Dacryocystorhinostomy into Contralateral Nasal Cavity

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Hello. My name is Mohammad Javed Ali, and today we will discuss a complex lacrimal surgery whereby we will perform a dacryocystorhinostomy into the contralateral nasal cavity. A brief about myself, I head the Govindram Seksaria Institute of Dacryology and the L.V. Prasad Eye Institute, and I exclusively work in the area of larimal drainage sciences both as a clinician and as a basic science scientist.

The outline of this introduction would hover around a few indications where we take this unusual route of performing a DCR and the significance of stereotactic guidance in achieving good outcomes. Now the term stereotactic guidance, or image guidance or navigation guidance, are used interchangeably. These are the references where you would find greater details about what I’m speaking on.

Now indications are broadly congenital arhinia or heminasal aplasias like you can see in the image on the right side. Now most of these hernias and heminasal aplasias, they usually have absent nasolacrimal ducts for obvious reasons and hence, there would be lacrimal drainage obstruction and they usually present with mucoceles. Really ordering hemirhinectomy, say for example following carcinoma excitions, also, those SALDO that happen subsequently can also be managed by this approach.

To exemplify, we will start with one case that we will be discussing right up to the six month outcome. Now this is a 16-year-old female who had presented with complains epiphora and discharge of the left eye since the past 12 years. And if you can see, that is left-sided heminasal aplasia. There is midfaced hypoplasia on the left side. The left eye is microphthalmic.

And if you see in the central image, you can see that the left atretic nasal cavity can easily be seen with a mark on the lip, which is suggestive of a past cleft lip repair. He had braces for dental alignment. The palate was high-arched. There was synophrys, hypertelorism, an anti-Mongoloid slant of the left eye with a microphthalmic eye, which was confirmed by the ultrasonography that you see.

The patient also had regurgitation of discharge on completion of the lacrimal sac area, which was again suggestive of a dilated sac as well as an obstructed lacrimal drainage part of it. The left nasal cavity, you can see it’s quite atretic. There’s a anteroinferior subtle perforation and a very small atretic corner in the distance. Now to this subtle perforation, one can visualize the concha bullosa of the other side. And the last image that you see on the right side is of the contralateral healthy nasal cavity with a large concha bullosa.

Radiological study is very important in these cases to assess the malformation. They extend and also force preoperative surgical planning. Here you can see that there’s a nice dilated lacrimal sac, which was clinically also evident, and the image on the right is a 3D reconstruction, which actually shows the hypoplastic left side of the face.

Now, if you look at the frontal process of the maxilla, also in the right side image, you can see that on the left side it is abnormal and it has fused directly with the nasal process of the frontal bone near the glabella. And this has a significance for the surgery, which I will discuss when we are dealing with that step of the surgery.

These are coronal images on the left and axial images on the right, which demonstrate the absence of the left maxillary sinus, ethmoid sinus, and the frontal sinus and the hypoplastic maxillary and the nasal bones. In the coronal cuts one can also appreciate the subtle defect that we saw on the endoscopy earlier.

So in view of the absent nasolacrimal ducts, discharge dilated lacrimal sac, and atretic nasal cavity without any recognizable structures on the ipsilateral side, a decision was taken to perform a DCR through the subtle window into the contralateral nasal cavity so that the lacrimal drainage system of the left side then subsequently drains into the right nasal cavity.

So I hope let’s get on with this exciting surgery. And I hope it is very useful for not only the beginners but also the experienced surgeons. Thank you.