaai Y, Al-Mujaini A. Transcanalicular laser- assisted dacryocystorhinostomy: First report from Oman. Indian J Ophthalmol. 2018;66:170–2. 2. Drnovsek-Olup B, Beltram M.  Transcanalicular diode laser-assisted dacryocystorhinostomy. Indian J Ophthalmol. 2015;58:213–7. 3. Jack MK.  Dacryocystorhinostomy: description of a transcanalicular method. Am J Ophthalmol. 1963;56:974–7. 4. Mirza S, Jones N. Laser-assisted dacryocystorhinostomy. Atlas of lacrimal surgery. 2007; Springer 5. Massaro BM, Gonnering RS, Harris GJ.  Endonasal laser dacryocystorhinostomy: a new approach to nasolacrimal duct obstruction. Arch Ophthalmol. 1990;108:1172–6. 6. Gupta SK, Kumar A, Agarwal S, Pandey P. Transcanalicular laser dacryocystorhinostomy using low energy 810 nm diode laser. Oman J Ophthalmol. 2012 Sep–Dec;5(3):171–4. 7. Plaza G, Beteré F, Nogueira A.  Transcanalicular dacryocystorhinostomy with diode laser: long-­ term results. Ophthalmic Plast Reconstr Surg. 2007;23:179–82. 8. Narioka J, Ohashi Y.  Transcanalicular-endonasal semiconductor diode laser-assisted revision surgery for failed external dacryocystorhinostomy. Am J Ophthalmol. 2008;146:60–8.

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9. Alañón Fernández MA, Alañón Fernández FJ, Martínez Fernández A, Cárdenas Lara M, Rodríguez Domínguez R, Ballesteros Navarro JM.  Endonasal and endocanalicular dacryocystorhinostomy by diode laser: preliminary results. Acta Otorrinolaringol Esp. 2004;55:171–6. 10. Caversaccio M, Frenz M, Schär P, Häusler R. Endonasal and transcanalicular Er:YAG laser dacryocystorhinostomy. Rhinology. 2001;39:28–32. 11. Woo KI, Moon SH, Kim YD. Transcanalicular laser-­ assisted revision of failed dacryocystorhinostomy. Ophthalmic Surg Lasers. 1998;29:451–5. 12. Piaton JM, Limon S, Ounnas N, Keller P.  Transcanalicular endodacryocystorhinostomy using Neodymium:YAG laser. J Fr Ophtalmol. 1994;17:555–67. 13. Dalez D, Lemagne JM.  Bull Soc Belge: trans canalicular dacryocystorhinostomy by pulse Holmium-YAG laser. Bull Soc Belge Ophtalmol. 1996;263:139–40. 14. Eloy P, Trussart C, Jouzdani E, Collet S, Rombaux P, Bertrand B, et al. Transcanalicular diode laser assisted

dacryocystorhinostomy. Acta Otorhinolaryngol Belg. 2000;54:157–63. 15. Smithard A, Wynne D, Bingham BJ, Jones NS.  Endonasal laser dacryocysto-rhinostomy: its role in anticoagulated patients. Laryngoscope. 2003;113:1034–6. 16. Szubin L, Papageorge A, Sacks E.  Endonasal laser-­ assisted dacryocysto-rhinostomy. Am J Rhinol. 1999;13:371–4. 17. Goel R, Garg S, Nagpal S, Sushil Kumar S, Kamal S.  Naso-cutaneous fistula following transcanalicular laser dacrocystorhinostomy. Saudi J Ophthalmol. 2014:69–71. 18. Yildrim Y, Can E.  Conventional dacryocystorhi nostomy in a failed Trans-canalicular laser assisted dacryocystorhinostomy. Indian J Ophthalmol. 2013;61:44–5. 19. Melike BY, Tolga Y, Umit T, Muhittin T, Mehmet A, Faruk OM, et  al. Prospective comparison of 3 dacryocystorhinostomy surgeries: external versus endoscopic versus transcanalicular multimode laser. Ophthalmic Plast Reconstr Surg. 2015;31:13–8.

Endoscopic Dacryocystorhinostomy in Post-­Traumatic Nasolacrimal Duct Obstruction

Trauma to the lacrimal sac and nasolacrimal duct (NLD) occurs as a result of mechanical injury and is often associated with facial trauma in 7–15% of cases [1–3]. It is also encountered during various endoscopic surgical procedures. Thus, broadly posttraumatic NLDO can be divided into two categories iatrogenic or non-­ iatrogenic trauma [2, 3]. 1. Iatrogenic causes include injury following endoscopic sinus surgery orbital surgeries, endoscopic median maxillectomy, extended maxillary mega antrostomy, inferior meatal antrostomy, inferior turbinectomy and rhinoplasty [2, 4–10]. Most of these conditions have been covered in a separate chapter on NLD overview 2. Non-iatrogenic causes include road traffic accidents, animal bite injuries and physical violence, etc. leading to nasoorbito-ethmoidal fracture that results in traumatic NLDO [2, 11, 12].

17.1 M  ode of NLD Injury in Nasoethmoid Fractures and Time of Evaluation of Lacrimal Drainage System (LDS) Trauma to the lacrimal sac and nasolacrimal duct (NLD) includes severe lacerations of the lacrimal sac and Le Fort II, and Le Fort III type naso-

17

ethmoid fractures [1–3] following high impact blunt trauma. The most common mode of injury is road traffic accident [1, 2, 13]. Bony fractures may incite inflammatory changes in the lacrimal drainage pathway leading to cicatrization and symptoms of NLD obstruction, even many years after the injury [14] The incidence of post-­ traumatic persistent epiphora due to NLDO needing dacryocystorhinostomy (DCR) ranges from 5% to 21% [7, 12, 15, 16]. Since the upper lacrimal pathway is protected by the medial canthal ligament and lacrimal obstruction usually occurs in the bony nasolacrimal canal [2]. Traumatic laceration and obstruction of NLD may occur during repair of maxillofacial injuries. Closed reduction of nasoorbital-ethmoid fractures leads to an obstruction in a patent NLD system [12]. The pattern and incidence of nasolacrimal injury in nasoorbital-ethmoid fractures was studied by Gruss et  al [12, 17] They evaluated the role of delayed assessment and DCR. Three out of five patients in their series treated with closed reduction and external plating, required a DCR for persistent NLD obstruction [17]. It is difficult to predict which injuries will result in nasolacrimal obstruction. Sometimes even in massive injuries, there is no damage to NLD.  The assessment of the lacrimal drainage system can be done during midfacial reconstruction by check syringing but it may not be helpful due to the oedema of NLD. A silicone stent can be placed gently provided there is no resistance to its passage [17]. When DCR is necessary, it

© Springer Nature Singapore Pte Ltd. 2021 N. Gupta, Endoscopic Dacryocystorhinostomy, https://doi.org/10.1007/978-981-15-8112-0_17

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should be performed when the healing process is complete, which is 3–6 months after the primary repair [2].

17.2 Clinical Presentation The patient may present with watering, discharge and swelling in the medial canthal area. Dacryocystitis or conjunctivitis may also be present in some cases [13–16, 18]. Epiphora may be of immediate or late onset and can be temporary or permanent. Immediate symptoms occur due to compression of the lacrimal pathway following oedema [2]. In the event of injury to the sac and duct epiphora may not resolve. Sometimes epiphora sets in late due to gradual inflammation and fibrosis following fracture. Since temporary epiphora is likely to resolve spontaneously in few months as mentioned in some studies, it is advisable that the surgical intervention should be planned after 6 months of trauma [2, 19] Permanent epiphora is often found to be associated with delayed treatment of facial fracture repair or bone loss in the lacrimal fossa area [2, 19].

Fig. 17.1  Scar along the dorsum of the nose with a depression anterior to the medial canthus denoting the site of the fractured frontal process of maxilla with puckering of the skin

17.3 Examination 17.3.1 Local Examination External scar with depression above the medial canthal area (Fig.  17.1), crooked nose due to the fractured frontal process of the maxilla (Fig.  17.2) and telecanthus (Fig.  17.3) may be present. Medial canthal displacement and telecanthus are seen in cases of severe nasoorbital ethmoid injuries [14]. Medial canthal tendon is part of orbicularis oculi muscle that envelops the lacrimal sac between its anterior and posterior limb and prevents injury to the lacrimal sac. The tendon has two limbs anterior and posterior that get inserted into the anterior and posterior lacrimal crest on the medial wall of the orbit respectively [20]. In the case of severe blunt trauma, laceration of medial canthal tendon may occur involving the lacrimal sac also (Fig. 17.3). Saddle nose may also be present in case of fracture of the nasal bones and frontal process

Fig. 17.2  External deformity of the nose in the form of the crooked nose to the right (Orange arrow) due to fracture of the left frontal process of maxilla (White arrow)

Fig. 17.3  Clinical photograph of a patient showing telecanthus with saddle nose due to nasal bridge collapse and right NLD obstruction following trauma

of the maxilla. The nasal bridge collapses and leads to a saddle nose deformity. Regurgitation on pressure over the lacrimal sac is positive in most of the cases.

17.3 Examination

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Fig. 17.5  Widespread synechiae between the septum and the lateral wall with a glimpse of the middle turbinate Fig. 17.4  Endoscopic view of the right nasal cavity of a patient in Fig.  17.3, demonstrating the hypertrophied uncinate process with anteriorly pushed maxillary line

17.3.2 Nasal Endoscopy Preoperative nasal endoscopy is an important step in the evaluation of patients with ­posttraumatic dacryocystitis. It may reveal the presence of hypertrophied uncinate process (Fig.  17.4), diffuse synechiae (Fig.  17.5), posttraumatic septal deviation (Fig. 17.6), adhesions, distorted middle turbinate or lateral wall anatomy.

17.3.3 Computed Tomographic Dacryocystography (CT DCG) Preoperative imaging in the form of CT DCG is a valuable tool in post-traumatic NLDO. CT DCG in case 1, shows contrast opacified superior portion of the right sac with soft tissue infiltration in the lower part (Fig. 17.7a). The right lacrimal sac is dilated with a normal lacrimal drainage system on the left (Fig. 17.7b). Multiple old healed fractures are seen along the floor of the orbit and medial wall of maxilla with callus formation. A small compressed and opaque right maxillary sinus is seen (Fig. 17.7c).

Fig. 17.6  Severe septal deviation to the right following trauma

In case 2, there is an old fracture at the sac NLD junction in coronal cut (Fig. 17.8). In sagittal cut fractured NLD is seen lying below with complete severance from the sac with the remodelling of bone (Fig. 17.9). In case 3, there is a fracture of the frontal process of maxilla with posteromedial displacement of the fractured fragment and its impaction into the ethmoid cells (Fig. 17.10).

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a

b

Fig. 17.8  CT scan axial section in another case of road traffic accident demonstrating fracture with callus formation around the left proximal NLD opening involving the lower part of the sac. Right nasolacrimal system normal

c

Fig. 17.7  CT DCG of the patient in Fig. 17.3 (a) CT scan of right post-traumatic NLD obstruction showing contrast opacified superior portion of the sac with soft tissue infiltration in the lower part. (b) The sac is dilated on the right side (Pink star) with an old fracture in NLD and normal lacrimal sac and NLD on the left (orange star). (c) Multiple fractures are seen  along the floor of the orbit, medial wall of maxilla with opaque right maxillary sinus. The right maxillary sinus is small and compressed

Fig. 17.9  Sagittal cut demonstrating fractured NLD with the remodelling of bone (arrow)

17.4  Surgical Management

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Fig. 17.10  An old case of severe faciomaxillary fractures following a road traffic accident in a young boy, demonstrating fracture at the superior border of the frontal process of maxilla. There is posteromedial displacement of

the fractures segment with impaction into the ethmoid cells. Intraoperatively this fractured segment was found to be impinging on the ethmoids seen under the suction tip and marked by a star

Fig. 17.11  Synechiae right nasal cavity between the septum and the lateral wall

Fig. 17.12  Infiltration of the synechiae and the lateral wall with saline adrenaline solution

17.4 Surgical Management • Local infiltration techniques were similar to what have been described in the chapter of surgical technique. Often the tissue over the lateral wall is found to be hypertrophied in posttraumatic cases. In cases where synechiae are present, infiltration is done over the synechiae and the lateral wall (Figs.  17.11 and

17.12). Synechiae is removed by ­microdebrider to get a better view of nasal structures (Fig.  17.13). The tissue over the lateral wall shows significant hypertrophy, uncinate process and a part of middle turbinate can be seen (Figs.  17.14 and 17.15) Bone on the lateral wall is first palpated to avoid cutting through the underlying tissue as there may be a previous bony defect following trauma. The middle

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Fig. 17.13  Thick band of synechiae is debrided Fig. 17.15  Close up view of the right lateral wall with distorted anatomy

Fig. 17.14 Improved visualization after synechiae release demonstrating extensive hypertrophy in the area of lacrimal sac on the lateral wall

turbinate serves as an important landmark. Although there are high chances of distortion of the middle turbinate anatomy due to trauma but often the attachment of the middle turbinate with th0e lateral wall can be identified.

• The incision through the scarred tissue sometimes needs to be given in multiple gentle strokes to make it a full-thickness incision. This is due to the dense fibrosis and hypertrophy of the nasal mucosa following trauma. The thick fibrotic mucoperiosteal flap is lifted using the Freer suction elevator and the underlying bone is examined (Fig. 17.16). Multiple fractures were seen in the frontal process of maxilla forming the lower part of the lacrimal fossa (Fig. 17.17). • Some amount of bone in the lower part of the fossa could be removed with Kerrison punch (Fig. 17.18). The bone was hard, uneven and only a small portion could be removed using the the punch. Most of the bone needs drilling in postraumatic cases and there are multiple drilling options (Fig.  17.19). A curved diamond burr on the microdebrider handle from Medtronic Inc US and Karl Storz UNIDRIVE S111 ENT SCB system was used for drilling. Continuous drilling was needed for a longer duration in post-traumatic cases

17.4  Surgical Management

a

239

b

Fig. 17.16 (a, b) Mucoperiosteal flap is found to be very thick requiring considerable force to lift it

Fig. 17.17  Multiple fractures can be noted over the frontal process of maxilla in the lower part of the fossa

as compared to primary acquired nasolacrimal duct obstruction cases. Once the sac started getting visible (Fig.  17.20), further drilling continued to gain a wide exposure (Figs. 17.21 and 17.22). A point came where soft tissue felt at the tip of the ball probe at the superior border of sac gave a perception of complete expo-

sure (Fig.  17.23). A probe when passed through the upper punctum at this stage, was found to be hitting the bone on superior tilt and its free movement was missing (Fig. 17.24). CT DCG findings were reviewed simultaneously and when correlated with intraoperative findings, this soft tissue was

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Fig. 17.18  Kerrison punch is used to remove the initial bone at the lower part of the lacrimal sac fossa

Fig. 17.20  Partial sac exposure is achieved after drilling

Fig. 17.19  Drilling is done over the frontal process of maxilla. The bone in such cases is usually very thick and hard with callus formation

Fig. 17.21  As the drilling continues up the sac can be seen to be pushed laterally with thick bone surrounding it from all around

found to be the skin prolapsing through a posttraumatic breach in the frontal process of maxilla (Fig.  17.23). This soft tissue was pushed laterally with a ball probe and further drilling continued (Fig. 17.25). • Presence of CT DCG films intraoperatively is helpful both ways. They can be studied before starting the surgery or can be referred back in

case of any unusual finding during surgery like in this case. Thus, drilling was continued superiorly to expose the hidden portion of the fundus of the sac above (Fig. 17.25). • On superior drilling, the complete sac comes in view with a demarcation line over the fundus (Blue arrow) that was created by a bony chip indenting the sac. (Fig.  17.26) The part

17.4  Surgical Management

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Fig. 17.22  Superior portion of the bone is drilled to expose the fundus of the sac

Fig. 17.24  Probe can be visualized through the sac but the superior surface of the probe is abutting the bone and free movement of the probe is restricted

Fig. 17.23 (a) Endoscopic view of the right nasal cavity demonstrating soft tissue on palpation with the ball pointer giving a false perception of the superior limit of sac exposure. (b) CT DCG demonstrates a bony defect (yellow arrow) at the corresponding site of the soft tissue

under the ball probe. The defect is created by a fractured segment of frontal process that got displaced superiorly impinging on the superior part of the fundus of the sac (yellow star), leaving a defect. The lower part of the sac (black star) can be seen lying below the bony breech

above the dividing line represents the portion that was hidden under the bony fragment (represented as a yellow star in Fig.  17.23). The CT DCG Image on the right demonstrates this bifurcation of the sac (blue arrow) (Fig. 17.26). • The lumen of the sac is examined with a ball probe and some granulations can be

seen in the lumen (Fig.  17.27). The substantial portion of the sac is seen above the common canalicular opening indicating adequate sac exposure (Fig.  17.28). The probe can be seen in the lumen with a clear view of common canalicular opening (Figs. 17.29 and 17.30).

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Fig. 17.25  Further drilling is done superiorly to expose the fundus of the sac

Fig. 17.27 Sac is completely marsupialized and its lumen is examined with a ball probe

Fig. 17.26  Complete sac comes in view with a demarcation line over the fundus (Blue arrow) that was caused by a bony chip indenting the sac. The CT DCG Image on the right demonstrates this bifurcation of the sac (blue arrow)

• Mitomycin C in a concentration of 0.2mg/ml is applied for 3  minutes [21] along with circumostial injection of Mitomycin C [22] followed by intubation (Fig. 17.31) A second situation has also been described that demonstrate lot of hypertrophied tissue covering the lacrimal sac area. The tissue is debrided, the lacrimal sac is exposed (Figs. 17.32

and 17.33). Thick lacrimal sac flaps are debrided and trimmed (Fig.  17.34). A wide sac exposure is achieved (Fig.  17.34 and 17.35) followed by common canalicular examination and intubation (Figs. 17.36 and 17.37). The stent is removed after 4  weeks. Postoperatively oral antibiotics, decongestants, nasal wash and steroid antibiotic eye drops are prescribed.

17.5  External Verses Endoscopic DCR in Post-Traumatic NLD Obstruction

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Fig. 17.28  Additional portion of the sac exposed after drilling the displaced bony fragment (Black star)

Fig. 17.30  Close up view of the common canalicular opening

Fig. 17.29  Bowman’s probe seen through the sac with a clear view of common canalicular opening The false superior limit of the sac is marked by an arrow

Fig. 17.31  Bicanalicular silicone stents placed

17.5 External Verses Endoscopic DCR in Post-Traumatic NLD Obstruction

fossa and NLD is altered with lot of scarring and the surgery carries an increased risk of failure [2]. Some of the studies prefer external DCR and discourage endoscopic, endonasal or laser DCR in posttraumatic NLD obstruction due to the loss of bony anatomical landmarks after trauma and subsequent surgery [2].

Management of traumatic NLD obstruction is  challenging unlike primarily acquired NLD obstruction as the anatomy of the bony lacrimal

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Fig. 17.32  Second situation  of posttraumatic NLD obstruction with extensive fibrosis and hypertrophy of the nasal mucosal flaps

Fig. 17.34  Sac is separated from the thick nasal mucosal flaps adhering to it and the sac is incised after the nasal mucosa is debrided

Fig. 17.33  The hypertrophied mucosal flaps are debrided and the sac is exposed. The Sac wall is adherent to the overlying mucosa.

Fig. 17.35  Wide sac exposure is seen after trimming the flaps with microdebrider

However, in our experience, a comprehensive preoperative evaluation including nasal endoscopy and CT DCG followed by drilling in the superior part under direct endoscopic visualization leads to excellent results. Safe and effective drilling leads to complete sac exposure. The nasal anatomy can be visualized and any associated nasal pathologies can be corrected. In post-­ traumatic cases, there are synechiae formation

in the nose and sometimes severe septal deviation may obstruct the site of neo-ostium. In these cases septoplasty should be dome simultaneously during endoscopic DCR.  A meticulous primary endoscopic DCR in posttraumatic NLDO can give 100% results [23, 24]. The other added advantage of endoscopic DCR is the absence of scar that is especially valuable in posttraumatic cases as the patient

17.5  External Verses Endoscopic DCR in Post-Traumatic NLD Obstruction

a

245

b

Fig. 17.36 (a, b) Marsupialized sac (star) is confirmed by probing

and screws the lacrimal sac marsupialization with flap formation can become a challenge in external DCR. This could be the reason for some authors to resort to dacryocystectomy (DCT) in such cases [2]. The current chapter describes different scenarios of posttraumatic NLD obstruction in which an endoscopic DCR surgery was performed with excellent results. Preoperative CT/CT DCG evaluation along with diagnostic nasal endoscopy and the availability of endoscopes and drills help in achieving the excellent outcome of endoscopic DCR even in complex cases of posttraumatic NLD obstruction.

Fig. 17.37  Completely marsupialized sac with bicanalicular intubation

already has multiple scars from injury and previous repair. Those patients who were operated by the external route reported the external DCR scar as a major problem [2, 19] despite satisfactory outcomes with a success rate of 92.8% to 100% [2, 22, 25]. In external DCR it may be difficult to create an adequate size bony ostium to expose the nasal mucosa due to lot of fibrosis and scarring. Due to the associated posttraumatic changes and postoperative presence of plates

Key Points • Post-traumatic NLDO manifests as a result of facial trauma. Road traffic accidents are the most common cause of epiphora. • Management of post-traumatic NLDO is challenging owing to multiple fractures, scarring and callus formation. CT and CT DCG are very helpful in preoperative assessment. • Endoscopic DCR in posttraumatic NLDO has excellent results as it involves drilling under direct visualization using high definition camera and endoscopes. It allows the correction of associated nasal conditions like deviated nasal septum and concha bullosa.

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References 1. Segal KL, Tsiouris AJ, Lelli GJ.  Trauma Lacrimal Sac and Nasolacrimal Duct. In: Schmidt-Erfurth U, Kohnen T, editors. Encyclopedia of Ophthalmology. Berlin, Heidelberg: Springer; 2017. 2. Mukherjee B, Dhobekar M.  Traumatic nasolacrimal duct obstruction: clinical profile, management, and outcome. European Journal of Ophthalmology. 2013;23(5):1. 3. Bartley GB. Acquired lacrimal drainage obstruction: an etiologic classification system, case reports, and a review of the literature. Part 2. Ophthal Plast Reconstr Surg. 1992;8:243–9. 4. Balaji SM.  Management of nasolacrimal duct injuries in mid-facial advancement. Ann Maxillofac Surg. 2015;5(1):93–5. 5. Hawes MJ, Segrest DR. Effectiveness of bicanalicular silicone intubation in the repair of canalicular lacerations. Ophthal Plast Reconstr Surg. 1985;1:185–90. [PubMed] [Google Scholar] 6. Shoshani Y, Samet N, Ardekian L, Taicher S. Nasolacrimal duct injury after Le-Fort I osteotomy. J Oral Maxillofac Surg. 1994;52:406–7. 7. Osguthorpe JD, Hoang G.  Nasolacrimal injuries: evaluation and management. Otolaryngol Clin North Am. 1991;24:59–78. 8. Demas PN, Sotereanos GC. Incidence of nasolacrimal injury and turbinectomy–associated atrophic rhinitis with Le-Fort I osteotomies. J Craniomaxillofac Surg. 1989;17:116–8. 9. Lauritzen C, Lilja J.  Nasolacrimal obstruction in craniofacial surgery. Scand J Plast Reconstr Surg. 1985;19:269–72. 10. Sarber KM, O’Connor PD, Doellman MS, Dagucon MJ, Chen PG, McMains KC, Weitzel EK.  Surgical relationship of the nasolacrimal system to the maxillary line: Performing safe mega antrostomy. Allergy Rhinol (Providence). 2015;6(3):e158–61. 11. Uralog˘ lu M, Erkin Unlü R, Ortak T, Sensöz O. Delayed assessment of the nasolacrimal system at naso-orbito-ethmoid fractures and a modified technique of dacryocystorhinostomy. J Craniofac Surg. 2006;17:184–9. 12. Gruss JS, Hurwitz JJ, Nik NA, Kassel EE. The pattern and incidence of nasolacrimal injury in naso-orbital-­ ethmoid fractures: the role of delayed assessment and dacryocystorhinostomy. Br J Plast Surg. 1985;38:116–21. 13. Ali MJ, Gupta H, Honavar SG, Naik MN. Acquired nasolacrimal duct obstructions secondary

to nasoorbito-­ ethmoidal fractures: patterns and outcomes. Ophthal Plast Reconstr Surg. 2012;28(4):242–5. 14. Schaefer DP.  Acquired etiologies of lacrimal sys tem obstructions. The Lacrimal System: Diagnosis, Management and Surgery. New York: Springer; 2006: 43–65. 15. Stranc MF.  The pattern of lacrimal injuries in naso-­ ethmoid fractures. Br J Plast Surg. 1970;23:339–46. 16. Arianti A, Irawati Y. Management of old naso-orbital fractures with ocular involvement and associated complications caused by facial trauma. Med J Indones. 2018;27:54–61. 17. Dryden RM, Wulc AE.  Pseudo-epiphora from cerebrospinal fluid leak: case report. Br J Ophthalmol. 1986;70:5760–4. 18. Jonathan JD, Jeffrey JW. Imaging and clinical evaluation of the lacrimal drainage system. Acquired etiologies of lacrimal system obstructions. The Lacrimal System: Diagnosis, Management and Surgery. New York: Springer; 2006: 85–87. 19. Becelli R, Renzi G, Mannino G, Cerulli G, Iannetti G. Posttraumatic obstruction of lacrimal pathways: a retrospective analysis of 58 consecutive naso-orbito-­ ethmoid fractures. J Craniofac Surg. 2004;15:29–33. 20. Russell EJ, Czervionke L, Huckman M, Daniels D, McLachlan D.  CT of the inferomedial orbit and the lacrimal drainage apparatus: normal and pathologic anatomy. AJNR. 1985;6:759–66. 21. Ali MJ, Marriappan I, Maddileti S, et al. Mitomycin C in dacryocystorhinostomy: the search for the right concentration and duration- a fundamental study on nasal mucosa and fibroblasts. Ophtha Plast Reconstr Surg. 2013;29:469–74. 22. Kamal S, Ali MJ, Naik MN.  Circumostial injection of mitomycin C (COS-MMC) in external and endoscopic dacryocystorhinostomy: efficacy, safety profile, and outcomes. Ophthalmic Plast Reconstr Surg. 2014;30(2):187–90. 23. Ali MJ, Singh S, Naik MN, Kaliki S, Dave TV.  Interactive navigation-guided ophthalmic plastic surgery: the utility of 3D CT-DCG-guided dacryolocalization in secondary acquired lacrimal duct obstructions. Clin Ophthalmol. 2017;11:127–33. Epub 2016 Dec 30 24. Ali MJ, Naik MN. Image-Guided Dacryolocalization (IGDL) in Traumatic Secondary Acquired Lacrimal Drainage Obstructions (SALDO). Ophthalmic Plast Reconstr Surg. 2015;31(5):406–9. 25. Nguyen M, Koshy JC, Hollier LH. Pearls of nasoorbitoethmoid trauma management. Semin Plast Surg. 2012;24(4):383–8.

Navigation Guided Surgery in Complex Lacrimal Drainage Disorders

The need for precise and safe minimally invasive surgery of the head and neck has led to the development of navigation guided tools to facilitate intraoperative localization of anatomical landmarks [1]. Computer enabled tracking devices are used to monitor the tip of the instrument in real time during surgery [1, 2]. The location of various registered instruments is depicted on a 3-dimensional view of the preoperative scans that are uploaded into the navigation system. Image-guidance surgery was initially developed for neurosurgical procedures and later it was found to be very useful in sinus surgeries. Owing to the high-resolution CT scan images displaying the bony sinus anatomy and the proximity of sinuses to the orbit and intracranial structures, the image-guided systems have been found to be very suitable for surgeries of sinuses and skull base [1, 3].

18.1 Types of Navigation System There are two main types of navigation systems available [4]. The infrared (optical) systems and the electromagnetic systems. Both systems have the same functions but are based on a different technology In all cases, is a device attached to the patient known as the head mask or head frame [5]. (Fig. 18.1) The optical system is also known as an infrared system. It uses infrared sensors along with

18

light-emitting structures or light reflectors that are fixed to the patient’s head with the help of a headband strap and fixed to a handheld probe. Both the headband and instrument must be in view of the system’s camera, or computer to be able to track the instrument within the nose and sinuses [6]. Electromagnetic systems, use electromagnetic fields that use reference points on the metallic headband of patients' forehead (Fig. 18.2) and a wired instrument that the surgeon uses during endoscopic nasal and sinus surgery. The use of navigation systems has been approved in revision surgery, extensive disease, anatomical distortion and close relation of pathology with the skull base and orbit or optic nerve, etc [1, 7]. Its continued use in orbitofacial surgery with the provision of preoperative manipulation of the images and intraoperative localization have proved to be invaluable [8]. The same indications are applicable in the case of endoscopic dacryocystorhinostomy (DCR). Although endoscopic DCR in primary acquired nasolacrimal duct obstruction has excellent results, which are at par with the external DCR [3, 7, 9, 10], in complex lacrimal drainage obstructions, locating the sac may be challenging. Introduction of navigation guided system has made it possible to operate complex lacrimal disorders with accurate target localization and reduced risk of complications [9–13]. This chapter describes the use of the Fusion compactTM ENT navigation system from

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Fig. 18.1  Fusion compactTM ENT Electromagnetic navigation system setup from Medtronic Inc USA

Medtronic Inc USA in the management of some of the complex cases of lacrimal drainage system obstruction (Figs.  18.1 and 18.2). Navigation guided surgery in two such cases has been described in this chapter. One patient had epiphora following radiotherapy for carcinoma of nasopharynx with complete charring of inferior turbinate and nasolacrimal duct along with sac damage. The other case had a history of multiple failed external DCR.  The external skin had gapped and CT scan demonstrated a high and inadequate bony window. Axial Scan was taken from the tip of the nose till the vertex in a slice thickness of 1mm for better accuracy. Slice spacing was kept equal to the slice thickness. The zero-gantry tilt should be maintained at all the time as per protocols to get the highest intraoperative accuracy. The image data was transferred to the electromagnetic Fusion compactTM ENT navigation system from Medtronic Inc USA.  It has a touchscreen interface with digital video input and output and 8

ports for AxiEM™ instruments. The data transfer takes place through an optical disc, CD-ROM and the images are imported into the workstation and checked for accuracy [1].

18.2 Situation1 A 38-year old man presented with epiphora following radiotherapy for carcinoma nasopharynx. On examination, he was found to have NLD obstruction and canaliculi were patent. Nasal endoscopy revealed complete destruction of left inferior turbinate and severe atrophy with the destruction of the middle turbinate. A roomy nasal cavity was seen with scarred nasal mucosa (Fig. 18.3). On the coronal CT section an air-filled wide left nasal cavity with a stump of middle turbinate was seen. A small contracted sac was opacified with contrast on the left indicating scarring and shrinkage of the sac lumen on the left side and a normal lacrimal system on the

18.2 Situation1

Fig. 18.2  Metallic headband is placed on the patient’s forehead for registering the instruments

Fig. 18.3  Endoscopic view of the left nasal cavity in a post irradiated case of carcinoma nasopharynx with a parallel CT picture showing a left roomy nasal cavity with the destruction of turbinates and septal deviation. A small

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right (Fig. 18.3). Such small contracted sac is difficult to locate  intraoperatively and carries  the risk of incomplete marsupialization. It was therefore planned to use navigation system in this case. The procedure of the navigation guided surgery is described below. A headband is required to be placed around patient’s head for registration and localization (Fig.  18.4). The headband has a central point marked by a slight depression at which the tip of the registration probe rests and the instrument is registered. The area of the surgical field in which we plan to work needs to be registered first. The tip of the registration probe moves around the eyebrows and nose so that a little wider area comes in the registered field (Fig. 18.5). This process needs experience and the tip has to be moved over the skin without losing its contact with the skin. Therefore, the skin is preferably kept stretched with the other hand for smooth and quick registration. For a beginner, this step of registration might have to be tried multiple times. The headband has two buttons for going back and forth during primary registration. In case of successful registration, ‘Next’ button is pressed and

contracted sac is opacified with contrast on the left indicating scarring and shrinkage of the sac lumen on the left side with a normal right lacrimal system

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Fig. 18.4  The tip of the registration probe is placed in the centre of the metallic headband

in case of a failed step ‘Back’ button is pressed to go back to the same step. Once the registration of the surgical area is complete the instruments are registered, calibrated and checked for accuracy by testing various landmarks. Once this is done, the device is ready for the surgery under image guidance. Only the registered equipment will be able to locate the anatomy intraoperatively and not all the instruments can be registered. Thus, the surgeon can choose the ones  needed more commonly like suction tip and forceps. Intermittent identification of the landmarks can be performed with the help of a registered probe. As the registered probe was placed in the roomy nasal cavity, its position on the corresponding CT section could be appreciated by the intersection of crosshairs in coronal, sagittal and axial views (Fig. 18.6). Further navigation facilitates accurate localization of the lacrimal sac. The infiltration and incision were carried out in the same manner. The bone was drilled and a

Fig. 18.5  The probe moves around the eyebrows and nose so that a little wider area comes in the registered field

18.3 Situation2

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Fig. 18.6  The registered probe was placed in the roomy nasal cavity, its position on the corresponding CT section could be appreciated by the intersection of crosshairs in coronal, sagittal and axial views

small sac was exposed, its location was checked on the navigation system and the sac was marsupialized (Fig. 18.7)

18.3 Situation2 A middle-aged man presented with the history of epiphora with multiple failed external DCR surgeries for nasolacrimal duct obstruction. On endoscopic examination, granulations were seen on the lateral wall with synechiae and an absent ostium. CT scan revealed previous high osteotomy with an intact overlying bone superior and inferior to the small bony defect. The sac walls were distorted with scarred tissue at the sac site and a small sac was seen filled with contrast material (Fig. 18.8). The sac area was obscured by thick fibrous tissue and loss of landmarks.

The registration pointer placed at the bone deficient area marked by puckered skin externally and its location was visualized on the image-guided system (Fig. 18.9). Endoscopic localization and exploration of the lacrimal sac were performed under image guidance (Fig. 18.10). In both these situations 1&2 there were chances of inadvertent entry into the orbit or skull base due to the loss of landmarks. Navigation guidance helped in accurate localization of the lacrimal sac in this situation. The sac was successfully marsupialized under navigation guidance followed by bicanalicular silicone stenting. Imaging modalities deliver high quality threeand four-dimensional images of detailed anatomy and pathology along with the tissue vascularity [2]. They have been used in a number of ­indications including functional endoscopic sinus

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Fig. 18.7  A small contracted sac was exposed following bone removal; its location was checked on the navigation system and the sac was marsupialized

Fig. 18.8  In another case of failed DCR, granulations were seen at the ostium site with distorted middle turbinate anatomy. On CT DCG, the sac walls were deformed

with scar tissue at the sac site and a small sac was seen filled with contrast material. The sac area was obscured by thick fibrous tissue and loss of landmarks

18.3 Situation2

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Fig. 18.9  The registration probe is placed at the bone deficient area marked by puckered skin externally and its location was visualized on the image-guided system

surgery [14–17], anterior and lateral complex skull base tumours [15, 16] and in complex lacrimal drainage disorders [9–13] In skull base tumour cases image fusion of CT and MRI data gives added information [18, 19]. Successful use of Image-guided lacrimal drainage surgery has been reported in congenital arhinia microphthalmia syndrome, posttraumatic lacrimal drainage obstruction, post cocaine use oroantral fistula with excessive scarring and in the insertion of Lester-Jones tube [9–13, 20]. The patient with cocaine abuse had bilateral NLDO, an oroantral fistula, obliteration of both meatuses and extensive scarring [20]. The other

middle-aged man who needed placement of a Lester John tube had history of maxillectomy and rhinotomy for sinonasal malignancy. The Lester Jones tube was placed in the opposite nasal cavity due to ipsilateral rhinectomy [8] . Both these cases would have been difficult without a navigation guided system. In revision cases with multiple failures, excessive scarring of the mucosa and the lacrimal sac wall hampers accurate localization of the sac. Image-guided surgery helps in precise identification of the scarred lacrimal sac and helps in differentiating it from the adjacent scarred tissues.

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Fig. 18.10  Endoscopic localization and exploration of the lacrimal sac was performed under image guidance

Key Points Navigation guidance plays a vital role in the management of such complex lacrimal surgeries by facilitating safe and precise surgery.

References 1. Rai D, Munjal M, Varun RV. Navigation in Endoscopic Sinus Surgery: the First Indian Experience. Indian J Otolaryngol Head Neck Surg. 2013;65(Suppl 2):394–9. 2. Peters TM.  Image-guidance for surgical procedures. Phys Med Biol. 2006;51(14):R505–40. 3. Metson R, Cosenza M, Gliklich RE, Montgomery WW.  The role of image-guidance systems for head and neck surgery. Arch Otolaryngol Head Neck Surg. 1999;125:1100–4. 4. Zabrina M.  Samarakkody, Baharudin Abdullah. The use of image guided navigational tracking systems for endoscopic sinus surgery and skull base surgery: A review. Egyptian Society of Ear, Nose, Throat and

Allied Sciences Egyptian Journal of Ear, Nose, Throat and Allied Sciences. 5. Leonard S, Reiter A, Sinha A, Ishii M, Taylor RH, Hager GD. Image-based navigation for functional endoscopic sinus surgery using structure from motion Proc SPIE 9784, Medical Imaging. 2016: Image Processing, 97840V. https://doi.org/10.1117/12.2217279. 6. Li L, Yang J, Chu Y, et  al. A novel augmented reality navigation system for endoscopic sinus and skull base surgery: a feasibility study. PLoS ONE. 2016;11(1):e0146996. 7. Citardi MJ, Batra PS.  Image-guided sinus surgery: current concepts & technology. Otolaryngologic Clinics of North America. 2005;38(3):439–52. 8. Morley AM, Collyer J, Malhotra R. Use of an image-­ guided navigation system for insertion of Lester-Jones tube in a patient with disturbed orbito-nasal anatomy. Orbit. 2009;28:439–41. 9. Ali MJ, Naik MN.  Image-guided dacryolocalization (IGDL) in traumatic secondary acquired lacrimal duct obstructions (SALDO). Ophthal Plast Reconstr Surg. 2015;31(5):406–9. 10. Freitag SK, Woog JJ, Kousoubris PD, Curtin  HD.  Helical computed tomographic

References d­acryocystography with three- dimensional reconstruction. A new view of the lacrimal drainage system. Ophthal Plast Reconstr Surg. 2002;18(2):121–32. 11. Ashenhurst M, Jaffer N, Hurwitz JJ, Corin SM.  Combined computed tomography and dacryocystography for complex lacrimal problems. Can J Ophthalmol. 1991;26(1):27–31. [PubMed] [Google Scholar] 12. Caldemeyer KS, Stockberger SM, Broderick LS.  Topical contrast enhanced CT and MR dacryocystography: imaging the lacrimal drainage apparatus of healthy volunteers. AJR Am J Roentgenol. 1998;171(6):1501–4. 13. Mannor GE, Millamn AL.  The prognostic value of preoperative dacryocystography in endoscopic transnasal dacryocystorhinostomy. Am J Ophthalmol. 1992;113(2):134–7. 14. Chu ST.  Endoscopic sinus surgery under naviga tion system--analysis report of 79 cases. J Chin Med Assoc. 2006;69(11):529–33. 15. Leonard S, Reiter A, Sinha A, Ishii M, Taylor RH, Hager GD.  Image-based navigation for functional

255 endoscopic sinus surgery using structure from motion. Proc SPIE Int Soc Opt Eng. 2016;9784:97840V. 16. Olson G, Citardi MJ. Image-guided functional endoscopic sinus surgery. Otolaryngol Head Neck Surg. 2000;123(3):188–94. 17. Burduk PK, Dalke K, Kaźmierczak W. Intraoperative navigation system in endoscopic sinus surgery. Otolaryngol Pol. 2012;66(4 Suppl):36–9. 18. Wiltfang J, Rupprecht S, Ganslandt O, Nimsky C, Keßler P, Mosgau SS, Fahlbusch R, Neukam FW. Intraoperative image–Guided surgery of the lateral and anterior skull base in patients with tumors or trauma. Skull Base. 2003;13(1):21–9. 19. Sure U, Alberti O, Petermeyer M, Becker R, Bertalanffy H.  Advanced image-guided skull base surgery. Surg Neurol. 2000;53(6):563–72. discussion 572 20. Day S, Hwang TN, Pletcher SD, Bhatki A, McCulley TJ. Interactive image-guided dacryocystorhinostomy. Ophthal Plast Reconstr Surg. 2008;24:338–40.

Endoscopic Dacryocystorhinostomy in Chronic Granulomatous Lesions of the Lacrimal Drainage System

Acquired lacrimal drainage obstruction may be primary acquired nasolacrimal duct obstruction (PANDO) or secondary acquired nasolacrimal duct obstruction (SALDO) [1]. PANDO is defined as an inflammation of unknown cause that eventually leads to occlusive fibrosis. SALDO occurs secondary to various causes like infection, inflammation, neoplastic, traumatic or mechanical causes [1, 2] This chapter focuses on the rare chronic granulomatous infections of the lacrimal drainage system (LDS) that pose a challenge in diagnosis as well in the management. Although lacrimal sac involvement occurs secondary to the nasal or systemic involvement, isolated involvement of the lacrimal sac may also occur. In the absence of typical features, the diagnosis may be missed. Thus, a high level of suspicion is needed. Various chronic granulomatous conditions involving lacrimal sac are tuberculosis of the LDS, rhinosporidiosis of the LDS, Wegner’s granulomatosis of LDS and sarcoidosis.

19.1 Tuberculosis (TB) of the LDS

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The involvement of lacrimal drainage system is even rarer and can be easily missed in the absence of pulmonary involvement [3].

19.1.2 Clinical Presentation and Examination Patients present with epiphora or dacryocystitis and the history of nasal symptoms may or may not be present. Regurgitation test (ROPLAS) is often negative in these patients. Nasal endoscopy reveals an unhealthy mucosa with crusting on the lateral wall and over the turbinates (Figs.  19.1 and 19.2). Diagnosis of NLD obstructions can be made with dacryocystography but does not help in identifying the presence of tuberculosis. Tuberculosis is known to spread by lymphohematogenous route and can infect any organ of the body and exhibits an unusual presentation. In tuberculosis of the LDS, the symptoms are non-­ specific and the diagnosis becomes a challenge in the absence of pulmonary tuberculosis. Thus, a high level of clinical suspicion is needed.

19.1.1 Incidence

19.1.3 Diagnosis

Primary tuberculosis of the nasolacrimal system is a rare entity [3]. Lacrimal drainage system involvement is usually secondary to nasal tuberculosis. Nasal tuberculosis accounts for approximately 6.7% of extrapulmonary tuberculosis.

Tuberculosis is often detected at different stages in different cases [3]. Clinically tuberculosis of the LDS should be suspected during preoperative assessment. Often there is primary nasal tuberculosis with LDS involvement. It should be

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Fig. 19.1  Endoscopic view of the right nasal cavity demonstrating unhealthy mucosa with crusting over the inferior turbinate in a case of nasal tuberculosis involving LDS

Fig. 19.3  A marsupialized left lacrimal sac with lumen filled with marble-like multiple granulomas around the common canalicular opening in a twice failed endoscopic DCR. AN; Agger nasi

failed surgeries. On endoscopic exploration, the sac had been nicely opened up in the previous surgery but granulation tissue was found to be filling the sac in the area around the common canalicular opening. (Fig.  19.3). Biopsy was taken and the tissue was sent for histopathology.

19.1.4 Histopathology

Fig. 19.2  Endoscopic view of the right nasal cavity demonstrating oedematous mucosa of the middle turbinate with granulations in the middle meatus area

s­uspected in cases with unexplained failures. A study reported 2 cases LDS TB, one presented as non-resolving nasal infection with epiphora, the other reported as a failure of the previous surgery. Endoscopic dacryocystorhinostomy (DCR) was performed in both cases and biopsy was taken. In a case reported here patient presented with persistent epiphora with previous two

Histopathological diagnosis is often made by the appearance of numerous caseating epithelioid cell granulomas with Langhans giant cells (Fig. 19.4), indicative of granulomatous rhinitis. This was supported by QuantiFERON-TB Gold In-Tube testing, tuberculin skin test and polymerase chain reaction.

19.1.5 Treatment Endoscopic DCR with intubation is performed and the patient is put on Anti-Tubercular Treatment as per RTNCP guidelines. Very few cases of nasolacrimal tuberculosis have been reported in the literature [4–9]. Tuberculosis

19.2 Rhinosporidiosis of LDS

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lacrimal sac rhinosporidiosis was published by Kirkpatric in 1916 [12, 19, 27].

19.2.1 Background

Fig. 19.4 Microphotograph showing epithelioid cell granulomas with Langhans giant cells

should be considered in cases of dacryocystitis in young patients with recurrent unexplained surgical failures.

The first case of lacrimal sac rhinosporidiosis was treated in 1949 by giving an incision and curetting the lacrimal sac area which was then packed with sulphonamide without much relief [10, 26]. Lacrimal sac rhinosporidiosis is notorious to recur and often a lacrimal sac fistula occurs that is resistant to further treatment [10, 26]. Excision of lacrimal sac polyp leads to recurrence due to incomplete removal as the bleeding is excessive [17, 20]. Advancement in technology with the introduction of high definition camera and endoscopes along with coblator have made it possible to perform meticulous excision of the lesion.

19.2 Rhinosporidiosis of LDS It is a chronic granulomatous disease caused by Rhinosporidium seeberi. Rhinosporidiosis is a waterborne disease and generally, occurs after swimming in stagnant freshwater ponds, lakes or rivers, but is also suspected to occur from dust or air [10]. The natural hosts of the aquatic parasite are fish and amphibians [11]. It commonly affects the mucous membrane but can also affect skin, trachea, lungs and rectum. Isolated lacrimal sac rhinosporidiosis is very rare [12]. Kuriakose coined the term oculosporidiosis in 1963 for rhinosporidiosis of the eye [10]. It was labelled as sporozoan belonging to subdivision coccidia but is now considered an aquatic protistan parasite belonging to the class mesomycetozoa [12–16]. Oculosporidiosis is found in 15% of the total rhinosporidiosis cases [14, 16, 17] and is prevalent in Southeast Asia, Srilanka and Southern India [18]. The most common age group affected is 15–40  years with a male predominance [17, 19–21]. Lacrimal drainage system involvement was seen to vary from 14.3% to 59.6 % cases [12, 14, 20, 22–25]. Isolated lacrimal sac involvement was found in 45.8% cases [26]. The first case of

19.2.2 Site Predilection and Spread of Rhinosporidiosis The most common site of involvement in rhinosporidiosis is the nose (83.3%), followed by ocular adnexa (11.2%), and other sites like larynx, trachea and bronchus (5.4%) [24, 25]. The lacrimal sac can get involved secondary to the nasal lesion [22, 28, 29], eye lesion through the lacrimal canaliculi to the sac [10, 30], through permeation along with the subepithelial connective tissue [10] or via the subepithelial lymphatic channels [19].

19.2.3 Clinical Presentation Patient presents with a fluctuant, boggy and painless swelling in the medial canthal area which feels like a bag of worms [26] (Fig.  19.5). Associated symptoms of blood-stained discharge from nose or eye should raise a high index of suspicion of rhinosporidiosis, especially in endemic areas. Regurgitation test may be negative but when positive, it may be serosanguinous,

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Fig. 19.6  Rhinosporidiosis mass in the lacrimal sac is seen as a hyperdense mass on computed tomography with bony erosion (arrow) Fig. 19.5  Clinical photograph of a patient with rhinosporidiosis of the lacrimal sac demonstrating a swelling in the medial canthal area extending along the infraorbital margin

­ ucopurulent, slimy and sprinkled with white m and reddish granular material.

19.2.4 Radiology in Lacrimal Sac Rhinosporidiosis Rhinosporidiosis mass in the lacrimal sac is seen as a hyperdense mass on computed tomography (CT) with bony erosion and subcutaneous extension (Fig. 19.6). Characteristic findings of “donut distribution” is found in some cases where the contrast passes through nasolacrimal duct in a circumferential manner till it drains in the inferior meatus on CT dacryocystography (DCG) with normal sac wash out [11].

19.2.5 Choice of Surgical Procedure Various surgical procedures are available for managing a lacrimal sac rhinosporidiosis like endoscopic DCR [31, 32] external DCR [18], modified DCR [18] and dacryocystectomy (DCT) [13, 20, 33, 34]. The extent of surgical resection in lacrimal sac rhinosporidiosis depends on the severity of grading of the disease as published earlier [26].

• Grade 1: Lesion limited to lacrimal sac lumen as a pedunculated or sessile mass or polyp ± nasolacrimal duct but no lesion in nose or eye • Grade 2: Lesion involving lacrimal sac, nasolacrimal duct and nose or eye • Grade 3: Lesion involving lacrimal sac, nasolacrimal duct and nose or eye and spread to skin ± Lacrimo-cutaneous fistula. Application of a uniform surgical procedure in all the cases of lacrimal sac rhinosporidiosis irrespective of the staging may lead to recurrence in the advanced cases. Grading of the disease helps in charting out a surgical plan [26]

19.2.6 Steps of Surgery • The nasal cavity in the case presented here shows synechiae from previous biopsy with a compromised working field (Fig. 19.7). Visualization is improved by releasing the septoturbinal synechiae with a blunt dissector (Fig.  19.8) and adequate space can be created (Fig. 19.9). • Rhinosporidiosis mass can be visualized on the septum, lateral wall and nasopharynx after synechiae release (Fig.  19.10). The mass is debrided (Fig. 19.11), till adequate debulking is achieved (Figs. 19.12 and 19.13). • Landmarks become clear and an incision can be given with the dissector alone as the nasal mucosa over the lateral wall of the nose is

19.2 Rhinosporidiosis of LDS

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Fig. 19.7  Endoscopic view of the right nasal cavity showing synechiae

Fig. 19.9  Adequate space creation can be seen between the septum and the lateral wall after synechiae release

Fig. 19.8  Endoscopic view of the right nasal cavity showing synechiae release with a blunt dissector

Fig. 19.10  Rhinosporidiosis mass can be visualized on the lateral wall, roof of the nose and septum

oedematous and fragile (Fig. 19.14). Bleeding is often profuse and frequent use of Coblator keeps the field clean and facilitates faster removal of the lesion. Flaps are raised and unhealthy, oedematous mucosa is debrided (Fig. 19.15). • Thick bone of the frontal process of the maxilla is drilled (Figs. 19.16 and 19.17). As the bone is drilled the sac contents start bulging into the nose and a big lump of rhinosporidiosis granules resembling fish eggs can be seen into the lumen of the sac (Figs. 19.18 and 19.19). This mass is debrided and removed (Fig. 19.20).

• Probing is done for confirmation; the mass is completely debrided with the clearance of the infected discharge (Fig. 19.21). The nasolacrimal duct is lifted off the bone from its distal end and removed and the base is coblated (Figs. 19.22 and 19.23). • In Grade 1 with a pedunculated or sessile mass lesion limited to lacrimal sac alone, a standard endoscopic DCR is performed. • in Grade 1 with mass completely filling the sac & involving nasolacrimal duct, a dacryocystectomy is done. A Nasolacrimal duct is

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19  Endoscopic Dacryocystorhinostomy in Chronic Granulomatous Lesions of the Lacrimal Drainage…

Fig. 19.11  Microdebrider is used to debride the mass as the first step

Fig. 19.13  Adequate space is created by removing the mass. The maxillary line is distorted and the overlying mucosa is unhealthy and oedematous

Fig. 19.12  The debulking is continued carefully

lifted off the bony groove and resected with cauterization of the base. • In grade 2, dacryocystectomy (DCT) with en bloc resection of nasolacrimal duct and cauterization of nasal or eye lesion is recommended along with a multidisciplinary approach. • In grade 3 extended DCT uncinectomy, ethmoidectomy, complete extirpation of the sac with en bloc resection of nasolacrimal duct is performed. Fistulectomy should be done in cases with coexistence of a fistula. • Complete drilling of the bone of lacrimal fossa and nasolacrimal duct that is frontal

Fig. 19.14  The area over the frontal process is palpated with a blunt suction dissector and lifted with the dissector itself. No incision is given with knife owing to the oedematous and fragile mucosa

process of maxilla, lacrimal bone and bony nasolacrimal duct is performed. The duct lumen is identified using a ball probe and the nasolacrimal duct is lifted off the bone and removed completely followed by 2% povidone-iodine wash. If the periorbita is infiltrated, bipolar cauterization is done along with the removal of orbital fat [26]. • The eye is examined for an infestation of cornea or conjunctiva with rhinosporidiosis. In cases with no involvement of puncta,

19.2 Rhinosporidiosis of LDS

263

Fig. 19.15  The bleeding areas is coblated to achieve haemostasis and to keep the field clean

Fig. 19.17  Bone removal proceeds up to expose the superior part of the sac

Fig. 19.16  Bone over the frontal process of the maxilla is drilled

Fig. 19.18  Lacrimal sac is opened and the rhinosporidiosis mass can be visualized coming out of the lumen of the sac

canaliculi or conjunctiva, the canalicular system is intubated after complete removal is ascertained. • Topical application of 5% Povidone-iodine for 2  minutes was performed as it causes metabolic inactivation of endospores [17] • Histopathology of the tissue revealed the sporangia of rhinosporidiosis at various stages of the life cycle. There was dense chronic inflammatory cell infiltrate mainly plasma cells and lymphocytes (Figs. 19.24 and 19.25). • Post-operatively the skin over the swelling comes back to normal (Fig. 19.26). Rigorous

follow-up and regular endoscopic checks are needed in these cases.

19.2.7 Post-Operative Instructions Regular check endoscopies should be done at 1wk, 2wk, 4wks. Any recurrence noted should be cauterized immediately. The role of Dapsone (Diamino-diphenyl-sulfone) in reducing the recurrence rate is attributed to an arrest of maturation of spores and any accentuated granulomatous response [18, 23].

264

19  Endoscopic Dacryocystorhinostomy in Chronic Granulomatous Lesions of the Lacrimal Drainage…

Fig. 19.19  Pressure is applied over the medial canthal area to push the complete mass into the nose

Fig. 19.21  A probe can be seen into the nose coming out of the lacrimal sac lumen

Fig. 19.20  Sac lumen is cleared by debriding the rhinosporidiosis mass

Fig. 19.22  Nasolacrimal duct is examined and a ball pointer is passed through the distal opening of NLD to lift the NLD from its bony groove

19.3 Wegener’s Granulomatosis of LDS

19.3.1 Management

Wegener’s granulomatosis is an inflammatory disease of unknown aetiology involving multiple organs [35]. Eye manifestations of Wegner’s granulomatosis include conjunctivitis, scleritis, uveitis, retinal vasculitis, optic neuropathy and corneal ulceration. Nasolacrimal duct obstruction has been reported in 7% of patients with this disease [36].

NLD can get involved by direct extension of nasopharyngeal disease. Wound necrosis and fistula formation have been reported in these cases following DCR by some authors [37]. Therefore, they suggested that dacryocystectomy should be considered in this disease. However, others have reported more encouraging results with DCR and have suggested the use of endoscopic DCR in Wegener’s disease

19.4 Sarcoidosis of LDS

265

Fig. 19.23  NLD is removed completely with the sac and the base is cauterized

Fig. 19.25  Enlarged view of the sporangia with spores

Fig. 19.24  Microphotograph of the lesion demonstrating sporangia of rhinosporidiosis at various stages of the life cycle with dense chronic inflammatory cell infiltrate mainly plasma cells and lymphocytes

[38, 39]. In active cases surgery is performed under a high dose of systemic prednisolone and cyclophosphamide cover [35].

19.4 Sarcoidosis of LDS Sarcoidosis is a systemic granulomatous disease of unknown aetiology [40]. It is believed to be due to exaggerated cellular immune response to a variety of self and non-self antigen [41, 42]. The course of sarcoidosis ranges from being asymptomatic to severe manifestations [40]. It affects people of all age groups with primary involvement of the lungs, lymph nodes, skin, abdomen or eyes.

Fig. 19.26 Post-operative clinical photograph of the patient

Sarcoidosis of the lacrimal sac is uncommon [40, 41] and may present with epiphora without any features of an underlying tumour of the lacrimal sac [40, 41]. It may also present as recurrent dacryocystitis, which may mask the diagnosis and can only be confirmed by histological findings of a noncaseating granulomas with, multinucleated giant cells with multiple epithelioid granuloma on biopsy obtained intraoperatively [41, 43–45].

266

19  Endoscopic Dacryocystorhinostomy in Chronic Granulomatous Lesions of the Lacrimal Drainage…

Sarcoidosis should be suspected during DCR surgery by an abnormal-looking nasal or lacrimal sac mucosa [40]. Endoscopic DCR with intubation along with the use of topical and systemic steroids given for a period of 3 months are helpful in maintaining the patency of lacrimal drainage system [40]. In the event of an unusual presentation of sarcoidosis, the other sites especially lungs should be searched for the sarcoidosis, even in the absence of respiratory complaints [41]. Key Points • Various chronic granulomatous conditions involving lacrimal sac are tuberculosis of the LDS, rhinosporidiosis of the LDS, Wegner’s granulomatosis of LDS and sarcoidosis • Chronic granulomatous infections of the lacrimal drainage system (LDS) pose a challenge in diagnosis as well in the management. In the absence of typical features, the diagnosis may be missed. Thus, a high level of suspicion is needed especially in cases of recurrent failure with an unknown cause. • Tuberculosis should be kept as the first possibility in chronic granulomatous infections of LDS. It should be considered in cases of unexplained recurrent failures following DCR. • Lacrimal sac rhinosporidiosis can be clinically diagnosed most of the times based on the history and examination but in nonendemic area a limited disease can be easily missed. • Rhinosporidiosis is notorious to recur and no set treatment guidelines are available. Grading the disease helps in deciding the extent of excision and in predicting the outcome.

References 1. Bartley GB. Acquired lacrimal drainage obstruction: an etiologic classification system, case reports, and a review of the literature. Part 1 Ophthalmic Plastic and Reconstructive Surgery. 1992;8(4):237–42. 2. Linberg JV, Steven A, McCormick SA.  Primary acquired nasolacrimal duct obstruction: a clinicopathologic report and biopsy technique. Ophthalmology. 1986;93(8):1055–63.

3. Gupta N, Janaki RV, Ali MJ. Primary nasal tuberculosis with lacrimal drainage involvement. International Journal of Paediatric Otorhinolaryngology. 2017;17:1–3. 4. Özer M, Özsurekçi Y, Cengiz AB, et al. Primary nasal tuberculosis in a 10 year-old girl. Can. J. Infect. Dis. Med. Microbiol. 2016:9128548. 5. Tosun F, Tozkoparan E, Erdurman C, et  al. Primary nasolacrymal tuberculosis diagnosed after dacryocystorhinostomy. Auris Nasus Larynx. 2007;34:233–5. 6. Wong SC, Healy V, Olver JM.  An unusual case of tubercular dacryocystitis. Eye. 2004;18:940–2. 7. Varley CD, Gross ND, Marx DP, et al. Tuberculosis of the nasolacrimal duct. Ophthal Plast. Reconstr. Surg. 2011;27:e129–31. 8. Al Malki AF, Issa TM, Riley F, et  al. Nasolacrimal tuberculosis in a patient with Conjunctivodacryocystorhinostomy. Ophthalmic Plast. Reconstr. Surg. 1999;15:213–6. 9. Abrol R, Nagarkar NM, Mohan H, et al. Primary bilateral tubercular dacryocystitis with preauricular lymphadenopathy: a diagnositic difficulty of recent times. Otolaryngol. Head. Neck Surg. 2002;126:201–3. 10. Kuriakose ET.  Oculosporidiosis: rhinosporidiosis of the eye. Br J Ophthalmol. 1963;47:346–9. 11. Suneer R, Sivasankari L.  Clinical profile of rhinosporidiosis in a tertiary care centre of an endemic area. Int J Otorhinolaryngol Head Neck Surg. 2018;4:659–62. 12. Mishra LK, Gupta S, Pradhan SK, Baisakh MR. Lacrimal sac rhinosporidiosis. Plast Aesthet Res. 2015;2:353–6. 13. Satyanarayana C.  Rhinosporidiosis with a record of 255 cases. Acta Otolaryngologica. 1960;51(3-4):348–66. 14. Pushker N, Kashyap S, Bajaj MS, et al. Primary lacrimal sac rhinosporidiosis with grossly dilated sac and nasolacrimal duct. Ophthal Plast Reconstr Surg. 2009;25:234–5. 15. Ashworth JH. On Rhinosporidium Seeberi (Wernicke 1903), with special reference to its sporulation and affinities. Trans R Soc Edinb. 1923;53:30142. 16. Arseculeratne SN.  Recent advances in rhinospo ridiosis and rhinosporidium Seeberi. Indian J Med Microbiol. 2002;20:119–31. 17. Nuruddin M, Mudhar HS, Osmani M, Roy SR. Lacrimal sac rhinosporidiosis: clinical profile and surgical management by modified dacryocystorhinostomy. Orbit. 2014;33(1):29–32. 18. Watve JK, Mane RS, Mohite AA, Patil BC. Lacrimal sac rhinosporidiosis. Indian J Otolaryngol Head Neck Surg. 2006;58(4):399–400. 19. David SS, Sivarama subrahmanyam P.  Ocular Rhinosporidiosis, a study of twenty cases. Indian J Ophthalmol. 1973;21:204–7. 20. Shrestha SP, Hennig A, Parija SC. Prevalence of rhinosporidiosis of the eye and its adnexa in Nepal. Am J Trop Med Hyg. 1998;59:231–4. 21. Chowdhury RK, Behera S, Bhuyan D, Das G. Oculosporidiosis in a tertiary care hospital of west-

References ern Orrisa, India: a case series. Indian J Ophthalmol. 2007;55:299–301. 22. Suseela V, Subramaniam KS.  Rhinosporidiosis and the eyes. Indian J Ophthalmol. 1975;23:1–4. 23. Sah BP, et  al. Lacrimal Sac Rhinosporidiosis: an Unusual Case Report. American Journal of Medical Case Reports. 2014;2(4):84–6. 24. Thakur SKD, Sah SP, Badhu BP. Oculosporidiosis in Eastern Nepal: a Report of five cases. Southeast Asian J Trop Med Public Health. 2002;33(2):362–4. 25. Shukla IM, Mukherjee PK, Verma S.  Primary rhinosporidiosis of the eye. International Congress of Ophthalmology ACTA XXVI. 1982;2:864. 26. Gupta N, Singla P, Pradhan B, Gurung U.  Lacrimal Sac Rhinosporidiosis; Case report and review of literature with a new grading system to optimize treatment. Saudi Journal of Ophthalmology. 2019;33(3):283. 27. Kirkpatrick H.  Two cases of rhinosporidium Kinealyi affecting the conjunctiva. Ophthalmoscope. 1912;10:430–2. 28. Mukherjee B, Mohan A, Sumathi V, Biswas J. Infestation of the lacrimal sac by Rhinosporidium Seeberi: a clinicopathological case report. Indian J Ophthalmol. 2013;61:588–90. 29. Jamison A, Crofts K, Roberts F, Gregory ME. Educational report: a case of lacrimal sac rhinosporidiosis. Orbit. 2016;35(5):254–7. 30. Rogers S, Waring D, Martin P.  Recurrent lacrimal sac rhinosporidiosis involving the periocular subcutaneous tissues, nasolacrimal duct and nasopharynx. Orbit. 2012;31(5):358–60. https://doi.org/10.3109/01 676830.2012.700548. 31. Rambo, VC. Proc. Indian Ophthal Soc. 1949; 10: 72. 32. Nerurkar NK, Bradoo RA, Joshi AA, Shah J, Tandon S. Lacrimal sac rhinosporidiosis: a case report. Am J Otolaryngol. 2004;25:423–5. 33. Rajesh Raju G, Sandeep S.  Lacrimal sac rhinosporidiosis and surgical management by transnasal endoscopic excision: a case series. Laryngoscope. 2018;128(12):2693–6. 34. Basu SK, Bain J, Maity K, Chattopadhyay D, Baitalik D, Majumdar BK, Gupta V, Kumar A, Dalal BS,

267 Malik A.  Rhinosporidiosis of lacrimal sac: an interesting case of orbital swelling. J Nat Sc Biol Med. 2016;7:98–101. 35. Kwan ASL, Rose GE.  Lacrimal drainage surgery in Wegener’s granulomatosis. Br J Ophthalmol. 2000;84:329–31. 36. Bullen CL, Liesegang TJ, McDonald TJ, et  al. Ocular complications of Wegener’s granulomatosis. Ophthalmology. 1983;90:279–90. 37. Holds JB, Anderson RL, Wolin MJ. Dacryocystectomy for the treatment of dacryocystitis in patients with Wegener’s granulomatosis. Ophthalmic Surg. 1989;20:443–4. 38. Glatt HJ, Putterman AM.  Dacryocystorhinostomy in Wegener’s granulomatosis. Ophthalmic Plast Reconstr Surg. 1990;6:207–10. 39. Hargwig PW, Bartley GB, Garrity JA. Surgical management of nasolacrimal duct obstruction in patients with Wegener’s granulomatosis. Ophthalmology. 1992;99:133–9. 40. Burduk PK, Seredyka-Burduk M, Kaźmierczak W, Dalke K. Sarcoidosis of the lacrimal sac as a cause of dacriostenosis. Otolaryngol Pol. 2013;67(2):109–12. https://doi.org/10.1016/j.otpol.2012.05.008. Epub 2012 May 7 41. Ramlee N, Ramli N, Liza-Sharmini AT.  Extrapulmonary sarcoidosis: unusual cause of epiphora. Singapore Med J. 2007;48(6):e168. 42. Newman LS, Rose CS, Maier LA.  Sarcoidosis. N Engl J Med. 1997;336:1223–34. Erratum in: N Engl J Med 1997; 337:139. Comment in: N Engl J Med 1997; 337: 789-90; author reply 791 43. Chapman KL, Bartley GB, Garrity JA, Gonnering RS. Lacrimal bypass surgery in patients with sarcoidosis. Am J Ophthalmol. 1999;127:443–6. 44. Karma A, Huhti E, Poukkula A.  Course and out come of ocular sarcoidosis. Am J Ophthalmol. 1988;106:467–72. 45. Harris GJ, William GA, Clarke GP. Sarcoidosis of the lacrimal sac. Arch Ophthalmol. 1981;99:1198–201.

Dacryoendoscopy in Lacrimal Drainage System

Dacryoendoscopy is the intraluminal visualization of the lacrimal drainage system  (LDS) using a miniature endoscope coupled to a high definition camera unit. It helps in complete visualization of the lacrimal pathway from punctum to the inferior meatus and has been used by a number of authors for various indications [1, 2]. Singh AD et  al described the procedure of dacryoplasty in 1992 using two prototype ultrathin fibrescopes PF-5 and XTUF-l1 (Olympus Co Ltd, Tokyo) [3]. They however adopted both, an anterograde as well as retrograde technique. Due to the flexibility of their microendoscope the scope when passed in an anterograde fashion through the punctum could only reach the sac through punctum and canaliculi but could not enter the NLD. They therefore combined it with the retrograde technique by removing the inferior turbinate in cadavers and introduced the scope from the inferior meatus side [3]. Ophthalmic application of an endoscope was first described by Thorpe in 1934 [4]. He used it in removing the intravitreal foreign bodies. Later fine calibre flexible fibreoptic endoscopes were designed and used in the treatment of intraocular and orbital surgery [5–7]. Transcanalicular micro endoscopic visualization of the lacrimal pathway was first described by Cohen et al. [8] in 1979 and the first flexible endoscopy of LDS was performed using a modified Juenemann probe followed by rigid Vitroptic endoscopes [9].

20

Dacryoendoscopy has been used in a variety of indications like congenital nasolacrimal duct obstruction (CNLDO), especially in refractory cases, laser dacryoplasty, microdrill dacryoplasty, primary acquired nasolacrimal duct (NLD) obstruction, individual and common canalicular obstructions and in understanding the physiology of lacrimal drainage system [2, 9–17]. A variety of endoscopes are available in various diameters with and without interventional ports. They come as dedicated dacryoendoscope like the ones manufactured by Fibertech (Fibertech, Tokyo, Japan) as RUIDO fiberscope MD10 (available in 0.7 and 0.9mm) [9] or as Sialoendoscope manufactured by Karl Storz Germany. Sialoendoscope has all the features needed for diagnostic and therapeutic uses in the lacrimal drainage system and is available in a wide range of dimensions. We used a 0.8mm Erlangen miniature straight forward 0° semiflexible endoscope. It has a scale and an attachment for  fibreoptic light transmission (Karl Storz, Tuttlingen, Germany) with a side port for irrigation coupled with a high definition IMAGE1 STM Karl Storz camera unit. (Figs.  20.1, 20.2, 20.3 and 20.4) Simultaneous viewing of the nose was performed using 4mm, 00 nasal endoscope. (Figs. 20.5 and 20.6)

© Springer Nature Singapore Pte Ltd. 2021 N. Gupta, Endoscopic Dacryocystorhinostomy, https://doi.org/10.1007/978-981-15-8112-0_20

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20.1 Dacryoendoscopy 20.1.1 Technique

Fig. 20.1  0.8mm Erlangen miniature straight forward 0° semiflexible endoscope. It has a scale and an attachment for fibreoptic light transmission (Karl Storz, Tuttlingen, Germany) with a side port for irrigation

Fig. 20.2  Camera head attachment of the dacryoendoscope with a port for the light source

Fig. 20.3 Markings over the dacryoendoscope at 5mm

Fig. 20.4  Side port for irrigation in dacryoendoscope

Dacryoendoscopy is performed in a way similar to probing the punctum. The punctum is dilated gradually by progressively larger size dilators for serial dilatation of the punctum. Dacryoendoscope is passed through the punctum into the canaliculi with a constant flush of saline through a side port by attaching a 2ml syringe (Fig. 20.7). Arthrograde or anterograde dacryoendoscopy is performed with the semirigid dacryoendoscope unlike the previous studies that used both arthrograde and retrograde technique owing the flexible miniature endoscope that could not be manoeuvred into NLD via anterograde route [3]. However, with a variety of new development in recent times, it has become possible to examine the entire system using anterograde technique [2]. The scope is gently advanced into the vertical canaliculus and is then tilted horizontally to enter into the lacrimal sac (Fig.  20.7). After reaching the sac the scope is turned to 90 degrees to advance it further into the sac and nasolacrimal duct. The sac and NLD are examined carefully with continuous saline flush through the side port by attaching a 2ml syringe. It keeps the tip of the scope clean and provides better visualization.

20.1 Dacryoendoscopy

271

Fig. 20.5  0.8mm Dacryoendoscope for intraluminal examination of the lacrimal drainage system and simultaneous and 4mm, 00 nasal endoscope for nasal examination

a

b

c

d

Fig. 20.6  Simultaneous use of each endoscope is demonstrated. a Dacryoendoscope is introduced through the upper punctum for intraluminal examination of the lacrimal drainage system. b Simultaneous viewing of the nose using 4mm, 00 nasal endoscope shows the glow from the tip of dacryoendoscope near the anterior attachment of the

middle turbinate. c Illumination from the tip of dacryoendoscope is seen in the inferior meatus indicating that the dacryoendoscope is at the distal end of NLD. d The tip can be seen perforating the membrane over the valve of Hasner

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endoscope helps in differentiating a proximal obstruction block from a distal NLD obstruction.

20.1.2 Findings Dacryoendoscopy involves examination from the punctum to the distal NLD opening at the valve of Hasner (Fig. 20.8). The appearance of the various structure has been described below

20.1.3 Puncta Puncta appear as a small depression with a tiny lumen and  raised surrounding mucosa (Fig.  20.8a). A continuation of punctal lumen into the canaliculus can also be visualized on close look. Magnified view of the punctum can be helpful in identification of any obvious membranous obstruction, punctal stenosis or punctal agenesis.

20.1.4 Canaliculi Fig. 20.7  Left dacryoendoscopy in a case of complex congenital nasolacrimal duct obstruction

The image obtained by dacryoendoscope is much smaller owing to the small diameter of the scope as compared to a larger 2.5 mm or 4 mm nasal endoscope. Therefore, the surgeon needs to constantly look at the screen to get accustomed to the various landmarks. The procedure needs a lot of patience as the tip of the scope keeps getting smeared with discharge obscuring our vision. Mucosal folds are seen to be projecting into the lumen of the sac and NLD.  Simultaneous visualization of the nose is often not needed but if available a dual camera approach can be used to assess the level of illumination of the nose to check the passage of dacryoendoscope in lacrimal drainage system. In cases of CNLDO a simultaneous visualization of the inferior meatus with 2.7mm nasal

They look whitish with the walls having smooth lined channels in patent lacrimal drainage system (Fig. 20.8b). The lumen may be filled with discharge and the canalicular wall is lined with inflamed mucosa in long-standing infections. The transition from horizontal canaliculus to common canaliculus can be identified by concentric ring-like mucosal folds at its entry into the lacrimal sac (Fig. 20.8c).

20.1.5 Lacrimal Sac It is easy to identify various landmarks in relation to the lacrimal sac as the sac is the most easily identifiable structure with a wider lumen that provides ease of manoeuvring the scope in different directions. Lacrimal sac has a distinct appearance of pinkish-red mucosa that looks brighter than the canaliculi and may have prominent mucosal folds (Fig.  20.8d). The appearance of the sac

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273

d

Sac Lumen

c

e

Common canaliculus

Proximal NLD opening

b

f

Mid segment NLD

g

Canaliculus

a

Valve of Hasner

Punctum

Fig. 20.8  Normal intraluminal appearance of various structures in the left lacrimal drainage system. a Punctum. b Canaliculi look as whitish structure with smooth mucosa. c Common canalicular opening. d Lacrimal sac looks pinkish with prominent mucosal folds and dis-

charge. e Sac duct junction with an outpouching of the mucosa on the left and a proximal NLD opening medially. f Mid NLD opening. g Valve of Hasner area with a patent distal NLD opening

d­ iffers in different cases depending on the severity of infection. Normal system with patent  NLD is easy to examine as the saline flushed through the side port keeps trickling into the nose  and provides clarity in the lacrimal drainage system lumen.

While in cases with an obstructed NLD the sac lumen is often filled with discharge and poses challenge as the NLD is already obstructed and the saline further keeps adding to the collection in the sac. The sac can be  emptied by pressing over the medial canthal area in such cases.

274

Sometimes a streak of blood may be seen the lacrimal sac due to the scope touching the lacrimal sac walls and can be cleared by flushing with saline.

20  Dacryoendoscopy in Lacrimal Drainage System

20.2.1 Membranous Obstruction (Fig. 20.9)

As the scope is advanced inferiorly into the sac, it reaches the sac duct junction. Before the sac narrows into NLD it displays a mucosal outpouching lateral to the proximal opening of the NLD, marked by a star in Fig. 20.8e. This out pouching occurs laterally in relation to proximal  NLD opening and helps in identifying the side of the lacrimal drainage system after documentation. In some cases, this outpouching may not be very prominent but the transition from sac to NLD is well defined. This sac and NLD junction were earlier labelled as the value of Kraus but was later identified as just the cavernous folds [18, 19].

In cases of CNLDO, the proximal NLD opening is patent (Fig. 20.9a) and the fluid can be seen getting collected at the bottom of the NLD as the distal opening is blocked by a membrane (Fig.  20.9b). As the membrane is perforated the site of the hole can be identified with the dacryoendoscopy and as the secretions flow into the nose, the view becomes clear and the opening is widened (Fig. 20.9c). If the procedure can be performed quickly and the safety of the scope is ensured, direct perforation of intact membrane over the valve of Hasner by the tip of the scope may become an acceptable modality in the future. However, in the current scenario, the scope is expensive and friable and once broken needs to  be replaced and thus can be reserved for recalcitrant CNLDO [2].

20.1.7 NLD

20.2.2 Dacryolith (Fig. 20.10)

A normal NLD has a proximal round or elliptical patent opening at the inferior end of the lacrimal sac that continues below into a narrow tunnel-like structure (Fig.  20.8f). Various mucosal folds can be visualized into the lumen of NLD and as the scope is advanced further and patent distal opening of the NLD guarded by valve of Hasner can be visualized in the inferior meatus [18] (Fig. 20.8g).

Concretions have been found in cases of recalcitrant CNLDO and their successful removal using dual endoscopy involving a dacryoendoscope and a nasal endoscope has obviated the need for dacryocystorhinostomy in certain selective cases of CNLDO [2]. Dacryoendoscopic visualization of the lacrimal sac and NLD in a refractory case of CNLDO can demonstrate concretions at sac duct junction (Fig.  20.10a). The membrane in these cases is perforated using a Bowman’s probe, the dacryoliths are dislodged, flushed with saline and pushed down the NLD lumen (Fig.  20.10b). Dacryolith is retrieved through the nose (Fig. 20.10c). A check syringing showed the free flow of dye into the inferior meatus with no regurgitation.

20.1.6 Sac Duct Junction

20.2 Dacryoendoscopy in CNLDO A number of studies have been published on the role of dacryoendoscopy in CNLDO in both primary as well as in refractory cases of CNLDO [2, 11–13, 20–24].. Various situations that can be handled using dacryoendoscopy have been described here

20.2  Dacryoendoscopy in CNLDO

275

1

2

3

Fig. 20.9  Dacryoendoscopic visualization of the membranous obstruction over the valve of Hasner in the inferior meatus. 1 Proximal patent lumen of NLD. 2 Ballooned

out membrane at the distal end of NLD. 3 Recanalization of NLD with the patent distal end marked by a hole at the site of perforation

20.2.3 Agenesis of NLD (Figs. 20.11 and 20.12)

puted tomographic scan of children who had difficulty in cannulating the NLD and were found to have agenesis of NLD [25]. Those with the partial formation of bony NLD revealed two depressions at the bottom of the sac on dacryoendoscopy, one denoting the usual outpouching at the sac duct junction marked by a white arrow (Fig. 20.11a) and a blind pit medi-

There could be partial or complete agenesis of NLD and both situations can be identified on DEN. It is suspected in cases where a probe fails to enter the inferior meatus under nasal endoscopic visualization. Coban DT et al did a com-

276

20  Dacryoendoscopy in Lacrimal Drainage System

1

2

3

Fig. 20.10  Dacryoendoscopic visualization of the lacrimal sac and NLD in a refractory case of CNLDO. 1 Concretions at sac duct junction. 2 Dacryolith can be seen

getting pushed down the NLD lumen. 3 Dacryolith is seen in the inferior meatus on nasal endoscopy

ally in place of proximal NLD opening marked by the yellow arrow in (Fig.  20.11b). A close view of the blind pit of NLD shows imperforate and malformed NLD with a blind bottom (Fig. 20.11c; yellow arrow). In case of complete

bony dysgenesis on dacryoendoscopy bottom of the sac looks like a blind avascular area with the absence of the NLD and a hard stop confirming it to be a case of bony dysgenesis of NLD. (Fig. 20.12a).

20.2  Dacryoendoscopy in CNLDO

277

a

b

c

Fig. 20.11 Dacryoendoscopic view of a complex CNLDO. a Lacrimal sac. b A partially formed NLD seen as  a  depression at the bottom of the sac. There are two depressions at the bottom of the sac, the lateral one (white arrow) represents the usual lateral outpouching of the sac

mucosa at the sac duct junction. The medial blind pit (yellow arrow) represents a malformed bony NLD. c A close view of the medial pit (NLD) demonstrates a blind bottom indicating initiation of formation of bony NLD with halted growth

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a

b

c

Fig. 20.12  Dacryoendoscopic view of bony dysgenesis of NLD. a Blind sac bottom with no NLD demarcation. b Nasal endoscopic view of the marsupialized sac  in the same case. The sac looks small ending inferolateral into the frontal process of maxilla with no NLD formation. c

Inferior meatus shows a tightly draped mucosa with no NLD opening seen and no transmitted light from the dacryoendoscope is visible indicating an obstruction lying higher up

Simultaneous viewing of inferior meatus showed no light reflection of the d­ acryoendoscopy indicating an obstruction lying higher up (Fig. 20.12c). On endoscopic dacryocystorhinostomy the sac looked small, ending blindly into

the frontal process of maxilla with no NLD (Fig. 20.12b). Gupta et  al. reported a study of 13 children who were referred for endoscopic dacryocystorhinostomy following single or multiple failed

20.4  Dacryoendoscopy Primary Acquired Nasolacrimal Duct Obstruction

279

probing [2]. They did dacryoendoscopic exami- lumen unlike in a normal canaliculus (Figs. 20.13a nation of all the cases and found bony dysgenesis and b). In acquired common canalicular stenosis, in four cases, dacryolith in four cases, an intact the lumen looks is obstructed with irregular membrane at the lower end of NLD in three cases unhealthy with unhealthy brownish tissue obstructand fibrosis of the lower NLD in two cases. ing it (Fig. 20.13c). Immediate post-trephination a Successful recanalization could be done in seven wide irregular common canalicular lumen can be cases while six underwent an endoscopic dacryo- visualized with a well-­healed mucosa 3 months cystorhinostomy [2]. post-operatively (Fig. 20.13d, e and f). Fujimoto M enrolled 54 cases of failed probImpending cases of complete canalicular ing, complex CNLDO and late probing. All cases obstructions can be identified on dacryoendoscopy underwent dacryoendoscopy assisted probing by reduction in canalicular extensibility. Early intuwith a success rate of 97% [11]. Heichel J did bation in these cases helps in preventing severe stedacryoendoscopy assisted probing in 18 eyes of nosis or obstruction. Dacryoendoscopy helps to 16pts. Nine cases had acute dacryocystitis, and identify various canalicular pathologies like nine had persistent chronic dacryocystitis. All oedema, stenosis, obstruction and false passages. cases underwent dacryoendoscopy assisted prob- Dacryoendoscopy also allows differentiation of ing with 100% success rate [21]. complete and partial stenosis of common canalicHidenori Sasaki did dacryoendoscopy in 13 uli, NLD and scar tissue [9]. Dacryoendoscopy eyes of 10 patients and found oedematous thick- assisted trephinations allows recanalization of canening and fibrous tissue at various sites in naso- aliculi or NLD using the Huco or Javate lacrimal lacrimal duct with 92% success rate [13]. Kumiko trephines. Dacryoendoscopy allows inferior meatal Kato did DEN in three cases of CNLDO with window creation or dacryorhinotomy, microdrill 66% success rate [23]. They found fibrosis of dacryoplasty and laser dacryoplasty [9, 12]. NLD in one case with obstruction at the bottom Dacryoendoscopy-guided membranotomy in of the lacrimal sac in two cases [23]. common canalicular obstruction resulted in 90% Matsumura1 Nozomi had a series of three success rate 12  months follow up. However, children, one was secondary to adenovirus infec- long-term follow up revealed restenosis at comtion acquired NLD obstruction, one case of pri- mon canalicular area [9, 12]. mary acquired nasolacrimal duct obstruction and third with Down’s syndrome. Two out of three cases were successful [20]. 20.4 Dacryoendoscopy Primary Sarbajna performed a dacryoendoscopy-­ Acquired Nasolacrimal Duct guided incision over the intranasal cyst in seven Obstruction cases of congenital Dacryocele in all seven with dacryocystitis in five cases [24]. Kakizaki H did The site of obstruction could be judged in 138 successful dacryoendoscopy assisted probing in a Primary acquired nasolacrimal duct obstruction case of Congenital dacryocele with dacryocysti- patients (149 NLD) using dacryoendoscopy. tis and found injection with haemorrhage in line Higher obstruction i.e. at the level of sac duct juncwith histology findings [22]. tion was found in 73.2% cases and lower NLD obstruction in the rest of the cases. The decision was made on the basis of transmitted light from 20.3 Dacryoendoscopy the tip of the dacryoendoscope light seen along the middle meatus on nasal endoscopy and in Canalicular Obstructions These cases were treated by inferior meatal Dacryoendoscopy helps in differentiating canalicu- dacryorhinotomy using radiofrequency scallar stenosis from complete obstruction. In case of pel. All cases underwent bicanalicular silicone congenital canalicular obstruction, there is a stenting with 87% success rate at 2  years smooth circumferential obstructive patholgy in  the ­follow-up [26].

20  Dacryoendoscopy in Lacrimal Drainage System

280

a

b

d

e

c

Probe

f

Fig. 20.13  Dacryoendoscopic view of the canalicular obstructions. a Congenital canalicular obstruction (white arrow). b Normal canalicular system with a patent lumen. c Acquired canalicular obstruction (black arrow). d Post-­ trephination lumen of the common canaliculus. e Well-­ healed canalicular lumen with DEN and instrument (white

arrow) seen in a post-endoscopic DCR with trephination of the common canalicular obstruction. f Air bubble at the common canalicular opening with concentric rings of mucosa deeper down. CC: Common canaliculus, LS: Lacrimal sac

20.5 Challenges of Dacryoendoscopy

• The equipment is delicate and expensive with extreme fragility. Once broken it cannot be repaired and needs to be replaced with a new one.

• The image size is small and less clear with difficulty in interpretation as most of the surgeons are used to large image with either a 2.5 mm or 4 mm nasal endoscope. • There is a steep learning curve as the visualization needs good surgeon assistant coordination. Saline flush through the side port needs to be done carefully as the dacryoendoscope shakes every time saline is flushed. Its tip hits one of the walls of the sac leading to the distortion of image. However, with continuous practice, it is possible to obtain a much better image.

Key Points • Dacryoendoscopy is a very useful tool for high definition  intraluminal examination of the lacrimal drainage system. • It has been used in a variety of indications like congenital nasolacrimal duct obstruction (CNLDO), especially the  refractory cases of CNLDO, primary acquired NLD obstruction, dacryoplasty and canalicular obstructions. However it has a steep learnig curve, the scope is very delicate, fragile and expensive limiting its use in routine practice. It is also important from

References

research point of view and heps in understanding the physiology of lacrimal drainage system.  • Its limitations include high cost, steep learning curve and lower success rates.

References 1. Müllnera K, Bodnera E, Mannor GE. Endoscopy of the lacrimal system. Br J Ophthalmol. 1999;83:949–52. 2. Gupta N, Singla P, Kumar S, Ganesh S, Dhawan N, Sobti P, Aggarwal S.  Role of dacryoendoscopy in refractory cases of congenital nasolacrimal duct obstruction. Orbit. 2019;39(3):183. https://doi.org/10. 1080/01676830.2019.1668434. 3. Singh AD, Singh A, Whitmore I, et  al. Endoscopic visualisation of the human nasolacrimal system: an experimental study. Br J Ophthalmol. 1992;76:663–7. 4. Thorpe HE.  Ocular endoscope. Trans Am Acad Ophthalmol, Otolaryngol. 1934;39:422–4. 5. Norris JL, Cleasby GW.  An endoscope for ophthalmology. Am J Ophthalmol. 1978;85:420–2227. 6. Norris JL, Cleasby GW.  Intraocular endoscopic surgery. Am J Ophthalmol. 1981;91:603–6. 7. Norris JL. Vitreous surgery viewed through an endoscope. Dev. Ophthalmol. 1981;2:15–6. 8. Cohen SW, Prescott R, Sherman M, et al. Dacryoscopy. Ophthalmic Surg. 1979;10:57–63. 9. Singh S, Ali MJ.  A review of diagnostic and therapeutic dacryoendoscopy. Ophthalmic Plast Reconstr Surg. 2019;35(6):1. 10. Athanasiov PA, Prabhakaran VC, Mannor G, et  al. Transcanalicular approach to adult lacrimal duct obstruction: a review of instruments and methods. Ophthalmic Surg Lasers Imaging. 2009;40:149–59. 11. Fujimoto M, Ogino K, Matsuyama H, et al. Success rates of dacryoendoscopy-guided probing for recalcitrant congenital nasolacrimal duct obstruction. Jpn J Ophthalmol. 2016;60:274–9. 12. Sasaki T, Sounou T, Sugiyama K. Dacryoendoscopic surgery and tube insertion in patients with common canalicular obstruction and ductal stenosis as a frequent complication. Jpn J Ophthalmol. 2009;53:145–50. 13. Sasaki H, Takano T, Murakami A. Direct endoscopic probing for congenital lacrimal duct obstruction. Clin Exp Ophthalmol. 2013;41:729–34. 14. Meyer-Rüsenberg HW, Emmerich KH. Modern lacrimal duct surgery from the ophthalmological perspective. Dtsch Arztebl Int. 2010;107:254–8. 15. Heichel J, Sandner A, Siebolts U, et al. Concretions and iatrogenic foreign bodies in the lacrimal system: treatment recommendations [in German]. HNO. 2016;64:403–16. 16. Takahashi Y, Suzuki T, Kakizaki H.  Lacrimal sac movement under intrasac pressure changes observed

281 with dacryoendoscopy. Ophthalmic Plast Reconstr Surg. 2014;30:313–4. 17. Kakizaki H, Takahashi Y, Mito H, et  al. Movement of the lacrimal canalicular wall under intracanalicular pressure changes observed with dacryoendoscopy. Ophthalmic Plast Reconstr Surg. 2015;31:73–4. 18. Maliborski A, Różycki R. Diagnostic imaging of the nasolacrimal drainage system. Part I.  Radiological anatomy of lacrimal pathways. Physiology of tear secretion and tear outflow. Med. Sci. Monit. 2014;20:628–38. 19. Paulsen F, Thale AB, Hallmann UJ, Schaudig U, Tillmann BN.  The cavernous body of the human efferent tear ducts: function in tear outflow mechanism. Investigative Ophthalmology & Visual Science. 2000;41(5):965–70. 20. Matsumura N, Satoshi G, Shin Y, Takeshi F, Maiko I, Mikio I, et  al. High-resolution dacryoendoscopy for observation for pediatric lacrimal duct obstruction. Am J Ophthalmol Case Rep. 2016;1:23–5. https://doi. org/10.1016/j.ajoc.2016.03.003. 21. Heichel J, Struck HG, Fiorentzis M, Hammer T, Bredehorn-Mayr T.  Case series of dacryoendoscopy in childhood: a diagnostic and therapeutic alternative for complex congenital nasolacrimal duct obstruction even in the first year of life. Adv Ther. 2017;34(5):1221–32. https://doi.org/10.1007/ s12325-017-0517-8. 22. Kakizaki H, Takahashi Y, Sa HS, Masayoshi I.  Congenital dacryocystocele: comparative findings of dacryoendoscopy and histopathology in a patient. Ophthalmic Plast Reconstr Surg. 2011;28(4):e85–6. https://doi.org/10.1097/IOP.0b013e31822de091. 23. Kato K, Matsunaga K, Takashima Y, Kondo M.  Clinical ophthalmology (Auckland, N.Z.) probing of congenital nasolacrimal duct obstruction with dacryoendoscope. Clin Ophthalmol. 2014;8:977–80. https://doi.org/10.2147/OPTH.S60377. 24. Sarbajna T, Takahashi Y, Paula Valencia MR, AnaMagadia MG, Ishikawa E, Kakizaki H. Dacryoendoscopy assisted nasal endoscopic marsupialization for congenital dacryocystocele. Int J Pediatr Otorhinolaryngol. 2018;115:54–7. https://doi. org/10.1016/j.ijporl.2018.09.017. 25. Coban DT, Beden U, Sonmez B, Elmali M, Erkan D. Unsuccessful probing and nasolacrimal canal agenesis in congenital epiphora. Orbit. 2010;29(6):363–6. https://doi.org/10.3109/01676830.2010.522298. 26. Sasaki T, Nagata Y, Sugiyama K. Nasolacrimal duct obstruction classified by dacryoendoscopy and treated with inferior meatal dacryorhinotomy: Part II. Inferior meatal dacryorhinotomy. Am J Ophthalmol. 2005;140:1070–4.

Balloon Dacryoplasty in Lacrimal Drainage System Disorders Using Coronary Angioplasty Balloons

Balloon dacryoplasty is a minimally invasive technique for treating various conditions of lacrimal drainage system. Initial nasolacrimal duct (NLD) dilatation was performed using sialography cannulas in 1978 [1, 2]. The term balloon dacryoplasty was first described in 1989 by Becker and Berry [2] and then angioplasty catheters were used by Munk et al. under fluoroscopic guidance [3]. Balloon dacryoplasty has been described as a technique used for dilatation of NLD and for balloon-assisted endoscopic dacryocystorhinostomy (DCR) without giving an incision [4]. We describe the use of Balloon dacryoplasty in congenital nasolacrimal duct obstruction (CNLDO) and in selective cases of functional epiphora using coronary angioplasty balloons. Various other indications of Balloon dacryoplasty have been described in the literature like partial NLD obstruction in adults, complete NLD obstruction, primary DCR, revision DCR and for dilatation of the ostium [5]. These studies have been published using LacriCATH for treating nasolacrimal duct obstruction in children as well as adults [2, 4, 5]. The LacriCATH lacrimal duct catheters are manufactured by Quest Medical, Inc. (Allen, TX) and FCI Ophthalmic, Paris, France and have been specifically designed for the lacrimal drainage system use [4]. Currently, the most common use of Balloon dacryoplasty is seen in selective cases of CNLDO. In adults its widespread acceptance still remains poor due to the high cost and uncertainty

21

of long-term results. To address these issues of cost and availability we chose coronary angioplasty balloons catheters in children presenting with CNLDO as also described in the previous study [6]. Coronary angioplasty balloons are available in multiple dimensions, are cost-­ effective, atraumatic and have all the features needed for lacrimal system procedures.

21.1 Balloon Dacryoplasty in Congenital Nasolacrimal Duct Obstruction (CNLDO) Congenital nasolacrimal duct obstruction (CNLDO) is usually the result of the failure of canalization of the distal end of the nasolacrimal duct (NLD) [7, 8]. A remarkably high rate of spontaneous resolution occurs (>90%) during the first 12  months of life and the majority of children do not require surgical treatment [7, 8]. Those with persistent epiphora undergo probing & irrigation. Endoscopic-assisted probing under general anaesthesia has now become the standard of care for children with persistent disease [7]. Those with recalcitrant CNLDO are treated with dacryoendoscopy assisted recanalization or endoscopic dacryocystorhinostomy [9]. The use of balloon dacryoplasty has been advocated in the selective cases of CNLDO [5] including older children, children with failed previous probing, and those with syndromic association of CNLDO [5, 10, 11]. Balloon dacryoplasty in CNLDO is

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the circumferential smooth dilation of the nasolacrimal duct. The success rate of paediatric balloon dacryoplasty using LacriCATH varied from 76% to 83% [10–14]. The high cost of the traditional balloon has been quoted as an important factor for limiting its use in developing countries [5]. Therefore, coronary angioplasty balloon catheters have been used and labelled as a suitable low-cost alternative to the traditional lacrimal duct catheters [6].

disorders. Rated burst pressure (RBP) is the pressure below which 99.9% of the balloons will not burst on single inflation. RBP may differ in different brands of available balloon and is specified by the manufacturing companies based on the results of the test with 95% confidence level. They are available under a variety of brand names and some of the brands that we used were Sapphire Orbusneich, Boston scientific and SPALNO Cardiomac. There is a different specification from the companies about the inflation pressure and the burst 21.1.1 Coronary Angioplasty pressure. For a 2mm and 2.5mm Boston Scientific Balloons balloon an inflation pressure of 6 atmosphere is sufficient with a burst pressure of 14 atmosheric Items needed for this procedure are introducer, unit (Kpa) and SPALNO Cardiomac have a high guide wire, balloon, inflation device, syringe, burst pressure of 24 atmospheric unit. Therefore, saline, fluorescein, punctal dilator, Bowman’s we mainly used percutaneous transluminal coroprobe along with endoscopic camera unit with nary angioplasty (SPALNO, Cardiomac, Haryana) monitor (Fig. 21.1) balloon catheter with and a high burst pressure of Coronary balloons have features and surgical 24 atmospheric unit. Cardiac catheters are long in outcomes comparable to that of traditional bal- size as they are designed for coronary angioloon catheters at a significantly reduced cost [6]. plasty. They come as packed coils with a protector They are available as compliant and non-­ that is placed over the balloon to maintain low compliant balloons in a large variety of dimen- profile and a mandrel are placed into the inner sions. They are cost-effective and have high rated lumen to preserve the patency of the catheter burst pressure that makes it safe to use in lacrimal (Figs.  21.2, 21.3). The distal section of the

Fig. 21.1  Coronary angioplasty balloon catheter set, including a coronary balloon catheter, a guide wire, syringe and an inflation device

21.1  Balloon Dacryoplasty in Congenital Nasolacrimal Duct Obstruction (CNLDO)

285

Fig. 21.4  The distal end of the coronary balloon with a tapering end Fig. 21.2 Percutaneous Transluminal Coronary Angioplasty Balloon that comes as a coil due to its long length

Fig. 21.3  A protector is placed over the balloon to maintain low profile and the mandrel preserves the patency of the catheter

c­ oronary balloon catheter has a dual lumen, the outer lumen is used for inflation of the balloon and the inner lumen allows passage of guidewires and help in the advancement of the catheter through the stenosis (Figs.  21.4, 21.5, 21.6 and 21.7). It has an inflatable balloon at one end and a hub with Luer lock mechanism at the other end. The Luer lock end gets attached to the inflation device. The inflation device has a manometer with pressure measurements in atmospheres (Figs. 21.8 and 21.9). The manometer also has a tube with a Leur lock arrangement to fill saline into it and also to engage it with the catheter

Fig. 21.5  Close-up view of the balloon demonstrating a double lumen. The outer lumen is used for the inflation of balloon

(Fig. 21.10). It functions with the help of a knob. The knob is rotated clockwise to inflate the balloon and its direction is reversed to the anticlockwise position during deflation. The average length of the bony NLD increases from 10mm to 17.9 mm, ranging from 8.4 to 15.3 mm in the children aged 2 weeks to 6 months and from 8.4 to 18.2  mm in the children aged 2 weeks to 34 months [15]. This shows that the rapid elongation of NLD takes place before 6 months of age [15]. We used balloon catheters with sizes 2.5 mm x 10 mm &

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Fig. 21.8  An inflation device with a Luer- lock hub and a manometer with pressure settings for inflation

Fig. 21.6  The inner lumen is used for introducing the guide wire

Fig. 21.9  A close-up view of manometer with pressure settings for inflation

Fig. 21.7  Guide wire insertion into the tip of the balloon catheter

2.75 mm x 10 mm. The former (2.5 mm) represents the diameter of the balloon in the inflated state and the later (10 mm) represents the length of the balloon in the inflated state. NLD was dilated at proximal and distal end by adjusting the balloon position under endoscopic visualization.

21.1.2 Procedure Under general anaesthesia inferior meatus is prepared (Fig. 21.11) by placing a merocel pack soaked

Fig. 21.10  A close-up view of the Luer lock hub

in 1:100,000 saline adrenaline solution for 5 minutes before the procedure. The punctum is dilated (Fig. 21.12) and probing is carried out under nasal endoscopic guidance as published earlier [8] and any obstruction or stenosis in the NLD is noted. Catheter is carefully removed from the plastic protector as there are chances of kinking of the shaft during removal. The balloon has different dimensions and can be inflated at the pressures

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Fig. 21.11  Inferior meatus is prepared for the direct visualization and assessment of the balloon Fig. 21.13  The tip of the balloon is tapered for easy insertion.

Fig. 21.12  Punctal dilatation is done prior to the insertion of the balloon catheter

recommended for that particular dimension. The catheter’s tip is tapered to facilitate its advancement through the stenosis (Fig. 21.13). The balloon is inserted on to the guidewire and is advanced into the NLD (Figs.  21.14, 21.15 and 21.16). A simultaneous endoscopic visualization of its tip into the inferior meatus gives an accurate judgement about its position (Fig.  21.17). The balloon is pushed into the NLD till a part of the balloon is visible at the valve of Hasner

Fig. 21.14  Tip of balloon is introduced through the punctum along with the guidewire.

(Fig.  21.18). The inflation device is filled with saline mixed with fluorescein by rotating the knob in the anticlockwise pattern (Fig.  21.19). Any trapped air in the device is removed and the Leur lock of the inflation device is then attached to the Leur lock of the balloon and the balloon is gradually inflated (Fig.  21.20). The clockwise rotation of the knob is continued till the pressure

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Fig. 21.17  A close-up view of the inferior meatus is shown Fig. 21.15  The balloon is introduced further into sac and NLD lumen

Fig. 21.18  Tip of the catheter can be seen in the inferior meatus

Fig. 21.16  Endoscopic view of the right nasal cavity demonstrating the tip of the guide wire into the inferior meatus

reaches up to 8 atmospheres on the radial dial of the inflation device. Simultaneous endoscopic assessment of the inferior meatus is done to check the progress of the balloon. The clockwise movement of the knob starts inflating the balloon into the inferior meatus (Figs. 21.21 and 21.22). The membrane can be seen getting ruptured circumferentially with the inflation of the balloon and the NLD opening is

widened. The balloon is maintained in inflated state for 90  seconds and then the deflation starts. Deflation is done by rotating the knob in the anticlockwise direction and the size of the balloon is again monitored endoscopically through the nose. The balloon is again inflated in the same position for 60 seconds and deflated again. Once the balloon is completely deflated the balloon catheter is pulled out of the punctum till the tip of the catheter and the balloon moves up into the NLD and the tip is no longer visible at the valve of Hasner. The proximal portion of the NLD is then dilated in the same way by repeating the cycle of inflation, deflation and inflation. Once the process is complete the inflation device is detached, balloon c­ atheter

21.1  Balloon Dacryoplasty in Congenital Nasolacrimal Duct Obstruction (CNLDO)

Fig. 21.19  The inflation device is filled with saline mixed with fluorescein dye

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Fig. 21.21  As the saline is pushed, the membrane can be seen getting ruptured circumferentially

Fig. 21.22  Inflation of the balloon leads to further widening of the NLD opening

Fig. 21.20  The Luer lock portion of the inflation device is hooked to the Luer lock end of the balloon

is removed and the lacrimal pathway is syringed. A free flow of saline indicates a patent NLD (Fig.  21.23). The procedure has no complications as the coronary catheter are soft, pliable and easy to use. The traditional dacryoplasty catheters have 2 markings at 10 and 15 mm to guide the position of the catheter inside the nasolacrimal

Fig. 21.23  Free flow of dye can be seen into the inferior meatus

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21  Balloon Dacryoplasty in Lacrimal Drainage System Disorders Using Coronary Angioplasty Balloons

Fig. 21.24  A traditional LacriCATH showing two marks (arrow) at 13 and 15mm to guide its position in NLD

duct and their balloon length was 13mm and 15mm [5, 6] (Fig.  21.24). However, these markings do not serve as an exact guide [6] as the dimensions of nasolacrimal duct shows individual variations and endoscopic visualization gives a good judgement about the position of the balloon Regarding diameter of the balloon also we felt that a proposed size of 2mm diameter balloon in a 2- year-old child as described earlier [5], was actually small for his size. We used a bigger diameter of 2.75 in most of the children and kept the length of the balloon as 8mm and10mm. Some of the earlier studies recommended using fixed dimension of 2mm diameter for less than 30 months of age and 3 mm for more than 30 months of the age which was not found to be a practical approach in view of a recent study that recommended further studies on CNLDO to reach a conclusion about the correct dimensions [5, 6].

21.1.3 Advantages of Using a Coronary Balloon over the Conventional LacriCATH The introduction of coronary balloons in balloon dacryoplasty has taken care of the availability issues and cost factor of dacryoplasty balloons. They are an effective and low-cost alternative to the traditional balloons in developing countries. A study compared the cost of the balloons available in India and quoted opticath costing US $ 350  in India against $ 260 pricing during the American Academy of Ophthalmology Congress. They added that the cost can be further cut down to 60 $ if the inflation device can be re-used following gas sterilization. The use of a coronary angioplasty balloons can significantly reduce the cost of dacryoplasty [6].

21.2 Balloon Dacryoplasty in Adults Balloon dacryoplasty  in adults has been used by various authors in the management of partial NLDO, complete obstructions, in primary DCR, revision DCR and in internal ostium dilatation with a variable success rate.

21.2.1 Complete NLD Obstructions Complete NLD obstructions were treated with balloon-assisted DCR using retrograde insertion of the catheter through the intranasal route. Probing was done as the first step to perforate the lacrimal bone in the posterior and inferior direction [5]. Multiple holes were created in the thin lacrimal bone and a Blakesley Forceps were introduced through this perforation into the nose to remove the mucosa and bone chips to enlarge the hole. A balloon was passed through the nose into this perforation and was inflated for 90 seconds and is pulled out in inflated state [5]. The balloon was deflated, passed into the osteum again and reinflated for 60 seconds and removed in the inflated state only to keep the window wide. This allowed an adequate size osteum in their study [5]. The various size of the balloon used for relieving the complete obstruction was 3mm, 5mm and 9mm. A 3mm and 5mm balloon can be passed through the canaliculi while a 9mm needs to be passed through the nose [5]. Completely obstructed NLD in adults was treated using a 3mm balloon by some authors [16–18] with a failure rates ranging from 41–44 %. However, other studies have reported better outcomes with a failure rate of only 10% [5, 16].

21.3  Balloon Catheter Dilatation of Common Canaliculus in Functional Epiphora

21.2.2 Role of Balloon in Ostium Dilatation

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other studies, the success rate of dilatation in common canalicular obstructions reportedly varied from 46% to 73% [22, 23, 26, 27]. Various modifications in the technique were Balloon dilatation is a minimally invasive procedure as compared to a revision DCR in a cica- made from time to time involving the retrograde trized ostium [19]. Those who favoured it in placement of the balloon in the sac, common revision DCR, stated that balloon dilatation helps canaliculus, superior canaliculus and advancing in clearing the area in front of the internal com- its tip beyond the punctum. The indications were mon opening [19], whereas a silicone tube only obstruction in the common canaliculus and the dilates the canaliculus and does not clear the con- LacriCATH balloons of different diameters were stricting fibrous tissues in the vicinity. Other used with different duration of inflation [22]. Given the elastic tendency of the walls of the studies however, reported no significant difference between balloon dilatation and stenting in canaliculus it can be dilated upto three times from its lumen of about 0.5–0.6  mm [29]. The adults [20, 21]. canalicular walls are lined by orbicular oculi muscle known as Riolan’s muscle [31]. This elastic tendency of the walls of the canaliculi as well 21.2.3 Revision DCR as lacrimal sac allows the alteration in their diamBalloon dilatation in revision DCR was done using eter to help in tear drainage and contribute to the 5mm and 9mm balloon catheters for failed exter- lacrimal pump [29, 30]. Based on this principle with the advent of nal and endonasal cases. The 5-mm catheters were used for early failures as a fistulous tract was good coronary balloons and its successful use in expected to be present [5]. The fistula was probed, the treatment of CNLDO we treated selective a Bowman’s probe was passed and the area in cases of functional epiphora by using coronary front of the common canaliculus was cleared. The angioplasty balloon via anterograde route. Use of 5-mm balloon catheter is then inserted through the LacriCATH by retrograde approach (through the upper canaliculus under endoscopic guidance, and nose) has been described by some authors [22] the cycle of inflation–deflation and inflation was but it is difficult to judge the position of balloon carried out followed by intubation. The 9-mm bal- in retrograde approach. we felt in anterograde loon catheter is used in a similar way but is intro- method punctum and the upper and lower canaliculi were not disturbed and the position of the duced through the nose [5]. balloon could be judged all the time under endoscopic visualization. We used a 1.5mm diameter coronary balloon with a length of 8mm (SPALNO, 21.3 Balloon Catheter Dilatation Cardiomac Haryana, India) for dilatation of the of Common Canaliculus common canaliculus. in Functional Epiphora Anatomical patency of the osteum was Balloon catheter dilation of the common cana- checked by endoscopic visualization of the liculus has been reported by various authors [22]. nasal cavity and the patency was confirmed by Some of them discouraged it because of the pos- the presence of dye in the nose as the first step. sible damage to the canaliculus or punctum [17, (Figs. 21.25 and 21.26). Guide wire was intro23–25], the others felt it to be a safe and effective duced and the balloons were passed over the guidewire through the upper punctum as procedure [18, 22, 26–28]. KO GY et  al. evaluated the safety and long-­ described in the technique above (Figs.  21.27 term effectiveness of balloon catheter dilation in and 21.28). Endoscopic visualization of the ICO the treatment of common canalicular obstruction ensured that the complete 8mm length of [22]. The overall success rate in their series of the1.5mm diameter balloon was first visual195 cases was 51% at 6  months follow up. In ized  into the nose (Figs.  21.28 and 21.29).

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21  Balloon Dacryoplasty in Lacrimal Drainage System Disorders Using Coronary Angioplasty Balloons

Fig. 21.25  Endoscopic view of a post operated case of external DCR with a good ostium but the dye drops instilled into the eye fail to appear into the nose

Fig. 21.26    Fluorescein dye can be visualized into the nose on irrigation but the dynamic flow of dye was missing

The  coronary catheter was then gently pulled out of punctum upto a length where approximately 3mm of this balloon lied into the common canaliculus and the rest was visible in the nose (Figs. 21.30 and 21.31). The balloon was then inflated and kept for 2 minutes as per published guidelines [22]. A dilated common cana-

Fig. 21.27  A guide wire is passed for the easy insertion of the balloon catheter

Fig. 21.28  A 1.5mm x8mm balloon is passed through the punctum into the common canaliculus to the nose. Initially the whole balloon is pushed into the nose

licular opening can be visualized with instant dye appearance into the nose (Figs.  21.32 and 21.33). Various studies have used different inflation timings of 1–5 minutes [18, 19, 24, 26–28, 31]. Ko YG et al found encouraging results by inflating the balloon for 2 minutes. They also ­commented that 2  minutes may be sufficient to tear the fibrotic component of the obstruction [22].

21.3  Balloon Catheter Dilatation of Common Canaliculus in Functional Epiphora

Fig. 21.29  Close-up view of the balloon exiting from the common canalicular opening

Fig. 21.30  The balloon getting pulled out gently from the punctal end in a way that approximately 3 mm of the balloon goes into the common canaliculus and the rest of it stays in the nose. The balloon is then inflated gradually

The procedure was performed in cases that had anatomical patency with a good ostium and patent syringing  but continued having significant epiphora and hypersecretion was ruled out. They were thus labelled as functional epiphora cases. Long-term stenting has been advocated in the management of functional epiphora with no side effects of long-term stent placement [31]. Based on the dilating effect of the stents we used balloon dilatation of ICO using coronary angioplasty balloons in cases of functional epiphora prior to stenting.

293

Fig. 21.31  Balloon getting inflated under endoscopic guidance

Fig. 21.32  A wide common canalicular opening is seen following dilatation

In 3 cases balloon dilatation of the internal common opening was performed to dilate the common canaliculus followed by stenting with encouraging results. The post-procedure Munk score got reduced to grade I from grade 3 and the dye disappeared in 5 seconds compared to 2 minutes earlier following balloon dilatation. Three months post-procedure patient’s symptoms improved significantly. However larger studies are needed to prove the efficacy and safety of balloon dilatation in functional epiphora.

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21  Balloon Dacryoplasty in Lacrimal Drainage System Disorders Using Coronary Angioplasty Balloons

Fig. 21.33  Instant flow of dye into the nose unlike the previous situation where dynamic flow of dye was absent but irrigation showed free flow

21.4 Conclusion Balloon dacryoplasty is a safe and effective method for treating NLD obstruction in children. Its use however in adults remained limited due to the high cost and poor long-term outcome. Introduction of coronary angioplasty balloon catheters in lacrimal practice  will help in  overcoming this limitation as they are low-cost alternative to the traditional LacriCATH.

References 1. Hanafee WN, Dayton GO. Dilatation of the nasolacrimal duct under radiographic control. Radiology. 1978;127:813–5. 2. Becker BB, Berry FD. Balloon catheter dilatation in lacrimal surgery. Ophthalmic Surg. 1989;20:193–8. 3. Munk PL, Lin DT, Morris DC.  Epiphora: treatment by means of dacryocystoplasty with balloon dilation of the nasolacrimal drainage apparatus. Radiology. 1990;177:687–90. 4. White WL, Popham JK, Fante RG. Balloon-assisted lacrimal surgery. In the Lacrimal System. New York, NY: Springer; 2006. p. 197–204. 5. Ali MJ, Naik MN, Honavar SG.  Balloon dacryoplasty: ushering the new and routine era in minimally invasive lacrimal surgeries. Int Ophthalmol. 2013;33:203–10.

6. Bothra N, Gupta N, Nowak R, Ali MJ.  The use of anterograde percutaneous transluminal coronary angioplasty balloons in congenital nasolacrimal duct obstruction: a cost-effective alternative to the traditional dacryoplasty balloons. Ophthalmic Plast Reconstr Surg. 2019;XX(XX):XX. 7. Gupta N, Chawla N, Bansal S, Das S. A comparison of the success rates of endoscopic-assisted probing in the treatment of membranous congenital nasolacrimal duct obstruction between younger and older children and its correlation with the thickness of the membrane at the valve of Hasner. Orbit. 2017;37:1–5. https://doi. org/10.1080/01676830.2017.1383483. 8. MacEwen CJ, Young JDH, Barras CW, Ram B, White PS. Value of nasal endoscopy and probing in the diagnosis and management of children with congenital epiphora. Br J Ophthalmol. 2001;85:314–f. 9. Gupta N, Singla P, Kumar S, Ganesh S, Dhawan N, Sobti P, Aggarwal S.  Role of dacryoendoscopy in refractory cases of congenital nasolacrimal duct obstruction. Orbit. 2019;39:183. https://doi.org/10.10 80/01676830.2019.1668434. 10. Lin AE, Chang YC, Lin MY, et  al. Comparison of treatment for congenital nasolacrimal duct obstruction: a systematic review and meta-analysis. Can J Ophthalmol. 2016;51:34–40. 11. Wladis EJ, Aakalu VK, Yen MT, et al. Balloon dacryoplasty for congenital nasolacrimal duct obstructiosn: a report by the American Academy of Ophthalmology. Ophthalmology. 2018;125:1654–7. 12. Tein DR, Young D. Balloon dilatation of nasolacrimal duct. J AAPOS. 2005;9:465–7. 13. Tao S, Meyer DR, Simon JW, et  al. Success of balloon catheter dilatation as a primary or secondary procedure for congenital nasolacrimal duct obstruction. Ophthalmology. 2002;109:2108–11. 14. Leuder GT. Balloon catheter dilatation for treatment of older children with nasolacrimal duct obstruction. Arch Ophthalmol. 2002;120:1685–8. 15. Moscato EE, Kelly JP, Avery Weiss A.  American Academy of Developmental Anatomy of the Nasolacrimal Duct: Implications for Congenital Obstruction. Ophthalmology ISSN 0161-­ 6420/10/$.Published by Elsevier Inc. 10.1016/j. ophtha.2010.03.030. 16. Kuchar A, Steinkogler FJ. Antegrade balloon dilatation of nasolacrimal duct obstruction in adults. Br J Ophthalmol. 2001;85:200–4. 17. Song HY, Ahn HS, Park CK, Kwon SH, Kim CS, Choi KC.  Complete obstruction of the nasolacrimal system. Part I.  Treatment with balloon dilatation. Radiology. 1993;186:367–71. 18. Janssen AG, Mansour K, Bos JJ.  Obstructed nasolacrimal duct system in epiphora: long term results of dacryoplasty by means of balloon dilatation. Radiology. 1997;205:791–6. 19. Lee A, Ali MJ, Li EY, et  al. Balloon dacryoplasty in internal ostium stenosis after endoscopic dacryocystorhinostomy. Ophthal Plast Reconstr Surg. 2014;30:7–10.

References 20. Kashkouli MB, Beigi B, Tarassoly K, et  al. Endoscopically assisted balloon dacryocystoplasty and silicone intubation versus silicone intubation alone in adults. Eur J Ophthalmol. 2006;16:514–9. 21. Kashkouli MB, Shahrzad SMD.  Re: “Balloon dacryoplasty in internal ostium stenosis after endoscopic dacryocystorhinostomy”. Ophthal Plast Reconstr Surg. 2014;30(4):1. 22. Gi Young Ko, Deok Hee Lee, Hyo-Sook Ahn, Hyun Ki Yoon, Kyu-Bo Sung, Ho-Young Song. Radiology VOL. 214, NO. 3Vascular and Interventional Radiology. Balloon Catheter Dilation in Common Canalicular Obstruction of the Lacrimal System: Safety and Long-term Effectiveness. 23. McCullough KM.  Nasolacrimal duct balloon dilatation. Clin Radiol. 1994;49:787–90. 24. Janssen AG, Mansour K, Krabbe GJ, van der Veen S, Helder AH. Dacryocystoplasty: treatment of epiphora by means of balloon dilation of the obstructed nasolacrimal duct system. Radiology. 1994;193:453–6. 25. Berkefeld J, Kirchner J, Müller HM, Fries U, Kollath J. Balloon dacryocystoplasty: indications and contraindications. Radiology. 1997;205(3):785–90.

295 26. Lee JM, Song HY, Han YM, et  al. Balloon dacryocystoplasty: results in the treatment of complete and partial obstructions of the nasolacrimal system. Radiology. 1994;192:503–8. 27. Ilgit ET, Yuksel D, Unal M, Akpek S, Isik S, Hasanreisoglu B.  Transluminal balloon dilatation of the lacrimal drainage system for the treatment of epiphora. AJR Am J Roentgenol. 1995;165:1517–24. 28. Song HY, Lee CO, Park S, et al. Lacrimal canalicular obstruction: safety and effectiveness of balloon dilation. J Vasc Interv Radiol. 1996;7:929–34. 29. Maliborski A, Różycki R. Diagnostic imaging of the nasolacrimal drainage system. Part I.  Radiological anatomy of lacrimal pathways. Physiology of tear secretion and tear outflow. Med Sci Monit. 2014;20:628–38. 30. Bochenek A, Reicher M, Anatomia Człowieka TV PZWL; Warszawa: 1989; 558–568 31. Shams PN, Chen PG, Wormald PJ, Sloan B, Wilcsek G, McNab A, Selva D.  Management of functional epiphora in patients with an anatomically patent dacryocystorhinostomy. JAMA Ophthalmol. 2014;132(9):1127–32.

Endoscopic Conjunctivodacryocystorhinostomy

Conjunctival dacryocystorhinostomy (DCR) involves the creation of a bypass route for the proximal lacrimal drainage system obstructions and creating an alternative route for tear flow [1–3]. This is done by the placement of a tube between the caruncle and the middle meatus anterior to the middle turbinate [1, 3]. As we know the lacrimal drainage system is divided into an upper and lower part. The upper part includes puncta and the canaliculi while the lower lacrimal pathway includes the lacrimal sac and nasolacrimal duct (NLD). The most common pathology found in the lacrimal drainage system is the NLD obstruction that is treated by endoscopic DCR with excellent results. However, any obstruction lying in the upper lacrimal pathway i.e. puncta and the canaliculi is difficult to treat. The treatment depends on the severity and the level of obstruction. The canalicular obstructions are a therapeutic challenge especially proximal canalicular obstructions are difficult to treat [1]. In cases of distal or common canalicular obstruction, canalicular trephination with intubation can be performed. However, the prerequisite for canalicular restoration surgery is that there should be more than 8 mm of the patent canaliculus available for canaliculoplasty. Less than 8  mm of the patent proximal canaliculus makes it unfit for canalicular reconstruction and thus conjunctival DCR is needed in these cases. Conjunctival DCR bypasses the canaliculi and sac with the creation

22

of direct communication between the conjunctiva and the nasal cavity. First by pass route between the conjunctival sac and the nasal cavity was created by an otorhinolaryngologist, J.  Heermann, in 1925. He inserted a tube through the lower canaliculus [4, 5]. Lester John did the same procedure through an external route in 1962 that came to be known as conjunctivodacryocystorhinostomy/dacryocystorhinostomy + Jones tube [6–9]. Thus, indications of conjunctival DCR include complete obstruction of the ipsilateral upper and lower canaliculi, punctal agenesis that is likely to be associated with canalicular maldevelopment, canalicular trauma involving both upper and lower proximal segment, failed attempts at canalicular reconstruction and post-tumour resection canaliculotomy etc. [1]. Thus, conjunctival DCR can be performed by both external as well as endoscopic approach depending on the surgeon’s comfort [10]. Conjunctivodacryocystorhinostomy performed by an external route is done by giving an incision into the medial canthal area with the placement of a Pyrex tube through the caruncle region. Advancement in technology and the availability of high definition camera units have enabled the endoscopic Conjunctivodacryocystorhinostomy. The external approach although is still preferred by ophthalmologists, but there is a wide acceptance of endonasal approach that is practiced more by the otorhinolaryngologists who are

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familiar with endonasal sinus surgery [2, 9]. The endonasal approach is advantageous as it allows better positioning of the tube, takes less time and is more precise leading to minimal bleeding [11, 12]. It is also useful in cases of failed canalicular surgery done with DCR, in which a bone window is already present [3]. The technique of endoscopic conjunctivo DCR(ECDCR) starts with the sac marsupialization following endoscopic DCR. The caruncle is cauterized using a bipolar cautery. A guidewire is introduced from the caruncle area into the nose under endoscopic visualization. The path of the guidewire is cut using a Graefe knife to create a tunnel. A Jones tube is inserted into the tunnel over the guidewire [1]. The length of the tube is kept 2–4  mm longer than the tunnel. The end of the tube can be directly visualized through the sac into the nose with minimum trauma and scarring. Endoscopic DCR allows examination of the sac lumen and any associated nasal pathology can also be corrected simultaneously. To minimize the risk of extrusion, the tube is fixed with a suture around its collar to [13, 14]. An alternative modified minimally invasive endoscopic conjunctival DCR has been described [15]. It involves creating a window below the caruncle into the lacrimal bone and introducing a tube [15]. The tube is fixed in a way that its nasal end lies between the septum and the lateral wall. Post-operatively Patients are prescribed a combination of antibiotic and steroid eye ointment and nose drops. Nasal douche is started1 week after the surgery. Patients are instructed not to blow their nose to avoid emphysema. Nasal endoscopy is done after 1week, 4 weeks and 3 months after surgery. The position of the tube is examined, its patency is checked by dye disappearance test. Patients are advised not to blow their nose and continue nasal douching. The success rate of conjunctival DCR varies from 41 and 100% [9, 16]. Complications involve granulations conjunctivitis, bleeding, closure of the tube, tube extrusion [6, 17] and malpositioning [18–20]. To prevent migration, the tubes with the provision of suturing through the small suture holes at the junction of the head and neck of a

22  Endoscopic Conjunctivodacryocystorhinostomy

tube can be used. Surgical emphysema may occur on blowing the nose. The tube should be cleaned daily by pouring water into the conjunctival sac and sniffing while the other side kept closed by pinching with a finger. Water entry into the nose indicates the patency of the tube.

22.1 Key Words Owing to the high complication rate, chances of blockage, non-functioning of the tube, cumbersome upkeep and low patient satisfaction rate this is not a widely practiced procedure.

References 1. Komínek P.  Conjunctivodacryocystorhinostomy with the Insertion of a Jones Tube. In: Weber RK, Keerl R, Schaefer SD, Della Rocca RC, editors. Atlas of lacrimal surgery. Berlin, Heidelberg: Springer; 2007. 2. Olver J.  Colour atlas of lacrimal surgery. Oxford: Butterworth-Heinemann; 2002. 3. Trotter WL, Meyer DR.  Endoscopic conjunctivodacryocystorhinostomy with Jones tube placement. Opthalmology. 2000;107:1206–9. 4. Denecke HJ, Denecke MU, Draf W, et  al. Die Operationen and den Nasennebenhühlen und der angrenzendenSchädelbasis. Berlin Heidelberg New York: Springer; 1992. 5. Heermann J.  RhinochirurgischeAspektebeiTränenwe gstenosen. Otorhinolaryngol Nova. 1991;1:227–32. 6. Hurwitz JJ.  The lacrimal system. Philadelphia: Lippincott-Raven; 1996. 7. Jones LJ.  Conjunctivodacryocystorhinostomy. Am J Opthalmol. 1965;59:773–83. 8. Jones LJ Conjunctive dacryocystorhinostomy. In: Yamaguchi M (ed), Recent advances on the lacrimal system. Kyoto 1978;69–70 9. Komínek P, Červenka S, Müllner K. The lacrimal diseases. Diagnostics and treatment. Prague: Maxdorf; 2003. 10. Trotter WL, Meyer DR.  Endoscopic conjunctivodacryocystorhinostomy with Jones tube placement. Opthalmology. 2000;107:1206–9. 11. Trotter WL, Meyer DR.  Endoscopic conjunctivodacryocystorhinostomy with Jones tube placement. Ophthalmology. 2000;107:1206–9. 12. Devoto MH, Bernardini FP, de Conciliis C. Minimally invasive conjunctivodacryocystorhinostomy with Jones tube. Ophthal Plast Reconstr Surg. 2006;4:253–5. 13. McNab AA. Manual of orbital and lacrimal surgery. Edinburgh: Churchill Livingstone; 1994.

References 14. Putterman AM.  Conjunctivodacryocystorhinostomy. In: Linberg JV, editor. Lacrimal surgery. New  York: Churchill Livingstone; 1988. p. 281–96. 15. Mj A, Honavar SG, Naik MN.  Endoscopically guided minimally invasive bypass tube intubation without DCR: evaluation of drainage and objective outcome assessment. Minim Invasive Ther Allied Technol. 2013;22:104–9. 16. Gonnering RS. Dacryocystorhinostomy and conjunctivodacryocystorhinostomy. In: Dortzbach RK, editor. Ophthalmic plastic surgery: prevention and management of complications. New York: Raven Press; 1994. p. 237–50.

299 17. Migliori ME, Putterman AM.  Recurrent Jones tube extrusion successfully treated with a modified glass tube. Ophthal Plast Reconstr Surg. 1989;5: 189–91. 18. Steinsapir KD, Glatt HJ, Putterman AM.  A 16-year study of conjunctival dacryocystorhinostomy. Am J Ophthalmol. 1990 Apr 15;109(4):387–93. 19. Sekhar GC, Dortzbach RK, Gonnering RS, Lemke BN.  Problems associated with conjunctivodacryocystorhinostomy. Am J Ophthalmol. 1991 Nov 15;112(5):502–6. 20. Rose GE, Wright JE. Isolated peripheral nerve sheath tumours of the orbit. Eye (Lond). 1991;5(Pt 6):668–73.

Training Aspects in Endoscopic Dacryocystorhinostomy and Role of Cadaver Dissection

Dissection is an important learning tool for any surgical procedure especially in endoscopic nasal and sinus surgeries as it demands coordination of hand movements under endoscopic visualization in a narrow three-dimensional nasal and sinus cavities [1, 2]. Therefore, learning in endoscopic nasal and sinus surgery involves constant practice with dissection on cadavers to gain dexterity in various surgical procedures. Due to a smaller number of cadavers available and ethical and validity issues of dissection on animal models, simulators and hands-on models have been developed [3, 4]. These surgical simulation devices have been installed in the anatomic dissection laboratory to improve the skill of trainee prior to surgery on live patients [5]. Lockheed Martin in 1998 developed a simulation device following the evidence of improved surgical technique using ES3 virtual endoscopic sinus surgery model [1, 5–10] Thereafter a number of alternatives models have been designed for training like S.I.M.O.N.T. neurotrainer (Prodelphus, Germany), Phacon sinus system (Phacon, Leipzig, Germany), and Kezlex endoscopic models (Ono and Co., Tokyo, Japan), etc. to provide only the basic training of endoscopic surgery and hand-eye coordination [3, 11]. Nathan et al did a comparative study of a low-­ fidelity and a high-fidelity endoscopic sinus surgery trainer with sinus instrumentation and the 00 endoscope. The difference between low-fidelity and high-fidelity model is that the low-fidelity trainer

23

is modified bovine gelatine constructed by embedding objects and obstacles in a cylindrical cavity and a high-fidelity trainer is a silicone-­based matrix over a bone-like plaster model [2]. This model is designed with moderate details of anatomy and provides a haptic feel during surgery [1]. Karl Storz training model for nasal and endoscopic training incorporates coronal sections reconstructed from a flexible polyurethane material, shaped into the nasal cavity and can be used for practicing nasal endoscopy. Simont Head model-Sinus model otoneuro (anterior skull base) trainer provides the facility of performing endonasal procedures under realistic conditions. Phacon sinus trainer (GmbH Karl-Heine, Leipzig Germany) offers an opportunity to learn endoscopic sinus surgeries and can be modified to learn endoscopic dacryocystorhinostomy (DCR) as well. It provides haptic feel of surgery as it reflects the diverse human tissue characteristics (such as bone, cartilage, muscle, skin and nerves). Lavigne et al reviewed the literature using simulation devices for training purposes. The various methods used were cadaveric models, 3D-printed models, virtual reality trainers, or a combination of these modalities. It was found that although the simulators have been proclaimed as a promising and cost-effective modality to be used in the residency training programmes these modalities of training carried a low level of learning effectiveness. The level of effectiveness of these training was judged on the basis of Kirkpatrick scale [12, 13].

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23.1 Training Trough Cadaver Dissection Cadaver dissection training courses are being conducted at our institution from time to time. Formalin preserved cadavers heads are provided to the candidates and two candidates are allotted one station with one faculty trainer at each station (Figs. 23.1 and 23.2). The candidates are trained to hold the endoscope in the non-dominant hand and the instrument in the dominant hand. Good control and coordination between two hands is learned by observing steps of the Fig. 23.1 Cadaver dissection training with a master set

Fig. 23.2 Individual groups with faculty trainer at each table

faculty trainer on the master monitor and simultaneously practicing those steps. Endoscopy should be done in an organized manner to avoid missing any finding [14]. For the purpose of orientation, the gross anatomy can be first explained on the sagittal cuts of a cadaver head. Various important structure shown on the sagittal cuts include superior, middle and inferior turbinate (Fig. 23.3). Nasolacrimal duct (NLD) can be seen exposed and the lower end of NLD can be seen with a Bowman’s probe insitu (Figs. 23.4 and 23.5).

23.1 Training Trough Cadaver Dissection

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Fig. 23.3  Sagittal section of a cadaver head to demonstrating superior, middle and inferior turbinate. ST; Superior turbinate, MT: Middle turbinate, IT; Inferior turbinate

Fig. 23.5  The lower end of NLD can be seen with a Bowman’s probe in situ marking the distal opening

Fig. 23.4  Nasolacrimal duct can be seen exposed with both middle and inferior turbinate in view

23.1.1 Steps of Nasal Endoscopy Steps of nasal endoscopy have been described in the chap. 3 on endoscopic anatomy. In brief various structures seen in the first pass are the area between the inferior turbinate and septum, inferior meatus, nasolacrimal duct opening and nasopharynx (Figs. 23.6, 23.7, 23.8, 23.9, 23.10 and 23.11). In second pass fontanelle or any accessory ostium, sphenoethmoid recess and superior turbinate are examined (Figs. 23.12 and 23.13). In third pass bulla ethmoidalis, hiatus semilunaris and infundibulum are examined (Fig. 23.14).

Fig. 23.6  Endoscopic view of the right nasal cavity demonstrating the anterior end of the inferior turbinate and septum

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Fig. 23.7  The endoscope is passed further, posterior end of the inferior turbinate and inferior meatus. IT; Inferior turbinate, IM; Inferior meatus

Fig. 23.8  View of left inferior meatus that houses the distal opening of NLD

23.2 E  ndoscopic DCR in Cadaveric Specimen After having hands-on experience in nasal endoscopy the surgery is taught as the next step. Often the instrumentation is initially difficult as both the hands move simultaneously. A 4mm O0 nasal

Fig. 23.9  Close up view of left NLD opening and area of valve of Hasner. LW; Lateral wall

Fig. 23.10  The scope is then negotiated towards the nasopharynx and the posterior end of the middle turbinate comes in view

endoscope is held in the left or the non-dominant hand and the instrumentation is done with the right or the more dominant hand. Often both hands move simultaneously and as the instrument goes in, automatically the other hand holding the endoscope also moves in. As a result, the scope gets close to the operating field with its lens getting smeared with blood and secretions. Repeated

23.2 Endoscopic DCR in Cadaveric Specimen

Fig. 23.11  View of nasopharynx with eustachian tube area and Torus tubarius NP; Nasopharynx

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Fig. 23.13  Middle meatus is examined next

Fig. 23.14  View of middle meatus with uncinate process and bulla ethmoidalis. UP; Uncinate process Fig. 23.12  The second pass involves negotiating the endoscope between the middle turbinate and septum

cleaning of the lens can be a frustrating experience. Therefore, the hand holding the endoscope should remain steady and only the instrument should move in and out. This comes with constant practice and is very helpful while performing surgery.

Steps of the endoscopic DCR have been demonstrated as described in the chapter on the surgical technique. O0 degree endoscope is focussed on the lateral wall of the nose to examine the area of the lacrimal sac. Uncinate process and bulla ethmoidalis are identified and the maxillary line is marked at the junction of the lacrimal bone with the frontal process of the maxilla (Fig. 23.15). An

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Fig. 23.15  Maxillary line (red dotted line) forms an important landmark for locating the lacrimal sac and is marked at the junction of the lacrimal bone with the frontal process of maxilla. FP; Frontal process of maxilla

Fig. 23.17  The mucoperiosteal flap is lifted up

Fig. 23.18  A posteriorly based mucoperiosteal flap is lifted completely and reflected over the middle turbinate Fig. 23.16  An incision is given on the lateral wall as described earlier

incision is given on the lateral wall as described earlier (Fig.  23.16). A posteriorly based mucoperiosteal flap is lifted and Kerrison punch is engaged inferiorly (Figs. 23.17, 23.18 and 23.19). Bone removal proceeds up till the complete sac marsupialization is achieved (Figs. 23.20, 23.21, 23.22, 23.23 and 23.24). The sac is incised and sac flaps are everted to visualize the common canaliculus.

23.2.1 Advantages of Cadaver Dissection It provides a certain level of anatomical knowledge and confidence in handling endoscope into narrow nasal cavity. The landmarks can be seen better due to the ease of manipulation and the surgery can be learned with no risk of serious complications. Instrumentation in the narrow nasal cavity has a steep learning curve with the risk of mucosal injury and bleeding during surgery in

23.2 Endoscopic DCR in Cadaveric Specimen

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Fig. 23.19  Kerrison punch is engaged inferiorly

Fig. 23.21  Bone removal proceeds up till the sac exposure is complete

Fig. 23.20  More sac is exposed (orange star) Fig. 23.22  The sac is incised using a sickle knife

live patients. Cadaver teaching programmes help in skill enhancement and minimize complications during surgery.

23.2.2 Comparison of the Cadaveric Dissection with Other Simulating Models Although multimedia and simulation programmes are increasingly being used for anatomy instruction, but their comparison with the cadav-

eric teaching programmes is lacking. Saltarelli et  al did a comparative analysis of multimedia technology with the actual human cadavers and found that the human cadaver laboratory provides a significant advantage over the multimedia simulation program [15]. Nathan et al evaluated simulator-based training methods for endoscopic sinus surgeries and suggested that even though there are significant innovation and validation of simulation-based

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while only 66.7% felt it was useful for teaching surgical skills. They however felt that the real feel of the mucosa and bony structures was missing in the models as compared to the cadavers [17]. Thus cadaveric dissection is the gold standard of endoscopic surgery training [10].

Fig. 23.23  The tip of the sickle is inserted into the lacrimal sac

Key Points  • Dissection is an important learning tool to gain surgical dexterity • A number of modern simulators and sinus models are available for hands-on real-time dissection. Cadaver dissection has no substitute and dissection-based teaching is crucial to anatomy education till date • Surgical training tools are equally important and traditional training under the supervision of senior surgeons helps the residents in attaining surgical dexterity. Acknowledgements I would like to acknowledge Dr. Poonam Singla for her valuable assistance in the cadaver dissection training programme.

References

Fig. 23.24  Sac lumen is seen with common canalicular area and sac flaps are everted to visualize the common canaliculus

training, these modalities should better be used as an adjuvant and not as a replacement of surgical training tools for residents [16]. Alwai et  al. studied the validity of three dimensionally printed endoscopic sinonasal surgery simulator. When compared to cadaver heads a total of 91.7% of the participants felt that the model was a useful tool for learning anatomy

1. Lindquist NR, Leach M, Simpson MC, Antisdel JL. Evaluating simulator-based teaching methods for endoscopic sinus surgery. Ear Nose Throat J. 2019; April 24 2. Burge SD, Bunegin L, Weitzel EK, McMains KC. The validation of an endoscopic sinus surgery skills training model: a pilot study. Am J Rhinol Allergy. 2012;26(5):409–13. 3. Bajaj J, Yadav YR, Pateriya A, Parihar V, Ratre S, Dubey A.  Indigenous inexpensive practice models for skill development in neuroendoscopy. J Neurosci Rural Pract. 2017 Apr–Jun;8(2):170–3. 4. Lee AY, Fried MP, Gibber M.  Improving rhinology skills with simulation. Otolaryngol Clin North Am. 2017;50(5):893–901. 5. Arora H, Uribe J, Ralph W, et  al. Assessment of construct validity of the endoscopic sinus surgery simulator. Arch Otolaryngol Head Neck Surg. 2005;131(3):217–21. 6. Fried MP, Sadoughi B, Gibber MJ, et al. From virtual reality to the operating room: the endoscopic sinus surgery simulator experiment. Otolaryngol Head Neck Surg. 2010;142(2):202–7. 7. Edmond C.  Impact of the endoscopic sinus surgical simulator on operating room performance. Laryngoscope. 2002;112(7 pt 1):1148–58.

References 8. Rudman DT, Stredney D, Sessanna D, et  al. Functional endoscopic sinus surgery training simulator. Laryngoscope. 1998;108(11 pt 1):1643–7. 9. Ruthenbeck GS, Hobson J, Carney AS, Sloan S, Sacks R, Reynolds KJ. Toward photorealism in endoscopic sinus surgery simulation. Am J Rhinol Allergy. 2013;27(2):138–43. 10. Varshney R, Frenkiel S, Nguyen LH, et  al. Development of the McGill simulator for endoscopic sinus surgery: a new high-fidelity virtual reality simulator for endoscopic sinus surgery. Am J Rhinol Allergy. 2014;28(4):330–4. 11. Hirayama R, Fujimoto Y, Umegaki M, Kagawa N, Kinoshita M, Hashimoto N, Yoshimine T. Training to acquire psychomotor skills for endoscopic endonasal surgery using a personal webcam trainer. J Neurosurg. 2013;118(5):1120–6. 12. Samia H, Khan S, Lawrence J, Delaney CP. Simulation and its role in training. Clin Colon Rectal Surg. 2013;26(1):47–55. 13. Lavigne P, Yang N.  Training and surgical simula tion in skull base surgery: a systematic review. Curr Otorhinolaryngol Rep. 2020;

309 14. Scott-Brown’s otorhinolaryngology: head and neck surgery 7th ed. Hodder Arnold Publication. Michael Gleeson, George G Browning, Martin Burton, Ray Clark, John Hibbert, Nicholas S Jones, Valerie J Lund, Linda M Luxon, John C Wakinson. Hodder Arnold UK.  Nasal endoscopy chapter 105. Rodney J Schlosser and David W Kennedy. Seventh edition 2008 15. Saltarelli AJ, Roseth CJ, Saltarelli WA. Human cadavers Vs. multimedia simulation: A study of student learning in anatomy. Anat Sci Educ. 2014;7(5):331–9. https://doi.org/10.1002/ase.1429. Epub 2014 Jan 10 1 6. Konge L, Lonn L.  Simulation-based training of surgical skills. Perspect Med Educ. 2016;5(1):3–4. 17. Alwani MM, Svenstrup TJ, Bandali EH, Sharma D, Higgins TS, Wu AW, Shipchandler TZ, Illing EA, Ting JY.  Validity testing of a three-dimensionally printed endoscopic sinonasal surgery simulator. Laryngoscope. 2019 Nov 12; https://doi.org/10.1002/ lary.28356. [Epub ahead of print]

Instrumentation in Endoscopic Dacryocystorhinostomy

External dacryocystorhinostomy (DCR) remained the gold standard technique even after the endoscopic approach came in practice [1]. Endoscopic DCR could not gain popularity due to the limited technology, lack of training facility, a steep learning curve and need of a cross-­ specialty collaboration. In this era of minimally invasive surgery, significant improvement has occurred in the technique of endoscopic DCR [2–5] owing to the evolution in surgical instruments, availability of high definition camera and endoscope unit along with an improvement in surgical skills. Better understanding of the anatomical position of the lacrimal sac emphasized the need of exposing the fundus of the sac for better results [6]. Thus, a superior osteotomy and creation of a large bony window with full sac marsupialization were adopted as a crucial step during endoscopic DCR. Bone removal during endoscopic DCR can be carried out by instruments such as Kerrison punch, powered drill, and lasers with the aim of improving results [7]. This chapter describes some of the basic equipment and instruments needed for endoscopic DCR. A variety of instruments have been described from chisel  and hammer to the  drill with irrigation attachment and microdebrider with  curved diamond burrs. Figures  24.1–24.38 demonstrates stepwise instrumentation in endoscopic DCR along with their description in the legend below each figure.

24

Fig. 24.1  A comprehensive Karl Storz endoscopy unit comprising of Medical monitor, Image 1S camera unit, Xenon nova 300 light source, AIDA and set of endoscopes along with accessories.

© Springer Nature Singapore Pte Ltd. 2021 N. Gupta, Endoscopic Dacryocystorhinostomy, https://doi.org/10.1007/978-981-15-8112-0_24

311

312 Fig. 24.2  A close-up view of the trolley demonstrating the medical monitor as the first component from the top with various options on the left of the screen on a blue panel. The option includes patient details, video recording, image capture, mode setting to CLARA, CHROMA and SPECTRA. STANDARD, exit option, white balance and brightness adjustment

Fig. 24.3  A close view of the compact unit of image 1S camera, AIDA™ meant for comprehensive implementation of all documentation requirements arising in surgical procedures.

24  Instrumentation in Endoscopic Dacryocystorhinostomy

24  Instrumentation in Endoscopic Dacryocystorhinostomy

a

b

Fig. 24.4 (A) IMAGE 1 SPIES (Storz Professional Image Enhancement System) camera comprising of FULL-HD with three-chip camera heads. The blue rim represents zooming option (a); The silver rim is meant for fine focussing (b); The black ring is meant for coupling with the endoscope head. When not in use the coupling ring is covered with a dummy attachment denoted by the black top (c). There are two black buttons on the camera head (d and e) that allows the surgeon to go to menu options in the camera unit. One can choose to go to the main menu by pressing button ‘d’ and scroll the menu up and down with button ‘e1’ and ‘e2’ and select the needed option. (B) Various options get displayed on blue panel as described in Fig. 24.2 like brightness adjustment, patient details, video recording, still picture capturing, camera

313

c

features with various options (described separately), an exit button that allows the surgeon to exit the menu after choosing the desired option and a white balancing option at the end. White balancing is done at the beginning of surgery and can be repeated intermittently if any colour compromise is noted during surgery. (C) Various camera features displayed on the screen are CLARA, CLARA+ CHROMA, CHROMA, SPECTRA A, SPECTRA B and Filter A. SPIES CLARA feature automatically brightens the dark areas of an image and SPIES CHROMA, enhances the red colour of the image, improves colour contrast in tissues and facilitates better visualization of blood vessels. SPECTRA is meant for colour shifting and Filter A setting is meant for semirigid micro-endoscopes like Dacryoendoscopes and Sialoendoscope

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Fig. 24.5  Sets of endoscopes include 4  mm 0°, 30° degree and 70° scopes. Though most of the surgery can be completed with 0°, provision of a 30° scope helps in visualization of any diverticulum etc. Additional availability of 2.5 mm scope may be helpful in paediatric patients

Fig. 24.7  A 0.8 mm dacryoendoscope with markings at 5 mm and a side port for irrigation

Fig. 24.8  A 0.8 mm dacryoendoscope with the camera coupling unit

Fig. 24.6  Close-up view of the tip of various endoscopes can guide us about the various angles

24  Instrumentation in Endoscopic Dacryocystorhinostomy

315

Fig. 24.11  Foot pedal for the IPC: It has 3 buttons for control during surgery. A foot switch to start the IPC, a knob to switch the mode from debrider to drilling and two other buttons for changing the direction of drilling

Fig. 24.9 Integrated power console system (IPC), (Medtronic Inc. USA) is a power console with a provision of connecting multiple hand pieces with an irrigation and suction facility

Fig. 24.10  Close view of the various attachment options. It has the facility of connecting up to four hand pieces at one time, including Microdebrider, Indigo TM drill, Stylus drill and endoscrub sheaths

316

24  Instrumentation in Endoscopic Dacryocystorhinostomy

Fig. 24.12  M5 microdebrider handle, a lightweight handle with the rotatable blade provides the comfort of drilling in a different direction without the need for removal and change of the blade

Fig. 24.13  A curved diamond burr with a guard and an irrigation channel Fig. 24.15 Ellman radiofrequency unit with unipolar and bipolar options

Fig. 24.14  Microdebrider blade with straight and curved blades

24  Instrumentation in Endoscopic Dacryocystorhinostomy Fig. 24.16  A Diode laser (980 nm infrared) using fibre optic cable or a rigid virteo retinal probe

Fig. 24.17  A Diode laser (980 nm infrared) using fibre optic cable or a rigid virteo retinal probe

317

318

24  Instrumentation in Endoscopic Dacryocystorhinostomy

Fig. 24.18  An instrument trolley with essential instruments needed for endoscopic DCR surgery

Fig. 24.19  Tilley’s nasal packing forceps is the first instrument needed for nasal packing

Fig. 24.20  Kilian’s nasal speculum used for nasal packing along with Tilley’s forceps

24  Instrumentation in Endoscopic Dacryocystorhinostomy

319

Fig. 24.22  Bard Parker long handle with 12 no blade for incising the sac and creating the flaps Fig. 24.21  Bard Parker long handle with 15 no blade for initial mucosal incision over the lateral wall

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24  Instrumentation in Endoscopic Dacryocystorhinostomy

Fig. 24.23  A sickle knife can be used for initial incision to create a mucoperiosteal flap in children with narrow nasal cavity

Fig. 24.24  A Suction elevator with a hole at the tip that keeps the field clear during mucoperiosteal flap elevation

24  Instrumentation in Endoscopic Dacryocystorhinostomy

Fig. 24.25  A Suction elevator with a hole at the tip as seen in enlarged view

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Fig. 24.26  An iris scissor used for mucosal incisions as well as for trimming the flap

Fig. 24.27  Kerrison punches in various shapes and sizes including a 90° tip, a 45° tip and a curved Kerrison punch tip with the magnified view of the tips

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24  Instrumentation in Endoscopic Dacryocystorhinostomy

Fig. 24.28  Kerrison punches in various shapes and sizes including a 90° tip, a 45° tip and a curved Kerrison punch tip with the magnified view of the tips

Fig. 24.30  A straight Blakesley Forceps

Fig. 24.31  A straight Blakesley Forceps with a closeup view showing its tip

Fig. 24.32  A curved Blakesley Forceps

Fig. 24.29  A ball pointer, an extremely important instrument for palpating the delicate areas like the junction of lacrimal bone with the inferior turbinate in the inferior part of the lacrimal fossa, everting the lacrimal sac flaps and for checking the superior limit of the osteotomy

Fig. 24.33  A curved Blakesley Forceps with a magnified view of its tip

24  Instrumentation in Endoscopic Dacryocystorhinostomy

Fig. 24.34  Lacrimal probing and irrigation set comprising of Nettleship punctal dilator, Bowman’s probe, syringe and irrigation canula

Fig. 24.35  Crescent knife with three side cutting edge, used for incising the lacrimal sac and for creating flaps. Though a 12 no blade on Bard Parker handle as described in Fig. 24.19 can also be used for incising the sac and creating the flap.

a

b

323

Fig. 24.36  A micro ear surgery forceps is very helpful in paediatric endoscopic DCR as multiple instruments need to simultaneously go into a narrow nasal cavity

Fig. 24.37  Sisler’s trephine for canaliculoplasty in cases with associated canalicular obstructions

e

c

d

Fig. 24.38  A collage to demonstrate evolution of instrumentation in endoscopic DCR. (a) Chisel and hammer, (b) Kerrison punch (c, d) Otological drills with drilling burrs

with the shaft of the burr covered with an atraumatic sheath. (e) M5 microdebrider with drilling and irrigation option with the comfort of rotatable blades

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Though some of the studies have reported comparable results obtained in endoscopic DCR with punch only or with the powered drill [8– 13]. We however feel drilling the superior part of the frontal process of maxilla helps in improving results of endoscopic DCR for a variety of reasons described in the Chap.  8 on improving results in endoscopic DCR.

References 1. Herzallah I, Alzuraiqi B, Bawazeer N, et al. Endoscopic Dacryocystorhinostomy (DCR): a comparative study between powered and non-powered technique. J of Otolaryngol—Head & Neck Surg. 2015;44:56. https://doi.org/10.1186/s40463-015-0109-z. 2. Gurler B, San I.  Long-term follow-up outcomes of non-laser intranasal endoscopic dacryocystorhinostomy: how suitable and useful are conventional surgical instruments? Eur J Ophthalmol. 2004;14(6):453–60. 3. Wormald PJ, A.  A. F.  P. S.  Angelo Tsirbas FRACO.  Powered endoscopic dacryocystorhinostomy. The lacrimal system. New  York: Springer; 2006. p. 223–35. 4. Anijeet D, Dolan L, Macewen CJ.  Endonasal versus external dacryocystorhinostomy for nasolacrimal duct obstruction. Cochrane Database Syst Rev. 2011;1:CD007097. 5. Wormald PJ. Powered endonasal dacryocystorhinostomy. Laryngoscope. 2002;112:69–71. 6. Wormald PJ, Kew J, Van Hasselt CA. The intranasal anatomy of the nasolacrimal sac in endoscopic dac-

ryocystorhinostomy. Otolaryngol Head Neck Surg. 2000;123:307–10. 7. 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 centre. Ophthalmology. 2005;112(8):1463–8. 8. Cabrerizo JR, Montserrat-Gili JR, León-Vintró X, Lopez-Vilas M, Rodríguez-Álvarez F, BonafonteRoyo S, et al. Endonasal endoscopic scalpel-forceps dacryocystorhinostomy vs endocanalicular diode laser dacryocystorhinostomy. Eur J Ophthalmol. 2013;23(1):7–12. 9. Naraghi M, Tabatabaii Mohammadi SZ, Sontou AF, Farajzadeh Deroee A, Boroojerdi M. Endonasal endoscopic dacryocystorhinostomy: how to achieve optimal results with simple punch technique. Eur Arch Otorhinolaryngol. 2012;269(5):1445–9. 10. Agarwal S.  Endoscopic dacryocystorhinostomy for acquired nasolacrimal duct obstruction. J Laryngol Otol. 2009;123(11):1226–8. 11. Yoshida N, Kanazawa H, Shinnabe A, Iino Y.  Powered endoscopic dacryocystorhinostomy with radiowave instruments: surgical outcome according to obstruction level. Eur Arch Otorhinolaryngol. 2013;270(2):579–84. 12. Saratziotis A, Emanuelli E, Gouveris H, Babighian G.  Endoscopic dacryocystorhinostomy for acquired nasolacrimal duct obstruction: creating a window with a drill without use of mucosal flaps. Acta Otolaryngol. 2009;129(9):992–5. 13. Jin H-R, Yeon J-Y, Choi M-Y. Endoscopic dacryocystorhinostomy: creation of a large marsupialized lacrimal sac. J Korean Med Sci. 2006;21(4):719–23.