Primary Endonasal Dacryocystorhinostomy

Abstract

With careful compliance to endoscopic surgical techniques with minimal tissue damage, preservation of mucosa, and the creation of mucosal flaps, endoscopic lacrimal surgery offers a positive alternative to external DCR with comparable outcomes. Its main advantages included the avoidance of an external scar, limited tissue dissection with minimal postoperative discomfort, and the possibility of doing early surgery in acute dacryocystitis. It may not be the operation of choice in midfacial trauma with distorted anatomy or when canalicular pathology is present.

Preoperative evaluation should focus on nasal anatomy. Proper nasal preparation with decongestants will facilitate the procedure, which can be done in most cases under local anesthesia. The propensity for bleeding and use of anticoagulants should be fully assessed.

The surgical steps include:

• Transillumination of the sac in the nose by placing a fiber optic probe in the upper canaliculus

• Mucosal incision and elevation to expose the frontal process of the maxilla and the lacrimal bone trying to avoid desinsertion of the uncinate process

• An osteotomy of the frontal process of the maxilla and removal of the lacrimal bone

• Sac and duct incision anteriorly with the formation of a posterior flap that is brought in contact to the nasal mucosal flap

• Bicanalicular intubation with placement of a small gel sponge over the flaps

The system is usually irrigated at 1 week and the tubes are removed at 1 month.

Complications include intra- and postoperative bleeding, intraorbital hemorrhages, and postoperative synechiae that can lead to failures. These complications can be avoided in most cases with proper preoperative evaluations and careful surgical techniques.

Surgical outcomes are now comparable to the external DCR and for endoscopic endonasal DCR is becoming the preferred procedure for uncomplicated nasolacrimal obstruction.