Endoscopic Dacryocystorhinostomy (DCR) in Children with Congenital Nasolacrimal Duct Malformations

  • Nishi Gupta

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This video explains indications of endoscopic DCR in children include acquired cases of NLD obstruction, traumatic obstructions, patients with systemic anomalies, and refractory cases of congenital nasolacrimal duct obstruction (CNLDO). Refractory CNLDO is the most common indication of endoscopic DCR in children.

This video talks about simple membranous obstructions in CNLDO response to conservative treatment methods like pressure on the lacrimal sac, topical antibiotics, probing, and silicone intubation if needed. All these lead to effective relief of obstruction. DCR is required only rarely for recalcitrant cases of CNLDO. The conditions that fall under refractory CNLDO include NLD variations, bony obstruction, no development of NLD, syndromic association, and craniofacial abnormality.

These refractory cases can be diagnosed with the help of nasal endoscopy as well as dacryoendoscopy. Patients of CNLDO having difficulty in a cannulating nasolacrimal canal during endoscopic guided probing indicate a malformed NLD. On nasal endoscopy, no NLD opening is seen in such cases, and nasal mucosa looks tightly draped in the inferior meatus. Adjuvant use of dacryoendoscopy further helps in confirming the diagnosis. Such patients cannot be treated by probing and syringing; thus, endoscopic DCR is the only definitive treatment.

The technique of Endoscopic dacryocystorhinostomy in children is essentially the same as in adults. However, small-size instruments and endoscopes are needed along with more expertise. The sac also looks different in different conditions, e.g., in acquired NLD obstructions on the endoscopic exploration of the lacrimal sac, the sac is full length with well-formed NLD. While in cases of bony dysgenesis of NLD, the sac size is small depending upon the point of the arrest of the NLD growth.

In cases of incomplete bony dysgenesis of NLD, during surgery, the lower part of the sac extends to the point that is a little short of the superior attachment of the inferior turbinate. In complete bony agenesis of NLD, the sac is small and can be seen ending into the maxilla bone, and NLD is entirely missing. To trace the NLD to achieve complete sac and NLD marsupialization, the surgeon may inadvertently enter into the orbit or maxillary antrum. This video demonstrates three video clips of different indications of NLDO children.

Introduction

This video covers the surgical techniques of endoscopic DCR in small children that pose a challenge due to a narrow nasal cavity.

About The Author

Nishi Gupta

Dr. Nishi Gupta is currently the Director and Head, Department of Otorhinolaryngology & Head & Neck Surgery at Dr Shroff’s Charity Eye and ENT Hospital, New Delhi, India. Dr Nishi Gupta obtained her MS degree in Otorhinolaryngology from MGIMS Wardha, Nagpur University in 1992 and trained at Great Ormond Street Hospital for Children, London. She popularized the technique of endoscopic dacryocystorhinostomy in the country. She has 28 years of experience in Otorhinolaryngology and is a Founder of Tele otology services in India in collaboration with Medtronic Inc USA, in 2013. Her special area of interest includes endoscopic sino-orbital, lacrimal and skull base surgeries. She has been conducting annual live surgical demonstration workshops and hands-on cadaver dissection training sessions on endoscopic sinus and lacrimal disorders for more than two decades.

She has published six projects on trans-nasal endoscopic procedures including books on Endoscopic Dacryocystorhinostomy, and Rhino-Orbito-Cerebral Mucormycosis with Springer.

 

About this video

Author(s)
Nishi Gupta
DOI
https://doi.org/10.1007/978-981-99-2025-9
Online ISBN
978-981-99-2025-9
Total duration
19 min
Publisher
Springer, Singapore
Copyright information
© Producer, under exclusive license to Springer Nature Singapore Pte Ltd. 2023

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Video Transcript

[MUSIC PLAYING]

Hello. My name is Nishi Gupta, and I work as director and head, Department of Otorinolaryngology at Dr. Shroff’s Charity, Eye and ENT Hospital, New Delhi, India. My area of interest includes endoscopic lacrimal, orbit, and sinus diseases. This is a video on endoscopic dacryocystorhinostomy in children with congenital nasolacrimal duct malformations.

The overview includes schematic representation of various anomalies, which can be better understood by first looking at this schematic diagram, where NLD can be seen opening into the inferior meatus. That’s the inferior turbinate. This is the lateral wall. And this is how a patent nasolacrimal duct looks.

If this duct is obstructed with a membrane, as seen in nasolacrimal duct obstruction in children, then it can be treated by simple probing, passing a Bowman’s probe through the upper punctum into the nasolacrimal duct. And the membrane can be perforated easily, allowing the secretions to flow into the inferior meatus and a natural recanalization of the nasolacrimal duct.

Now, various anomalies that are likely to present in nasolacrimal duct have been depicted with the help of these four diagrams. And there are videos on each condition. The first anomaly is the absent membranous NLD with a bony block, as we can see here. So in this case, this is how the inferior meatus looks. This is a schematic diagram. And on endoscopic examination, there is no NLD opening seen into the inferior meatus. The inferior turbinate has been retracted medially.

That’s the lateral wall in the right nasal cavity. There is no NLD opening. And when the sac was opened, it was found to be dilated. And there was no opening seen inferiorly. At the bottom of the sac, there was no continuation into the nasolacrimal duct.

The second condition is the non canalization of the distal NLD. In this case, as we can see, the NLD has formed. But the lower membranous part of the NLD is completely obliterated with the help of this thick tissue, which failed to recanalize. And if the probe is passed in this condition, then probe can be seen into the granulation tissue. And even if probing is done, the syringing fails in these cases. And when the sac is opened, we can see the lower part of the nasolacrimal duct has granulations and will be shown subsequently in the video of this particular case.

This is the third case, where the nasolacrimal duct has been partially developed. Like in this case, we can see that the bony NLD has not formed till the vault of the inferior meatus. And it has just stopped short of the axilla of the inferior meatus. So in this situation, again, no opening will be seen in the NLD. The sac is small, as we can see here. It is ending into the bone of the maxilla. And invariably, the lacrimal sac is filled with the granulation tissue in these conditions.

The fourth condition is the absent bony NLD. As we can see here, that the sac has formed fully, but the bony NLD is not formed. So it looks like there is a complete agenesis of the NLD. In this condition, the diagnosis is made by dual endoscopy. That is using a 4mm endoscope through the nose and a 0.8mm sialendoscopy or dacryoendoscopy through the upper punctum.

So this finding of dacryoendoscopy has been demonstrated in another video on dacryoendoscopy in refractory cases. Here, we’ll talk about the inferior meatal examination. As we can see here, this is the area which has been represented here with the help of endoscopic picture. The mucosa of the inferior meatus seems to be tightly draped along the axilla of the inferior meatus. And there is no NLD opening seen.

The sac was very short, and it was found ending into the maxillary bone. And that’s the intraoperative view, which will be explained later. This is a comparative diagram of all four situations that have been described in this video.